Intracranial infection and acute obstructive hydrocephalus after lateral ventricle central neurocytoma resection: case report and review of the literature

Intracranial infection and acute obstructive hydrocephalus after lateral ventricle central neurocytoma resection: case report and review of the literature | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Intracranial infection and acute obstructive hydrocephalus after lateral ventricle central neurocytoma resection: case report and review of the literature Shandong Jiang, Zhangqi Dou, Siqi Tao, Gao Chen, Zhiwei Shen This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4510036/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Central neurocytoma (CN) is a rare neurogenic intraventricular tumor that accounts for 0.25–0.5% of all intracranial tumors. Surgery is the cornerstone of therapy in most instances. Postoperative complications such as intracranial infection and hydrocephalus may be serious and even fatal. However, there are few reports on the management of complications after CN resection. Case presentation: The authors described a 41-year-old male patient, whose CN was near the interventricular foramen with a high Ki-67 index. Seven days following surgery, an intracranial infection struck the patient. On the seventeenth day, the patient experienced signs of obstructive hydrocephalus, including headache, unconsciousness, and gatism. One month after surgery, the patient recovered and was discharged with no sequela through high-grade antibiotics, lumbar cisterna drainage and external ventricular drainage. Conclusions For CN with elevated Ki-67 or growing in the lateral ventricle, particularly in the anterior region close to the interventricular foramen, obstructive hydrocephalus was more likely to be complicated after surgery. The temporary external ventricular drainage may be a substitute for VP shunt, avoiding maintenance risks and complications of VP shunt during long-term drainage. Besides, we also need to etiologically personalize the treatment approaches based on the various stages of patient for maximum clinical benefit. Central Neurocytoma lateral ventricle obstructive hydrocephalus intracranial infection Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Central neurocytoma (CN) was first reported by Hassoun et al. in 1982, defining the tumor as a unique pathological entity with neuronal differentiation based on two cases 1 . The tumor is composed of uniform small cells with narrow cytoplasm and round nuclei named neurocytes 2 . As a rare neurogenic tumor, CN presents only 0.25–0.5% of all intracranial tumors and typically develops in individuals aged 20 to 40 3,4 . In terms of clinical location, CN is predominately found in the anterior region of the lateral ventricle and tends to attach to the septum pellucidum near the foramen of Monro 5 . Due to the obstruction of the interventricular foramen, several patients may present with increased intracranial pressure and hydrocephalus, causing subsequent headaches, convulsions, nausea, vomiting, altered mental status, and memorial or visual damage 6 . According to an analysis of 127 cases, patients with CN frequently presented with headaches and visual changes, and the duration of clinical symptoms and signs were generally less than 6 months 3 . Surgery is the primary treatment for CN, then chemotherapy and radiotherapy can be utilized after weighing the benefits and risks for personalized therapy. As a rare CNS WHO grade II tumor, complications after surgical resection are rarely reported 7 . Postoperative complications like intracranial infection and hydrocephalus may be serious and even mortal, which requiring sufficient clinical attention 8 . A proper diagnosis of CN can be achieved based on radiological imaging and histopathological assessment 9 . Diagnostic procedures usually begin with a computed tomography (CT) or magnetic resonance imaging (MRI). In a CT scan, CN usually appears as an iso-dense to hyper-dense or mixed-dense mass which is frequently detected inside the lateral ventricles. MRI imaging shows a low signal in the T1 sequence and a high signal in the T2 sequence with variable contrast enhancement 10 . Ultimately, a definite diagnosis of CN can be yielded via histopathological analysis as the gold standard 11 . Due to CN’s rarity and clinical similarities to other brain tumors, differential diagnosis of CN is essential to distinguish from ependymoma, astrocytoma, intraventricular oligodendroglioma, or primary cerebral neuroblastoma 12,13 . In the present paper, we reported a patient with a lateral ventricle CN with high Ki-67 index. After tumor resection, the patient was complicated by intracranial infection and obstructive hydrocephalus. By applying timely and effective interventions including high-grade antibiotics, lumbar drainage, and external ventricular drainage, the patient recovered and was discharged from hospital after one month. As there are currently few reports on the management of postoperative complications. The present case may offer valuable clinical reference to manage postoperative complications following CN resection. Patient Information A 41-year-old male was admitted to the Department of Neurosurgery with the diagnosis of an intraventricular mass, who had no special and significant medical, family, and psychosocial history, including relevant genetic information. In the previous 6 months, he reported the abrupt numbness and hypoesthesia in the right limb with the deterioration of memory, sporadically accompanied by walking instability and expressional disorder. Patients initially did not pay attention to symptoms and did not seek medical intervention until relatives noticed the deterioration of his memory. Clinical Findings He denied suffering from headaches, dizziness, nausea and vomiting, or limb movement disorders. Shallow sensation including thermo-esthesia and algesthesia, in the right limb was decreased, occasionally accompanied by walking instability. Timeline In the previous 6 months, the patient first experienced numbness in the right limb, which self-healing after several minutes. Then, hypoesthesia in the right limb appear about 5months ago. Without any medical intervention until one weak ago, families noticed that his memory was declining, as he forgot what he had just done or repeated questions he had asked before. Then, the patient was admitted to the Department of Neurosurgery with the diagnosis of an intraventricular mass. During hospitalization, the patient's treatment process and condition changes are shown in Supplementary Fig. 1. Diagnostic Assessment During the neurological examination, besides the decrease of algesthesia and thermos-esthesia and unsteady gait, no other positive neurological sign was found. A head MRI was examined at the local hospital, discovering a left intraventricular mass suspected as an ependymoma with hydrocephalus. Preoperative brain MRI revealed an irregular 17*28*35mm mass in the left lateral ventricle near the foramen of Monro (Fig. 1 ). The mass showed vague margins, an equal low signal in T1 sequence, heterogeneous enhancement in T1-weighted image with gadolinium, and a heterogeneous hyperintensity in T2 sequence, which was radiologically diagnosed as an ependymoma. Based on imaging manifestations and clinical symptoms, the patient was preliminarily diagnosed as a left ventricle tumor and obstructive hydrocephalus. The histopathological results indicated that the tumor consisted of small round monomorphic cells presenting small monomorphic nuclei and fine-grained chromatin, with dense blood capillaries. The pathological diagnosis was CN, CNS WHO grade II. There was no evidence of abnormal mitotic activity or obvious cell atypia. Immunohistochemical analysis revealed synaptophysin (Syn), neuronal nuclei (NeuN) and cell adhesion molecular L1 (L1CAM) were positive ( Supplementary Fig. 2 ). Glial fibrillary acidic protein (GFAP) was not detected. What is more, the Ki-67 index was high, from 5–10%, which was a marker of tumor cell proliferation. Therapeutic intervention After completing preoperative examinations, left ventricular tumor resection using an interhemispheric transcallosal approach and external ventricular drainage were scheduled. During the surgery, the tumor was found to be highly infiltrative to the surrounding brain. All visible tumor tissues were removed with the aid of a surgical microscope. The intraoperative freezing result suggested a low-grade glioma not excluding CN or ependymoma. Postoperative MRI showed a gross-total resection with no residual lesion, acute bleeding, or ischemia (Fig. 2 ). Follow-up and Outcomes After surgery, the right limb numbness disappeared, accompanied by the improvement of superficial sensation of the right limb. On the fourth day after the operation, the ventricular drainage tube was pulled out after the exclusion of intracranial infection through a lumbar puncture. On the seventh day, the patient had a sudden fever with a temperature of 38.7℃. Cerebrospinal fluid (CSF) test from the second lumbar puncture indicated that karyocyte count was 2400×10 6 /L↑, erythrocyte count was 390×10 6 /L↑, and neutrophile count was 84%↑. CSF biochemistry indicated that chlorine was 119.3mmol/L↓, glucose was 1.99mmol/L↓, and protein was 79.8mg/dL↑. Besides, the intracranial pressure was 330 mmH 2 O. Vancomycin (1.0g q12h) and meropenem (1.0g q8h) were administrated to treat the postoperative intracranial infection. Subsequently, the continuous lumbar cisterna drainage was applied for further anti-infection. The drainage tube was placed for 3 days, and 350ml of light and yellow CSF was drained out. On the ninth day, the patient’s temperature returned to normal, and CSF reexamination showed that karyocyte count was 361×10 6 /L↑, neutrophile granulocyte count was 21%↑, chlorine was 117.2mmol/L↓, glucose was 1.79mmol/L↓, protein content was 93.6mg/dL↑, and the intracranial pressure was 160 mmH 2 O, which demonstrated that the intracranial infection was controlled. On the 15th day after surgery, A head CT scan indicated a slight enlargement of both ventricles compared to the previous imaging. The patient did not have any obvious symptom with a normal temperature. The latest CSF examination indicated that karyocyte was 88×10 6 /L↑, neutrophile granulocyte was 7%↑, chlorine was 111.1mmol/L↓, glucose was 2.66mmol/L, and protein content was 93.4mg/dL↑. The patient was monitored with conservative treatments. On the 17th day after surgery, the patient suddenly presented severe headache, urinary and fecal incontinence, unconsciousness, and unresponsiveness. MRI showed a significant enhancement around the operative area, with disappeared ambient cistern and bilateral ventricle enlargement, especially the left ventricle (Fig. 3 A-B). On diffusion-weighted imaging (DWI) sequence, the component of tumor showed restricted diffusion (Fig. 3 C). After eliminating the intracranial infection, ventricular dilation was possibly attributed to obstructive hydrocephalus. External ventricular drainage was immediately performed to treat hydrocephalus. The day after the operation, the patient’s urinary and fecal incontinence and unsteady gait disappeared with significantly improved consciousness, response and headache. CT reexamination indicated the hydrocephalus and ventricular enlargement were significantly ameliorated via a proper localization of the ventricular drainage tube (Fig. 3 D). During the 12-day drainage, a total of 2656ml of limpid and yellowish CSF was extracted. Two days later, the patient was discharged with no headache, fever, nausea or vomiting, convulsions, limb sensation, or movement disorder. MRI reexamination before discharge demonstrated the normal lateral ventricle and total tumor resection without heterogeneous hyperintensity remaining (Fig. 4 ). Discussion Through analyzing 223,404 brain tumor patients collected by the National Cancer Database between 2004 and 2015, researchers discovered that 868 (0.4%) patients were diagnosed as CN 14 . The average age at the time of diagnosis was 31 years old and the typically size of the tumor was 4–5 centimeters. Regarding the distribution of CN, there were 622 intraventricular tumors, 168 extraventricular tumors 4 . In general, CN is located within the ventricles, more commonly in the anterior region of the lateral ventricle, which is consistent with the present case 15 . Despite as a benign tumor in histology, in some cases, CN possesses increased mitotic activity and results in potentially fatal consequences, such as hydrocephalus, cerebral hernia or tumor hemorrhage 16 . Therefore, it has been assigned to the 2021 World Health Organization (WHO) classification grade two 17 . Up to now, there is no official guideline on how to treat CN, so treatment options are often individualized based on specific findings. Surgery is presently the cornerstone of CN treatment 18 . Patients with CN often present with a sizable tumor burden and are well managed with surgical resection. A favorable prognosis of CN can be achieved by gross total resection or subtotal resection. For individuals who have undergone subtotal tumor resection, the prognosis can be improved with postoperative adjuvant radiotherapy 19 . Given the favorable prognosis of CN patients, efforts to improve tumor control should be carefully weighed against the long-term risks associated with adjuvant therapy like radiation. After patient’s consent, left ventricular tumor resection and external ventricular drainage were scheduled. On the 17th day after surgery, obstructive hydrocephalus reappeared. After excluding intracranial infection, we considered the following three possibilities for this complication. First, hydrocephalus might be secondary to oppression by regional cerebral ischemic infarction and edema in the operative area. Second, hydrocephalus might be caused by intracranial infection which obstructed the circulation of CSF. Third, for high Ki-67 proliferation fraction and enhancement under the corpus callosum through sagittal T1-weighted image, we also suspected whether obstructive hydrocephalus was secondary to tumor recurrence and its compression. In our case, the location of CN was near the foramen of Monro which is the channel of CSF circulation from the lateral ventricle to the third ventricle. Besides, the tumor closely adhered to the septum pellucidum and choroid plexus. Although the tumor was surgically separated from the parenchyma as carefully as possible, ischemic infarction and edema in the operative area were inevitable. Overall, we considered that the hydrocephalus was caused by temporary postoperative edema pressing on the interventricular foramen. How to treat hydrocephalus? The definitive hydrocephalus management includes endoscopic third ventriculostomy (ETV) and ventriculoperitoneal (VP) shunts. The use of temporary measures, including external ventricular drainage (EVD), Ommaya reservoir insertion, or lumbar drainage may also be adopted as per the age and clinical setting 20 . Since its inception, VP shunting is probably more privileged in controllability for long-time draining. Despite advances in shunt technology, the incidence of VP shunt failure is as high as 30% in the first year, 40% by the second year, and almost 85% by 10 years 21 . Besides, more attention is required to manage possible complications that seriously affect the quality of life during a lifelong CSF diversion. Therefore, the selection of a temporary drainage or VP shunt should be carefully assessed based on proper individualization and different clinical stages. Comprehensively considering the pathogenesis of hydrocephalus and the patient's condition, we adopted temporary external ventricular drainage instead of VP shunt or ETV. Three reasons for the selection are: ( 1 ) we speculated the obstruction symptoms would improve after the edema subsided; ( 2 ) external ventricular drainage might achieve similar therapeutic effects as the VP shunt, avoiding the risks and sequelae caused by the long-term VP shunt; ( 3 ) the majority of infection-induced hydrocephalus are communicating hydrocephalus rather than obstructive hydrocephalus. After 12-day drainage, the hydrocephalus completely disappeared with improved symptoms and reduced enhancement signal under the corpus callosum in MRI, which was considered as fibroplasia. These findings collectively verified our deduction and excluded the possibility of tumor recurrence. Therefore, for postoperative hydrocephalus in patients with CN, especially with infarction and edema in the surgical area, temporary external ventricular drainage may be a substitute for VP shunt. Besides, in term of treatment of CN, gross total surgical resection is the optimal treatment, and the postoperative prognosis is generally satisfactory, with 5-year and 10-year overall survival rates of 96% and 82%, respectively 5 . However, CN may possess increased aggressiveness when the proliferation index of Ki-67 is higher than 2–3%, which can be categorized as atypical CN with histological features of anaplasia like increased mitotic activity and microangiogenesis 14 . Although the Ki-67 index is reported that may not well correlate with histologic features of malignancy, it does closely correlate with the clinical outcome of patients 22 . According to a case report, aggressive behavior characterized by CN progression was noted in two patients, with unusually high proliferation rates of 5.3% and 11.2% 23 . In our case, the Ki-67 proliferation index of CN was from 5–10%, suggesting a stronger capability for invasion and metastasis, and an increased risk of tumor recurrence after surgery. For tumors with a high Ki-67 fraction, adjuvant therapy should be considered in advance. Therefore, although the tumor was resected totally with no sign of recurrence, the current patient also accepted radiotherapy after discharge for high Ki-67 proliferation fraction. Given this, the Ki-67 may represent an excellent predictor of the biologic and clinical activity of CN, and may be of benefit in selecting patients who need postoperative radiotherapy 24 . Multi-case analysis is warranted to determine the relationship between biological markers and malignant behavior of CN to optimize postoperative treatments. Conclusion CN is a rare and benign neuroepithelial tumor commonly located in intraventricular regions or the foramen of Monro. Removal through surgery is the basis of treatment. However, there are few publications on the management of complications following surgery for aggressive CN with a special location. For postoperative intracranial infection, in addition to the administration of high-grade antibiotics, timely and standardized lumbar cisterna drainage contributes to controlling infection. Besides, the treatment for hydrocephalus should be customized, because short-term external ventricular drainage may achieve similar effects as VP shunt, avoiding maintenance risks and complications of VP shunt during long-term drainage, thus conferring better quality of life. Furthermore, for CN with high Ki-67 or atypical characteristics, adjuvant therapy like radiotherapy may be beneficial to improving prognosis. Of course, the therapeutic impact and intervening opportunity of adjuvant radiation need to be further established, particularly in patients undergoing,subtotal resection. Lastly, we anticipate that these lessons will serve as sources of clinical experience and treatment guidelines for the management of CN and its complications. Declarations Ethical Approval and Consent to participate This case report was approved by human Research Ethics Committee, the Second Affiliated Hospital of Zhejiang University School of Medicine on 10/25/2023. The ethics case number was I20231269. The patient gave consent to be included in the study. Consent for publication The patient has given written consent for this report to be published. Availability of data and materials Data and material are not publicly available, but can be requested. Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest . Funding We did not receive any funding for this research. Author s’ c ontributions Conception and design: Z.S. and G.C. Acquisition of data: S. J and S. T. Analysis and interpretation of data: Z.S. Drafting of the article: S. J. Critically revising the article: Z. D. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Z.S. Administrative/technical/material support: S. T. Study supervision: Z.S. Acknowledgments We thank Lingzhi Yu for her comments on the manuscript. References Gkmd D, Hpmd S, Hkmd I, Gcmd J, Cmd BK. Central neurocytoma. Cancer, 1997;79(10):1995-2002. Hung YC, Lee CC, Yang HC, et al. Stereotactic radiosurgery for central neurocytomas: an international multicenter retrospective cohort study. J Neurosurg. 2020;134(3):1122-1131. Hassoun J, Sylemezoglu F, Gambarelli D, et al. Central Neurocytoma: A Synopsis of Clinical and Histological Feature. Brain Pathol, 2010;3(3):297-306. Hsu PW, Hsieh TC, Chang CN, Lin TK. Fourth Ventricle Central Neurocytoma: Case Report. Neurosurgery. 2002;50(6):1365-1367. Lee SJ, Bui TT, Chen CHJ, et al. Central Neurocytoma: A Review of Clinical Management and Histopathologic Features. Brain Tumor Res Treat. 2016;(2):49-57. Wang M, Zhou P, Zhang S, Liu X, Jiang S. Clinical Features, Treatment and Long-term Outcomes of Central Neurocytoma: A 20-Year Experience at a Single Center. World Neurosurg. 2018;109:e59-e66. Schmidt MH, Gottfried ON, Koch CSV, Mcdermott MW. Central Neurocytoma: A Review. J neuro-oncology. 2004;66(3):377-84. Alwalily MH. Decision Making in Management Of Lateral Ventricular Tumors. Life Sci J. 2014;11(12):953-963. Alsadiq MN, Al Sadah ZM, Butt S, Aldahmen AA. Central Neurocytoma with Hemorrhagic Presentation Case Report and Review of the Literature. Case Rep Surg. 2022:9731987. Chen CL, Shen CC, Wang J, Lu CH, Lee HT. Central neurocytoma: A clinical, radiological and pathological study of nine cases. Clin Neurol & Neurosur. 2008;110(2):129-136. Kocaoglu M, Ors F, Bulakbasi N, Onguru O, Ulutin C, Secer HI. Central neurocytoma: proton MR spectroscopy and diffusion weighted MR imaging findings. Magn Reson Imaging. 2009;27(3):434-440. Shunji, Nishio, Takato, et al. Tumours around the foramen of Monro: clinical andneuroimaging features and their differential diagnosis - ScienceDirect. J Clin Neurosci. 2002;9(2):137-141. Niiro T, Tokimura H, Hanaya R, et al. MRI findings in patients with central neurocytomas with special reference to differential diagnosis from other ventricular tumours near the foramen of Monro. J Clin Neurosci. 2012;19(5):681-686. Wang H, Li WS, Shi DJ, He HY, Guo Y. Central Neurocytoma: Clinical, Pathological, and Imaging Findings in 5 Cases. Neurosurgery Quarterly. 2011;21(1):44-49. Chen H, Zhou R, Liu J, Tang J. Central neurocytoma. J Clin Neurosci. 2012;19(6):849-853. R usiecki D, Lach B, Manoranjan B, et al. Progression of atypical extraventricular neurocytoma to anaplastic ganglioglioma. Hum Pathol. 2017;59:125-130. Louis DN, Arie P, Pieter W, et al. The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro-Oncology. 2021;23(8):1231-1251. Brokans A, Ozolina E, Bicans K, Platkajis A. Central Neurocytoma with Extensive Intratumoral Hemorrhage: A Case Report. Am J Case Rep. 2023;24:e940160. Han S, Yang Z, Yang Y, et al. Individual Treatment Decisions for Central Neurocytoma. Front Neurol. 2020;11:834. Kvarta MD, Sharma D, Castellani RJ, et al.Demyelination as a harbinger of lymphoma: a case report and review of primary central nervous system lymphoma preceded by multifocal sentinel demyelination. Bmc Neurol. 2016; 16(1):72. Hochstetler A, Raskin J, Blazer-Yost BL. Hydrocephalus: historical analysis and considerations for treatment. Eur J Med Res. 2022;27(1):168. Fujimaki T, Matsuno A, Sasaki T, Toyoda T, Kirino T. Proliferative activity of central neurocytoma: Measurement of tumor volume doubling time, MIB-1 staining index and bromodeoxyuridine labeling index. J Neurooncol. 1997;32(2):103-109. Ashkan K, Casey AT, D'Arrigo C, Harkness WF, Thomas DG. Benign central neurocytoma. Cancer. 2000;89(5):1111-1120. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterial.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4510036","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":310529523,"identity":"8ebe06b2-98e6-4280-8bdb-0d6983667c1e","order_by":0,"name":"Shandong Jiang","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Shandong","middleName":"","lastName":"Jiang","suffix":""},{"id":310529524,"identity":"8486dc9d-6c58-4d9d-82c0-8f9543ec75bf","order_by":1,"name":"Zhangqi Dou","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Zhangqi","middleName":"","lastName":"Dou","suffix":""},{"id":310529525,"identity":"2383c3b5-7d44-4f42-9ca2-1ce0af2ca8c3","order_by":2,"name":"Siqi Tao","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Siqi","middleName":"","lastName":"Tao","suffix":""},{"id":310529526,"identity":"e91be1ed-bbbc-4809-bce3-38867b3041d7","order_by":3,"name":"Gao Chen","email":"","orcid":"","institution":"Zhejiang University","correspondingAuthor":false,"prefix":"","firstName":"Gao","middleName":"","lastName":"Chen","suffix":""},{"id":310529527,"identity":"6659c765-82cb-4f60-986c-6cbea36d6884","order_by":4,"name":"Zhiwei Shen","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIie3RMQqDMBSA4ScWpxTXVwp6hZSOXsYudRI6OSuCUw8gdOgZeoOEQCdxbrFDj+DoYGkTcTZ2KzT/kLwhHwkEwGT6yUSqVg+Ayc2ZRfhAtt8QayC7YZ1F/IwXq64X0TmrKLSJAPeU6u7gxZoQEWdpRa2yFoAPNk1skASwiXOoqL0sBFAMp4kD6mG0iRxFXnMIkQRJ2IREEWsOQeB5QNh7U8L1wI91RPCmIX4p+L3r974cLs8uCTy31BBAtsBxGD6TaM7L3NRux0F/2GQymf6zDyxcRsLbGi+/AAAAAElFTkSuQmCC","orcid":"","institution":"Zhejiang University","correspondingAuthor":true,"prefix":"","firstName":"Zhiwei","middleName":"","lastName":"Shen","suffix":""}],"badges":[],"createdAt":"2024-05-31 15:46:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4510036/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4510036/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58516837,"identity":"1027476a-4257-4970-9bb8-18c371339100","added_by":"auto","created_at":"2024-06-17 16:52:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":75053,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative MRI. A: Axial T1-weighted image demonstrated that the tumor had an equal low signal, with the left ventricle remarkably enlarged. B: Axial T2-weighted image showed a tumor with hetero geneous hyperintensity located in the anterior region of the left lateral ventricle with obstructive hydrocephalus. C: Axial T1-weighted image with gadolinium demonstrated inhomogeneous enhancement, considering an ependymoma. D: Sagittal T1-weighted image with gadolinium demonstrated the tumor occupied the left lateral ventricle near the foramen of Monro.\u003c/p\u003e","description":"","filename":"FIG.1..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/4008f829b9819a72367cd41e.jpg"},{"id":58516839,"identity":"0896be6e-ca69-492b-b272-12c62ea9131e","added_by":"auto","created_at":"2024-06-17 16:52:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":80196,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative MRI. A: Axial T1-weighted image demonstrated a gross-total resection without heterogeneous signal remaining. Hydrocephalus was significantly relieved. B: Axial T2-weighted image showed total tumor resection with lateral ventricle pneumocephalus. C: Axial T1-weighted image with gadolinium demonstrated total tumor resection without heterogeneous enhancement in the lateral ventricle. D: Sagittal T1-weighted image with gadolinium exhibited the surgical cavity and total tumor resection without enhancement.\u003c/p\u003e","description":"","filename":"FIG.2..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/6527c7d6fe161e99280faec9.jpg"},{"id":58516840,"identity":"fc5c2d0b-a5a3-420a-a07a-9661dde6e16f","added_by":"auto","created_at":"2024-06-17 16:52:33","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":77911,"visible":true,"origin":"","legend":"\u003cp\u003eMRI reexamination 17 days after surgery and CT reexamination after external ventricular drainage. A: Axial T1-weighted image with gadolinium showed \u0026nbsp;lateral ventricles enlarged especially in the left ventricle, and the midline shifted slightly to the right with an inhomogenous enhancement around the operative area. B: Sagittal T1-weighted image with gadolinium revealed the enhanced region under the corpus callosum. The supratentorial ventricle was enlarged than before. C: DWI sequence showed an irregular hyperintensity signal in the left enlarged ventricle. D: CT image after external ventricular drainage showed that the drainage tube was located in the lateral ventricle. Hydrocephalus was significantly relieved and the lateral ventricle was back to normal.\u003c/p\u003e","description":"","filename":"FIG.3..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/7d26e7a3da0a7c233f7484c3.jpg"},{"id":58517716,"identity":"ae3e36fd-3fc5-48a8-8bd5-f41c3ed79fcb","added_by":"auto","created_at":"2024-06-17 17:00:32","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":72005,"visible":true,"origin":"","legend":"\u003cp\u003eMRI reexamination before discharge. A: Axial T1-weighted image demonstrated the totally resected operative area, healed hydrocephalus, and restored lateral ventricles. B: Axial T2-weighted image showed total tumor resection without heterogeneous hyperintensity remaining. C: DWI sequence showed hyperintensity signal disappeared. D: Sagittal T1-weighted image with gadolinium exhibited that the region of enhancement under the corpus callosum was significantly reduced. The enhanced segment was considered fibroplasia.\u003c/p\u003e","description":"","filename":"FIG.4..jpg","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/62b9e01d10f549836eb949a4.jpg"},{"id":63970320,"identity":"1d055608-d970-4f8b-afe1-26216bd9c354","added_by":"auto","created_at":"2024-09-04 10:52:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":654216,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/1ff8a9dd-b617-4af6-b621-629688ba77c0.pdf"},{"id":58516841,"identity":"207309e4-8bf0-4487-bb34-c6d7dbb16f5d","added_by":"auto","created_at":"2024-06-17 16:52:33","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":378021,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-4510036/v1/688246e68a835a7bb84317a0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intracranial infection and acute obstructive hydrocephalus after lateral ventricle central neurocytoma resection: case report and review of the literature","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCentral neurocytoma (CN) was first reported by Hassoun et al. in 1982, defining the tumor as a unique pathological entity with neuronal differentiation based on two cases\u003csup\u003e1\u003c/sup\u003e. The tumor is composed of uniform small cells with narrow cytoplasm and round nuclei named neurocytes\u003csup\u003e2\u003c/sup\u003e. As a rare neurogenic tumor, CN presents only 0.25–0.5% of all intracranial tumors and typically develops in individuals aged 20 to 40\u003csup\u003e3,4\u003c/sup\u003e. In terms of clinical location, CN is predominately found in the anterior region of the lateral ventricle and tends to attach to the septum pellucidum near the foramen of Monro\u003csup\u003e5\u003c/sup\u003e. Due to the obstruction of the interventricular foramen, several patients may present with increased intracranial pressure and hydrocephalus, causing subsequent headaches, convulsions, nausea, vomiting, altered mental status, and memorial or visual damage\u003csup\u003e6\u003c/sup\u003e. According to an analysis of 127 cases, patients with CN frequently presented with headaches and visual changes, and the duration of clinical symptoms and signs were generally less than 6 months\u003csup\u003e3\u003c/sup\u003e. Surgery is the primary treatment for CN, then chemotherapy and radiotherapy can be utilized after weighing the benefits and risks for personalized therapy. As a rare CNS WHO grade II tumor, complications after surgical resection are rarely reported\u003csup\u003e7\u003c/sup\u003e. Postoperative complications like intracranial infection and hydrocephalus may be serious and even mortal, which requiring sufficient clinical attention\u003csup\u003e8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eA proper diagnosis of CN can be achieved based on radiological imaging and histopathological assessment\u003csup\u003e9\u003c/sup\u003e. Diagnostic procedures usually begin with a computed tomography (CT) or magnetic resonance imaging (MRI). In a CT scan, CN usually appears as an iso-dense to hyper-dense or mixed-dense mass which is frequently detected inside the lateral ventricles. MRI imaging shows a low signal in the T1 sequence and a high signal in the T2 sequence with variable contrast enhancement\u003csup\u003e10\u003c/sup\u003e. Ultimately, a definite diagnosis of CN can be yielded via histopathological analysis as the gold standard\u003csup\u003e11\u003c/sup\u003e. Due to CN’s rarity and clinical similarities to other brain tumors, differential diagnosis of CN is essential to distinguish from ependymoma, astrocytoma, intraventricular oligodendroglioma, or primary cerebral neuroblastoma\u003csup\u003e12,13\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the present paper, we reported a patient with a lateral ventricle CN with high Ki-67 index. After tumor resection, the patient was complicated by intracranial infection and obstructive hydrocephalus. By applying timely and effective interventions including high-grade antibiotics, lumbar drainage, and external ventricular drainage, the patient recovered and was discharged from hospital after one month. As there are currently few reports on the management of postoperative complications. The present case may offer valuable clinical reference to manage postoperative complications following CN resection.\u003c/p\u003e "},{"header":"Patient Information","content":"\u003cp\u003eA 41-year-old male was admitted to the Department of Neurosurgery with the diagnosis of an intraventricular mass, who had no special and significant medical, family, and psychosocial history, including relevant genetic information. In the previous 6 months, he reported the abrupt numbness and hypoesthesia in the right limb with the deterioration of memory, sporadically accompanied by walking instability and expressional disorder. Patients initially did not pay attention to symptoms and did not seek medical intervention until relatives noticed the deterioration of his memory.\u003c/p\u003e"},{"header":"Clinical Findings","content":"\u003cp\u003eHe denied suffering from headaches, dizziness, nausea and vomiting, or limb movement disorders. Shallow sensation including thermo-esthesia and algesthesia, in the right limb was decreased, occasionally accompanied by walking instability.\u003c/p\u003e"},{"header":"Timeline","content":"\u003cp\u003eIn the previous 6 months, the patient first experienced numbness in the right limb, which self-healing after several minutes. Then, hypoesthesia in the right limb appear about 5months ago. Without any medical intervention until one weak ago, families noticed that his memory was declining, as he forgot what he had just done or repeated questions he had asked before. Then, the patient was admitted to the Department of Neurosurgery with the diagnosis of an intraventricular mass. During hospitalization, the patient's treatment process and condition changes are shown in Supplementary Fig.\u0026nbsp;1.\u003c/p\u003e"},{"header":"Diagnostic Assessment","content":"\u003cp\u003eDuring the neurological examination, besides the decrease of algesthesia and thermos-esthesia and unsteady gait, no other positive neurological sign was found. A head MRI was examined at the local hospital, discovering a left intraventricular mass suspected as an ependymoma with hydrocephalus. Preoperative brain MRI revealed an irregular 17*28*35mm mass in the left lateral ventricle near the foramen of Monro (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The mass showed vague margins, an equal low signal in T1 sequence, heterogeneous enhancement in T1-weighted image with gadolinium, and a heterogeneous hyperintensity in T2 sequence, which was radiologically diagnosed as an ependymoma. Based on imaging manifestations and clinical symptoms, the patient was preliminarily diagnosed as a left ventricle tumor and obstructive hydrocephalus.\u003c/p\u003e\u003cp\u003eThe histopathological results indicated that the tumor consisted of small round monomorphic cells presenting small monomorphic nuclei and fine-grained chromatin, with dense blood capillaries. The pathological diagnosis was CN, CNS WHO grade II. There was no evidence of abnormal mitotic activity or obvious cell atypia. Immunohistochemical analysis revealed synaptophysin (Syn), neuronal nuclei (NeuN) and cell adhesion molecular L1 (L1CAM) were positive (\u003cb\u003eSupplementary Fig.\u0026nbsp;2\u003c/b\u003e). Glial fibrillary acidic protein (GFAP) was not detected. What is more, the Ki-67 index was high, from 5–10%, which was a marker of tumor cell proliferation.\u003c/p\u003e"},{"header":"Therapeutic intervention","content":"\u003cp\u003eAfter completing preoperative examinations, left ventricular tumor resection using an interhemispheric transcallosal approach and external ventricular drainage were scheduled. During the surgery, the tumor was found to be highly infiltrative to the surrounding brain. All visible tumor tissues were removed with the aid of a surgical microscope. The intraoperative freezing result suggested a low-grade glioma not excluding CN or ependymoma. Postoperative MRI showed a gross-total resection with no residual lesion, acute bleeding, or ischemia (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"Follow-up and Outcomes","content":"\u003cp\u003eAfter surgery, the right limb numbness disappeared, accompanied by the improvement of superficial sensation of the right limb. On the fourth day after the operation, the ventricular drainage tube was pulled out after the exclusion of intracranial infection through a lumbar puncture. On the seventh day, the patient had a sudden fever with a temperature of 38.7℃. Cerebrospinal fluid (CSF) test from the second lumbar puncture indicated that karyocyte count was 2400×10\u003csup\u003e6\u003c/sup\u003e/L↑, erythrocyte count was 390×10\u003csup\u003e6\u003c/sup\u003e/L↑, and neutrophile count was 84%↑. CSF biochemistry indicated that chlorine was 119.3mmol/L↓, glucose was 1.99mmol/L↓, and protein was 79.8mg/dL↑. Besides, the intracranial pressure was 330 mmH\u003csub\u003e2\u003c/sub\u003eO. Vancomycin (1.0g q12h) and meropenem (1.0g q8h) were administrated to treat the postoperative intracranial infection. Subsequently, the continuous lumbar cisterna drainage was applied for further anti-infection. The drainage tube was placed for 3 days, and 350ml of light and yellow CSF was drained out.\u003c/p\u003e\u003cp\u003eOn the ninth day, the patient’s temperature returned to normal, and CSF reexamination showed that karyocyte count was 361×10\u003csup\u003e6\u003c/sup\u003e/L↑, neutrophile granulocyte count was 21%↑, chlorine was 117.2mmol/L↓, glucose was 1.79mmol/L↓, protein content was 93.6mg/dL↑, and the intracranial pressure was 160 mmH\u003csub\u003e2\u003c/sub\u003eO, which demonstrated that the intracranial infection was controlled. On the 15th day after surgery, A head CT scan indicated a slight enlargement of both ventricles compared to the previous imaging. The patient did not have any obvious symptom with a normal temperature. The latest CSF examination indicated that karyocyte was 88×10\u003csup\u003e6\u003c/sup\u003e/L↑, neutrophile granulocyte was 7%↑, chlorine was 111.1mmol/L↓, glucose was 2.66mmol/L, and protein content was 93.4mg/dL↑. The patient was monitored with conservative treatments. On the 17th day after surgery, the patient suddenly presented severe headache, urinary and fecal incontinence, unconsciousness, and unresponsiveness. MRI showed a significant enhancement around the operative area, with disappeared ambient cistern and bilateral ventricle enlargement, especially the left ventricle (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA-B). On diffusion-weighted imaging (DWI) sequence, the component of tumor showed restricted diffusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). After eliminating the intracranial infection, ventricular dilation was possibly attributed to obstructive hydrocephalus. External ventricular drainage was immediately performed to treat hydrocephalus. The day after the operation, the patient’s urinary and fecal incontinence and unsteady gait disappeared with significantly improved consciousness, response and headache. CT reexamination indicated the hydrocephalus and ventricular enlargement were significantly ameliorated via a proper localization of the ventricular drainage tube (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eD). During the 12-day drainage, a total of 2656ml of limpid and yellowish CSF was extracted. Two days later, the patient was discharged with no headache, fever, nausea or vomiting, convulsions, limb sensation, or movement disorder. MRI reexamination before discharge demonstrated the normal lateral ventricle and total tumor resection without heterogeneous hyperintensity remaining (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThrough analyzing 223,404 brain tumor patients collected by the National Cancer Database between 2004 and 2015, researchers discovered that 868 (0.4%) patients were diagnosed as CN\u003csup\u003e14\u003c/sup\u003e. The average age at the time of diagnosis was 31 years old and the typically size of the tumor was 4\u0026ndash;5 centimeters. Regarding the distribution of CN, there were 622 intraventricular tumors, 168 extraventricular tumors\u003csup\u003e4\u003c/sup\u003e. In general, CN is located within the ventricles, more commonly in the anterior region of the lateral ventricle, which is consistent with the present case\u003csup\u003e15\u003c/sup\u003e. Despite as a benign tumor in histology, in some cases, CN possesses increased mitotic activity and results in potentially fatal consequences, such as hydrocephalus, cerebral hernia or tumor hemorrhage\u003csup\u003e16\u003c/sup\u003e. Therefore, it has been assigned to the 2021 World Health Organization (WHO) classification grade two\u003csup\u003e17\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eUp to now, there is no official guideline on how to treat CN, so treatment options are often individualized based on specific findings. Surgery is presently the cornerstone of CN treatment\u003csup\u003e18\u003c/sup\u003e. Patients with CN often present with a sizable tumor burden and are well managed with surgical resection. A favorable prognosis of CN can be achieved by gross total resection or subtotal resection. For individuals who have undergone subtotal tumor resection, the prognosis can be improved with postoperative adjuvant radiotherapy\u003csup\u003e19\u003c/sup\u003e. Given the favorable prognosis of CN patients, efforts to improve tumor control should be carefully weighed against the long-term risks associated with adjuvant therapy like radiation.\u003c/p\u003e \u003cp\u003eAfter patient\u0026rsquo;s consent, left ventricular tumor resection and external ventricular drainage were scheduled. On the 17th day after surgery, obstructive hydrocephalus reappeared. After excluding intracranial infection, we considered the following three possibilities for this complication. First, hydrocephalus might be secondary to oppression by regional cerebral ischemic infarction and edema in the operative area. Second, hydrocephalus might be caused by intracranial infection which obstructed the circulation of CSF. Third, for high Ki-67 proliferation fraction and enhancement under the corpus callosum through sagittal T1-weighted image, we also suspected whether obstructive hydrocephalus was secondary to tumor recurrence and its compression. In our case, the location of CN was near the foramen of Monro which is the channel of CSF circulation from the lateral ventricle to the third ventricle. Besides, the tumor closely adhered to the septum pellucidum and choroid plexus. Although the tumor was surgically separated from the parenchyma as carefully as possible, ischemic infarction and edema in the operative area were inevitable. Overall, we considered that the hydrocephalus was caused by temporary postoperative edema pressing on the interventricular foramen.\u003c/p\u003e \u003cp\u003eHow to treat hydrocephalus? The definitive hydrocephalus management includes endoscopic third ventriculostomy (ETV) and ventriculoperitoneal (VP) shunts. The use of temporary measures, including external ventricular drainage (EVD), Ommaya reservoir insertion, or lumbar drainage may also be adopted as per the age and clinical setting\u003csup\u003e20\u003c/sup\u003e. Since its inception, VP shunting is probably more privileged in controllability for long-time draining. Despite advances in shunt technology, the incidence of VP shunt failure is as high as 30% in the first year, 40% by the second year, and almost 85% by 10 years\u003csup\u003e21\u003c/sup\u003e. Besides, more attention is required to manage possible complications that seriously affect the quality of life during a lifelong CSF diversion. Therefore, the selection of a temporary drainage or VP shunt should be carefully assessed based on proper individualization and different clinical stages.\u003c/p\u003e \u003cp\u003eComprehensively considering the pathogenesis of hydrocephalus and the patient's condition, we adopted temporary external ventricular drainage instead of VP shunt or ETV. Three reasons for the selection are: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) we speculated the obstruction symptoms would improve after the edema subsided; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) external ventricular drainage might achieve similar therapeutic effects as the VP shunt, avoiding the risks and sequelae caused by the long-term VP shunt; (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) the majority of infection-induced hydrocephalus are communicating hydrocephalus rather than obstructive hydrocephalus. After 12-day drainage, the hydrocephalus completely disappeared with improved symptoms and reduced enhancement signal under the corpus callosum in MRI, which was considered as fibroplasia. These findings collectively verified our deduction and excluded the possibility of tumor recurrence. Therefore, for postoperative hydrocephalus in patients with CN, especially with infarction and edema in the surgical area, temporary external ventricular drainage may be a substitute for VP shunt.\u003c/p\u003e \u003cp\u003eBesides, in term of treatment of CN, gross total surgical resection is the optimal treatment, and the postoperative prognosis is generally satisfactory, with 5-year and 10-year overall survival rates of 96% and 82%, respectively\u003csup\u003e5\u003c/sup\u003e. However, CN may possess increased aggressiveness when the proliferation index of Ki-67 is higher than 2\u0026ndash;3%, which can be categorized as atypical CN with histological features of anaplasia like increased mitotic activity and microangiogenesis\u003csup\u003e14\u003c/sup\u003e. Although the Ki-67 index is reported that may not well correlate with histologic features of malignancy, it does closely correlate with the clinical outcome of patients\u003csup\u003e22\u003c/sup\u003e. According to a case report, aggressive behavior characterized by CN progression was noted in two patients, with unusually high proliferation rates of 5.3% and 11.2%\u003csup\u003e23\u003c/sup\u003e. In our case, the Ki-67 proliferation index of CN was from 5\u0026ndash;10%, suggesting a stronger capability for invasion and metastasis, and an increased risk of tumor recurrence after surgery. For tumors with a high Ki-67 fraction, adjuvant therapy should be considered in advance. Therefore, although the tumor was resected totally with no sign of recurrence, the current patient also accepted radiotherapy after discharge for high Ki-67 proliferation fraction. Given this, the Ki-67 may represent an excellent predictor of the biologic and clinical activity of CN, and may be of benefit in selecting patients who need postoperative radiotherapy\u003csup\u003e24\u003c/sup\u003e. Multi-case analysis is warranted to determine the relationship between biological markers and malignant behavior of CN to optimize postoperative treatments.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCN is a rare and benign neuroepithelial tumor commonly located in intraventricular regions or the foramen of Monro. Removal through surgery is the basis of treatment. However, there are few publications on the management of complications following surgery for aggressive CN with a special location. For postoperative intracranial infection, in addition to the administration of high-grade antibiotics, timely and standardized lumbar cisterna drainage contributes to controlling infection. Besides, the treatment for hydrocephalus should be customized, because short-term external ventricular drainage may achieve similar effects as VP shunt, avoiding maintenance risks and complications of VP shunt during long-term drainage, thus conferring better quality of life. Furthermore, for CN with high Ki-67 or atypical characteristics, adjuvant therapy like radiotherapy may be beneficial to improving prognosis. Of course, the therapeutic impact and intervening opportunity of adjuvant radiation need to be further established, particularly in patients undergoing,subtotal resection. Lastly, we anticipate that these lessons will serve as sources of clinical experience and treatment guidelines for the management of CN and its complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThis case report was approved by human Research Ethics Committee, the Second Affiliated Hospital of\u0026nbsp;\u003c/em\u003e\u003cem\u003eZhejiang\u0026nbsp;\u003c/em\u003e\u003cem\u003eUniversity School of Medicine on 10/25/2023. The ethics case number was I20231269.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe patient gave consent to be included in the study.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe patient has given written consent for this report to be published.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData and material are not publicly available, but can be requested.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe did not receive any funding for this research.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u003cstrong\u003es\u0026rsquo;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;c\u003c/strong\u003e\u003cstrong\u003eontributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConception and design: Z.S. and G.C.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcquisition of data: S. J and S. T.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalysis and interpretation of data: Z.S.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDrafting of the article: S. J.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCritically revising the article: Z. D.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReviewed submitted version of manuscript: all authors.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eApproved the final version of the manuscript on behalf of all authors: Z.S.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAdministrative/technical/material support: S. T.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStudy supervision: Z.S.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eWe thank Lingzhi Yu for her comments on the manuscript.\u003c/em\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGkmd D, Hpmd S, Hkmd I, Gcmd J, Cmd BK. Central neurocytoma. Cancer, 1997;79(10):1995-2002.\u003c/li\u003e\n\u003cli\u003eHung YC, Lee CC, Yang HC, et al. Stereotactic radiosurgery for central neurocytomas: an international multicenter retrospective cohort study. J Neurosurg. 2020;134(3):1122-1131.\u003c/li\u003e\n\u003cli\u003eHassoun J, Sylemezoglu F, Gambarelli D, et al. Central Neurocytoma: A Synopsis of Clinical and Histological Feature. Brain Pathol, 2010;3(3):297-306.\u003c/li\u003e\n\u003cli\u003eHsu PW, Hsieh TC, Chang CN, Lin TK. Fourth Ventricle Central Neurocytoma: Case Report. 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Central neurocytoma: A clinical, radiological and pathological study of nine cases. Clin Neurol \u0026amp; Neurosur. 2008;110(2):129-136.\u003c/li\u003e\n\u003cli\u003eKocaoglu M, Ors F, Bulakbasi N, Onguru O, Ulutin C, Secer HI. Central neurocytoma: proton MR spectroscopy and diffusion weighted MR imaging findings. Magn Reson Imaging. 2009;27(3):434-440.\u003c/li\u003e\n\u003cli\u003eShunji, Nishio, Takato, et al. Tumours around the foramen of Monro: clinical andneuroimaging features and their differential diagnosis - ScienceDirect. J Clin Neurosci. 2002;9(2):137-141.\u003c/li\u003e\n\u003cli\u003eNiiro T, Tokimura H, Hanaya R, et al. MRI findings in patients with central neurocytomas with special reference to differential diagnosis from other ventricular tumours near the foramen of Monro. J Clin Neurosci. 2012;19(5):681-686.\u003c/li\u003e\n\u003cli\u003eWang H, Li WS, Shi DJ, He HY, Guo Y. Central Neurocytoma: Clinical, Pathological, and Imaging Findings in 5 Cases. 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Front Neurol. 2020;11:834.\u003c/li\u003e\n\u003cli\u003eKvarta MD, Sharma D, Castellani RJ, et al.Demyelination as a harbinger of lymphoma: a case report and review of primary central nervous system lymphoma preceded by multifocal sentinel demyelination. Bmc Neurol. 2016; 16(1):72.\u003c/li\u003e\n\u003cli\u003eHochstetler A, Raskin J, Blazer-Yost BL. Hydrocephalus: historical analysis and considerations for treatment. Eur J Med Res. 2022;27(1):168. \u003c/li\u003e\n\u003cli\u003eFujimaki T, Matsuno A, Sasaki T, Toyoda T, Kirino T. Proliferative activity of central neurocytoma: Measurement of tumor volume doubling time, MIB-1 staining index and bromodeoxyuridine labeling index. J Neurooncol. 1997;32(2):103-109.\u003c/li\u003e\n\u003cli\u003eAshkan K, Casey AT, D\u0026apos;Arrigo C, Harkness WF, Thomas DG. Benign central neurocytoma. Cancer. 2000;89(5):1111-1120.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Central Neurocytoma, lateral ventricle, obstructive hydrocephalus, intracranial infection","lastPublishedDoi":"10.21203/rs.3.rs-4510036/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4510036/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eCentral neurocytoma (CN) is a rare neurogenic intraventricular tumor that accounts for 0.25\u0026ndash;0.5% of all intracranial tumors. Surgery is the cornerstone of therapy in most instances. Postoperative complications such as intracranial infection and hydrocephalus may be serious and even fatal. However, there are few reports on the management of complications after CN resection.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase presentation:\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe authors described a 41-year-old male patient, whose CN was near the interventricular foramen with a high Ki-67 index. Seven days following surgery, an intracranial infection struck the patient. On the seventeenth day, the patient experienced signs of obstructive hydrocephalus, including headache, unconsciousness, and gatism. One month after surgery, the patient recovered and was discharged with no sequela through high-grade antibiotics, lumbar cisterna drainage and external ventricular drainage.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFor CN with elevated Ki-67 or growing in the lateral ventricle, particularly in the anterior region close to the interventricular foramen, obstructive hydrocephalus was more likely to be complicated after surgery. The temporary external ventricular drainage may be a substitute for VP shunt, avoiding maintenance risks and complications of VP shunt during long-term drainage. Besides, we also need to etiologically personalize the treatment approaches based on the various stages of patient for maximum clinical benefit.\u003c/p\u003e","manuscriptTitle":"Intracranial infection and acute obstructive hydrocephalus after lateral ventricle central neurocytoma resection: case report and review of the literature","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-17 16:52:28","doi":"10.21203/rs.3.rs-4510036/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"181c4fc5-07d4-465b-9dc6-61a47b031080","owner":[],"postedDate":"June 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-04T10:43:56+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-17 16:52:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4510036","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4510036","identity":"rs-4510036","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}