The patient is a nine-year-old female who presented with headache, agitation, urinary frequency, and progressive visual deficits over the past two years. A large sellar and suprasellar lesion was detected on a CT scan, and a ventriculoperitoneal (VP) shunt was placed to relieve the progressive symptoms of hydrocephalus (Figure ). MRI solidified the initial suspicion of CC, where the lesion was hyperintense on T1- and T2-weighted images, without any significant, enhancing solid component on postcontrast T1-weighted images, consistent with the high protein and cholesterol contents of CC (Figure ).\nA few days prior to surgery and despite no signs of VP shunt failure, the patient’s exam was notable for acute confusion, severe ataxia, and bilateral blindness. The NTVA was performed using a rigid neuroendoscope (Aesculap AG, Tuttlingen, Germany). The cyst was accessed through a right frontal burr hole, and the contents were drained. The neuroendoscope was advanced to the right lateral ventricle, where cyst wall calcifications were visible through the thinned and elevated neural elements. The choroid plexus was then identified and tracked back to the foramen of Monro. The cyst wall was sampled and the cyst was punctured, draining a copious gray-to-green liquid content with debris. Simultaneous irrigation with a Ringer’s solution and suctioning cleared the contents of the cyst; adjacent neurovascular structures were clearly visible at the end of the procedure.\nThe postoperative course was uneventful, and all symptoms improved in the immediate postoperative period, except for visual loss. Histopathology confirmed the diagnosis of CC. The patient did not develop any symptoms of chemical meningitis on close follow-up. Her pituitary function remained normal postoperatively as well as on long-term follow-up. We opted not to pursue any additional surgical or adjuvant therapy due to the lack of any obvious solid tumor component on postoperative MRI, very thin residual cyst wall, and extensive basal extension with involvement of the critical structures (Figure ). Follow-up MRIs showed no evidence of tumor regrowth or re-accumulation of cystic contents (Figure ).
A 75-year-old woman with a known intracranial mass referred to our outpatient clinic. The lesion was incidentally discovered after a head computed tomography (CT) scan that she had in the past for the evaluation of a confusion episode secondary to hypoglycemia (diabetes mellitus being the only comorbidity in this patient). Magnetic resonance imaging (MRI) of her brain revealed a cystic sellar mass with mass effect on the right lateral ventricle []. The patient had ophthalmologic and endocrinologic evaluations that demonstrated a left temporal, a right superior temporal visual field deficit, and panhypopituitarism. Based on these imaging and clinical findings, the diagnosis of a craniopharyngioma was made. She was then placed on steroid therapy as well as hormone replacement therapy, and surgical resection was planned. In the interim, she began developing severe lower extremity weakness that delayed surgery. A diagnosis of steroid-induced myopathy was made.\nImmediately after the evaluation of her lower extremity weakness, the patient presented to the ED with an acute onset of altered mental status. Her Glasgow Coma Scale (GCS) score on initial presentation was 10. Noncontrast head CT imaging demonstrated changes in the density of the cyst and the density of the ventricular cerebrospinal fluid (CSF) []. Subsequent MRI of the brain was strongly suggestive of intraventricular rupture of the cyst []. Intraventricular cyst rupture was confirmed by a lumbar puncture that demonstrated marked pleocytosis with elevated levels of cholesterol and lactate dehydrogenase identified by CSF analysis. Given these findings, a diagnosis of chemical ventriculitis was made.\nThe patient was initially started on high-dose steroid therapy with significant improvement of her level of consciousness (GCS: 13/15). Once her clinical condition was medically optimized, the patient was taken to the operating room for endoscopic-assisted intracystic placement of an Ommaya reservoir []. Cytopathologic analysis of the aspirate revealed proteinaceous material, blood, and histiocytes, some with hemosiderin. She underwent shunt placement for continued ventriculomegaly 5 days after Ommaya reservoir placement. Her condition improved, and she was discharged from the Intensive Care Unit within 2 weeks from her admission.