• HPI: The patient a 27 year old male who presented with a month of intermittent nausea and vomiting. In addition, he has been having dizziness, diarrhea, and gait disturbance for about 1 week. He denies headache, visual changes, numbness/tingling/weakness in the extremities. 

    PMH: Mood disorder 
    GERD 
    Hypertension 

    Social History: Works as a computer programmer. Drinks in moderation. Does not smoke. 

    Exam: Nonfocal 

    Figure 1. Axial post contrast T1-weighted MRI (left) and pre contrast (right) demonstrates a heterogeneously enhancing mass filling the fourth ventricle.

    Figure 2. Sagittal post contrast T1-weighted MRI demonstrates heterogeneous centered within the fourth ventricle and extends up the cerebral aqueduct into the posterior inferior aspect of the third ventricle.

    Figure 3. Coronal FLAIR MRI demonstrates heterogeneous tumor, with focal cyst like areas and hemorrhage or calcification, centered within the fourth ventricle and extends up the cerebral aqueduct into the posterior inferior aspect of the third ventricle.

    1. Which of the following would you use to approach this tumor?

    2. If intraoperative frozen biopsy demonstrated atypical choroid plexus papilloma (WHO Grade II), what would you do?

    3. The patient’s hydrocephalus does not resolve following tumor resection. Which would you elect to do?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Please add any suggestions or comments regarding this case:

    • Sub occipital transvermian 4th ventricular approach
    • Telovelar approach is appropriate. However, the most apical portions will mostly be beyond reach. A supracerebellar infratentorial approach may be needed in addition.
    • Most decisions would be made at time of operation.
    • Suboccipital telovelar in semisittimg position. It might be I would do the third ventriculostomy first.
    • I would use a sub occipital midline approach splitting the inferior vermis. I believe the superior aspect of the tumor could be brought down into the 4th ventricle if not invading the pia.
    • Telovelar?
    • If raised ICP symptoms were severe- first ETV and biopsy, followed by a midline infratentorial surgery, but in this case- direct definitive surgery more appropriate.
    • Ah intrsventricular aptoach that if neceary could be extended to a supra cerebellar
    • The nuances of this case include the adherence of the tumor to the ventricular floor, such that while I would attempt complete resection, I would be careful not to make that a priority over the outcome of an awake and functional patient. Further, I might use both the infra tentorial supra-cerebellar approach in combination with the initial telovelar approach; an option that was not available on the menu. Finally, adjuvant therapy for atypical choroid plexus papillomas is met with failure in my experience commonly if the tumor burden is substantial. Seeding is an additional difficult concern.
    • I practice in Alabama, which DOES NOT APPEAR on your list of practice locations above. Maybe you think there are no neurosurgeons here...? Curtis J Rozzelle, MD Curtis.Rozzelle@chsys.org
    • I think initial approach should be infratentorial, and splitting of vermis to access the 4th ventricle, debulk partially and, depending on histology, consider focused beam radiosurgery.
    • Practice in Alabama.
    • I would like to operate this patient by combined infratentorial supracerebella approach and telovelar approach.
    • This kind of tumor could be too a epidermoid cyst and it seems to me that the apropiatte aproach is supracerebellar infratentorial.
    • Pre-op evd, try to wean, take back for etc as necessary

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