Neurosurg. R e v . 15 0992) 303-306
M e n i n g i o m a s o f the lateral ventricle. R e p o r t on six cases Hakan Caner ~, Bekta~ A~ikgiiz 1, Tun~alp l)zgen ~, Ahmet (~olak l, and Behsan Onol z ~Departments of Neurosurgery and 2Pathology, School of Medicine, Hacettepe University, Ankara, Turkey
Abstract
2 Patients and analysis of data
In this study 6 patients who had meningioma of the lateral ventricle are reviewed. The incidence is 1.8% of cases of meningiomas in our series. Microsurgical techniques were employed in all patients. There was no death and the follow-up period was between 5 months and 10 years. No recurrence was seen. Although the origin of these tumors is still not known, DUNN and KERNOHAN note that the choroid plexus has the potential for the production of meningothelial, fibrous, or mixed patterns. Our pathological results confirmed this suggestion.
One patient was a six-year-old child and the others were adults of ages ranging from 37 to 45 years. The clinical data are summarized in tables I and II.
Keywords: Lateral ventricle, meningiomas. 1 Introduction Meningioma of the lateral ventricle, although generally considered to be extremely rare, is of particular clinical and pathological significance [3, 6]. CUSmNG and EISENHARDT[3] w e r e first to use the term "choroidal tumors of the plexuses" (which lie in the ventricle) in their series of 313 intracranial meningiomas. So far different incidences of meningioma of the lateral ventricle have been reported in the literature; recent tabulations have revealed a higher proportion, probably related to routine CT scan evaluation of all patients with headache admitted to neurosurgery units. The incidence is thought to be 0 . 5 - 2% of all intracranial meningiomas [2, 4, 9, 11, 14, 16]. Retrospective analysis of lateral ventricular neoplasms of the brain revealed the most c o m m o n neoplasms were plexus papilloma (20%) and meningioma (18%) [12]. In this study the records and neuroradiological and pathological findings of six patients who had surgical intervention for meningioma of the lateral ventricle are analysed and the literature is reviewed. 9 1992by Walter de Gruyter & Co. Berlin - New York
CT was performed on five patients. The tumor was enhanced by administration of contrast media in four patients (Figure 1). One patient had an isodense lesion. Three patients showed an area of decreased attenuation coefficient with edema adjacent to the tumor. Calcification was seen in two patients. Tumors were located within the left lateral ventricle in four patients and in right lateral ventricle in two. Angiography was performed in all cases: five were subjected to transfemoral cerebral angiography, one to intravenous digital angiography (IV-DSA) (Figure 2). A definitive shift of the internal cerebral vein, anterior cerebral artery and enlarged posterior choroidal artery were the most c o m m o n findings. All patients demonstrated evidence of dilatation of the temporal horn of the lateral ventricle, tumor neovascularity, and vascular blush at the site of tumor. The surgical approach to the tumor was through the posterior parietal cortex. Microsurgery was used for all patients and bleeding was carefully controlled. Total piecemeal removal of the tumor was achieved in five patients, subtotal removal in one patient. Total removal was not possible in case 5 at the first intervention because of profuse bleeding. The second intervention was made one year later and total removal was achieved. Ultrasonic aspiration was used in the last two cases; this made the operative procedure easier. The postoperative course was uneventful in most cases. H o m o n y m o u s hemianopsia was observed in one patient. Epilepsy, which was well controlled
304
Caner et al., Lateral ventricle meningiomas
Table I. Clinical data of the cases of intraventricular meningiomas [1] Case
Sex
Age
Symptoms
Neurotogic Exam.
Duration
1
M
37
Headache
Grade I papilledema
5 months
2
F
6
Headache Weakness on the left
Grade I papilledema VIth nerve paresis Hemiparesis
3 months
3
F
45
Headache Weakness on the right
Grade III papilledema Homonymous hemianopsia Hemiparesis
4
F
44
Headache
Grade II papilledema Weakness on the left
8 months
5
M
45
Headache
Grade I papilledema Speech disturbance
1 months
6
M
32
Headache
Grade I papilledema
3 months
48 months
Table II. Clinical data of the cases of intraventricular meningioma [2] Case
Neurorad. exam. (CT or Angio)
Pathology
Postop. neurol, exam. (new neurol, findings)
1
Left lateral intraventricular mass with enlarged choroidal artery (Anglo.)
Meningothelial
Left homonymous hemianopsia
2
Right lateral intraventricular mass with shift of ant. and middle cerebral aa. (Angio.)
Predominantly fibrous
3
Left lateral intraventricular mass with hydrocephalus
Predominantly fibrous
4
Right lateral intraventricular hyperdense mass with calcification
Meningothelial
5
Left lateral intraventricular hyperdense mass
Angiomatous
6
Left lateral intraventricular mass with calcification
Meningothelial and fibroblastic
by anticonvulsants, was seen in another. There were no deaths related to surgery. The follow-up period was between five months and ten years. N o recurrence has been seen so far. Histologic examination revealed that the tumors were p r e d o m i n a n t l y fibrous in two, meningothelial in two, p s a m m o m a t o u s and a n g i o m a t o u s in one, and mixed in one case.
3 Discussion In our series, the incidence o f lateral ventricle meningiomas is 1.8% o f all meningiomas. The incidence in children is not mentioned in the lit-
erature and only sporadic cases have been reported [2, 5, 7, 11, 17, 19]. In our series the m a i n symptoms were related to increased intracranial pressure. The only s y m p t o m s and signs which h a d a localizing value and were frequently present were visual field defects or hemianopsia, which occurred when the t u m o r h a d reached a certain size. A l t h o u g h CT scanning is best suited to determine the site, size, density and vascularity o f the lesion, a n g i o g r a p h y is still necessary to determine supplying arteries [12]. Since i. v. D S A provides sufficient i n f o r m a t i o n to preoperatively d o c u m e n t the arterial supply to the meningioma, which is mainly from the postero-lateral choroidal arteries, it was Neurosurg. Rev. 15 (1992)
Caner et al., Lateral ventricle meningiomas
305
Figure 1. CT of a patient with meningioma in lateral ventricle showing enhancement of the tumor by administration of contrast media and dilatation of the temporal horn.
Figure2. Intravenous digital angiography of a case showing marked neovascularity and vascular blush of meningioma.
considered preferable in these tumors. The patients could not be evaluated by magnetic resonance (MR) in this study but it has been reported that M R findings do not help eliminate alternative diagnoses [121.
5, 10, 15, 19]. In two of our cases tumors had contact with the choroid plexus and may have originated from the tela choroidea, in the other four the tumors had no contact but could have originated from the tela conjunctiva of the vessels. Although ABORT and COURVILLE[1] reported that the these tumors are almost fibrous, DUNN and KERNOHAN [8] suggested that the choroid plexus has the potential for the production of meningothelial, fibrous or mixed patterns. WALL [18] reported eight lateral intraventricular meningiomas which differed in histological structures as do meningiomas elsewhere. In our series the histopathological results supported the suggestion of DUNN and KERNOHAN [8].
There was no hospital death in the present series although rates of 9 - 1 1 % have been reported [1, 8, 18]. The only major complication was seizures in one case. These were controlled by suitable anticonvulsants. Although neither recurrence nor metastasis occurred in our series, spinal metastasis after removal of malignant meningioma has been reported [13]. The origin of these tumors is still controversial. It is thought that they arise from the arachnoidea of the choroid plexus or tela conjunctiva of vessels since meningothelial inclusion bodies are normally present in the arachnoid of the tela choroidea [3,
In conclusion; the prognosis is very good when the lateral intraventricular meningioma can be totally removed with microsurgical techniques. This should be attempted in all cases.
References
[1] ABBORTKH, CB COURVILLE:Intraventricle meningiomas, review of literature and report of 2 cases. Bull Los Angeles Neurot Soc 8 (1942) 12-28 [2] BRETPH, S GNARm, F COHADON:Les meningiomas du ventricle lateral. 3 observations recentes. Neurochirurgie 35 (1989) 5 - 1 2 [3] CUSHINGH, H EISENHARDT:Meningiomas; Their classification, regional behavior, live history and surgical end results. Springfield III [4] DANDY WE: Bening encapsulate tumours in the lateral ventricles of the brain. Ann Surg 106 (1937) 492 - 503 Neurosurg. Rev. 15 (1992)
[5] DELANDSHEERJM"Les meningiomas du ventricle lateral. Neurochirurgie 11 (1965) 3 - 5 7 [6] DE LA TORRE E, E ALEXANDER,CH DAVIS, DL CRANDELL:Tumours of the lateral ventricles of the brain. Report of eight cases, with suggestions for clinical management. J Neurosurg 209 (1963) 461 470 [7] DIAZ P, A MAILLO, F MORALES,JA GOMEZ-MORETA, J HERNANDEZ:Multiple meningiomas of the fourth ventricle in infancy: case report. Neurosurg 26 (1990) 1 0 5 7 - 1 0 6 0
306 [8] DUNNJ, JW KERNOHAN:Observations on the origin of meningioma from the choroid plexus of the lateral ventricle. J Neurot Neurosurg Psychiat 17 (1954) 91 - 103 [9] FORNARI M, M SAVOLARDA, G MORELLO: Meningiomas of the lateral ventricles. Neuroradiological and surgical considerations in 18 cases. J Neurosurg 54 (1981) 6 4 - 7 4 [10] GARDNER WJ, OA TURNER: Primary fibroblastic tumours of the choroid plexus of the lateral ventricles. A clinicopathological study of three cases. Sur Gynec Obstet 66 (1938) 804-809 [11] GASSELMM, H DAVIES: Meningiomas in the lateral ventricle. Brain 84 (1961) 605-627 [12] JELINEKJ, JG SMIRNIOTOPOULOS,JE PARISI,M KANZER: Lateral ventricular neoplasms of the brain: differential diagnosis on clinical, CT, and MR findings. AJR 155 (1990) 365-372 [13] KAMIYAK, T INAGAWA,R NA6ASAKO:Malignant intraventricular meningioma with spinal metastasis through cerebrospinal fluid. Surg Neurol 32 (1989) 213-218
Caner et al., Lateral ventricle meningiomas
[14] KOBAYASHI S, ]7t OKAZAKI, C MACCARTY: Intraventricular meningiomas. Mayo Clin Proc 46 (1971) 7 3 5 - 741. [15] KOTWICAZ, L JAGODZINSKI,L POLLS:Meningiomas of the lateral ventricle. Neurochirurgia 28 (1985) 1 9 9 - 201 [16] MACCARTYCS, SF TAYLOR:Intracranial meningitis; Experiences at the Mayo Clinic. Neurol Med Chit Tokyo 19 (1979) 569--574 [17] PANDYA P, K CHISHTI, CM BANNISTER: A third ventricular meningioma in a child. Br J Neurosurg 4 (1990) 129--133 [18] WALLAE: Meningiomas within the lateral ventricle. J Neurol Neurosurg Psychiat 17 (1954) 91-103 [19] ZULC~tKJ: Brain tumours: Their biology and pathology. Second american edition. Springer, New York i965 Submitted January 7, 1991. Accepted October 21, 1991. Hakan Cancer M. D. Bestekar Sok 19/15 Kavaklidere Ankara 06680 Turkey
Neurosurg. Rev. 15 (1992)
M e n i n g i o m a s o f the lateral ventricle. R e p o r t on six cases Hakan Caner ~, Bekta~ A~ikgiiz 1, Tun~alp l)zgen ~, Ahmet (~olak l, and Behsan Onol z ~Departments of Neurosurgery and 2Pathology, School of Medicine, Hacettepe University, Ankara, Turkey
Abstract
2 Patients and analysis of data
In this study 6 patients who had meningioma of the lateral ventricle are reviewed. The incidence is 1.8% of cases of meningiomas in our series. Microsurgical techniques were employed in all patients. There was no death and the follow-up period was between 5 months and 10 years. No recurrence was seen. Although the origin of these tumors is still not known, DUNN and KERNOHAN note that the choroid plexus has the potential for the production of meningothelial, fibrous, or mixed patterns. Our pathological results confirmed this suggestion.
One patient was a six-year-old child and the others were adults of ages ranging from 37 to 45 years. The clinical data are summarized in tables I and II.
Keywords: Lateral ventricle, meningiomas. 1 Introduction Meningioma of the lateral ventricle, although generally considered to be extremely rare, is of particular clinical and pathological significance [3, 6]. CUSmNG and EISENHARDT[3] w e r e first to use the term "choroidal tumors of the plexuses" (which lie in the ventricle) in their series of 313 intracranial meningiomas. So far different incidences of meningioma of the lateral ventricle have been reported in the literature; recent tabulations have revealed a higher proportion, probably related to routine CT scan evaluation of all patients with headache admitted to neurosurgery units. The incidence is thought to be 0 . 5 - 2% of all intracranial meningiomas [2, 4, 9, 11, 14, 16]. Retrospective analysis of lateral ventricular neoplasms of the brain revealed the most c o m m o n neoplasms were plexus papilloma (20%) and meningioma (18%) [12]. In this study the records and neuroradiological and pathological findings of six patients who had surgical intervention for meningioma of the lateral ventricle are analysed and the literature is reviewed. 9 1992by Walter de Gruyter & Co. Berlin - New York
CT was performed on five patients. The tumor was enhanced by administration of contrast media in four patients (Figure 1). One patient had an isodense lesion. Three patients showed an area of decreased attenuation coefficient with edema adjacent to the tumor. Calcification was seen in two patients. Tumors were located within the left lateral ventricle in four patients and in right lateral ventricle in two. Angiography was performed in all cases: five were subjected to transfemoral cerebral angiography, one to intravenous digital angiography (IV-DSA) (Figure 2). A definitive shift of the internal cerebral vein, anterior cerebral artery and enlarged posterior choroidal artery were the most c o m m o n findings. All patients demonstrated evidence of dilatation of the temporal horn of the lateral ventricle, tumor neovascularity, and vascular blush at the site of tumor. The surgical approach to the tumor was through the posterior parietal cortex. Microsurgery was used for all patients and bleeding was carefully controlled. Total piecemeal removal of the tumor was achieved in five patients, subtotal removal in one patient. Total removal was not possible in case 5 at the first intervention because of profuse bleeding. The second intervention was made one year later and total removal was achieved. Ultrasonic aspiration was used in the last two cases; this made the operative procedure easier. The postoperative course was uneventful in most cases. H o m o n y m o u s hemianopsia was observed in one patient. Epilepsy, which was well controlled
304
Caner et al., Lateral ventricle meningiomas
Table I. Clinical data of the cases of intraventricular meningiomas [1] Case
Sex
Age
Symptoms
Neurotogic Exam.
Duration
1
M
37
Headache
Grade I papilledema
5 months
2
F
6
Headache Weakness on the left
Grade I papilledema VIth nerve paresis Hemiparesis
3 months
3
F
45
Headache Weakness on the right
Grade III papilledema Homonymous hemianopsia Hemiparesis
4
F
44
Headache
Grade II papilledema Weakness on the left
8 months
5
M
45
Headache
Grade I papilledema Speech disturbance
1 months
6
M
32
Headache
Grade I papilledema
3 months
48 months
Table II. Clinical data of the cases of intraventricular meningioma [2] Case
Neurorad. exam. (CT or Angio)
Pathology
Postop. neurol, exam. (new neurol, findings)
1
Left lateral intraventricular mass with enlarged choroidal artery (Anglo.)
Meningothelial
Left homonymous hemianopsia
2
Right lateral intraventricular mass with shift of ant. and middle cerebral aa. (Angio.)
Predominantly fibrous
3
Left lateral intraventricular mass with hydrocephalus
Predominantly fibrous
4
Right lateral intraventricular hyperdense mass with calcification
Meningothelial
5
Left lateral intraventricular hyperdense mass
Angiomatous
6
Left lateral intraventricular mass with calcification
Meningothelial and fibroblastic
by anticonvulsants, was seen in another. There were no deaths related to surgery. The follow-up period was between five months and ten years. N o recurrence has been seen so far. Histologic examination revealed that the tumors were p r e d o m i n a n t l y fibrous in two, meningothelial in two, p s a m m o m a t o u s and a n g i o m a t o u s in one, and mixed in one case.
3 Discussion In our series, the incidence o f lateral ventricle meningiomas is 1.8% o f all meningiomas. The incidence in children is not mentioned in the lit-
erature and only sporadic cases have been reported [2, 5, 7, 11, 17, 19]. In our series the m a i n symptoms were related to increased intracranial pressure. The only s y m p t o m s and signs which h a d a localizing value and were frequently present were visual field defects or hemianopsia, which occurred when the t u m o r h a d reached a certain size. A l t h o u g h CT scanning is best suited to determine the site, size, density and vascularity o f the lesion, a n g i o g r a p h y is still necessary to determine supplying arteries [12]. Since i. v. D S A provides sufficient i n f o r m a t i o n to preoperatively d o c u m e n t the arterial supply to the meningioma, which is mainly from the postero-lateral choroidal arteries, it was Neurosurg. Rev. 15 (1992)
Caner et al., Lateral ventricle meningiomas
305
Figure 1. CT of a patient with meningioma in lateral ventricle showing enhancement of the tumor by administration of contrast media and dilatation of the temporal horn.
Figure2. Intravenous digital angiography of a case showing marked neovascularity and vascular blush of meningioma.
considered preferable in these tumors. The patients could not be evaluated by magnetic resonance (MR) in this study but it has been reported that M R findings do not help eliminate alternative diagnoses [121.
5, 10, 15, 19]. In two of our cases tumors had contact with the choroid plexus and may have originated from the tela choroidea, in the other four the tumors had no contact but could have originated from the tela conjunctiva of the vessels. Although ABORT and COURVILLE[1] reported that the these tumors are almost fibrous, DUNN and KERNOHAN [8] suggested that the choroid plexus has the potential for the production of meningothelial, fibrous or mixed patterns. WALL [18] reported eight lateral intraventricular meningiomas which differed in histological structures as do meningiomas elsewhere. In our series the histopathological results supported the suggestion of DUNN and KERNOHAN [8].
There was no hospital death in the present series although rates of 9 - 1 1 % have been reported [1, 8, 18]. The only major complication was seizures in one case. These were controlled by suitable anticonvulsants. Although neither recurrence nor metastasis occurred in our series, spinal metastasis after removal of malignant meningioma has been reported [13]. The origin of these tumors is still controversial. It is thought that they arise from the arachnoidea of the choroid plexus or tela conjunctiva of vessels since meningothelial inclusion bodies are normally present in the arachnoid of the tela choroidea [3,
In conclusion; the prognosis is very good when the lateral intraventricular meningioma can be totally removed with microsurgical techniques. This should be attempted in all cases.
References
[1] ABBORTKH, CB COURVILLE:Intraventricle meningiomas, review of literature and report of 2 cases. Bull Los Angeles Neurot Soc 8 (1942) 12-28 [2] BRETPH, S GNARm, F COHADON:Les meningiomas du ventricle lateral. 3 observations recentes. Neurochirurgie 35 (1989) 5 - 1 2 [3] CUSHINGH, H EISENHARDT:Meningiomas; Their classification, regional behavior, live history and surgical end results. Springfield III [4] DANDY WE: Bening encapsulate tumours in the lateral ventricles of the brain. Ann Surg 106 (1937) 492 - 503 Neurosurg. Rev. 15 (1992)
[5] DELANDSHEERJM"Les meningiomas du ventricle lateral. Neurochirurgie 11 (1965) 3 - 5 7 [6] DE LA TORRE E, E ALEXANDER,CH DAVIS, DL CRANDELL:Tumours of the lateral ventricles of the brain. Report of eight cases, with suggestions for clinical management. J Neurosurg 209 (1963) 461 470 [7] DIAZ P, A MAILLO, F MORALES,JA GOMEZ-MORETA, J HERNANDEZ:Multiple meningiomas of the fourth ventricle in infancy: case report. Neurosurg 26 (1990) 1 0 5 7 - 1 0 6 0
306 [8] DUNNJ, JW KERNOHAN:Observations on the origin of meningioma from the choroid plexus of the lateral ventricle. J Neurot Neurosurg Psychiat 17 (1954) 91 - 103 [9] FORNARI M, M SAVOLARDA, G MORELLO: Meningiomas of the lateral ventricles. Neuroradiological and surgical considerations in 18 cases. J Neurosurg 54 (1981) 6 4 - 7 4 [10] GARDNER WJ, OA TURNER: Primary fibroblastic tumours of the choroid plexus of the lateral ventricles. A clinicopathological study of three cases. Sur Gynec Obstet 66 (1938) 804-809 [11] GASSELMM, H DAVIES: Meningiomas in the lateral ventricle. Brain 84 (1961) 605-627 [12] JELINEKJ, JG SMIRNIOTOPOULOS,JE PARISI,M KANZER: Lateral ventricular neoplasms of the brain: differential diagnosis on clinical, CT, and MR findings. AJR 155 (1990) 365-372 [13] KAMIYAK, T INAGAWA,R NA6ASAKO:Malignant intraventricular meningioma with spinal metastasis through cerebrospinal fluid. Surg Neurol 32 (1989) 213-218
Caner et al., Lateral ventricle meningiomas
[14] KOBAYASHI S, ]7t OKAZAKI, C MACCARTY: Intraventricular meningiomas. Mayo Clin Proc 46 (1971) 7 3 5 - 741. [15] KOTWICAZ, L JAGODZINSKI,L POLLS:Meningiomas of the lateral ventricle. Neurochirurgia 28 (1985) 1 9 9 - 201 [16] MACCARTYCS, SF TAYLOR:Intracranial meningitis; Experiences at the Mayo Clinic. Neurol Med Chit Tokyo 19 (1979) 569--574 [17] PANDYA P, K CHISHTI, CM BANNISTER: A third ventricular meningioma in a child. Br J Neurosurg 4 (1990) 129--133 [18] WALLAE: Meningiomas within the lateral ventricle. J Neurol Neurosurg Psychiat 17 (1954) 91-103 [19] ZULC~tKJ: Brain tumours: Their biology and pathology. Second american edition. Springer, New York i965 Submitted January 7, 1991. Accepted October 21, 1991. Hakan Cancer M. D. Bestekar Sok 19/15 Kavaklidere Ankara 06680 Turkey
Neurosurg. Rev. 15 (1992)
