Intraventricular astrocytoma causing seizures in a young male

Ganesh Veerabhadraiah1, Sumana B Palleger2, Vivek Chandra3, Manjunath Reddy4, Yashoda5

1HOD-Neurosurgery, Kauvery Hospital, Electronic City, Bangalore

2Senoir Consultant-Neurosurgery, Kauvery Hospital, Electronic City, Bangalore

3Neuro – Anesthetist, Kauvery Hospital, Electronic City, Bangalore

4Senior Registrar, Neurosurgery, Kauvery Hospital, Electronic City, Bangalore

5Physician Assistant, Kauvery Hospital, Electronic City, Bangalore

Case Presentation

A 19-year-old previously healthy male presented with two episodes of sudden loss of consciousness, each lasting 10–15 minutes, accompanied by abnormal jerky limb movements, uprolling of the eyes, and tongue biting—clinically consistent with generalized tonic-clonic seizures. Postictally, he experienced transient amnesia but returned to baseline orientation and speech within minutes.

Clinical Examination

On arrival, his Glasgow Coma Scale was E4V5M6 (GCS 15), with no focal neurological deficits. He had no prior history of seizures or similar episodes.

Imaging and Diagnosis

Urgent non-contrast CT scan of the brain revealed a space-occupying lesion within the lateral ventricles, predominantly on the left side, causing obstructive hydrocephalus. MRI confirmed a well-defined intraventricular mass extending near the foramen of Monro and third ventricle, leading to CSF flow obstruction. Differential diagnoses included central neurocytoma, low-grade astrocytoma, and ependymoma.

Preoperative Management

To manage raised intracranial pressure and prevent further seizures, the patient was started on mannitol, steroids, and antiepileptic medications. Neurosurgical intervention was planned due to hydrocephalus, mass effect, and recurrent seizures.

Surgical Approach

The patient underwent neuro-navigation-guided transcortical craniotomy for excision of the intraventricular tumor. Intraoperatively, the tumor was soft but not suckable, minimally vascular, and adherent to the septum pellucidum. A Cavitron Ultrasonic Surgical Aspirator (CUSA) was used for precise debulking. A small remnant (<2 mm), adherent to critical structures (likely internal cerebral vein and fornix), was intentionally left to avoid neurological deficits. Septum pellucidum fenestration was performed to reestablish CSF flow between ventricles.

Postoperative Course

The patient was extubated on the same day, fully conscious, and neurologically intact. A postoperative CT showed clear ventricles and no residual tumor. He mobilized on post-op day 1 and was discharged by day 3. At 1-week follow-up, wound healing was satisfactory, and at 1-month review, he was neurologically normal and seizure-free.

Histopathology

Final biopsy reported pilocytic astrocytoma (WHO Grade I). Given the gross total resection and non-enhancing nature of the tumor on MRI, a decision was made to observe with serial imaging at 6-month and annual intervals. Adjuvant radiotherapy was deferred but remains an option if recurrence occurs.

Complexity of Surgery for Intraventricular Pilocytic Astrocytoma

Deep-Seated Location

The tumor lies within the ventricular system, often near critical structures like the fornix, thalamus, and internal cerebral veins, increasing the risk of memory deficits, venous injury, or neurological impairment.

Obstructive Hydrocephalus

The tumor frequently blocks CSF pathways (e.g., foramen of Monro or third ventricle), causing raised intracranial pressure, seizures, or unconsciousness — requiring urgent decompression.

Surgical Approach Challenges

Accessing the tumor requires a transcortical or transcallosal route, which must be carefully planned with neuronavigation to avoid eloquent brain areas and minimize cortical damage.

Tissue Consistency and Adherence

Pilocytic astrocytomas may be minimally vascular yet firm and adherent, often not amenable to suction or standard debulking techniques, requiring use of CUSA (Cavitron Ultrasonic Surgical Aspirator) and fine microsurgical dissection.

Balancing Radical Resection vs Safety

While total excision offers excellent prognosis, small tumor remnants near vital veins or memory pathways (e.g., fornix) may need to be intentionally preserved to avoid permanent neurological deficits.

Points to Note

  • Sudden episodes of loss of consciousness and seizures in young individuals warrant urgent neuroimaging.
  • Intraventricular tumors can present subtly but carry significant risk due to hydrocephalus and raised ICP.
  • Modern neurosurgical tools such as neuronavigation and CUSA aid in safely excising deep-seated brain tumors with minimal complications.
  • Gross total resection of low-grade tumors like pilocytic astrocytomas offers excellent prognosis with vigilant follow-up.

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