Neurosurg Rev (2006) 29: 3035
DOI 10.1007/s10143-005-0414-5
ORIGINA L ARTI CLE
Alexander Bertalanffy . Karl Roessler .
Oskar Koperek . Ellen Gelpi . Daniela Prayer .
Markus Neuner . Engelbert Knosp
Intraventricular meningiomas: a report of 16 cases
Received: 9 March 2005 / Revised: 22 June 2005 / Accepted: 2 August 2005 / Published online: 24 September 2005
# Springer-Verlag 2005
Abstract Meningiomas of the ventricle system are ex-
tremely rare. We report on a series of 16 intraventricular
meningiomas (IVMs) treated at our institution between
1980 and 2004, with a special interest on the surgical
outcome of using the intra/interparietal and parieto-occip-
ital approach and the benefits of neuronavigation. A
retrospective analysis of the medical files for clinicoradio-
logical findings, surgical interventions and surgical out-
come was carried out. In 16 IVM patients with a female/
male ratio of 11:5, age ranged from 24 years to 84 years
(median 44 years). Duration of symptoms ranged from a
few days to several years, and the cardinal symptoms were
signs of increased intracranial pressure (86%), followed by
corticospinal tract signs (43%), visual field defects (36%),
cognitive changes (29%) and seizures (7%). The majority
of tumours was located in the trigone (88%), and one was
found in each the temporal horn and in the fourth ventricle.
Tumour size ranged from 2.5 cm to 8 cm (median 5 cm),
and the radiological appearance was uniform. The neu-
ropathological workup revealed most IVMs as menin-
gothelial, transitional (mixed) or lymphoplasmacyte-rich
meningiomas (81%). Three tumours were classified as
atypical (19%) and the MIB-1 proliferation index ranged
from 1% to 40%. Complete resection was possible in all
but one case. The trigonal IVMs were resected via an
intraparietal/interparietal or parieto-occipital approach, and
neuronavigation was used in eight tumours. We encoun-
A. Bertalanffy (*) . K. Roessler . M. Neuner . E. Knosp
Neurosurgical Department, Medical University of Vienna,
Waehringer Guertel 18-20,
1090 Vienna, Austria
e-mail: alexander.bertalanffy@meduniwien.ac.at
Tel.: +43-1-404002566
Fax: +43-1-404004566
O. Koperek . E. Gelpi
Institute of Neurology, Medical University of Vienna,
Vienna, Austria
D. Prayer
Division of Neuroradiology, Department of Radiology,
Medical University of Vienna,
Vienna, Austria
tered one perioperative death and one severely disabled
patient. All other patients had a Glasgow outcome scale
score of 5, and most of the pre-existing symptoms dis-
appeared or improved after surgery. IVMs are a surgically
curable tumour entity in most cases. The intraparietal/
interparietal and parieto-occipital approach is very safe,
and neuronavigation allows early devascularisation of the
tumour.
Keywords Meningioma . Intraventricular . MIB-1 .
Surgery . Neuronavigation
Introduction
Meningiomas are usually benign tumours that are thought
to originate from arachnoid cap cells (cells forming the
outer lining of the arachnoid membrane), related cells such
as arachnoidal fibroblasts, or perhaps the meningeal
precursor cellthe so-called meningoblast [33]. They ap-
pear predominantly in women, with a female-to-male ratio
of 2:1 [4, 11, 19]. The occurrence in the general population
varies from 1.5 to 5.5 per 100 000 inhabitants, and they
account for 13.4% to 40% of all intracranial tumours,
representing the second most common primary brain
tumour in adults [4, 6, 18, 32, 34]. The incidence of
meningiomas increases with age and demonstrates a peak
occurrence in the sixth and seventh decade [19]. The
distribution of intracranial meningiomas demonstrates the
highest incidence at the convexity (35%), followed by
parasagittal (20%), sphenoidal (20%), infratentorial (13%),
tuberculum sellae (3%) and other locations (4%) [1]. An
intraventricular appearance is very rare and ranges from
1% to 5% of all intracranial meningiomas [1, 2, 4, 6, 9]. A
higher incidence is reported in von Recklinghausens
disease, at 16.6% [5], and in children8% to 11% [11, 21,
35]. Intraventricular meningiomas (IVMs) account for
9.8% to 14% of all intraventricular tumours and for 20% of
lateral ventricle tumours [13, 25]. Within the ventricular
system, they are usually found in the trigone of the lateral
ventricle (80%), followed by the third (15%) and fourth

Table 1 Presenting signs/symptoms and outcome, excluding two
patients with incidental findings (n=14)
Symptoms Total (%) Improved (%) New
Signs of increased 12 (86%) 12 (100%)
intracranial pressurea
Corticospinal tract signsb 6 (43%) 5 (83%) 1d
Visual field defect 5 (36%) 3 (60%) 2 In two patients the IVM was an incidental finding. In the
Cognitive changesc 4 (29%) 4 (100%)
Seizures 1 (7%) 2 from a few days to 7 years (median 6 months). The most
Cranial nerve dysfunction 1d
a
Headaches, nausea, vomiting and disturbed state of consciousness
b
Hemiparesis and/or hemihypaesthesia
c
Dysphasia/aphasia, dyslexia/alexia, dysgraphia/agraphia and dys-
calculia/acalculia
d
Meningioma adherent to the bottom of the 4th ventricle (CN V, -XI,
-X palsy, tetraparesis)
(5%) ventricles [2, 4, 9, 23, 26]. They are commonly
believed to arise either from the stroma of the choroid
plexus or from the tela choroidea [33].
We report on our series of 16 intraventricular meningiomas,
with a special emphasis on the clinico-radiological appear-
ance and neuropathological findings. In addition, we discuss
the surgical approach and the benefit of neuronavigation.
Material and methods
We performed a retrospective review of patients suffering
from IVMs who were treated at the Neurosurgical Depart-
ment, Vienna Medical School, between 1980 and 2004. The
medical records, surgical records and imaging studies were
analysed.
For neuropathological examination, formalin-fixed and
paraffin-embedded tumour specimens of all 16 cases were
retrieved from the files of the Institute of Neurology,
Medical University of Vienna, where 35 m-thick sec-
tions were cut for routine histological processing and
stained with haematoxylin and eosin. Additionally, immu-
nohistochemical analysis, using anti-Ki67 antibodies (MIB-1,
mAb, 1:50, DAKO, Denmark), was performed. For antigen
retrieval, sections were boiled for 20 min in citrate buffer.
As a secondary system we used the ChemMate detection
kit (DAKO). The proliferation index was determined by
immunohistochemical staining of proliferation-associated
nuclear protein Ki67 (MIB-1). Five hundred tumour nuclei
were counted by eye; grid and percentage of labelled and
unlabelled nuclei were assessed in the tumour regions with
the highest mitotic activity.
The outcome was measured with the Glasgow outcome
scale (GOS) [14].
Results
For the period between 1980 and 2004 we identified 16
intraventricular meningiomas in our patients files, repre-
senting an incidence of 1.5% of all cranial meningiomas.
31
Age ranged from 24 years to 84 years (median 44 years),
and we observed a female predominance, with a female:
male ratio of 2.2:1.
Clinical presentation
symptomatic patients, the duration of symptoms ranged
common initial symptoms prior to hospitalisation, such as
headaches, nausea, vomiting and disturbed state of con-
sciousness, including one patient who was comatose at the
time of admission, were related to increased intracranial
pressure (86%). In addition, we observed sensomotor
deficits (43%), e.g. hemiparesis and/or hemihypaesthesia,
visual field deficits (36%) and seizures (7%). The four
largest left-sided IVMs (68 cm diameter) caused cognitive
changes such as dysphasia/aphasia, dyslexia/alexia, dys-
graphia/agraphia and dyscalculia/acalculia (Table 1).
Radiological appearance
Tumour size ranged from 2.5 cm to 8 cm (median 5 cm).
Fourteen tumours were located in the trigone of the lateral
ventricle (88%); one was found in each of the temporal
horn (6%) and the fourth ventricle (6%). Of 15 lateral
ventricle meningiomas, the side affected was nearly equal,
with 53% right-sided and 47% left-sided tumours.
On CT and MRI all tumours presented as a well-defined
mass. After application of contrast medium, all tumours
displayed a homogeneous strong enhancement. Hydro-
cephalus or a trapped temporal or occipital horn and peri-
tumoral oedema was observed in all but the three smallest
IVMs. Minimal-to-massive calcifications were observed in
half of the cases, and cystic/necrotic parts within the tu-
mour were absent.
Angiography was available in four trigonal IVMs and
showed that the tumours had been supplied by either both
anterior and posterior choroidal arteries or by only pos-
terior choroidal arteries (Table 2).
Table 2 Neuroradiological features (CT 16, MRI 10, angiography: 4).
AChA Anterior choroidal artery, PChA posterior choroidal artery
Neuroradiological feature Number Percentage
CT/MRI: clear demarcation 16 100%
Homogeneous contrast enhancement 16 100%
Hydrocephalus 14 88%
Peritumoral oedema 13 81%
Calcification 8 50%
Cysts/necrosis 0 0
Angiography: AChA supply 3 75%
PChA supply 4 100%
32
Fig. 1 Coronal MRI scan, T1-
weighted after contrast, demon-
strating a typical trigonal IVM
occupying the cella media and
the temporal horn of the right
lateral ventricle (left). Three
months after complete intra-
parietal resection, no residual
tumour; part of the surgical
corridor (arrow, right)

Histological appearance Interventions and outcome

All tumours showed characteristic features of meningioma.
On the basis of plain histology, the tumours were classified
according to WHO criteria (WHO 2000) as meningothelial
meningioma (8/16), transitional (mixed) meningioma (4/16),
lymphoplasmacyte-rich meningioma (1/16) and atypical
meningioma (3/16).
Proliferation indices assessed by immunohistochemical
MIB-1 staining ranged from 1% to 11% but were 13%,
23% and 40% in the atypical meningiomas.
Because of old age and poor medical condition, one patient
was treated by endoscopic biopsy and CSF shunting alone.
In the other 15 patients, complete tumour resection was
possible in 14 patients (93%); one resection was incom-
plete due to extensive calcifications and adhesion to the
ventricle wall. The fourth-ventricle meningioma was re-
sected via a suboccipital approach; the temporal horn
meningioma was mimicking a sphenoidal meningioma and
was resected via a pterional route. As no tumour attach-

Fig. 2 Snapshot of the Med-

tronic StealthStation during the
resection. Two trajectories are
planned to the choroid plexus of
the temporal horn and the cella
media. The tip of the pointer is
placed at the plexus of the
temporal horn

ment to the skull base was found we split the sylvian fissure
and found a tumour between the middle cerebral artery
branches originating from the temporal horn. For the 14
trigonally located IVMs we used a parietal approach
either through the superior parietal lobule or through the
interparietal sulcus or a parieto-occipital approach in all
cases (Fig. 1). In the last eight procedures a neuronaviga-
tion system was used (Easy-Guide, Philips, Da Best, The
Netherlands, and StealthStation TREON, Medtronic,
Minneapolis, Minn., USA) (Fig. 2).
In the early 1980s one patient died from intracerebral
haemorrhage during the postoperative course, and the
fourth ventricle meningioma was very adherent to the
brainstem, resulting in severe neurological deficit with
tetraparesis, bilateral CN V palsy, CN IX and CN X palsy
(GOS 3). Signs of increased intracranial pressure dis-
appeared in each patient. Cognitive deficits improved in all
(4/4), sensomotor deficits in most (5/6) cases. Even three
out of five visual field deficits were ameliorated. As new
postoperative symptoms, we observed visual field deficits
and seizures in two patients each (Table 1).
Discussion
In most cases, IVMs are surgically curable tumour entities.
The intraparietal/interparietal and parieto-occipital ap-
proach can be used very safely in the dominant and non-
dominant hemisphere. Neuronavigation systems offer the
benefits of exact surgical planning and the opportunity to
dissect the tumours blood supply at the beginning of the
resection.
The first IVM was reported by Shaw in 1854 [31]. Since
then, more and more reports on IVMs have been published,
and, in 1986, Criscuolo and Symon identified 400 cases in
the literature [4]. In a recent publication by Nakamura et al.
132 additional cases were supplemented, resulting in a total
of 532 reported IVMs to date [26]. Of these tumours the
majority was located in the trigone (77.8%), followed by
the third (15.6%) and fourth (6.6%) ventricles. IVMs are
reported to have an incidence of 1% to 5% of all in-
tracranial meningiomas and comprised 1.5% in our series
[1, 2, 4, 6, 9]. Patients ages ranged from 24 years to 84
years, and we observed a high predominance of women;
the ratio of women to men was 11:5.
Usually, these tumours reach a large size before patients
become symptomatic, and diameters of 6 cm and more are
not uncommon [8, 12, 15]. Duration of symptoms, from the
first sign to the diagnosis of an intraventricular tumour, is
reported to last from a few months up to 20 years [4, 8, 12].
Over 60 years ago, Cushing and Eisenhardt had already
summarised these symptoms in their classical publication,
in detail, as lateral ventricle syndrome [6]. Summarizing
the literature, one finds that symptoms caused by trigonal
tumours are non-specific. The most common symptoms
reported are headaches, nausea and vomiting, as well as
visual field defects, speech disturbances, sensomotor def-
icits and seizures [4, 8, 12, 22]. These symptoms can be
easily explained by the typical location in the trigone, their
33
mass effect, or the surrounding brain oedema. In our series,
duration of symptoms also varied widely, from a few days
to 7 years. The main symptoms we observed were signs of
increased intracranial pressure, sensomotor deficits, visual
field defects and cognitive defects in the case of large left-
side tumours. Overall, tumour incidence, distribution of
patients ages and gender, duration of symptoms and the
symptoms themselves in our series correspond to those in
previous reports [4, 8, 12].
Radiology
With CT and MRI, neurosurgeons nowadays possess non-
invasive tools to diagnose intraventricular tumours easily.
Depending on neuroradiological features in combination
with location and age distribution, a high percentage of
radiological diagnoses of IVMs can be made by excluding
choroids plexus carcinoma/papilloma, ependymoma, glio-
ma or central neurocytoma [13, 20]. MRI and CT, now-
adays, give us enough information to plan the resection of
an IVM. The surgically important question concerning
displacement of the anterior choroidal artery by the tumour
can be answered by MRI angiography alone, without the
use of the invasive diagnostic tool of intra-arterial angiog-
raphy and its related risk of complications.
The radiological appearance is similar to meningiomas
at other locations. Calcifications are reported to appear in
47% of all cases; peritumoral oedema can be present [3, 4,
8, 12, 13, 20, 22]. For our 16 IVMs, angiography was
performed in four patients, CT in 16 patients and MRI in
ten patients, and our findings correspond to those of pre-
vious reports (Table 2).
Neuropathology
Owing to their various histological characteristics, menin-
giomas are of great interest to pathologists. Today, we
distinguish between many histological subtypes [19].
Reports about intraventricular meningiomas verified ac-
cording to these currently accepted criteria and reports on
proliferation indices are very rare [4, 8, 12, 26]. In our
series the majority of tumours were of the meningothelial
or mixed type (75%) and, interestingly, 19% were atypical.
The MIB-1 proliferation index was high and ranged from
1% to 11% but was 14%, 23%, and 40% in the atypical
cases.
Surgery
The deep location, the proximity of motor, sensory, optical,
and language cortex, as well as the optic radiation and the
anatomy of the blood supply, make the removal of that
tumour a neurosurgical challenge. For resection of tri-
gonally located meningiomas different approaches were
described. The goal of all approaches is to minimise the
risk of postoperative deficits by using small corticotomies,
34
minimal retraction of surrounding functional brain tissue,
early access and interruption of the tumours blood supply
and piece-by-piece resection. In 1938, Cushing and
Eisenhardt advocated a temporoparietal approach [6].
Later, a transfrontal approach, a posterior middle temporal
gyrus approach, a posterior inferior temporal gyrus ap-
proach, a parieto-occipital approach and a transcallosal
approach were championed [7, 8, 15, 16, 28]. Nowadays,
the most frequently used approaches are the parieto-
occipital, the middle temporal gyrus and the trans-splenial
[23]. The paramedian parieto-occipital approach offers
good overall access to the tumour but less access to the
tumours blood supply. It can be used in both the dominant
and non-dominant hemisphere, and the risk of direct
damage to the optic radiation is low. The middle temporal
gyrus approach offers the advantage of early occlusion of
the tumour-feeding anterior and posterior choroidal artery
branches, as well as decompression of a possibly trapped
temporal horn, but there is the disadvantage of damage to
the inferior portion of the optic radiation, as well as
language deficits, if such an approach is used in the
dominant hemisphere. The trans-splenial approach causes
fewer postoperative seizures than does the transcortical ap-
proach (up to 29%), and speech as well as visual disturbances
should not occur. However, it has the disadvantage of a
possible visualverbal disconnection syndrome [2, 4, 810,
1517, 24]. To decompress a hydrocephalus, preoperative
internal CSF shunting and external ventricular drainage
remain an alternative [7]. In a case report, Couillard et al.
took advantage of a combined temporal and parietal
approach, resulting in total tumour resection and excellent
clinical outcome [3]. Fornari et al. favoured the paramedian
parieto-occipital approach, with complete tumour removal,
in all 18 cases. They found a high mortality rate (22%)
in the en-bloc-resection group, compared with that of
piecemeal resection. They also stated that no approach
permitted the preliminary occlusion of all the feeding
vessels, which is also true for the temporal approach if the
anterior choroidal artery (AchA) is displaced medial of the
tumour, proven in half of their cases. With the parieto-
occipital approach, occlusion of the feeding vessels be-
comes possible as soon as the size of the tumour is reduced
by endotumoral piece-meal removal [8]. Criscuolo and
Symon preferred the middle or inferior temporal gyrus
approach and achieved total tumour resection in all but one
of their ten IVMs, with good clinical results and amelio-
ration of visual field defects in two cases. They observed no
mortality; postoperative morbidity was the deterioration of
memory in one patient and a new hemianopia in another
patient, when the inferior temporal gyrus approach was
used [4]. As the most common neurological deficit, visual
field disturbances were reported, which recovered within a
few weeks but also could persist as a new permanent
symptom [3, 4, 27].
Only one report exists about the use and efficacy of a
computer-assisted stereotactic approach for intraventricular
tumours, including three IVMs [24]. Morita has been using
a stereotactic frame-dependant system (COMPASS Ste-
reotactic System, Stereotactic Medical Systems, Rochester,
Minn., USA), in combination with cylindrical stereotactic
retractors, since 1980. Morita and Kelly described the
efficacy of displaying the tumour, the position of sulci, the
route through non-essential brain tissue, and multiplanar
trajectories. Thus, damage to normal brain tissue, and
morbidity, can be reduced. They achieved total tumour
resection in all three IVMs. In our institution we have
gained much experience in neuronavigational procedures
during the past decade [29, 30]. The use of these systems is
of benefit to the patients, as they allow a small skin incision
and small craniotomy. In addition, an exact localisation of
the entry point, with regard to possible bridging veins, is
possible, and a multiplanar trajectory to the tumour helps
the surgeon to avoid eloquent structures during approach
and resection. Besides the advantage of gaining space for
surgery by simple puncture of a trapped temporal or
occipital horn, neuronavigation allows for identification
and early dissection of the choroidal arteries. Thus, a
completely avascular tumour can be easily resected.
Conclusion
The clinical presentation and radiological appearance of
IVMs are uniform. In most cases they are surgically curable
tumour entities. The intraparietal/interparietal and parieto-
occipital approach is very safe in both hemispheres, and
neuronavigation allows early devascularisation of the
tumour.
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