PMC4672579_01
Radiological findings. (a and b) Initial magnetic resonance imaging study revealed leptomeningeal enhancement especially at the inferior portion of the fourth ventricle and suprasellar region (white arrows), ventricles were dilated. (c and d) In posterior fossa, bilateral mass located in the lower part of both foramina Luschka and midline mass located just superior from the foramen Magendie. Follow-up magnetic resonance imaging (1 week after steroid treatment) showed attenuation of the leptomeningeal enhanced lesions and hydrocephalus was improved
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F1
After emergent EVD, the magnetic resonance imaging (MRI) revealed diffuse leptomeningeal enhancement, and obvious enhanced mass lesion at the inferior wall of the third ventricle extended to the suprasellar region [Figure 1a and b], and obstructive mass lesions extended to the outlet of the fourth ventricle; bilateral mass located in the lower part of both foramina Luschka and midline mass located just superior from the foramen Magendie. Ten days after admission, MRI showed a reduction of leptomeningeal enhancement, and an improvement of hydrocephalus [Figure 1c and d].
Intraoperative findings of the fourth ventricle floor. (a) the protruding mass lesions located just superior from the foramen Magendie (black arrows) and outlet of the fourth ventricle was obstructed by nodular lesions. (b) Ventriculostomy was performed at the obstruction of the fourth ventricle outlet. (c) Biopsy of the nodular lesions by endoscopy using forceps
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F2
Operative findings showed that smoothly thickened third ventricle floor without protruding mass lesion, and biopsy of the nodular lesions just superior from the foramen Magendie was performed [Figure 2a and c]. Endoscopic fenestration of foramen Magendie was performed to establish the flow of CSF [Figure 2b].
Pathological findings of nodular lesions of the fourth ventricle outlet. Photograph was taken at x400 magnification. H and E staining revealed granuloma containing giant cells
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F3
Pathological findings of the nodular lesions showed noncaseating epithelioid cell granuloma with multinucleated giant cells negative to tuberculin reaction [Figure 3].