PMC8720420_01
Top row-axial T1 (left), T2 (middle) and sagittal T2 (right) magnetic resonance imaging (MRI) showing pineal tumour dorsal to the midbrain, and resultant aqueductal stenosis. Bottom row-axial (left), sagittal (middle) and coronal (right) T1 post-contrast MRI showing homogenous enhancement of lesion, obstructive hydrocephalus and surrounding vascular structures.
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F1
The patient had an urgent magnetic resonance imaging (MRI) brain done [Figure 1] which demonstrated non-communicating hydrocephalus.
T1 axial (left, sagittal (middle) and coronal (right) magnetic resonance imaging showing craniometrics for endoscopic third ventriculostomy (ETV) at the floor of the third ventricle, and ideal trajectory for tumor biopsy. As noted on the sagittal image, there was a significant distance between the ideal trajectories for the ETV and biopsy, necessitating dual bur holes. The left frontal pre-coronal bur hole was placed 5.19 cm from the glabella, with a measured distance of 10.789 cm to the tumour. The right coronal bur hole for the ETV was placed 11 cm from the nasion, with a measured distance of 8.15 cm to the floor of the third ventricle.
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F2
A direct and simple trajectory would however be achieved by the use of a left-sided bur hole [Figures 2 and 3].
T1 post-contrast axial images showing trajectory through the foramen of Monro on right (left image), which does not target tumour, and the approach via the left foramen (right image) which directly enters into the pineal tumor.
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F3
A direct and simple trajectory would however be achieved by the use of a left-sided bur hole [Figures 2 and 3].
Clockwise from top left-endoscopic entry into the left foramen of Monro, with choroid plexus, septal vein and thalamostriate vein visible. Top right-view within foramen of Monro. Bottom right-view of vascular appearing pineal tumor from the third ventricle. Bottom left-forniceal columns inferior to tumor.
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F4
The third ventricle was entered, and the tumor was identified as a red, vascular lesion on the posterior wall of the third ventricle [Figure 4].