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Fourth Ventricular Lesions
A 2-year-old boy presenting with unsteadiness and lethargy.
An 8-year-old boy presenting with emesis and headache.
A 45-year-old man with morning headaches and occasional nausea and vomiting.
A 32-year-old Latin American woman presenting with a severe headache.
DESCRIPTION OF FINDINGS
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Case A: A large T2 hyperintense heterogeneously enhancing, intraventricular mass with extrusion through the foramen of Magendie.
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Case B: A T2 isointense, mildly enhancing, intraventricular mass with spinal drop metastases.
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Case C: A small, T2 isointense, minimally enhancing fourth ventricular mass.
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Case D: A solid cystic, partially enhancing fourth ventricular mass with mild periventricular edema.
Diagnosis
Case A
Ependymoma (proven by pathology)
Case B
Medulloblastoma (proven by pathology)
Case C
Subependymoma (proven by pathology)
CaseD
Intraventricular neurocysticercosis (IVNCC) (presumptive; positive serology in an immigrant from Latin America)
Summary
Fourth ventricular masses are much more common in the pediatric population than in adults. In children, medulloblastomas and ependymomas are the most common masses found in the fourth ventricle. Other pediatric posterior fossa primary neoplasms, including pilocytic astrocytoma and brainstem glioma, occasionally may grow exophytically into the fourth ventricle and mimic a mass of ventricular origin.
In adults, primary neoplasms also may occur in the fourth ventricle, including subependymomas and choroid plexus papillomas (CPPs). Although a hemangioblastoma rarely arises within the fourth ventricle, it should be considered in the setting of von Hippel Lindau disease. Metastases that occur both via CSF spread (central nervous system neoplasms) and hematogenous spread (systemic neoplasms) also must be considered.
IVNCC, although rare, most commonly occurs in the fourth ventricle and should be considered in the setting of a cystic fourth ventricular lesion in the appropriate clinical history.
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