Symtomatic Subependymoma Of The Lateral Ventricle: A Rare Entity –A Case report and review of literature

摘要

Objective: Subependymomas of the lateral ventricle are very rare, benign, noninvasive and slowly growing tumors. The most common site being fourth ventricle followed by lateral, third ventricles, septum pellucidum and spinal cord. Many cases are asymptomatic and discovered at autopsy in elderly patients. Symptomatic cases often present in middle aged patients with hydrocephalus.This tumor was first described by Scheinker in 1945 as a separate entity. Settings: Grant Medical College & Sir J.J Group of Hospitals, byculla, Mumbai, Maharashtra, India. Methods: A 25 year old male presented with a history of sudden onset headache and giddiness. CT scan and MRI scans with contrast were suggestive of a heterogeneous mass lesion in the atria of lateral ventricle. Patient was operated upon with craniotomy and complete excision of lesion. Results: Patient had a stormy course post-operatively. He has been following up regularly with gradual recovery. Conclusion: Subependymal tumors are rare especially in the lateral ventricles. Complete surgical excision with follow up should be the goal to achieve cure. Introduction Subependymomas are rare, noninvasive, benign tumors. Most commonly they arise in the fourth (50-60%) and lateral ventricles (30-40%). Rarely do they arise in the third ventricle, septum pelludicum and the spinal cord. They are classified histological, according to the World Health Organization (WHO) classification as Grade I tumors. Due to the widespread use of pre-operative imaging an increasing number of asymptomatic subependymomas has been detected. However due to their rarity and variable imaging characteristics, reliable preoperative diagnosis remains challenging. Case Report A 25 year old male was admitted to our hospital with a 5 day old history of headache and giddiness which was sudden in onset and gradually progressive in nature. Headache was associated with occasional visual obscurations with blurring of vision while getting up in the morning.On neurological examination, higher mental functions were normal; Visual acuity was 6/9 in right eye and 6/36 in left eye and Fundus was normal. The rest of the cranial nerves, as well as motor and sensory examinations were normal. Cerebellar signs, Romberg’s test and gait were normal.X-ray skull was normal. On C.T. scan ( Fig.1) with contrast there was ill defined heterogenous mass lesion in atrium of left lateral ventricle and differential diagnosis were given as Hemorrhage, Ependymoma and Astrocytoma.MRI scans (Fig.2) were showing ill defined heterogenous lesion hypo intense on T1 weighted images, hyper intense on T2 weighted images with minimal contrast enhancement.The patient was operated upon with left parieto-occipital craniotomy with endoscopic assisted transcortical excision of left ventricular lesion. Intra-operatively, lesion was present in the atrium of left lateral ventricle with thalamic extension. The lesion was soft, suckable, vascular, with areas of gray and black. Near total excision was achieved and brain was lax at the end of procedure. Frozen report was given as low grade glioma.The patient had a stormy post operative recovery with ventilation for 7 days and gradual weaning off. The patient had convulsions post-op which were controlled with anticonvulsants. Tracheostomy was done on post-operative day 4. The patient was gradually weaned off tracheostomy and was removed. 3 sittings of hyperbaric oxygen therapy were given. The patient was gradually weaned off Ryles tube feeds and started on oral feeds. At the time of discharge patient was conscious, dull, obeying commands and accepting oral feeds. Histopathological examination (Fig.3) was showing vaguely lobular pattern with clustering of tumor cells. Individual cells were monomorphic, round to oval nuclei with bland chromatin. Focal nuclear pleomorphism was noted. Mitoses were absent. Stroma is gliofibrillary with presence of microcysts. Hemorrhage and hemosiderin is noted suggestive of Subependymoma (WHO gr