Third-ventricle cholesterol granuloma: An exceptional intraventricular localization

Background: Cholesterol granuloma (CG) is a rare chronic inflammatory benign lesion resulting from cholesterol crystal deposition and a foreign-body giant cell reaction. These masses most often arise within the temporal bone or nasal sinuses. Intracerebral CGs are extremely rare and may mimic other cystic lesions, such as craniopharyngiomas. Primary involvement of the third ventricle has not been previously reported. Case Description: A 49-year-old female presented with a 1-year history of progressive frontal headache, worse in the morning and partially relieved throughout the day. Symptoms worsened over the past 4 months and were associated with nausea and blurred vision. Computed tomography (CT) revealed an intraventricular hypodense nodule with coarse calcifications. Magnetic resonance imaging demonstrated an expansile lesion within the third ventricle, hyperintense on T1-weighted images and heterogeneously hypointense on T2/fluid-attenuated inversion recovery (FLAIR) sequences, causing moderate supratentorial hydrocephalus. Given symptomatic obstructive hydrocephalus and signs of intracranial hypertension, staged management was performed with initial ventriculoperitoneal shunting followed by transcallosal interhemispheric resection. Histopathology confirmed CG. Postoperative motor deficit was graded according to the Medical Research Council scale as Grade III, with progressive improvement. Postoperative CT demonstrated complete removal and resolution of ventricular dilatation. Conclusion: Third-ventricle CG may mimic cystic craniopharyngioma. Correlation of clinical, radiological, and pathological findings is essential. Complete surgical resection provides excellent outcomes with a low risk of recurrence.