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Agenesis of Anterior Falx Cerebri in Patient with Planned Interhemispheric Approach to Third Ventricle Mass
Nathan W Finch1, Dale Ding2, Edward H Oldfield2
1Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia, USA.
Insights
Partial agenesis of the falx cerebri is rare in normal adults. This case highlights how this anomaly can affect surgical approaches to third ventricular masses, necessitating alternative surgical strategies.
Area of Science:
- Neuroanatomy
- Neurosurgery
- Developmental Biology
Background:
- Agenesis of the falx cerebri is typically associated with pediatric developmental anomalies.
- Isolated agenesis of the falx cerebri in developmentally normal adults is exceptionally rare.
- This report details a unique case involving a third ventricular mass and partial anterior falx agenesis.
Observation:
- A 60-year-old woman presented with neurological deficits due to a third ventricular mass causing obstructive hydrocephalus.
- Preoperative imaging did not reveal the partial agenesis of the falx cerebri.
- Intraoperative findings confirmed the absence of the anterior falx cerebri, leading to altered surgical planning.
Findings:
- The patient had partial agenesis of the anterior falx cerebri, an anomaly not previously reported in a developmentally normal adult with a superior sagittal sinus.
- The absence of the falx cerebri caused dense adhesions between the medial frontal lobes.
- The third ventricular mass was identified as an epidermoid cyst.
Implications:
- Partial agenesis of the falx cerebri can significantly impact surgical access to midline and third ventricular lesions.
- Preoperative identification of falx agenesis is crucial for planning appropriate neurosurgical approaches.
- This case underscores the importance of recognizing rare anatomical variations in adult neurosurgery.
Background:
Complete or partial agenesis of the falx cerebri may occur in pediatric patients with developmental anomalies. However, isolated agenesis of the falx in a developmentally normal adult is exceptionally rare. We describe the first reported case of a patient with a third ventricular mass associated with partial agenesis of the anterior falx cerebri, a circumstance that influenced surgical access to a third ventricular epidermoid cyst.
Case Description:
A 60-year-old developmentally normal woman presented with progressively worsening aphasia and altered mental status. Brain magnetic resonance imaging showed obstructive hydrocephalus from a third ventricular mass. An anterior interhemispheric transcallosal approach was planned to remove the tumor. However, upon dural opening there was no evidence of a falx cerebri, an anomaly visible but not reported on the prior imaging studies. An interhemispheric fissure was present, but the medial frontal lobes were densely adherent, with multiple traversing veins within the superficial arachnoid of the fissure. Therefore, a left frontal transcortical approach was performed for microsurgical resection of the tumor. Histopathologic analysis identified the lesion to be an epidermoid cyst.
Conclusions:
Partial agenesis of the falx cerebri is exceedingly rare in a developmentally normal adult, particularly in the presence of an anatomically normal superior sagittal sinus. If present, however, it is important to note this association preoperatively because partial agenesis of the falx cerebri precludes an interhemispheric transcallosal approach to the lateral and third ventricles.
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