Third
Ventricle
Meningioma
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
YA-YEN
LEE,’
Mimicking
SHU-REN
LIN,’
AND
Although meningiomas occur at any age, they are predominantly adult tumors. In a review of a 2,620 case series of intracranial tumors in childhood, the incidence of meningioma was estimated at 1 [1], in contrast to that of adults, which is around 10%-15% [2-5]. Intraventnicular meningiomas are very rare. The major meninseries,
by Cushing
and
Eisenhardt
[2],
region
medium
Olivecrona
nerves
removed.
There
was
side.
Thorough
evaluation
did
not
reveal
Received October 13, 1978; accepted ‘Department of Radiology. University S.
A. 2
after revision
were
noted.
December
of Rochester
Medical
was
noted
in the
choroid
plexus
(fig. 1C). Cerebral angiognaphy revealed distal posterior medial choroidal artery
attached to the anterior superior of the third ventricle, was found
of the
portion of the and completely (fig. ex-
Although
tumors
ventricle
arising
are
rare,
and radiographically. structing the flow vomiting,
meningothelial
visual
from
they
the
evoke
anterior
interest
Their symptoms of the cerebrospinal impairment,
and
superior
both
clinically
result from obfluid. Headache,
acute
illedema are due to intermittent men of Monro. When the tumors
intermittent
pap-
of the foralarge, persistent obstructive hydrocephalus develops Tumors considered in the differential diagnosis are: (1) colboid cyst, (2) meningioma, (3) ependymoma, and (4) choroid plexus
obstruction become .
papilloma.
Colboid
cysts
do
not
contain
calcium;
in the region the possibility
of
therefore,
cal-
the foramen of Monro of colboid cyst. Angio-
graphically, the internal cerebral vein, as seen in the lateral view, may be flattened and displaced downward in its posterior third due to dilated lateral ventricles. The anterior third of the internal cerebral vein may be elevated, curving concavely downward around the cyst [9]. In our case, the anterior third of the internal cerebral vein was slightly elevated but was not the typical humping described by others [9]. Although a faint choroid blush and the hypertrophied distal posterior choroidal arteries can be seen in the colloid cyst [10], it is probably more common in other third ventricle tumors, such as meningiomas (as in our case). A well defined oval or round mass of about 2.5 cm or less with a smooth ,
margin, and associated with tion of the lateral ventricle,
of
enhancement
calcifications
Calcification
with
pressure.
intracranial
in the
a marked
pattern
study
definite
1B).
A meningioma
neurofibromatosis. Plain skull films showed separation of the sutures and increased digital markings, indicative of increased intracranial No
mass
with
occasional psammoma bodies was verified histologically 3B). The postoperative course was essentially uneventful, cept for an episode of questionable seizure.
third
no definite
evidence
round
associated
Discussion
motor or sensation deficit. The Romberg test was normal, but the patient had poor heel walking. Superficial and deep tendon reflexes were unremarkable. Babinski’s sign was elicited on the right
(fig.
cium in tumors virtually excludes
intact.
circumscribed
of Monro
obstructive hydnocephalus (fig. 1A). A significant was noted after intravenous injection of contrast
(fig. 3A), firmly choroid plexus
Report
were
fonamen
with a faint tumor blush in the region of the foramen of Monro (fig. 2). A colboid cyst was diagnosed preoperatively. At night frontal craniotomy a tan-colored, 1 .5 cm solid mass
41/2
All the cranial
a 1 .5 cm well
of the lateral ventricles a slightly hypertrophied
M. G., a 10-year-old white boy, was in good health until months before admission when he began having occasional episodes of blurred vision with “black lines” after standing up quickly from a reclining position. One night in the month before admission, he was awakened by severe headache and abdominal pain, followed by nausea and vomiting. He was later awakened by severe stiffness and tenderness on the right side of the neck, and a private physician found bilateral papilledema without definite localizing signs. Later, he was transferred to Strong Memorial Hospital for further neurologic evaluation. Neurobogic examination revealed the patient was slightly ataxic.
Cyst in a Child
A. HORNER2
of the
degree of enhancement
[3], and Simpson [4], with a total of 1 241 cases, showed that only 3% of the meningiomas arose within ventricles. In 1942, Abbott and Courville [6] reviewed 50 reported intraventricular meningiomas and found only four were in patients 10 years old or younger. Of the 50 meningiomas, 28 were in the left lateral ventricle, 15 were in the right lateral ventricle, and only two originated in the third ventricle. In these two third-ventricle meningiomas, one occurred in a 36-year-old woman, while the other occurred in an 11-year-old girl. Of particular interest is that most of these were either fibrous, fibroblastic, or psammomatous meningiomas. In 1955, Heppner [7] reported two cases of third ventricle meningiomas in children, both located in the posteniorthird ventricle. Merten etal. [8] emphasized the increased frequency of calcification and higher mcidence of location in the posterior fossa and within the ventricles of meningiomas in children and adolescents, but meningiomas originating in the third ventricle were not mentioned. A case of third ventricle meningioma with radiographic features of colboid cyst in a 10-year-old boy is reported here. Case
FREDERICK
demonstrated
.5%
gioma
a Colloid
density
CT
[11-14].
CT will
slightly
demonstrate
greater
of the
moderate is always
than
lesion
to marked present on
a smooth brain
will
tissue.
be shown
mass
dilatathe air with
a
A significant
after
contrast
27, 1978. Center,
601
Elmwood
Avenue,
Rochester,
New
York
14642.
Address
reprint
requests
to
Lin.
Departments
AJR 132:669-671 © 1 979 American
of Pediatrics ,
AprIl 1979 Roentgen Ray
and Neurology.
University
of Rochester
Medical
669 Society
Center,
Rochester,
New York 14642. 0361
-803x/79/1324-0669
$0.00
670
CASE
REPORTS
AJR:132,
Fig.
1 -At
level
April
of
1979
foramen
of
Monro. A, Without contrast, mass with density slightly higher than normal brain
tissue.
B,
With
contrast
en-
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
hancement, lesion is well circumscnibed 1.5 cm mass. C, At 1 cm higher, calcification in lateral ventnides associated with marked obstructive
hydrocephalus.
‘:‘ ‘
.‘
4
‘,
‘
-:
C
1’
:‘
:‘.‘t
.
-.
4
Fig. medial
2.-Lateral posterior
view, choroidal
late arterial phase. artery with faint
Slightly hypertrophied tumor blush (arrows).
distal
-,.‘
V ‘
““
is given
in the air study colloid
[10,
and
11,
15,
16].
The
CT are virtually
combined
..;
findings
pathognomonic
\,.J
tumors
in
childhood,
Choroid very rare
from colloid cysts. Most are located in lateral ventricles and rarely in the third The surface of these tumors is bobulated and resembling cauliflower [5]. CT often shows ensolid masses with a small central lucency [17]. [5,
plexus 18].
papilbomas of They are usually
the roof
of the ventricle,
contrast
to the
these tumors ular frondlike enhancement be seen
in both
illoma. In our case, The calcification
well
the third attached
as are colloid
circumscribed
cysts.
colboid
ventricle superiorly
are to
However, cysts
[18,
in 19],
tend to be lobulated, and appear as irregintraventricular masses with significant on CT [17]. In addition, calcification may ependymomas
and
choroid
‘#{149} ,
-
,‘ -,
.
‘..,
-
,,t’ ...
distinguishable the fourth and tufted, hanced
,,
_
i.
:.#{149}‘
.
.,
.
1,
are ,‘:
ventricle.
.
-i,:;-
of a .,‘
common
I.
‘:‘.,::#{149}
.-
cyst.
Ependymomas,
d)P_
)
t”_
.
4
material
,z
,
plexus
pap-
CT findings most resembled a colloid cyst. of choroid plexus of the lateral ventri-
:
:
.
.‘
,.? ‘
..
.
.
‘q
L#{224}-
Fig. 3.-A, Solid mass. B. Meningioma of the meningothelial Psammoma body (arrow). (Low power magnification.)
pattern.
des was believed to be unrelated to the tumor. Such calcification is very unusual in a patient this age, and its etiology remains unclear. Thorough evaluation failed to reveal evidence of neurofibromatosis. At surgery, a well circumscribed
third
ventricle
mass
arising
was found
from
the
anterior
and a meningioma
roof
of the
was verified.
AJR:132,
April
CASE
1979
REFERENCES 1
.
Jefferson
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
third
G, Jackson
ventricles.
H: Tumors
of the lateral
and of the
R Soc Med 32:1105-1137, 1939 2. Cushing H, Eisenhardt L: Meningiomas. Their Classification, Regional Behavior, Life History, and Surgical End Results. Springfield, Thomas, 1938 3. Olivecrona H: The panasagittal meningiomas. J Neurosurg 4:327-341, 1947 4. Simpson D: The recurrence of intracranial meningioma after surgical treatment. J Neurol Neurosurg Psychiatry 20:
22-39,
Proc
1957
5. Z#{252}lchKJ: Brain
York, Springer,
Tumors:
Their
Biology
and
Pathology.
New
1965
6. Abbott KH, Courvzlle CB: Intraventriculan meningiomas. Review of the literature and report of two cases. Bull Los Angeles Neurol Soc 7 : 12-28, 1942 7. Heppnen F: Meningiomas of the third ventricle in children.
Review of the literature uneventful recovery after BeIg
30:472-481,
1955
8. Merten DF, Gooding tunes of meningiomas diatrRadiol 2:89-96, 9. Batnitzky
5, Sarwar
B: Colboid 341, 1974 10.
Sackett
CA, Newton TH: The radiologic in childhood and adolescence. 1974 M, Leeds
cysts of the third
JF, Messina
and report of two cases with surgery. Acta Neurol Psychiatr
Pe-
NE, Schechter MM, Azar-Kia Radiology 1 1 2 : 327-
ventricle.
AV, Petito
fea-
CK: Computed
tomography
REPORTS
671
and magnification vertebral angiotomography in the diagnosis of colloid cysts of the third ventricle. Radiology 116: 95-100, 1975 1 1 . Lee KF, Lin SA: Neuroradiology of Sellar and Juxtasellar Mass Lesions. Springfield, Ill., Thomas, 1979 12. Little JK, MacCarty CS: Colloid cysts of the third ventricle. J Neurosurg 40 : 230-235 , 1974 13. Sage MR. McAllister VL, Kendall BE, Bull JWD, Moseley IF:
Radiology
in the diagnosis
of colloid
cysts
of the third
14.
ventricle. BrJ Radio! 48:708-723, 1975 Taveras JM , Wood EH : Diagnostic Neuroradiology Baltimore, Williams & Wilkins, 1976, pp 434-437
,
15.
Davis
tumors.
DO:
CT
in
the
diagnosis
of
supratentonial
2d ed.
Semin Roentgenol 12 :97-100, 1977 16. Osborn AG, Wing SD: Thin-section computed tomography in the evaluation of third ventricular colloid cyst. Radiology 124:257-258, 1977 17.
Naidich
TP,
Lin
JP,
Leeds
NE,
Pudlowski
Primary tumors and other masses fourth ventricle. Differential diagnosis raphy. Neuroradiology 14 : 153-174, 18. Rovit RL, Schechter MM, Chodnoff ilbomas: observation on radiographic 608-617, 1976 19. Thompson JA, Harwood-Nash DC, diology of childhood chonoid plexus 116-133, 1973
AM,
Naidich
JB:
of the cerebellum and by computed tomog1977 P: Choroid plexus papdiagnosis. AJR 110: Fitz CR: The neuronaneoplasms. AJR 118:
Ventricle
Meningioma
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
YA-YEN
LEE,’
Mimicking
SHU-REN
LIN,’
AND
Although meningiomas occur at any age, they are predominantly adult tumors. In a review of a 2,620 case series of intracranial tumors in childhood, the incidence of meningioma was estimated at 1 [1], in contrast to that of adults, which is around 10%-15% [2-5]. Intraventnicular meningiomas are very rare. The major meninseries,
by Cushing
and
Eisenhardt
[2],
region
medium
Olivecrona
nerves
removed.
There
was
side.
Thorough
evaluation
did
not
reveal
Received October 13, 1978; accepted ‘Department of Radiology. University S.
A. 2
after revision
were
noted.
December
of Rochester
Medical
was
noted
in the
choroid
plexus
(fig. 1C). Cerebral angiognaphy revealed distal posterior medial choroidal artery
attached to the anterior superior of the third ventricle, was found
of the
portion of the and completely (fig. ex-
Although
tumors
ventricle
arising
are
rare,
and radiographically. structing the flow vomiting,
meningothelial
visual
from
they
the
evoke
anterior
interest
Their symptoms of the cerebrospinal impairment,
and
superior
both
clinically
result from obfluid. Headache,
acute
illedema are due to intermittent men of Monro. When the tumors
intermittent
pap-
of the foralarge, persistent obstructive hydrocephalus develops Tumors considered in the differential diagnosis are: (1) colboid cyst, (2) meningioma, (3) ependymoma, and (4) choroid plexus
obstruction become .
papilloma.
Colboid
cysts
do
not
contain
calcium;
in the region the possibility
of
therefore,
cal-
the foramen of Monro of colboid cyst. Angio-
graphically, the internal cerebral vein, as seen in the lateral view, may be flattened and displaced downward in its posterior third due to dilated lateral ventricles. The anterior third of the internal cerebral vein may be elevated, curving concavely downward around the cyst [9]. In our case, the anterior third of the internal cerebral vein was slightly elevated but was not the typical humping described by others [9]. Although a faint choroid blush and the hypertrophied distal posterior choroidal arteries can be seen in the colloid cyst [10], it is probably more common in other third ventricle tumors, such as meningiomas (as in our case). A well defined oval or round mass of about 2.5 cm or less with a smooth ,
margin, and associated with tion of the lateral ventricle,
of
enhancement
calcifications
Calcification
with
pressure.
intracranial
in the
a marked
pattern
study
definite
1B).
A meningioma
neurofibromatosis. Plain skull films showed separation of the sutures and increased digital markings, indicative of increased intracranial No
mass
with
occasional psammoma bodies was verified histologically 3B). The postoperative course was essentially uneventful, cept for an episode of questionable seizure.
third
no definite
evidence
round
associated
Discussion
motor or sensation deficit. The Romberg test was normal, but the patient had poor heel walking. Superficial and deep tendon reflexes were unremarkable. Babinski’s sign was elicited on the right
(fig.
cium in tumors virtually excludes
intact.
circumscribed
of Monro
obstructive hydnocephalus (fig. 1A). A significant was noted after intravenous injection of contrast
(fig. 3A), firmly choroid plexus
Report
were
fonamen
with a faint tumor blush in the region of the foramen of Monro (fig. 2). A colboid cyst was diagnosed preoperatively. At night frontal craniotomy a tan-colored, 1 .5 cm solid mass
41/2
All the cranial
a 1 .5 cm well
of the lateral ventricles a slightly hypertrophied
M. G., a 10-year-old white boy, was in good health until months before admission when he began having occasional episodes of blurred vision with “black lines” after standing up quickly from a reclining position. One night in the month before admission, he was awakened by severe headache and abdominal pain, followed by nausea and vomiting. He was later awakened by severe stiffness and tenderness on the right side of the neck, and a private physician found bilateral papilledema without definite localizing signs. Later, he was transferred to Strong Memorial Hospital for further neurologic evaluation. Neurobogic examination revealed the patient was slightly ataxic.
Cyst in a Child
A. HORNER2
of the
degree of enhancement
[3], and Simpson [4], with a total of 1 241 cases, showed that only 3% of the meningiomas arose within ventricles. In 1942, Abbott and Courville [6] reviewed 50 reported intraventricular meningiomas and found only four were in patients 10 years old or younger. Of the 50 meningiomas, 28 were in the left lateral ventricle, 15 were in the right lateral ventricle, and only two originated in the third ventricle. In these two third-ventricle meningiomas, one occurred in a 36-year-old woman, while the other occurred in an 11-year-old girl. Of particular interest is that most of these were either fibrous, fibroblastic, or psammomatous meningiomas. In 1955, Heppner [7] reported two cases of third ventricle meningiomas in children, both located in the posteniorthird ventricle. Merten etal. [8] emphasized the increased frequency of calcification and higher mcidence of location in the posterior fossa and within the ventricles of meningiomas in children and adolescents, but meningiomas originating in the third ventricle were not mentioned. A case of third ventricle meningioma with radiographic features of colboid cyst in a 10-year-old boy is reported here. Case
FREDERICK
demonstrated
.5%
gioma
a Colloid
density
CT
[11-14].
CT will
slightly
demonstrate
greater
of the
moderate is always
than
lesion
to marked present on
a smooth brain
will
tissue.
be shown
mass
dilatathe air with
a
A significant
after
contrast
27, 1978. Center,
601
Elmwood
Avenue,
Rochester,
New
York
14642.
Address
reprint
requests
to
Lin.
Departments
AJR 132:669-671 © 1 979 American
of Pediatrics ,
AprIl 1979 Roentgen Ray
and Neurology.
University
of Rochester
Medical
669 Society
Center,
Rochester,
New York 14642. 0361
-803x/79/1324-0669
$0.00
670
CASE
REPORTS
AJR:132,
Fig.
1 -At
level
April
of
1979
foramen
of
Monro. A, Without contrast, mass with density slightly higher than normal brain
tissue.
B,
With
contrast
en-
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
hancement, lesion is well circumscnibed 1.5 cm mass. C, At 1 cm higher, calcification in lateral ventnides associated with marked obstructive
hydrocephalus.
‘:‘ ‘
.‘
4
‘,
‘
-:
C
1’
:‘
:‘.‘t
.
-.
4
Fig. medial
2.-Lateral posterior
view, choroidal
late arterial phase. artery with faint
Slightly hypertrophied tumor blush (arrows).
distal
-,.‘
V ‘
““
is given
in the air study colloid
[10,
and
11,
15,
16].
The
CT are virtually
combined
..;
findings
pathognomonic
\,.J
tumors
in
childhood,
Choroid very rare
from colloid cysts. Most are located in lateral ventricles and rarely in the third The surface of these tumors is bobulated and resembling cauliflower [5]. CT often shows ensolid masses with a small central lucency [17]. [5,
plexus 18].
papilbomas of They are usually
the roof
of the ventricle,
contrast
to the
these tumors ular frondlike enhancement be seen
in both
illoma. In our case, The calcification
well
the third attached
as are colloid
circumscribed
cysts.
colboid
ventricle superiorly
are to
However, cysts
[18,
in 19],
tend to be lobulated, and appear as irregintraventricular masses with significant on CT [17]. In addition, calcification may ependymomas
and
choroid
‘#{149} ,
-
,‘ -,
.
‘..,
-
,,t’ ...
distinguishable the fourth and tufted, hanced
,,
_
i.
:.#{149}‘
.
.,
.
1,
are ,‘:
ventricle.
.
-i,:;-
of a .,‘
common
I.
‘:‘.,::#{149}
.-
cyst.
Ependymomas,
d)P_
)
t”_
.
4
material
,z
,
plexus
pap-
CT findings most resembled a colloid cyst. of choroid plexus of the lateral ventri-
:
:
.
.‘
,.? ‘
..
.
.
‘q
L#{224}-
Fig. 3.-A, Solid mass. B. Meningioma of the meningothelial Psammoma body (arrow). (Low power magnification.)
pattern.
des was believed to be unrelated to the tumor. Such calcification is very unusual in a patient this age, and its etiology remains unclear. Thorough evaluation failed to reveal evidence of neurofibromatosis. At surgery, a well circumscribed
third
ventricle
mass
arising
was found
from
the
anterior
and a meningioma
roof
of the
was verified.
AJR:132,
April
CASE
1979
REFERENCES 1
.
Jefferson
Downloaded from www.ajronline.org by 38.124.169.220 on 11/14/15 from IP address 38.124.169.220. Copyright ARRS. For personal use only; all rights reserved
third
G, Jackson
ventricles.
H: Tumors
of the lateral
and of the
R Soc Med 32:1105-1137, 1939 2. Cushing H, Eisenhardt L: Meningiomas. Their Classification, Regional Behavior, Life History, and Surgical End Results. Springfield, Thomas, 1938 3. Olivecrona H: The panasagittal meningiomas. J Neurosurg 4:327-341, 1947 4. Simpson D: The recurrence of intracranial meningioma after surgical treatment. J Neurol Neurosurg Psychiatry 20:
22-39,
Proc
1957
5. Z#{252}lchKJ: Brain
York, Springer,
Tumors:
Their
Biology
and
Pathology.
New
1965
6. Abbott KH, Courvzlle CB: Intraventriculan meningiomas. Review of the literature and report of two cases. Bull Los Angeles Neurol Soc 7 : 12-28, 1942 7. Heppnen F: Meningiomas of the third ventricle in children.
Review of the literature uneventful recovery after BeIg
30:472-481,
1955
8. Merten DF, Gooding tunes of meningiomas diatrRadiol 2:89-96, 9. Batnitzky
5, Sarwar
B: Colboid 341, 1974 10.
Sackett
CA, Newton TH: The radiologic in childhood and adolescence. 1974 M, Leeds
cysts of the third
JF, Messina
and report of two cases with surgery. Acta Neurol Psychiatr
Pe-
NE, Schechter MM, Azar-Kia Radiology 1 1 2 : 327-
ventricle.
AV, Petito
fea-
CK: Computed
tomography
REPORTS
671
and magnification vertebral angiotomography in the diagnosis of colloid cysts of the third ventricle. Radiology 116: 95-100, 1975 1 1 . Lee KF, Lin SA: Neuroradiology of Sellar and Juxtasellar Mass Lesions. Springfield, Ill., Thomas, 1979 12. Little JK, MacCarty CS: Colloid cysts of the third ventricle. J Neurosurg 40 : 230-235 , 1974 13. Sage MR. McAllister VL, Kendall BE, Bull JWD, Moseley IF:
Radiology
in the diagnosis
of colloid
cysts
of the third
14.
ventricle. BrJ Radio! 48:708-723, 1975 Taveras JM , Wood EH : Diagnostic Neuroradiology Baltimore, Williams & Wilkins, 1976, pp 434-437
,
15.
Davis
tumors.
DO:
CT
in
the
diagnosis
of
supratentonial
2d ed.
Semin Roentgenol 12 :97-100, 1977 16. Osborn AG, Wing SD: Thin-section computed tomography in the evaluation of third ventricular colloid cyst. Radiology 124:257-258, 1977 17.
Naidich
TP,
Lin
JP,
Leeds
NE,
Pudlowski
Primary tumors and other masses fourth ventricle. Differential diagnosis raphy. Neuroradiology 14 : 153-174, 18. Rovit RL, Schechter MM, Chodnoff ilbomas: observation on radiographic 608-617, 1976 19. Thompson JA, Harwood-Nash DC, diology of childhood chonoid plexus 116-133, 1973
AM,
Naidich
JB:
of the cerebellum and by computed tomog1977 P: Choroid plexus papdiagnosis. AJR 110: Fitz CR: The neuronaneoplasms. AJR 118:
