Maximal safe resection is the standard of care for high-grade gliomas (HGG). Surgeons often strive to remove the entire contrast-enhancing volume. However, this aggressive approach can lead to inadvertent ventricular entry in glioma surgery. Recent evidence suggests that opening the ventricular system during resection may facilitate the spread of tumor cells into the cerebrospinal fluid.

The Relationship Between Ventricular Entry and Metastasis

A large retrospective study from the MD Anderson Cancer Center analyzed 884 patients with supratentorial HGG. The researchers found that 44% of these patients experienced ventricular entry during their first resection. Additionally, the study highlighted that ependymal contact (EC) on preoperative imaging strongly predicts the likelihood of the ventricle being opened during surgery. While ependymal contact itself increases risk, the actual entry into the ventricle appears to be the critical driver for future complications.

Clinical Impact of Ventricular Entry in Glioma

The development of leptomeningeal metastasis (LM) is a serious complication for glioma patients. The study revealed that patients who had the ventricle opened were significantly more likely to develop LM. Specifically, the risk of metastasis at three years was 14.6% for those with ventricular entry, compared to only 7.4% for those without. Despite this nearly twofold increase in metastasis risk, the data showed no significant difference in overall survival (OS) between the two groups. This suggests that while ventricular entry in glioma resection facilitates dissemination, other factors may play a more dominant role in determining the patient's ultimate prognosis.

Management Considerations for Surgeons

Neurosurgeons must balance the benefits of achieving a gross-total resection with the risks of CSF seeding. When a tumor is in close proximity to the ventricles, the probability of entry increases. Consequently, clinicians should monitor these patients more closely for signs of leptomeningeal spread. Therefore, awareness of tumor contiguity to the ventricles is vital for postoperative surveillance and patient counseling.

Frequently Asked Questions

Does ventricular entry during glioma surgery affect patient survival?

While ventricular entry significantly increases the risk of leptomeningeal metastasis, current research suggests it does not significantly impact overall survival in patients with high-grade gliomas.

What is the relationship between ependymal contact and ventricular entry?

Ependymal contact is a strong predictor of ventricular entry. Tumors touching the ventricle wall are much more likely to result in the ventricle being opened during surgical resection.

How much does ventricular entry increase the risk of leptomeningeal metastasis?

Studies indicate that ventricular entry nearly doubles the risk of developing leptomeningeal metastasis over a three-year period following the initial surgery.

Disclaimer: This content is for informational and educational purposes only. It does not constitute medical advice or establish a doctor-patient relationship. Refer to the latest local and national guidelines for clinical practice.

References

Abi Faraj C et al. Ventricular entry and postoperative leptomeningeal metastasis after resection of supratentorial high-grade glioma. J Neurosurg. 2026 Feb 13. doi: 10.3171/2025.9.JNS25526. PMID: 41687103.

Roelz R et al. Surgical ventricular entry is a key risk factor for leptomeningeal metastasis of high grade gliomas. Sci Rep. 2015 Dec 4;5:17758. doi: 10.1038/srep17758.

Mistry AM et al. Comparative analysis of subventricular zone glioblastoma contact and ventricular entry during resection in predicting dissemination, hydrocephalus, and survival. Neurosurgery. 2019 Dec 1;85(6):E924-E932. doi: 10.1093/neuros/nyz144.