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dr-deepak-patkar

Dr. Deepak Patkar
Director - Medical Services
Head, Department of Imaging
Nanavati Super Speciality
Hospital, Mumbai

Dr. Mitusha Verma
Consultant - Imaging Services
Nanavati Super Speciality
Hospital, Mumbai










“It is important to be aware of the ectopic location of craniopharyngioma so that timely diagnosis is made and further complications during surgery due to tumour adherence are avoided”.


Getting Down To Curing A Headache

Deciphering a headache and surgical removal
of a tumour inside the brain

THE CASE
A 15-year-old boy was presented with complaints of sudden onset of severe headache, on and off episodes of vomiting for the past 1.5 months which was also increasing in frequency. The headache was bi-frontal in location and not associated with postural changes. There was no history of seizure, loss of consciousness, altered sensorium or weakness in the limbs. The detailed neurological examination revealed no sensory or motor deficits.

THE PROCEDURE
The MRI report revealed a large well-defined lesion in the region of the third ventricle. It was isointense on T1, hyperintense on T2 and did not suppress on FLAIR. There were few foci of blooming noted in the periphery of the lesion which corresponded to the foci of calcification on screening CT. Contrast enhanced MRI showed mild enhancement of the wall of the lesion with few foci of nodular enhancement in the periphery. In addition to obstructive hydrocephalus, there was superior displacement of the body of corpus callosum and prominent perioptic spaces suggesting increased intracranial tension. The imaging findings on MRI did not distinguish an intraventricular craniopharyngioma from an atypical colloid cyst.

The tumour was surgically removed by a right parasagittal, pericoronal craniotomy via an interhemispheric, interforniceal approach with excision of the third ventricle. The tumour was found to be expanding the third ventricle and was stuck to its floor. Histopathology revealed a cystic lesion lined by stratified squamous epithelium with lymphocytic inflammatory infiltrate and cholesterol clefts within the wall suggesting adamantinomatous subtype of craniopharyngioma.

THE RESULT
The Patient has recovered well post surgery and is doing extremely fine

DISCUSSION
Craniopharyngiomas are benign neoplasms arising from the craniopharyngeal duct. Their location is determined by the embryological events in the suprasellar region. Rare ectopic locations include third ventricle, nasopharynx, pineal gland, sphenoid sinus and clivus. Our case was an entirely intrinsic intraventricular craniopharyngioma arising from the floor of the third ventricle extending into the foramen of monroe. The tumour was largely indistinguishable from an atypical colloid cyst. Other differentials include ependymal cyst, arachnoid cyst and neurocysticercosis of 3rd ventricle. Intraventricular craniopharyngiomas present with manifestations of raised intracranial pressure as was present in our case.