PMC8769436_01
(a, b) Head CT at presentation showed hydrocephalus with disproportionately large fourth ventricle. (c) MRI T2WI taken before ETV clearly showed enlarged fourth ventricle and suggested aqueduct stenosis, which was denied by endoscopic observation. (d) MRI taken after ETV showed normalization of the size of fourth ventricle and aqueduct seemed patent. (e, f) Plain head CT showed recurrence of hydrocephalus with expanded fourth ventricle. (g, h) CT taken after second endoscopic surgery showed the appropriate placement of the tube in aqueduct and the improvement of hydrocephalus. CT: computed tomography, ETV: endoscopic third ventriculostomy, MRI: magnetic resonance imaging, T2WI: T2-weighed image.
nmccrj-8-399-g001.jpg
PMC8769436_01_nmccrj-8-399-g001.jpg
F1
MRI showed hydrocephalus with fourth ventricle disproportionately enlarged (Figs. 1a and 1b), which required an emergent ventricular drainage. MRI showed no abnormal enhancement in the cranial space (Figs. 2a and 2b) and no abnormality was found in CSF cytology and CSF profile including cell number, sugar, and protein. Then, endoscopic third ventriculostomy (ETV) was performed for the permanent treatment of hydrocephalus, which was effective enough for her symptoms to disappear (Fig. 1d). Although preoperative MRI suggested aqueduct stenosis (Fig. 1c), endoscopic observation revealed the patency of aqueduct and no abnormality on the ventricular wall, providing no suggestive findings to determine the cause of hydrocephalus at this point. Twenty-two months after onset, she was brought to our emergent room with conscious disturbance, and head CT showed recurrence of hydrocephalus with expanded fourth ventricle (Figs. 1e and 1f).
(a, b) MRIs with gadolinium taken after ETV showed no abnormal enhancement on ventricular wall. Possible dural enhancement was seen, which might have been caused by the change in intracranial pressure after ETV. (c, d) Contrast MRI taken after second endoscopic surgery showed abnormal enhancement on the ventricular walls in lateral and fourth ventricle. Dural enhancement was not obvious. ETV: endoscopic third ventriculostomy, MRI: magnetic resonance imaging.
nmccrj-8-399-g002.jpg
PMC8769436_01_nmccrj-8-399-g002.jpg
F2
MRI showed hydrocephalus with fourth ventricle disproportionately enlarged (Figs. 1a and 1b), which required an emergent ventricular drainage. MRI showed no abnormal enhancement in the cranial space (Figs. 2a and 2b) and no abnormality was found in CSF cytology and CSF profile including cell number, sugar, and protein.
Surgical view of third ventricle around aqueduct under endoscope on second operation and pathological findings of the tissue from ventricular wall. (a) Prominent inflammatory change on the ventricular wall and the obstruction of aqueduct with membrane were observed on second operation. (b) Pathological examination showed diffusely proliferation of atypical small cells with large nuclei and (c) immunostaining for CD79a was strongly positive, compatible with B-cell lymphoma.
nmccrj-8-399-g003.jpg
PMC8769436_01_nmccrj-8-399-g003.jpg
F3
Endoscopic observation revealed prominent inflammatory change on the ventricular wall involving aqueduct (Fig. 3a), which apparently obstructed the CSF flow. Small specimen was taken from the wall of the ventricles and sent to pathological evaluation, which resulted in B-cell lymphoma (Figs. 3b and 3c).