Endoscopic endonasal transplanum transtuberculum resection of a large solid choroid plexus papilloma of the third ventricle

Abstract

Choroid plexus papilloma (CPP) is a highly vascular solid or mixed solid-cystic tumor. Previously described resection techniques for the more common solid CPP in the third ventricle have all been through the transcranial route. The authors review the literature and describe a patient who, to their knowledge, is the first successful resection of a large, completely solid CPP of the third ventricle through an entirely endoscopic, extended transphenoidal approach. Using modern neuroendoscopic methods and closure techniques, a gross total resection was accomplished and a successful closure without postoperative cerebrospinal fluid leak was achieved despite the presence of preoperative hydrocephalus. For appropriately selected lesions, an extended endonasal skull base resection can be performed successfully for vascular tumors despite the presence of preoperative hydrocephalus.

Introduction

Choroid plexus papilloma (CPP) is a benign intraventricular neoplasm, most often of the lateral ventricle in children [1], but favoring the fourth ventricle in adults [2]. CPP of the third ventricle has been described, both as a primary site [2] and as a site of metastasis along cerebrospinal fluid (CSF) pathways [3]. Grossly, these tumors are usually solid with cystic components, but may rarely be purely cystic [4], [5]. Resection techniques for CPP of the third ventricle that have been described include combined transventricular neuroendoscopic and transcranial microsurgical approaches [6], [7], and recently purely ventricular neuroendoscopic for a cystic CPP [4]. Resection of the solid form of this tumor through an endoscopic skull base approach has been considered challenging due its high vascularity. To our knowledge it has never been reported. The presence of hydrocephalus, often associated with this tumor, also has prevented surgeons from using the endoscopic endonasal route due to an increased risk of postoperative CSF fistula. In this case report, we describe the first total resection of a solid CPP of the third ventricle entirely through an endoscopic extended transphenoidal approach.