Surgical management of cavernous malformations of the third ventricle

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✓ In order to determine adequate therapeutic approaches for cavernous malformations of the third ventricle, the authors reviewed a series of five such malformations managed at their institution and nine others reported in the literature. Four subgroups were identified in terms of the site of origin and could be characterized by different clinical manifestations: visual field defects and endocrine function deficits in patients with malformations in the suprachiasmatic region (six cases); symptoms caused by hydrocephalus in those with malformations in the foramen of Monro region (five cases); and deficits of short-term memory in those with malformations in the lateral wall (two cases) or of the floor of the third ventricle (one case). Unlike cavernous malformations at other locations, malformations of the third ventricle frequently demonstrated rapid growth (43%) and mass effects (71%). The surgical or autopsy findings suggested that the growth was attributable to repeated intralesional hemorrhages. Extralesional hemorrhage was also not uncommon, occurring in 29% of patients. Such tendencies require the adoption of a more aggressive approach to this particular group of cavernous malformations as compared to those in other locations. The risks of regrowth and extralesional hemorrhage appear to be reduced only by complete excision. The surgical approaches adopted should be aimed at providing the best access to the site where the malformation has arisen. The translamina terminalis approach for cavernous malformations in the suprachiasmatic region, the transventricular or transcallosal interfornicial approaches for those in the foramen of Monro region and the transvelum interpositum approach for those in the lateral wall or the floor of the third ventricle appear to be appropriate. In order to select the adequate surgical approach, precise diagnosis of the site of origin is crucial. In addition to neuroimaging techniques, the patient's initial symptoms provide valuable information.

Article Information

Address reprint requests to: Yoichi Katayama, M.D., Ph.D., Department of Neurological Surgery, Nihon University School of Medicine, 30 Oyaguchi Kamimachi, Itabashi-ku, Tokyo 173, Japan.

© AANS, except where prohibited by US copyright law.

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Figures

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    Schematic representations of the four subgroups of cavernous malformations of the third ventricle. The dotted lines indicate the site of origin and the arrows the direction of the surgical approaches.

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    Axial magnetic resonance (MR) T1-weighted images after intravenous infusion of contrast medium in Case 4 of our series. A: Preoperative MR image showing a cavernous malformation in the lateral wall of the mid-third ventricle. B: Image obtained after excision of the malformation via the transvelum interpositum approach showing no residual malformation.

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    Axial computerized tomography scans after intravenous infusion of contrast medium in Case 1 of our series. A: Scan obtained after subtotal excision (14 months before readmission) showing a small enhanced lesion in the suprachiasmatic region. B: Scan obtained 1 year later (2 months before readmission) demonstrating that the mass had grown slightly and had become partially calcified. C: Scan obtained at the time of readmission showing that the mass had grown extensively. The third ventricle is markedly extended and a hypodense zone is present around the diencephalon.

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    Photomicrographs of the malformation in Case 1 obtained at autopsy. A: Section showing thin-walled capillary spaces of varying sizes filled with red blood cells. The walls are closely contiguous and composed wholly of a single layer of endothelial cells and collagen with no cellular stroma. H & E, × 170. B: Lower magnification photomicrograph showing multiple cavities filled by old and new clots of varying sizes at various stages of organization and calcification. H & E, × 68.

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    Sagittal magnetic resonance (MR) T1-weighted images after intravenous infusion of contrast medium in Case 5 of our series. A: Preoperative MR image showing a cavernous malformation arising from the floor of the third ventricle. B: Image obtained after excision of the malformation via the transfrontal, subchoroidal transvelum interpositum approach demonstrating no evidence of residual malformation.

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