Reversal of Cognitive Dysfunction by Total Removal of a Large Lateral Ventricle Meningioma: A Case Report with Neuropsychological Assessments
A 66-year-old, right-handed man earned his living by cultivating agricultural products and cooking. His highest level of educational was high school graduation. He had no past medical history and had been incidentally diagnosed with a right ventricular meningioma 20 years earlier. He had no neurological symptoms and was conservatively followed up because the tumor diameter was about 1 cm. However, the tumor had gradually increased in size on MRI during these 20 years. Finally, over the past year, his working performance had started to deteriorate. He experienced increasing difficulty in concentrating on various tasks (making errors while cooking, miscalculations, and aprosexia) and gradually exhibited inappropriate social behaviors (abusive words, violent manner, and juvenile behavior). His short-term memory also declined. Therefore, he was referred to our hospital for further examination. A standard neurological examination performed on admission revealed no definite abnormalities such as auditory agnosia, left hemispatial neglect, 2-point discrimination, callosal signs, optic ataxia, and astereognosis. Callosal signs such as auditory disconnection syndrome, extinction, and left-hand apraxia were absent. His visual field was kept intact on Goldmann visual field testing. MRI showed a large round mass in the trigone of the right lateral ventricle with a diameter of 5.2 cm and large perifocal edema around the ventricle limbic structure. The signal of the mass was low and high on T1- and T2-weighted images, respectively. The entire mass was strongly enhanced with Gd-DTPA (fig. ). Cystic formation was observed lateral to the tumor. The midline structures were shifted to the left, and cerebral edema was observed in the white matter around the tumor. MR tractography could clearly localize the optic radiations around the tumor (fig. ). Cerebral angiography showed that the posterior lateral choroidal artery was the main feeder of the tumor. Based on these findings, the tumor was diagnosed as meningioma. Then, cognitive function was precisely evaluated, using the Mini-Mental State Examination (MMSE), Standard Language Test of Aphasia (SLTA), and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The scores on the MMSE and SLTA were within normal limits: 27 points and normal, respectively. On the other hand, RBANS revealed that the patient had marked impairment of attention, language, visuospatial/constructional abilities, and delayed memory function (fig. ).\nPrior to surgery, the lateral posterior choroidal artery was embolized via a microcatheter, using n-butyl-2-cyanoacrylate. MRI following embolization showed that the major part of the tumor was not further enhanced. Two days later, the patient underwent total tumor removal. A large temporoparietal craniotomy was performed, and the dura mater was opened. Under intraoperative navigation, the tumor was exposed through a 2-cm corticotomy on the superior temporal gyrus. The tumor was totally removed without any significant bleeding. Transfusion was not performed.\nThe postoperative course was uneventful, and the patient's motor and visual functions were intact. Moreover, a standard neurological examination performed after tumor removal revealed no abnormalities such as auditory agnosia, hemispatial neglect, 2-point discrimination, callosal signs, optic ataxia, and astereognosis. Callosal signs such as disconnection syndrome, left-hand apraxia, and auditory extinction were also absent. His visual field was kept intact on Goldmann visual field testing. Total tumor removal was confirmed on follow-up MRI. Neuropsychological examinations were repeated 13 days after surgery. Results showed that all scores on RBANS significantly improved back to the normal range (fig. ). Difficulty in concentrating on various tasks and the exhibiting of inappropriate social behaviors were completely resolved. He could perform various tasks (without making errors while cooking, miscalculation, and aprosexia) in his daily living after tumor removal. He was discharged and returned to his former position. A histopathological examination confirmed the diagnosis of fibrous meningioma. The mib-1 index was 2.3%.