Case Study: Cystic tumour of the 3rd Ventricle

A young lady in her early 30s presented to her GP with a short history of headaches and visual disturbance. Over a longer period of time, she had been investigated for infertility. An MRI scan of the brain revealed a large solid and cystic tumour of the 3rd ventricle. It appeared to be compressing the optic chiasm inferiorly and also causing early obstructive hydrocephalus.

Below are representative images from the preoperative MRI.

A. Mid-sagittal

B. Coronal

Visual field testing showed loss of the inferior temporal field, worse on the right.

Surgery was performed, semi-urgently, because of the visual loss. Via a right frontotemporal craniotomy, the tumour was approached above the optic chiasm, via the lamina terminalis (the anterior wall of the 3rd ventricle). The tumour cyst was drained and a partial removal of the solid components performed. A complete resection was not attempted as the tumour was adherent to surrounding structures, including the optic chiasm and the walls of the 3rd ventricle.

There were no complications. Immediately following surgery, her vision returned to normal.

A postoperative MRI scan (day 1), showed effective decompression of the 3rd ventricle.

A. Sagittal

B. Coronal

The histology confirmed that this tumour was a Craniopharyngioma. A sample of low power and high power histological images is shown here.

Craniopharyngiomas are uncommon tumours that occur in the region of the 3rd ventricle and pituitary gland. They are benign and slow growing lesions, but can be very difficult to treat. Surgical resection is the primary mode of management, but complete resection may be difficult, since the tumours often are adherent to adjacent critical structures. In attempting a complete removal, the surgeon can damage the visual apparatus leading to visual loss or blindness, stroke from vascular injury or hypothalamic damage, leading to a long term and permanent syndrome which includes weight gain and hyperphagia.

In this particular case, no other treatment is planned. Radiotherapy or reoperation may be useful at some point in the future.

By Professor David Walker BMedSc, MBBS, PhD, FRACS

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