Original Article Clinical Outcome after Transcortical Approach for Lateral Ventricular Neoplasms

Egyptian Journal of Neurosurgery Volume 29 / No. 2 / April - June 2014 19-24 Original Article Clinical Outcome after Transcortical Approach for Lateral Ventricular Neoplasms ARTICLE INFO Received: 1 March 2014 Accepted: 25 June 2014 Key words: Transcortical approach, Transcallosal approach, Lateral ventricular tumors, Hydrocephalus Ahmed Elsayed* Department of Neurosurgery, Cairo University, Egypt ABSTRACT Background: Tumors of the lateral ventricle account for less than 1% of intracranial tumors. They can be removed through the transcortical or the transcallosal approach. Objectives: The aim of this study is to evaluate the patient s outcome and complications of transcortical excision of tumors located in the lateral ventricle. Patients and Methods: Our series included twenty patients studied prospectively; twelve males and eight females, the mean age was 37 years. These patients were operated upon in the Neurosurgery Department, Cairo university hospitals from 2010 to 2013.Transcortical approach was chosen for tumor excision for all cases. Patients were followed up clinically for 18-36 months. Results: Gross-total excision of the tumor was achieved in fourteen patients and subtotal resection in six patients. The most common preoperative presenting symptoms included signs of increased intracranial pressure (ICP) in 65% of patients, seizures in 15%, obstructive hydrocephalus in 35%, personality changes and cognitive impairment in 5% of patients. Along postoperative follow-up 15(75%) patients had good clinical outcome with no permanent deficit and returned to their active life, fair outcome with permanent deficit occurred in four cases (20%) and three patients suffered from meningitis who were cured except for one case (5%). Common adverse effects included seizures, meningitis, and hydrocephalus. Conclusion: Transcortical approach for excision of lateral ventricle tumors can provide a good clinical outcome. It is considered a safe and effective technique with some limitations. Total tumor removal and prognosis is variable according to histopathological features. 2014 Egyptian Journal of Neurosurgery. Published by MEDC. All rights reserved INTRODUCTION Tumors of the lateral ventricle are uncommon lesions. They form less than 1% of intracranial tumors. 16 Obstruction of the normal cerebrospinal fluid (CSF) pathways or compression of the adjacent neural structure is the common symptoms caused by these tumors. 7 Hydrocephalus or a trapped occipital horn can be observed in patients with large tumors and forms the initial presentation in most of cases. 4 Tumors may arise from the ventricular wall or from the surrounding structures and expand inside the ventricle. According to histopathological features, lateral ventricle tumors are benign, malignant or cystic. 6 Both the transcallosal and the transcortical routes are used for the excision of lateral ventricular masses. 9 Planning and performing surgery via the transcallosal or transcortical approach depends on localization and origin of the tumor, tumor size, and tumor extension. 10 The transcortical approach to the lateral ventricles should be designed considering functional cortical areas avoidance, minimizing retraction, and acquiring early control of feeding *Corresponding Author: Ahmed Elsayed Department of Neurosurgery, Cairo University, Egypt E-mail: drahmed-73@hotmail.com, Tel.+2/01223409034 vessels. Adjuvant treatment can improve functional outcomes after surgery as radiotherapy, radiosurgery and chemotherapy. 2,12,20 The aim of this study is to evaluate efficacy of transcortical approach for excising tumors located in the lateral ventricle through discussing its outcome and complications. PATIENTS AND METHODS This prospective study included 20 patients with lateral ventricular tumors. Twelve (60%) were males and eight (40%) were females, the range of age varied from 17 to 69 years with mean age of 37 years. Cases were operated upon in the Neurosurgery Department, Cairo University Hospitals from 2010 to 2013.All patients underwent personal history taking, general and neurologic examinations. Tumors were radiologically diagnosed by CT scan and magnetic resonance imaging (MRI). Patients were followed clinically for 18-36 months. All patients were operated upon by transcortical approach. The tumor was located in the frontal horn in four cases, ventricular body in nine cases, trigone in three cases, atrium in two cases and temporal horn in 2 cases. Patients are commonly presented with signs of increased ICP (65%), Egyptian Journal of Neurosurgery 19

obstructive hydrocephalus (35%), personality changes, cognitive impairment and visual defects (20%). Clinical presentation and preoperative data of the patients is listed in table1. Table 1: Patients Preoperative Data Data Value Age (yrs) 37 (17-69) Sex Male: female 12male:8female symptoms and signs increased ICP13 obstructive hydrocephalus7 seizure3 visual field defect 3 cognitive deficits1 Transcortical approaches were carried out through middle frontal gyrus, superior parietal lobule, middle temporal gyrus and occipitotemporal gyrus for tumors according to location of the tumor in the lateral ventricle. (Table 2) External ventricular drain (EVD) was inserted after tumor excision for 7-10 days (mean: 8.6 days) to identify cases which will need ventriculo-peritonial shunting later. Histopathological analysis was done to specimens obtained intraoperativly to identify tumor type. Table 2: Location of tumor No Approach % Frontal horn 4 middle frontal gyrus 20 Atrium 2 superior parietal lobule 10 Temporal horn 2 middle temporal gyrus 10 Trigone 3 occipitotemporal gyrus 15 Body 9 middle frontal gyrus 45 RESULTS Among twenty patients included in this study, Gross-total excision of the tumor was achieved in fourteen (70%) patients and subtotal resection in six (30%) patients. The benign or low-grade tumors which formed 70% of tumors included in this study were totally removed (Fig. 1a-c). But malignant tumors or large benign tough tumors (30%) were removed subtotally. Along postoperative follow-up fifteen (75%) patients had good clinical outcome with no or minor permanent deficit (temporary hemiparesis in one case, seizures in five, temporary language deficit in one case) and returned to their active life, fair outcome with permanent deficit (hemiparesis in one case, visual field deficit in three cases) occurred in four cases (20%). Death was reported in one case (5%) complicated by intractable meningitis. (Table 3) After surgery, EVD was inserted for all patients and removed after 7-10 days (mean: 8.6 days) after clearance of cerebrospinal fluid (CSF) from any blood and excluding persistent hydrocephalic changes that needed permanent CSF diversion. In cases with meningitis, EVD was left for longer time (12-26 days with the mean of 20 days) and it has been changed weekly to minimize bacterial colonization. Table 3: Clinical Outcome of the patients at end follow-up Clinical outcome No. % Good outcome; with no or minor permanent deficit (temporary hemiparesis (5%), seizure 15 75 disorder (33%), temporary language deficit (5%)) Fair outcome; with permanent deficit (hemiparesis (5%), visual field deficit (15%)) 4 20 Death 1 5 20 Egyptian Journal of Neurosurgery

Fig. 1 a: Preoperative T1 weighted image of MRI brain with contrast, axial cuts showed lateral ventricular tumor. Fig. 1 b: Preoperative T1 weighted image of MRI brain with contrast, sagittal cuts showed lateral ventricular tumor. Fig. 1 c: PostoperativeT1 weighted image of MRI brain with contrast, sagittal cuts for the same patient showed total removal of the tumor via transcortical route (superior parietal lobule) Postoperative Complications reported in this study were five cases of long term seizures, three cases of meningitis, one case of hemiparesis and nine cases developed postoperative hydrocephalus. In the three cases of meningitis, two of them improved after treatment by antibiotics depending on culture and sensitivity done but later needed permanent CSF diversion. (Table4) Totally, the fourteen cases of preoperative obstructive hydrocephalus and postoperative developed communicating hydrocephalus had a ventricleperitoneal (V-P) shunt. Egyptian Journal of Neurosurgery 21

Table 4: Complications No. % Seizures 5 25 Meningitis 3 15 Postoperative hydrocephalus 9 45 Hemiparesis 1 5 Histological diagnosis was astrocytoma in six patients, choroid plexus papilloma in three patients, ependymoma in four cases, meningioma in three cases, subependymoma in two cases, central neurocytoma in one case, and primitive neuroectodermal tumor in one case. Subtotal excision was achieved in three cases of astrocytoma, a case of each ependymoma, meningioma and primitive neuroectodermal tumor. (Table 5) Adjuvant treatment as radiotherapy, radiosurgery was given to the six patients with subtotal excision of the tumor to improve Functional outcomes after surgery. Four cases had external beam radiation therapy and two had stereotactic radiosurgery. Table 5: Pathology No Gross Total Excision Subtotal Excision Astrocytoma 6(30%) 3 3 Choroid plexus papilloma 3(15%) 3 - Ependymoma 4(20%) 3 1 Meningioma 3(15%) 2 1 Subependymoma 2(10%) 2 - Central neurocytoma 1(5%) 1 - Primitive neuroectodermal tumor 1 (5%) - 1 DISCUSSION Tumors of the lateral ventricle are rare tumors. Variant types of tumors occur within the lateral ventricle. Most of these tumors are benign or lowgrade lesions, commonly astrocytoma, choroid plexuspapilloma, meningioma and ependymoma. 19 The literature mentioned that 45% - 60% of tumors rise in the body or frontal horn of the lateral ventricles, 25%- 50% in the atrium or trigone, and about 20% in the foramen of Monro. 3 Some series reported that tumors of lateral ventricle is frequently located in the atrium, frontal horn, temporal horn and septum and other series indicated that the tumor was located in the ventricular body (41,3%), atrium (15,2%), temporal horn (13%), occipital horn (10,9%), frontal horn and foramen of Monro (10,9%), and septum pellicidum (8,7%). 18 In this study localization of tumor was ventricular body (45%), frontal horn (20%), Trigone (15%), atrium (10%) and temporal horn(10%). Resection of these lesions is possible via the transcorticalor transcallosal route. The approach of choice is not clear globally and a debate is arising about which approach is preferred for excision of the lateral ventricular tumors. 6,13 To decide the approach whether transcallosal or transcortical, this should be based according to the best and safest access to the tumor, it depends on the localization, extension of the tumor within the ventricle, involvement of dominant hemisphere, the tumor size, the origin of the vascular feeding branches, the venous drainage and the histopathological features. The chosen approach must fit with the purpose of surgery either total or subtotal tumor removal. 11,18 The approach used in this study was the transcortical approach; it was planned after preoperative radiological evaluation of the tumor. Several precautions were taken as cortical incisions were made in the gyri not the sulci avoiding critical areas and excessive retraction by manipulating the microscope to avoid neural tissue damage and vascular injury. Wide visualization of the lateral ventricle can be achieved through this approach. The total tumor resection rate via the transcortical approach in this series was 70%.After surgery, EVD was inserted for all patients and removed after 7-10 days after clearance of cerebrospinal fluid (CSF)from any blood or removed after 12-26 days in cases of meningitis.70% of patients needed permanent CSF diversion. Tumor histopathology contributed in determining extent of tumor resection in this study. Benign or low-grade lesions were removed totally but Malignant tumors or large benign tough tumors were removed subtotally (30%) and followed by adjuvant radiotherapy or radiosurgery according to obtained pathology. In other related studies total tumor resection rate was approximately 60%. 19 Also common clinical presentation of the patients were signs of increased intracranial pressure (65%) and obstructive hydrocephalus,this is similar to other studies which mentioned that signs of ICP (67.7%) and mental disturbance were the most common symptoms in tumors of the lateral ventricle. 1 Reviewing functional outcome after either total or subtotal tumor resection viatranscortical approach in 22 Egyptian Journal of Neurosurgery

this study, 75% of patients had good clinical outcome with no or minor permanent deficit and returned to their active life, 20% had fair outcome with permanent deficit.death was reported in 5%of patients complicated with meningitis. Brian et al. 5 reported that 70% of patients had an excellent outcome and The mortality rate was 8% mainly due to tumor progression or progressive systemic metastatic disease. In series of Ellenbogen,86% were able to attend work and/or school postoperatively. 8 Many cohorts consider that complications of the surgical treatment of lateral ventricular tumors is relatively high regardless of the surgical approach, transcallosal approach complications were commonly bridging veins injury, disconnection syndrome, postoperative seizures and meningitis. 2,11,21 Long term seizures (25%), meningitis (15%), postoperative hydrocephalus (45%) and hemiparesis (5%) were the common complications reported in this series. Potential postoperative complications after resection of an intraventricular mass reviewed by other authors included seizure (varied from 18.2% to 19%), small intracerebral haematoma, subdural hygroma, hemiparesis and language deficits. 13,16 Permanent CSF diversion for hydrocephalus is widely reported after excision of the lateral ventricle tumors. Richard et al. 17 reported that Approximately 10 to 50% of patients will ultimately require CSF diversion. In this study 70% of patients needed ventricle-peritoneal (V-P) shunt The common Histological diagnosis in this study was astrocytoma (30%), choroid plexus papilloma (15%), ependymoma (20%), meningioma (15%). In another series which included 30patients, common pathology reported was astrocytoma in 26.7% of cases, ependymoma in 16.7% of cases and meningioma in 10% of patients. 1 Tumor histopathology and infiltration in addition to the concern for injury to adjacent critical structures limited the extent of resection. Subtotal excision was achieved in three cases of astrocytoma, one case of ependymoma, large tough meningioma tumor and one case of primitive neuroectodermal tumor. Choice of the transcortical route in this study depended on the anatomical location of the tumor. Some Recent studies mentioned that although maximum visualization of the lateral ventricle was limited by gentle frontal lobe retraction but this can be overcome by using endoscopic-assisted microsurgical technique. The transcallosal approach to tumors of the lateral ventricle implies minimal retraction to the brain minimizing its injury but it provides narrow interhemispheric corridor to the surgeon. 14,22 Many neurosurgeons prefer the transcortical approach for lesions involving the lateral ventricles as they consider it a simple, safe and flexible approach that offers superior working space and provides access to all chambers of the lateral ventricle. 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