Interdisciplinary Neurosurgery xxx (xxxx) xxx–xxx

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Interdisciplinary Neurosurgery
journal homepage: www.elsevier.com/locate/inat

Technical Notes & Surgical Techniques

Intraventricular meningioma: Neurosurgical challenge worth taking

⁎
Jitender Chaturvedi (Assistant Professor)a, , Garga Basu (Senior Resident)a, Divya Singh (Senior
Resident)b, Neha Singh (Associate Professor)b, Anil Sharma (Assistant Professor)c, Harsh Deora
(Assistant Professor)d, Priyadarshi Dikshit (Senior Resident)e
a
Department of Neurosurgery, AIIMS, Rishikesh, India
b
Department of Pathology, AIIMS, Rishikesh, India
c
Department of Neurosurgery, AIIMS, Raipur, India
d
Department of Neurosurgery, SGPGI, Lucknow, India
e
Department of Neurosurgery, NIMHANS, Bangalore, India

A B S T R A C T

Intraventricular meningiomas (IVM) are rare and constitutes only 1% of all such tumours, intracranially. This is supported by the fact that there had only been two
case series from India. Both these studies are from major centres and have reported just nine and twelve cases of IVM respectively, over a span of twelve years. As
compared to larger lesions, smaller ones do not manifest early, due to sufficient accommodating space provided by the ventricular system. Large lesions often present
with features of raised intracranial pressure, with or without localising signs, and sometimes with visual field cuts. We encountered one such large intraventricular
lesion, in the trigone of left lateral ventricle of a thirty-five-year-old female, who had a hydrocephalic attack & operated upon early. Lesion was confirmed to be a
fibroblastic meningioma. Appropriate & timely surgical intervention has potential to save life of these patient. Possibility of such encapsulated lesion should always
be kept in mind with clinico-radiological coherence.

1. Introduction
Meningioma within the ventricles is a rare pathology occurrence.
When found, almost all are noticed in lateral ventricles and preferably
on left side, with trigone being the most common site [1,2].
Intraventricular meningiomas (IVM) are rare and this is evidenced
by the fact that there have been only two case series from India. Both
these studies are from major centres and have reported just nine and
twelve cases of IVM respectively, over a span of twelve years [1,3]. As
compared to larger lesions, smaller ones do not manifest early, due to
sufficient accommodating space provided by the ventricular system.
Large lesions often present with features of raised intracranial pressure,
with or without localising signs, and sometimes with visual field cuts.
We encountered one such large intraventricular lesion, in the tri-
gone of left lateral ventricle in a thirty-five-year-old female, which was
confirmed to be a fibroblastic meningioma.
2. Case report
A Thirty-five old lady presented to neurosurgery OPD, with com-
plaints of generalised and moderate headache for last 10 months, with
worsening intensity in last 2 months. There was no history of seizures,
loss of consciousness and motor, sensory or visual deficits. On
examination, the only positive finding was bilateral papilledema. MRI
Brain (Fig. 1a–d) revealed an intraventricular lesion in the trigonal
region of right lateral ventricle with trapped and dilated right temporal
horn and moderate dilatation of both lateral ventricles with periven-
tricular signal changes. Lesion was hypo-intense on both T1 & T2-
weighted images, well defined within the trigone of right lateral ven-
tricle. The lesion had a lobulated appearance and was enhancing bril-
liantly & diffusely on contrast administration. On plain CT images
(Fig. 2), lesion was moderately hyper-dense without any calcification.
She was admitted on the same day she presented to OPD and routine
pre-operative work up was started for craniotomy and excision of the
lesion. However, on the early morning of second day post admission,
she deteriorated in sensorium and was found to be M2 response, leaving
us with no time for the planned preoperative workup. An urgent in-
tubation and left frontal extra-ventricular drainage (EVD) placement
was done, which improved her response to M4 status.
She was taken up for surgery immediately after EVD insertion, right
parieto-temporal craniotomy and superior parietal lobule approach to
trigone was selected for targeting the lesion. Tumour was well cir-
cumscribed, lobulated and firm to hard in consistency, occupying whole
of the trigone and body of the right lateral ventricle extending into right
temporal horn. Lifting the tumour was difficult as firm consistency
prevented a strong grip by even large biopsy forceps, but slight

⁎
Corresponding author at: Department of Neurosurgery, AIIMS, Rishikesh, Uttarakhand 249203, India.
E-mail address: jitender.nsurg@aiimsrishikesh.edu.in (J. Chaturvedi).

https://doi.org/10.1016/j.inat.2018.10.019
Received 1 May 2018; Received in revised form 22 October 2018; Accepted 28 October 2018
2214-7519/ © 2018 Published by Elsevier B.V.

Please cite this article as: Chaturvedi, J., Interdisciplinary Neurosurgery, https://doi.org/10.1016/j.inat.2018.10.019
J. Chaturvedi et al.
elevation of the tumour released significant amount of CSF under
pressure from trapped & sequestered temporal horn. Lesion was dis-
sected off the surrounding structures carefully, especially multiple &
large draping veins. It was adherent to the choroid plexus medially,
from which its blood supply was coagulated. With caution it was pos-
sible to deliver the lesion in-toto. At closure, another EVD was put at the
operative site. Post-operatively, she was kept intubated & ventilated
overnight. On post-operative day one, she was M6 response with both
2
Interdisciplinary Neurosurgery xxx (xxxx) xxx–xxx
Fig. 1. a. T1-weighted images without contrast shows
Hypo- to Iso-intense well defined & lobulated lesion
within the trigonal region of right lateral ventricle with
trapped and dilated right temporal horn and moderate
dilatation of both lateral ventricles with periventricular
signal changes. b. Lesion is hypo- to Iso-intense on T2-
weighted images as well, suggestive of fibrous nature of
the pathology. In addition, perilesional oedema is also
revealed. c. Axial image after contrast administration,
lesion enhances brilliantly & diffusely. d. In Coronal
images, note the bulk of the tumour filling the trigone
and body of the lateral ventricle. Blood supply from
anterior choroidal vessel is also appreciated.
pupils equal and reacting to light and no motor deficits. Both the EVDs
were removed sequentially at day three and four. Post-op CT scan
(Fig. 3) revealed complete excision of the tumour and no evidence of
hydrocephalus, infarct or haematoma.
The excised lesion was sent for histopathological examination. On
gross examination, the tumour measured 5 × 3 × 3 cm. The external
surface of the tumour was nodular, irregular, with focal areas of con-
gestion (Fig. 4), and cut section was firm, grey white and homogenous.
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Fig. 2. CT axial images shows an intraventricular lesion, which is moderately hyper dense without any calcification. Hydrocephalus and trapped temporal horn of the
ventricle seen as noted in MRI.

Fig. 3. Post-operative CT axial image shows complete excision of the lesion. No evidence of hydrocephalus, infarct or haematoma at operative site.

Histopathological examination revealed a tumour composed of spindle
shaped cells, arranged in a fascicular and focally storiform pattern i.e.
loosely arranged pattern of whorls of spindle shaped cells. The tumour
cells had ovoid to elongated plump nuclei with abundant eosinophilic
cytoplasm, with spindled out cytoplasmic ends (Fig. 5). The stroma
showed prominent areas of collagenisation, seen as thick eosinophilic
bands of collagen, intersecting the clusters of tumour cells. Also seen
were thin walled dilated blood vessels punctuating the tumour. Based
on these findings, a final diagnosis of fibroblastic meningioma, WHO
grade I was established.
3. Discussion
Ventricle is a rare site for meningioma to occur. Intra-ventricular

3
J. Chaturvedi et al.
Fig. 4. Firm, nodular tumour with an irregular external surface and focal areas
of congestion.
meningioma (IVM) constitutes approximately 1% of all intracranial
meningiomas [4,5]. IVM arise from arachnoid cells contained within
the choroid plexus, which have been demonstrated to be migrated
along with choroid plexus by the 25th week of gestation, at the time of
invagination of ventricular system [6]. As choroid plexus is bulkier in
the lateral ventricles, meningioma is relatively more common in lateral
ventricle as compared to third or fourth ventricles. Further, according
to some studies, left side lateral ventricle harbours meningioma slightly
more commonly as compared to the right side [4,7,8].
As ventricles provide abundant accommodating space, symptoms
begin to appear only when the lesion grows to a significantly large
sizes. Features of raised ICP without localisation, visual field cuts and
opposite site motor/sensory symptoms are common features of these
tumours.
CT helps in identifying obstructive hydrocephalus; and calcification
within the lesion, if present. Tumour may be hypo or isointense on T1-
weighted images of MRI, and almost always reveals diffuse and brilliant
enhancement on administration of gadolinium. Histologically, fibro-
blastic meningioma is the most common type identified in the lateral
ventricles, as is the case in our patient. Fibrous component makes this
tumour to appear hypo-intense on T2-weighted images [9].
Anterior and/or posterior choroidal vessels are the feeders for these
lesions. Complete excision gives permanent cure to the patient, there-
fore this should be the goal of surgery. Surgical planning should be
highly cautious and precise, more specifically when the approach to the
lesion requires dominant lobe trajectory. Coagulating the blood supply
of the tumour as early as possible should be the target of the surgeon
during intraventricular surgical navigation. This target should never be
Fig. 5. A. Scanner view showing tumour cells arranged in a prominent fascicular and storiform pattern [Hematoxylin and Eosin stain (H&E), ×40]. B. Tumour
composed of clusters of spindle cells intersected by prominent areas of collagenisation (H&E, ×100). C. High magnification showing spindle shaped tumour cells with
plump ovoid nuclei, and eosinophilic cytoplasm with tapering ends. Also seen are thick eosinophilic collagen bands surrounding the cell clusters (H&E, ×400).
4
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Fig. 6. Sketch Diagram of Meningioma in Right Trigone and various surgical
corridors to reach at it. Yellow curved & Green straight arrow represents
anterior & posterior Trans-cortical Trans-ventricular approaches, respectively.
Blue & red arrows represents Posterior Inter-hemispheric & trans-splenial routes
respectively. 1 & 3 shows right and left temporal horns; 2 represents the septum
while 4 & 5 shows choroid plexus and Meningioma in right atrium, respectively.
(For interpretation of the references to color in this figure legend, the reader is
referred to the web version of this article.)
gained at the cost of brain injury secondary to excessive brain retrac-
tion. Therefore, attempts to control feeding vessel of a large tumour
should be avoided early in the surgery, which will compromise brain
retraction. Coagulating the surface of the tumour and utilisation of
internal decompression to prevent avulsion of the feeding vessel is quite
useful for minimising this brain retraction.
Various surgical corridors to enter the ventricles are posterior
temporoparietal, superior parietal lobule, posterior interhemispheric,
trans-splenial. Shortest route to the trigonal region is superior parietal
lobule, which was chosen by us in the present case. These approaches
are being depicted in the sketch shown in Fig. 6. Yellow curved and green
straight arrow represent transcortical; while blue and red arrows mark
J. Chaturvedi et al.
the posterior interhemispheric and transcallosal approaches to atrium.
We chose transcortical route as represented by green straight arrow as
this approach prevents visual morbidity as it allows the surgeon to be in
orientation to optic radiation in longitudinal direction from cerebral
convexity surface to the deep area of the operative site. Thorough wash
with saline, meticulous haemostasis and placement of intraventricular
drainage tube are recommended for prevention of postoperative in-
traventricular hematoma.
Intraventricular meningioma is a rare tumour. Surgery for these
lesions is challenging but highly satisfactory, if done with proper
planning and meticulous surgical techniques. Following the basic
principles of micro-neurosurgery and keeping oneself oriented within
the surgical anatomy of ventricles gives back, a patient with no deficits
and acceptable outcomes. Even after deterioration in sensorium and
sure death in case of no intervention, thoughtful planning and quick
responses of surgeon can save a life, which is worth living for years.
These pleasant results should be served to each and every patient suf-
fering from similar pathology.
Interdisciplinary Neurosurgery xxx (xxxx) xxx–xxx
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