Management of a Giant Intraventricular Meningioma with a Minimally Invasive Port Technique: Case Report and Review of Intraventricular Pathologies

Introduction: Intraventricular tumors account for a small proportion of all adult intracranial tumors; ∼7% of all brain tumors are intraventricular. Although these lesions are rare, their exact diagnosis can be elusive based on radiographic findings because these tumors can arise from different neural tissue depending on their precise location: the ventricular wall, the choroid plexus, or the septum pellucidum. In addition, certain lesions may appear intraventricular but in fact are exophytic and invade the ventricular system from the surrounding brain parenchyma. The most common lesions seen in the ventricular system are the following: ependymoma, subependymoma, central neurocytoma, choroid plexus tumors, and meningioma.

Case Report: Our patient presents as a fifty-three year old woman with an aggressive history of primary cancer involving her breast and ovary. Upon presentation, she complained of symptoms of elevated intracranial pressure, including headache. She also had a right homonymous hemianopsia and speech changes. Routine imaging revealed a giant homogeneously enhancing tumor involving the left atrium that appeared consisted with a meningioma or metastasis. There was a significant amount of mass effect from the lesion with associated peritumoral vasogenic edema. In addition, because of its size, the tumor did involve the deep venous structures. Because of her history of primary cancer, her symptoms, and the radiographic findings, the patient and family were counseled to surgically remove the mass. The surgical plan included a multi-stage resection because of the involvement of the deep venous system and because of the size of the mass. A minimally invasive Vycor® port system was used to excise the tumor.

Conclusion: In an attempt to reduce operative morbidity, port technology has been advanced. To our knowledge our case is the first example of a giant intraventricular meningioma removed via the Vycor® port system. Post-operatively, our patient had no radiographic abnormalities or clinical neurologic deficit as a result of her surgery, which we believe is the consequence of limiting tissue retraction and salvaging her venous structures.

Although there have been multiple published case series supporting the efficacy and safety of tubular systems for the removal of deep-seated lesions, there are no studies that use diffusor tensor imaging to prove the superiority of port surgery in salvaging white matter tracts. Further studies investigating the potential clinical benefit associated with less damage to these subcortical fibers would be useful to expand the applications of the minimally invasive port technique.