Characteristic and Management of Symptomatic Septum Pellucidum Cyst in Extreme Elderly Patient: Case Report and Literature Review

Abstract

Septum pellucidum cyst is rare and is defined as a fluid-filled space between the lateral ventricles; it has a width of 10 mm or more. In this case report, a surgical patient of symptomatic septum pellucidum cyst (SPC) in extreme age is described. To the best our knowledge, this is the first report of an extremely aged patient with symptomatic SPC that was successfully treated using a flexible neuroendoscope. An 85-year-old male complained of gradually worsening gait disturbance, dementia, and urinary incontinence without headache and was admitted to our hospital. MRI revealed a huge cyst between the lateral ventricles as well as ventricle dilatation with periventricular hyperintensity in T2-weighted image. The patient was diagnosed with symptomatic hydrocephalus with SPC and underwent neuroendoscopic fenestration of the cyst with the use of a flexible endoscope without cerebrospinal fluid shunt placement. Immediately after the surgery, the patient's gait disturbance and dementia were dramatically improved. In extremely aged patients, SPC tended to develop with idiopathic normal pressure hydrocephalus-like symptoms, including gait disturbance without increasing intracranial pressure, sensorimotor disturbances, and psychological disorders. Neuroendoscopic cyst fenestration with the use of a flexible scope for SPC is a less-invasive procedure and should be considered even for extreme elderly symptomatic patients.

Keywords: elderly patient; endoscopic fenestration; flexible endoscope; hydrocephalus; septum pellucidum cyst.

Fig. 1

Magnetic resonance images before the operation demonstrated a cystic lesion between the bilateral anterior horns of the lateral ventricles with periventricle hyperintensity in T2-weighted image (a, b, c). T1-weighted coronal image with gadolinium administration revealed the bilateral septal veins (arrowhead) located lateral to the cyst (d). The cyst wall expanded to the corpus callosum and the floor of the third ventricle. The aqueduct (arrow) was not obstructed by the cyst (e).

Fig. 2.

Intraoperative photographs during neuroendoscopic fenestration of the septum pellucidum cyst. a: The medial wall of the right lateral ventricle (asterisk) was expanded with lateral bowing by the septum pellucidum cyst, and the right foramen of Monro exhibited a slit-like characteristic (arrow). b: After fenestration of the cyst wall, the anterior cerebral arteries, duplicated anterior communicating arteries (harpoon), and their perforators were observed through the dilated wall of the cavum septum pellucidum. c: The stoma-fenestrated right lateral ventricle and the septum pellucidum lamina (double asterisk) were patent, and the right foramen of Monro (double arrow) dilated after the neuroendoscopic fenestration. A1: anterior cerebral artery horizontal potion, A2: anterior cerebral artery vertical potion. CP: choroid plexus of the right lateral ventricle.

Fig. 3

Coronal magnetic resonance image 6 months after surgery demonstrated flow void near the stoma in the T2-weighted image. The size of the lateral ventricles was normalized, and the periventricular hyperintensity area diminished.