CLINICAL STUDIES

NEUROPSYCHOLOGICAL EFFECTS OF THIRD VENTRICLE

TUMOR SURGERY
Melissa A. Friedman, Ph.D.
The Brain and Spine Center, The
University of Texas M. D.
Anderson Cancer Center, and
Department of Psychology,
University of Houston, Houston,
Texas
Christina A. Meyers, Ph.D.
The Brain and Spine Center, The
University of Texas M. D.
Anderson Cancer Center, Houston,
Texas
Raymond Sawaya, M.D.
The Brain and Spine Center, The
University of Texas M. D.
Anderson Cancer Center, Houston,
Texas
Reprint requests:
Christina A. Meyers, Ph.D.,
Department of Neuro-oncology,
University of Texas M. D.
Anderson Cancer Center, Box 431,
1515 Holcombe Boulevard,
Houston, TX 77030.
Email: cameyers@mdanderson.org.
Received, May 7, 2002.
Accepted, November 11, 2002.
OBJECTIVE: This study assessed the neuropsychological outcome of patients after
surgical treatment for third ventricle brain tumors. Neuropsychological consequences
of surgical intervention can have a major impact on patients’ quality of life and
therefore have important implications for treatment planning.
METHODS: A retrospective analysis of 33 patients’ neuropsychological data was
performed. All patients received a comprehensive neuropsychological evaluation after
treatment for a primary brain tumor in the third ventricular region. Twenty-six patients
underwent surgery, 14 via the transcallosal approach and 12 via a subfrontal, left
transcortical, right pterional, or infratentorial supracerebellar approach. Seven patients
were not treated by surgical intervention.
RESULTS: There was a significantly elevated frequency of cognitive impairment rela-
tive to normative values in memory, executive functioning, and fine manual speed and
dexterity. There were no differences in mean neuropsychological scores between
patients who underwent surgery and those who did not. There were no differences in
mean performance on the basis of surgical approach, tumor infiltration, or history of
cranial irradiation. Repeated measures data available for two patients revealed mem-
ory impairment before and after surgery, and one patient experienced major improve-
ment after surgery on a measure of mental flexibility and problem solving.
CONCLUSION: Patients with third ventricle tumors are at risk for developing impair-
ments in memory, executive function, and fine manual speed and dexterity, which are
domains associated with frontal subcortical functions. In the current study, different
types of treatment were not associated with differential cognitive sequelae, and
surgical intervention did not account for cognitive deficits.
KEY WORDS: Cognition, Neuropsychology, Surgery, Third ventricle, Tumors
Neurosurgery 52:791-798, 2003 DOI: 10.1227/01.NEU.0000053367.94965.6B www.neurosurgery-online.com

T
he objective of this study was to evaluate and describe
the neuropsychological status, relative to normal func-
tioning, of patients with tumors in the third ventricle of
the brain after surgery and to identify factors that may account
for the variability in performance in such patients. Neuropsy-
chological outcome is highly relevant to treatment planning
for patients with third ventricle brain tumors because of the
risk of damaging brain structures in the third ventricular
region during treatment. Group studies and individual case
reports suggest that cognitive deficits, particularly in memory,
are associated with tumors in this region (11, 37, 39, 45).
Studies of nontumor pathological entities, such as infarcts and
alcoholic Korsakoff’s syndrome, associate similar memory
deficits with damage to structures in the third ventricular
region (10, 14, 20, 30, 32, 41). The third ventricular structures
and tracts crucial to memory functioning include the thala-
mus, mamillary bodies, mamillothalamic tract, fornix, and
internal medullary lamina (31).
Cognitive impairments may result from tumor effects as
well as from treatment effects. Direct and indirect tumor ef-
fects include increased intracranial pressure, tumor compres-
sion of structures important for memory (25, 27), and tumor
infiltration of memory structures (22, 34). Treatment effects
may include surgical manipulation and resulting damage to
structures important for cognitive functioning. In addition,
many patients receive cranial irradiation, which is known to
exert protracted and irreversible demyelinating effects on sub-
cortical white matter. Such effects are associated with cogni-
tive slowing and decline in memory and executive functioning
(13, 35). The neuropsychological effects of chemotherapy are
thought to be acute and reversible except in cases of intra-
arterial or intraventricular administration; protracted treat-

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FRIEDMAN ET AL.
ment toxicity is considered attributable to cranial irradiation,
although the synergistic toxicity of radiation administered
concurrently with chemotherapy has yet to be delineated in
the literature (36).
The purpose of the present study was to evaluate and
describe the neuropsychological outcome of a relatively large
sample of third ventricle tumor patients and to identify factors
influencing neuropsychological outcome. This objective in-
cluded evaluating the differential effects of surgical treat-
ments, tumor type, and radiation therapy on patients’ neuro-
psychological performance.
PATIENTS AND METHODS
Thirty-three patients, including 17 females and 16 males,
were studied retrospectively. Their average age was 31 years
(standard deviation [SD], 13 yr; range, 13–63 yr). The average
education level of the patients was 14 years (SD, 3 yr; range,
8–20 yr). All patients had been diagnosed with tumors in the
third ventricular region of the brain. The average time be-
tween diagnosis and evaluation was 31 months (SD, 56 mo;
median, 8 mo; range, 1 wk to 250 mo). Twenty-six patients
underwent surgical resection of their tumors, and postopera-
tive neuropsychological data were available for all of them;
preoperative data also were available for two patients. The
seven patients who did not undergo surgical resection also
received a neuropsychological evaluation. For the two patients
who had both pre- and postoperative evaluations, the postop-
erative evaluation was used in the statistical analyses.
Before their neuropsychological evaluation, 20 patients had
symptoms of and were treated for increased intracranial pres-
sure associated with acute hydrocephalus. Treatment of these
patients consisted of a cerebrospinal fluid diversion procedure
to improve cerebrospinal fluid circulation, such as an external
ventriculostomy, a ventriculoperitoneal shunt, or fenestration
TABLE 1. No. of patients in the surgical, radiation, and tumor type groups
No cranial irradiation
Surgical approach Tumor type
No surgery (n ⫽ 7) Extra-axial intraventricular
Infiltrative
Total
Transcallosal (n ⫽ 14) Extra-axial intraventricular
Infiltrative
Total
Other (n ⫽ 12) Extra-axial intraventricular
Infiltrative
Total
792 | VOLUME 52 | NUMBER 4 | APRIL 2003
of a ventricular wall such as that of the posterior third
ventricle.
A biopsy procedure had been performed on seven patients
before their neuropsychological evaluations. Of these, four
underwent a needle biopsy in which a cannula was passed
through the cortex under either stereotactic or endoscopic
visual guidance. The remaining three patients underwent an
open biopsy, one via a right pterional approach, and two via
a left frontal transcortical approach. When patients were
grouped into surgical categories for comparisons, the latter
three patients were grouped in the category corresponding to
their biopsy approach, as the cranial and brain manipulation
required for the open biopsy were similar to those performed
for the surgical resection.
Patients were grouped on the basis of three variables: tumor
type, surgical treatment, and whether they had a history of
receiving cranial irradiation therapy. Table 1 lists the number
of patients in each of these groups. Fourteen patients under-
went cranial irradiation (with or without chemotherapy), and
19 did not. Regarding tumor type, patients were grouped
according to their pathological tumor diagnosis in one of two
categories: extra-axial intraventricular tumors (n ⫽ 18), which
usually are well-circumscribed and slow-growing tumors; or
infiltrative tumors (n ⫽ 15), which tend to be faster-growing
tumors that are invasive of surrounding structures or infiltra-
tive of white matter and densely cellular. Table 2 lists the
pathological diagnoses within each category.
As listed in Table 1, there were three categories for surgical
treatment: no surgery (n ⫽ 7), surgery via the anterior tran-
scallosal approach (n ⫽ 14), and surgery via other approaches
(n ⫽ 12). The “other surgery” category included patients who
received the subfrontal (n ⫽ 2), left frontal transcortical (n ⫽
4), right pterional (n ⫽ 3), or infratentorial supracerebellar
approach (n ⫽ 2). As this study required a retrospective re-
view of records, there was one patient whose surgical ap-
Received cranial irradiation
Total
(n ⴝ 19) (n ⴝ 14)
3 2 5
1 1 2
4 3 7
3 2 5
4 5 9
7 7 14
6 1 7
2 3 5
8 4 12
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 THIRD VENTRICLE TUMOR SURGERY

problem solving (Comprehension), verbal reasoning (Similar-

TABLE 2. Tumor pathology by tumor type group ities), and graphomotor speed (Digit Symbol). Verbal memory
Tumor No. was assessed using the Verbal Selective Reminding Test
(VSRT) (9, 21), which provides measures of storage and de-
Extra-axial intraventricular layed recall of a word list. Some patients also were tested with
Ependymoma 2 the Hopkins Verbal Learning (8) and the immediate and de-
Craniopharyngioma 5 layed measures of the Logical Memory tests from the Wech-
Colloid cyst 2 sler Memory Scale (43). Executive functioning was measured
Central neurocytoma 3 using the Booklet Category Test (16, 18), the Trail Making Test
Germinoma 6 Part B (18, 38), and Digit Span Backward (28, 44). Motor speed
and dexterity were tested with the Grooved Pegboard (33).
Infiltrative
Visuoperceptual measurements included the Trail Making
Pineoblastoma 2
Test Part A (18, 38) for simple visual tracking speed and the
Low-grade glioma 8
Benton Test of Facial Recognition (7) for discrimination of
Anaplastic glioma 3
complex visual stimuli. The Benton Visual Retention Test (5,
Glioblastoma multiforme 2
49), Administration A, was used as a measure of working
memory for visual forms. Language functioning was mea-
sured using tests of the Multilingual Aphasia Examination (6),
proach could not be determined, and this patient was included including Controlled Oral Word Association as a test of rate of
in the “other” category. These subgroups were combined for fluency, the Visual Naming test, and the Token Test of aural
the purpose of conducting statistical analyses because individ- comprehension.
ually they were very small.
The no-surgery group consisted of patients who had not
undergone surgical resection of their tumor. For these pa-
tients, it was determined by their physician that the tumor RESULTS
type had a high likelihood of responding to radiation or
Independent sample t tests revealed no differences between
chemotherapy, or its effects would be treated best by palliat-
neuropsychologically unimpaired and impaired patients with
ing symptoms of increased intracranial pressure with a cere-
respect to in age, education, or time since diagnosis. Table 3
brospinal fluid diversion mechanism.
lists the mean standardized score and the percentage of pa-
One patient underwent two operations via the anterior tran-
tients displaying mildly and severely impaired performance
scallosal approach before the neuropsychological evaluation.
for each neuropsychological test. (Standard scores are pre-
Documentation clearly indicated that the second operation
sented in the form of z scores or percentiles. A z score repre-
used the same approach and reopened the incisions made
sents, in SD units, the degree to which a score deviates from
during the previous operation. This patient’s neuropsycholog-
the mean of the normative population. With the population
ical performance was later evaluated individually to ensure
mean set at a z score of 0.00, 68.26% of individuals are ex-
that her status in this regard did not confound the results of
pected to obtain a z score between ⫺1.00 and 1.00. Approxi-
the study.
mately 13.59% of individuals are expected to obtains a z score
Determination of which surgical approach would be used
between ⫺1.00 and ⫺2.00, 2.14% between ⫺2.00 and ⫺3.00,
for each participant was made by the neurosurgeon. Such
and 0.13% lower than ⫺3.00. The same frequency expectations
determination was made according to the objective of obtain-
apply to the respective positive z scores.) Mildly impaired
ing maximal exposure of the lesion, with minimal injury to
performance was defined as a score at least 1.5 SDs below the
normal neural and vascular structures. The location of the
published, adjusted normative mean for that test. By use of
tumor within the ventricle, therefore, was a primary consid-
this criterion, in the normal population, mildly impaired per-
eration in determining the surgical approach.
formance would be expected to occur in approximately 6.7%
of people. Severely impaired performance was defined as a
Measures score at least 2.5 SDs below the published, adjusted normative
Selection of neuropsychological tests was in accordance mean for that test. In the normal population, severely im-
with the objective of providing a comprehensive description paired performance would be expected to occur in less than
of cognitive performance in this population. Only tests with 1% of people. Binomial tests were conducted to determine the
standardized procedures, published evidence of reliability extent to which observed impairment frequencies differed
and validity, and normative data were selected. General intel- from normative expectation. As listed in Table 3, greater than
lectual functioning was measured using subtests of the Wech- expected frequency of mild impairment was demonstrated on
sler Adult Intelligence Scale–Revised (WAIS-R) (44), including measures of memory, executive function, and manual speed
those measuring patients’ fund of worldly information (Infor- and dexterity, and greater than expected frequency of severe
mation), attention span (Digit Span), sustained concentration impairment was demonstrated on measures of memory and
(Arithmetic), nonverbal reasoning (Block Design), real-world manual speed and dexterity.

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FRIEDMAN ET AL.

TABLE 3. Mean z scores, percentage mildly impaired, and percentage severely impaired by neuropsychological testa
Percentage Percentage
Mean z score
Test No. mildly impaired severely impaired
(SD)
(z score <ⴚ1.5) (z score <ⴚ2.5)

Intellectual function (WAIS-R)

Verbal IQ 25 ⫺0.68 (0.77) 12 0
Information 28 ⫺0.51 (0.98) 14 4
Digit Span total (forward and backward breakdown, 33 ⫺0.37 (0.83) 6 0
below)
Arithmetic 31 ⫺0.28 (0.84) 0 0
Comprehension 24 ⫺0.68 (0.83) 13 4
Similarities 32 ⫺0.34 (1.04) 9 3
Block Design 32 ⫺0.19 (0.84) 3 0
Digit Symbol 33 ⫺0.56 (1.07) 27b 0
Verbal memory
Word Recall-Immediate (VSRT/CLTR) 21 ⫺2.06 (1.56) 67b 43b
Word Recall-Delayed (VSRT) 21 ⫺2.38 (2.14) 67b 43b
Word Recall-Immediate (Hopkins/sum of trials) 6 ⫺2.24 (1.62) 67b 67b
Word Recognition (Hopkins/Discrimination Index) 6 ⫺2.01 (2.86) 50b 33b
Story Recall-Immediate (WMS-R/Logical Memory) 7 ⫺1.55 (1.18) 57b 29b
Story Recall-Delayed (WMS-R/Logical Memory) 7 ⫺3.46 (3.50) 57b 43b
Visual Memory (BVRT error score) 19 ⫺0.93 (1.78) 26b 16b
Attention/executive functioning
Digit Span Forwardc (WAIS-R) 32 6 (raw span) 6 0
Digit Span Backwardc (WAIS-R) 32 4 (raw span) 28b 3
Booklet Category test 16 ⫺1.16 (1.32) 44b 13b
Trail Making test A 30 ⫺1.23 (2.08) 27b 20b
Trail Making test B 29 ⫺1.89 (2.83) 35b 28b
Manual speed and dexterity
Grooved pegboard-Right 25 ⫺2.46 (3.23) 52b 40b
Grooved Pegboard-Left 25 ⫺1.69 (2.27) 36b 24b
Visual perceptual ability
Facial recognition 20 45th percentile 10 5
Language ability (MLAE)
Visual naming 25 51st percentile 20 12b
Fluency (COWA) 33 35th percentile 24b 9b
Language comprehension (Token test) 24 42nd percentile 13 4
a
SD, standard deviation; WAIS-R, Wechsler Adult Intelligence Scale–Revised; IQ, intelligence quotient; VSRT, Verbal Selective Reminding Test; CLTR; continuous
long-term retrieval; WMS-R, Wechsler Memory Scale-Revised; BVRT, Benton Visual Retention Test; MLAE, Multilingual Aphasia Examination; COWA, Controlled
Oral Word Association.
b
Observed impairment frequency greater than normative expectation, binomial test; P ⬍ 0.01.
c
Forward span of 4 is considered mildly impaired, and 3 or less is considered severely impaired. Backward span of 3 is considered mildly impaired, and 2 or less
severely impaired. Adapted from, Lezak M: Neuropsychological Assessment. New York, Oxford University Press, 1995, ed 3 (28).

Independent sample t tests revealed no significant differ-
ence with regard to any of the major grouping variables (i.e.,
tumor type, surgical intervention, or whether patients re-
ceived cranial irradiation) for any neuropsychological test. For
example, on the Delayed Recall measure of the VSRT, which is
expected to be sensitive to damage to memory structures in
the third ventricular region, mean performance was similar
across groups, as was impairment frequency (Table 4). The
largest mean difference in that measure, for any of the com-
parisons, amounted to an approximate difference in recall of
only one word. This was the comparison between the tran-
scallosal group, with a mean z score of ⫺1.90 (or 7 of 12
words), and the no-surgery group, with a mean z score of
⫺2.72 (or 6 of 12 words).
The four patients who underwent the left frontal transcor-
tical approach did not display greater language impairment
than any other group. None of these four patients in the left
frontal transcortical group displayed any impairment on nam-
ing of visual stimuli or aural comprehension. One patient in
the transcallosal group underwent two operations before the

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TABLE 4. Comparison of mean z scores across group variables on Verbal Selective Reminding Test delayed recalla
Tumor type
Extra-axial
Infiltrative
intraventricular
(n ⴝ 12)
(n ⴝ 9)
Mean ⫾ SDb ⫺2.65 ⫾ 2.10 ⫺2.01 ⫾ 2.27
Percentage impaired 56% 75%
(z score ⱕ⫺1.5)
a
SD, standard deviation.
b
Independent sample t tests comparing patients by tumor type, surgical group, and radiation group revealed no statistically significant differences between
comparison groups.
neuropsychological evaluation. According to the surgical re-
ports, the second operation reopened the incisions made dur-
ing the first procedure. Scrutiny of this patient’s performance
revealed that all of her scores were at ⫺0.33 SDs or better,
which suggests average or better performance across cognitive
domains.
The effect on patient performance of shunting as a remedy
for hydrocephalus was evaluated. Independent sample t tests
revealed no differences on any neuropsychological test be-
tween patients who did and those who did not undergo a
shunting procedure.
Preoperative neuropsychological data were available for
two patients. One of these patients was a 36-year-old woman
who underwent the supracerebellar approach for resection of
a low-grade glioma and fenestration of the posterior third
ventricle to relieve hydrocephalus; she did not receive adju-
vant radiation or chemotherapy. Her preoperative neuropsy-
chological evaluation revealed severe impairment in verbal
memory (immediate and delayed measures of the VSRT),
higher-order reasoning and problem solving (Category Test),
and bimanual speed and dexterity (Grooved Pegboard). Her
performance was generally intact on WAIS-R intellectual
subtests. Follow-up evaluation, conducted 2 months after sur-
gery, revealed stability of impairment in memory and in man-
ual speed and dexterity, but improvement by more than 3 SDs
in higher-order reasoning and problem solving, which prob-
ably was largely attributable to the relief of hydrocephalus
and a practice effect.
The other patient for whom pre- and postoperative data
were available was a 63-year-old woman diagnosed with an
anaplastic astrocytoma who had a history of cranial irradia-
tion and chemotherapy before undergoing resection via the
transcallosal approach; she required no intervention for hy-
drocephalus. Her preoperative neuropsychological evaluation
revealed severely impaired verbal recognition memory (Hop-
kins Verbal Learning Test, Discrimination Index) and border-
line performance on a measure of working memory (Digit
Span Backward), with intact performance in all other cognitive
domains. Follow-up evaluation conducted 13 months after
tumor resection revealed stability of performance in all areas
NEUROSURGERY
THIRD VENTRICLE TUMOR SURGERY
Surgical approach Cranial irradiation
Received
Transcallosal Other approach No surgery No irradiation
irradiation
(n ⴝ 8) (n ⴝ 6) (n ⴝ 7) (n ⴝ 12)
(n ⴝ 9)
⫺1.90 ⫾ 2.22 ⫺2.61 ⫾ 1.80 ⫺2.72 ⫾ 2.53 ⫺2.41 ⫾ 2.25 ⫺2.35 ⫾ 2.16
63% 83% 57% 67% 67%
except verbal recall, which declined into the severely impaired
range; this decrement could be attributable to the delayed
effects of cranial irradiation, surgical intervention, or other
factors.
DISCUSSION
The results presented here indicate that patients with third
ventricle tumors have a greater frequency of impairments in
memory, executive functioning, and manual speed and dex-
terity than the normal population. Other studies of patients
with third ventricle tumors also detected impairments in these
cognitive domains (12, 15, 17, 19, 24, 26, 29, 40, 42, 46–48).
These findings are consistent with known functional neuro-
anatomy, as the third ventricle lies among various tracts that
interconnect brain regions and structures known to be associ-
ated with such memory, executive, and motor functions.
Elevated frequency of mild impairment, defined by perfor-
mance more than 1.5 SDs below the normative mean (below
the 7th percentile), was demonstrated in memory (57–67% of
patients), executive functioning (27–44% of patients), and
manual speed and dexterity (36–52% of patients). A large
subset of the patients displayed particularly severe impair-
ment in memory and in manual speed and dexterity, with 43%
of patients performing more than 2.5 SDs below the normative
mean (below the 1st percentile) on memory tests (Table 3). Our
impairment frequencies are higher than those reported in
previous research studies, in which, for instance, only 7 to 23%
of patients were impaired in memory performance (17, 23, 47).
This suggests that the risk for cognitive impairment in this
population may be greater than previously thought.
Amnestic syndromes generally are characterized by prom-
inent memory deficit with relatively preserved general intel-
lectual functioning (3). The preserved abilities in our third
ventricle tumor patients were those often associated with in-
tellectual and higher cortical functions. For instance, the
WAIS-R Verbal intelligence quotient scores, as well as scores
on WAIS-R subtests assessing fund of information, mental
arithmetic, real-world problem solving, abstract verbal rea-
soning, and visuospatial analysis revealed no statistically sig-
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FRIEDMAN ET AL.
nificant elevation in impairment frequency. Nor was signifi-
cant impairment frequency observed in measures of complex
visual discrimination (Facial Recognition) or aural language
comprehension (Token Test). Together, these findings suggest
that a subset of patients displayed an amnestic syndrome,
which probably was secondary to diencephalic disruption.
The finding of a pattern of impairment in some cognitive
domains with intact performance in others highlights the im-
portance in this field of research of comprehensive neuropsy-
chological evaluations, with selection of tests sensitive to im-
pairment across domains. In this patient sample, for instance,
use of the WAIS-R intelligence quotient score alone would not
have allowed for the detection of impaired versus preserved
functions.
In this study, mean performance did not vary according to
whether patients underwent surgery as treatment for their
tumors. In fact, the seven patients who did not undergo sur-
gical intervention, and the two patients evaluated preopera-
tively, were as impaired in memory, executive, or motor func-
tions as were patients who did undergo surgery. Among
patients who underwent surgery, mean performance did not
vary according to whether they underwent the transcallosal
approach or the other approaches combined. Performance also
did not vary according to whether patients underwent radia-
tion treatment or whether they had an infiltrative versus in-
traventricular extra-axial tumor. Finally, patients who under-
went the left frontal transcortical approach exhibited no
evidence of greater language impairment than those who un-
derwent any other approach. These results suggest that poorer
performance could not be attributed to surgical intervention,
radiation therapy, or tumor type.
Previous studies using pre- and postoperative evaluations
support the finding that surgical intervention does not neces-
sarily induce cognitive impairments. Honegger et al. (23) stud-
ied 13 patients treated surgically for craniopharyngiomas and
reported that 12 of the patients displayed no memory impair-
ment after surgery, and mean scores were stable or improved
from pre- to postoperative evaluations. Bellotti et al. (4) stud-
ied 31 tumor patients evaluated after third ventricular sur-
gery. Although postoperative memory deficits were detected,
all 12 patients who received a preoperative evaluation dis-
played the presence of the deficit at that time. Donnett et al.
(17) studied 22 patients, 12 of whom received preoperative
evaluations, and found that 50% of those who received pre-
operative evaluations displayed impairments in memory and
executive functioning, and 66% of those with baseline impair-
ments displayed resolution of impairments after surgery.
Hutter et al. (24) studied 18 patients treated for third ventricle
tumors with transcallosal surgery; of the four who received a
preoperative evaluation, all exhibited improvement, particu-
larly in memory, after surgery.
The current study provided pre- and postoperative data for
two patients. Both displayed preoperative memory impair-
ments that were not resolved at the postoperative evaluation.
One of these patients, a 36-year-old woman, also displayed
preoperatively impaired performance on a test of higher-order
796 | VOLUME 52 | NUMBER 4 | APRIL 2003
reasoning and problem solving that resolved after surgery.
The improvement was attributed to relief of hydrocephalus
and the likelihood of a practice effect. This postoperative
improvement on the measure of higher-order reasoning, in the
context of stable impairment in memory and fine manual
speed and dexterity, serves as an example of the possibility for
dissociation within individuals of impairments across cogni-
tive domains and demonstrates that different pathological
mechanisms in patients with third ventricle tumors may affect
different cognitive domains.
Although patient performance did not differ significantly
by comparison group, it is possible that the detection of group
differences was impeded by low statistical power. A larger
sample would confer greater statistical power. On the Delayed
Recall measure of the VSRT, for instance, the difference be-
tween the mean z score in the transcallosal surgery group and
the no-surgery group (Table 4) was 0.82, equal to a difference
in recall of approximately 1 word on the 12-item list. A power
analysis revealed that a sample of 130 patients per group
would be required to detect a statistically significant differ-
ence of this magnitude. However, even if such statistical sig-
nificance were established in a study, the clinical significance
of such a difference would be debatable.
Although mean group differences were not significant,
there was very large variability of performance within groups
(Table 4), which suggests that variables other than those iden-
tified in this study may have accounted for variability in
cognitive performance. For instance, this study did not control
for the effects of time since diagnosis, which may have mod-
erated the effects of tumor type; tumor infiltrativeness may
have had its greatest effects on patients with longer duration
since diagnosis, in whom there had been more time for infil-
tration to occur. Similarly, the ability of this study to detect
delayed radiation effects might have been improved if it had
included an evaluation of the effects of amount of time since
radiation or dose of radiation.
The following recommendations are made for future stud-
ies. First, to test the effects of surgical intervention, future
studies should use a prospective design with pre- and post-
operative evaluations and a no-surgery comparison group.
Second, studies should control for the effects of different ma-
nipulations within surgical groupings, particularly for tran-
scallosal surgery patients. The transcallosal approach may
include one of several possible routes for entry into the third
ventricle from the lateral ventricle (e.g., via an interforniceal
route [1, 2], via a dilated foramen of Monro, via incision of a
forniceal column to enlarge the foramen of Monro, and via a
subchoroidal route [48]), and these routes involve manipula-
tion of different memory structures. In the current study,
combining patients who underwent different entry routes in
the transcallosal group may have masked the unique effects of
any one route. Third, the effects of tumor and treatment vari-
ables, in addition to those evaluated here, should be consid-
ered, and future studies may control for variables such as
extent of tumor resection, degree of preoperative impairment,
time since diagnosis, and time since cranial irradiation.
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CONCLUSION
In summary, patients in this study displayed a high inci-
dence of impairment after surgery in the domains of memory,
executive function, and fine manual speed and dexterity,
which are associated with frontal subcortical circuitry. These
results are consistent with those of prior neuropsychological
outcome studies in this population, in which cognitive deficits
were present after surgery but could not be attributed to the
direct effects of surgical intervention. Results of this study
suggest that cognitive outcome is not differentially affected by
the treatment approaches used.
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Acknowledgment
The authors received no financial support in conjunction with this article.
COMMENTS
T he anatomic and pathophysiological basis for neurocognitive
deficits in patients with third ventricle tumors can be difficult
to decipher. A myriad of direct and indirect effects, alone or in
combination, can contribute to these deficits: hydrocephalus,
compression or invasion of critical neuronal pathways coursing
through or adjacent to the third ventricle, and the effects of
surgery, radiation, or chemotherapy. Optimization of patient
management depends on delineating causative effects.
Using a battery of tests, Friedman et al. provide an impor-
tant contribution by evaluating the postoperative neuropsy-
chological function of patients with third ventricle tumors.
The cognitive impairments found in these patients are greater
than those reported in previous, less comprehensive studies. It
is unfortunate that the retrospective nature of this study was
unable to provide more than two patients with pre- and
posttreatment evaluations. A larger number of patients with
preoperative baseline evaluations would be helpful in sepa-
rating tumor-related versus treatment-related effects. Al-
though the report provides evidence of interesting trends and
a relative lack of differences between patients who underwent
surgery and radiation therapy, the small size of the sample
groups may prohibit detection of these differences. The au-
thors provide useful recommendations for future studies, in-
cluding prospective pre- and postoperative evaluations and
Future Meetings—Congress of Neurological Surgeons
The following are the planned sites and dates for future annual meetings of the
Congress of Neurological Surgeons:
2003 Denver, CO
2004 San Francisco, CA
2005 Boston, MA
2006 Chicago, IL
Future Meetings—American Association of
Neurological Surgeons
The following are the planned sites and dates for future annual meetings of the
American Association of Neurological Surgeons:
2003 San Diego, CA
2004 Orlando, FL
2005 New Orleans, LA
2006 San Francisco, CA
798 | VOLUME 52 | NUMBER 4 | APRIL 2003
appropriate control groups to distinguish between the effects
of treatment versus tumor.
Jeffrey N. Bruce
New York, New York
T he authors describe a very high incidence of neurological
deficit related to the occurrence and treatment of lesions
around the third ventricle. This has been documented in pre-
vious reports. The value of this article is its emphasis on the
magnitude of the risk and the fact that there is no clearly safer
method of avoiding the deficit, at least according to the data
presented. Problems with the article include the heterogeneity
of the patients and the approaches as well as the retrospective
nature of the review. The lack of a negative cognitive effect of
radiation is surprising and probably is related to the short time
between radiation and evaluation. Although this study pre-
sents interesting data, it does not answer the questions raised
by its objective. These answers will await a better-planned,
prospective study.
Charles J. Hodge, Jr.
Syracuse, New York
T his is a descriptive study that is limited by the low number
of patients and the absence of preoperative data for all but
two patients. However, this report illustrates the significant
cognitive problems faced by patients with lesions around the
third ventricle. It is slightly surprising that no clear differences
could be identified among the various surgical approaches,
disease processes, and presence of hydrocephalus.
The neurocognitive effects of brain tumors and surgery
have not been reported extensively. To the patient, these lim-
itations in cognitive ability are very important in resuming a
“normal” life and returning to the preoperative lifestyle. Fur-
ther studies such as this are needed.
Joseph M. Piepmeier
New Haven, Connecticut
October 18–23
October 16–21
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October 7–12
April 26–May 1
May 1–6
April 16–21
April 22–27
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