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Choroid Plexus Papilloma
Prem
Sheth*, Rahul Verma**, Ryan Dias*** |
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| Choroid plexus papillomas are one of the
rare intracranial tumours, benign in nature and seen more in childhood
than in adult life. We present below one such rare case. |
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| Introduction |
| Choroid plexus papillomas are
one of the rare intracranial tumours. They are benign in
nature. They are seen more in childhood than in adult life.
They originate from the tufts of villi within the ventricular
system which normally produce cerebrospinal fluid. They
have a varied mode of presentation. Radioimagining is a
very good and accurate tool to their diagnosis. Their management
requires the use of medical therapies in addition to the
preferred surgical removal of the tumour. Certain cases
are known to have residual complications with poor neuropsychological
outcome. |
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| Case Report |
A 3 year old child with no prior illness
in the past sustained a fall (trivial in nature) following
which she had vomiting, was admitted for head injury in
a hospital. CT scan was done, it revealed - a choroid
plexus papilloma in the body and trigone of the left lateral
ventricle and a uncompensated communicating hydrocephalus.
Three days later the patient was admitted in hospital
for the same. The child had complaints of headache and
the fundus examination revealed gross papilloedema. An
MRI done revealed a well defined lesion within the posterior
left lateral ventricle suggestive of a choroid plexus
papilloma with associated periventricular ooze.
Surgery was done for the removal of the tumour. “Left
parieto occipital craniotomy with complete excision of
the left trigonal papilloma (endoscopically assisted)
with the insertion of an omaya reservoir”. Postoperatively
the child was doing well with no complaints of headache
or irritability, the skin flap was flush with the surrounding
skin. The CT scan showed complete resection of the lesion.
The patient was discharged on phenytoin, acetazolamide
and sodamint.
Few days following the discharge the child had complaints
of vomiting, excessive crying and swelling of the skin
flap. CT scan done revealed hydrocephalus with periventricular
ooze and haemorrhage in the ventricle. The child was readmitted
because of increasing complaints and aspiration from both
the swollen skin flap and the omaya reservoir was done.
Patient improved and was discharged. Thereafter weekly
aspirations were done till the haemorrhage in the ventricle
decreased. Patient was admitted again 3 weeks later and
in view of increasing hydrocephalus a ventriculo peritoneal
shunt inserted. Thereafter patient was well. |
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Fig. 1a |
Fig. 1b |
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Fig. 2 |
Fig. 1c
Figs. 1a,b,c : Pre operative MRI shows a well defined intensely
enhancing cauliflower like lesion within the posterior left
lateral ventricle suggestive of choroid plexus papilloma.
There is associated hydrocephalus with periventricular ooze.
1. Sagittal view, 2. Coronal view, 3. Axial view |
| Fig. 2 : Post operative CT scan - choroid plexus papilloma
excised, some amount of ventricular distortion with moderate
hydrocephalus, decrease in the periventricular ooze with
some amount of iv blood noted, intraventricular shunt noted. |
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| Discussion |
Choroid plexus tumours account for 0.4
to 1% of all intracranial tumours. 70% of these present
before the age of 2 years. They may present in the form
of hydrocephalus and raised intracranial pressure or seizures
or sub arachnoid haemorrhage or focal neurological deficits.
Hydrocephalus, the more commoner presentation is due to
increased production of cerebrospinal fluid or from blockage
of the normal drainage pathways.
Some theories state that they are congenital in origin
while others state that they are related to infections
with simian vacuolating virus (sv40). In children they
normally present in the lateral ventricle whereas in adults
they are normally infratentorial. A male to female ratio
of 2.8:1 has been noted in studies. Most are histologically
benign (papilloma) whereas a malignant form (carcinoma)
can also exist.
Histologically a choroid plexus papilloma is a neuroepithelial
lined papillary projection of the ventricular ependyma,
it has a core of fibrovascular tissue lined with low cuboidal
neuroepithelium.
The management of such papilloma is surgical removal
of the tumour in toto. Analysis and studies have revealed
the benefit of gross total resection. Just shunting without
resection is not good enough. Surgery normally has good
results but at times multiple surgeries may be needed
for complete excision. Total removal of the tumour may
not cure the hydrocephalus which may be due to high CSF
protein, haemorrhage from tumour or surgery and ependidymitis.
Nowadays in addition to surgery use of medical therapy
(with drugs like acetazolamide) in combination is found
to have good results. Complications which may be neurological
or psychological are known to influence the outcome. |
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| References |
| 1. |
Cheryl Palmer, et al. Update
on cpp. Emedicine 2003. |
| 2. |
Buxton N, Punt J. Choroids plexus
papilloma producing symptoms. Paed Neurosurgery
1997; 27 (2) : 108-11. |
| 3. |
Fitzpatrick LK, Aronson LJ, Cohen
KJ. Is there requirement of adjunct therapy for CPP
that is completely resected? J Neuroncol
2002; 57 (2). |
| 4. |
Huang H, Reis R, Yonekawa Y. Identification
of human brain tumours of DNA sequences specific for
sv40. Brain Pathol 1999; 9 (1) : 33-34. |
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EXERCISE TRAINING IS BENEFICIAL IN HEART
FAILURE
Exercise training reduces mortality and hospital
admission in patients with chronic heart failure.
In a meta-analysis including nine trials, the
ExTra MATCH Collaborative compared exercise training
with usual care in patients with chronic heart
failure. The researchers found a significantly
lower mortality (22% v 26%, P = 0.015) and an
increased median time to hospital admission (371
v 426 days) when patients exercised. They conclude
that, in patients with chronic heart failure due
to ventricular dysfunction, exercise training
significantly improves survival.
BMJ, 2004; 328 : 189.
HYPERTENSIVE? SEE YOU EVERY SIX MONTHS
Following up patients with controlled hypertension
every six months will not affect blood pressure
control, adherence, and patients' satisfaction.
Birtwhistle and colleagues conducted a randomised
equivalence trial on 609 patients receiving medical
treatment for essential hypertension, following
them up every three or six months for three years.
They found that control of blood pressure, patients'
satisfaction, and adherence to treatment were
similar, but 20% of patients in both groups had
poor control of blood pressure during the study.
Follow up interval may not be the most important
factor in the control of hypertension by family
practitioners, the authors say.
BMJ, 2004; 328 : 204.
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