Giant velum interpositum meningioma in a child
A 3-year-old girl presented with history of difficulty in walking since 2 months. She had a normal perinatal history and developmental milestones until the current symptoms. On examination, she had papilledema. There was asymmetric spastic quadriparesis (left worse than right). The computed tomography (CT) head [] revealed a large hyperdense uniformly enhancing lesion occupying the intraventricular space (bilateral lateral as well as third ventricles) with a thin rim of calcification. On magnetic resonance (MR) imaging [], the lesion appeared isointense on T1, mildly hypointense on T2 and showed uniform enhancement. There was no dural tail or enhancement. The internal cerebral veins (ICV) appeared stretched out and displaced laterally and the cerebral peduncles were splayed []. Because of the asymmetric extension into the right frontal horn, a transcortical, transventricular approach was taken. The tumor was identified in the medial wall of the right lateral ventricle under the septal wall, which was stretched over it. It was firm, fibrous and minimally vascular. Gradual internal debulking revealed the location of the tumor entirely within the third ventricle, displacing the internal cerebral veins around it laterally. These were carefully dissected and preserved. Within the third ventricle (which was grossly dilated), the tumor occupied all the recesses. The tumor lobules could be delivered free from all the recesses except in the region of the pineal recess where there was dense adherence to the confluence of the great veins extending into what would have been the potential space of the velum interpositum. In the absence of any other site of attachment, this was most likely the site of origin of the tumor. The tumor was removed gross, totally shaving it off the great veins. An external ventricular drain was placed before closure. The intraoperative blood loss was 400 mL. Postoperatively, the child recovered well. The external ventricular drain was gradually clamped and removed. On the fourth postoperative day, she became drowsy. The drain cerebrospinal fluid revealed growth of Acinetobacter baumannii and, on commencing antibiotic therapy with meropenem, she improved remarkably. The postoperative MRI [] revealed no residual tumor. The deep venous system was intact on the venography []. There was a small area of ischemia in the anterior commissure on the right side. She subsequently had an uneventful course and was discharged on the 14th postoperative day after completing a 10-day course of antibiotics, with minimal residual left hemiparesis. The histopathology revealed a transitional meningioma (WHO grade I) and she was advised a regular clinical follow-up.