PMC5629841_01
(a and b) Initial coronal and sagittal CT study that demonstrated an intraventricular hemorrhage modified Graeb of 11. (c) Notice in the second preoperative CT a right subdural hygroma and obstructive hydrocephalus. (d-f) Magnetic resonance imaging (MRI) showed a late subacute hemorrhage at the posterior TV and the aqueduct of Sylvius. T2-weighted, T1-weighted simple and contrasted T1 were all hyperintense. (g-i) MRI three days after the surgery demonstrated a gross total resection
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F1
Computed tomography (CT) demonstrated an intraventricular hemorrhage Graeb 6 and modified Graeb of 11 [Figure 1a and b]. TV and the aqueduct of Sylvius, involving the pars anterior, ampulla, and pars posterior. T1-weighted, T2-weighted and gradient-echo images were all hyperintense [Figure 1]. CT revealed a right subdural hygroma [Figure 1], obstructive hydrocephalus, and an isodense lesion at the posterior TV and the aqueduct. MRI obtained 3 days after the surgery demonstrated a gross total resection and adequate third ventriculostomy flow [Figure 1].
(a and b) Endoscopic third ventriculostomy was performed using blunt forceps. (c-f) A subacute hemorrhagic lesion was observed. Grasping forceps and bipolar coagulator were used to dissect away the CM and clots from the borders of the aqueduct and TV. Notice that T2 and gradient-echo images showed a hypointense rim due to hemosiderin. (g and h) Endoscopic inspection revealed no residual lesion. Postoperative MRI demonstrated a gross total resection (caudal arrow) and adequate third ventriculostomy flow (rostral arrow)
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F2
Both T2 and gradient-echo images showed a hypointense rim owing to hemosiderin [Figure 2]. An endoscopic third ventriculostomy (ETV) was performed using blunt forceps [Figure 2]. Given the friable nature of the lesion, the clot and cavernous malformation [Figure 2] were removed in multiple pieces through the cerebral endoscopic path. Finally, endoscopic inspection revealed no residual lesion [Figure 2], and the cortex was plugged with an absorbable gelatin compressed sponge (Gelfoam, Puurs, Belgium).