Acute Obstructive Hydrocephalus: An Unexpected Cause of Cardiac Arrest.

BACKGROUND: Emergency physicians are well-versed in managing cardiac arrests, including the diagnostic and therapeutic steps after return of spontaneous circulation. Neurologic emergencies are a common cause of out-of-hospital cardiac arrest and must remain high in the differential diagnosis, as such cases often require specific interventions that may deviate from more common care pathways. Performing a noncontrast head computed tomography (NCHCT) scan after cardiac arrest has been found to change management, although the optimal timing of this imaging is unclear. CASE REPORT: This is the case of a young, pregnant woman who presented to the emergency department after cardiac arrest with return of spontaneous circulation in the prehospital setting. She was found to have acute obstructive hydrocephalus on NCHCT, which was later confirmed to be due to a previously undiagnosed colloid cyst of the third ventricle. This acute obstruction resulted in myocardial stunning and, ultimately, cardiac arrest. Although outcomes are often dismal when the cause of arrest is secondary to neurologic catastrophe, this patient survived with completely intact neurologic function. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although acute obstructive hydrocephalus due to a colloid cyst adjacent to the third ventricle is a rare condition, it is a potentially reversible neurologic cause of out-of-hospital cardiac arrest. However, positive outcomes depend on obtaining the diagnosis rapidly with neurologic imaging and advocating for neurosurgical intervention. This case supports the recommendation that emergency physicians should strongly consider post-cardiac arrest neurologic imaging when another cause is not immediately obvious.

Septostomy and Monroplasty in Isolated Lateral Ventricle After Removal of a Third Ventricle Colloid Cyst: 2-Dimensional Operative Video.

Isolated unilateral hydrocephalus (IUH) is a condition caused by unilateral obstruction of the foramen of Monro.1 Etiopathogenic causes include tumors, congenital lesions, infective ventriculitis, intraventricular haemorrhage, and iatrogenic causes such as the presence of contralateral shunts.2,3 Neuroendoscopic management is considered the "gold-standard" treatment in IUH.4 Even if endoscopic septostomy and foraminoplasty in IUH are well-known procedures,5,6 IUH after an interhemispheric transcallosal transchoroidal approach for removal of a III ventricle colloid cyst is a complication barely described in literature. Video 1 describes this rare complication and the neuroendoscopic treatment adopted, including the operative room setup, patient's positioning, instrumentation needed, and a series of intraoperative tips for the performance of septostomy and Monroplasty via a single, precoronal burr hole. The scalp entry point and endoscope trajectory, homolateral to the dilated ventricle, were planned on the neuronavigation system. The avascular septal zone away from the septal veins and body of the fornix was reached, and the ostomy was performed. At the end of the procedure, Monroplasty was performed, too. The procedure was effective in solving the hydrocephalus and patient's clinical picture. No surgical complications occurred. Imaging demonstrated an evident and progressive reduction of enlarged lateral ventricle. In authors' opinion, the single burr-hole approach, ipsilateral to the enlarged ventricle, provides an optimal identification the intraventricular anatomy and allows Monroplasty to be performed, if deemed feasible during surgery. The patient consented to the procedure. The participants and any identifiable individuals consented to publication of their images.

Colloid Cyst: Revision of Third Ventricular Zones for Risk Stratification of Hydrocephalus.

OBJECTIVE: We sought to reclassify the "anatomic risk zones of colloid cysts" as proposed by Beaumont et al, by proposing newer landmarks, and to assess predictive value for the risk of occurrence of hydrocephalus with the new classification compared with the old. METHODS: A retrospective cohort of 122 cases of colloid cyst of third ventricle were categorized into zones 1, 2, or 3 based on Beaumont's classification (old zone) and our classification (new zone) based on radiologic images. We attempted to recategorize these zones by assigning new anatomic landmarks. The difference in zonal distribution of colloid cyst and association with hydrocephalus was studied using the 2 methods of zonal classification. RESULTS: Per the old zone classification, 3/122 patients were in zone 2, whereas 21/122 were in zone 2 per the new zone classification. The new zone method had a higher specificity (36.21% vs. 5.263 %) and positive predictive value (63.37% vs. 54.23%) for occurrence of hydrocephalus in patients with colloid cyst. The Spearman correlation showed better correlation with the new method for occurrence of hydrocephalus (rho = 0.4 [P < 0.00000] vs. 0.2 [P = 0.011]). CONCLUSIONS: Symptomatic colloid cysts are more likely to develop hydrocephalus and sudden acute deterioration. The colloid cyst risk score is a step towards objective decision making, with scope for modification such as the one that we have attempted with new zone classification to achieve superior prognostic ability.

Acute diffuse cerebral vasospasm as a complication of endoscopic resection of a colloid cyst: a case report.

BACKGROUND: Endoscopic resection can be used for removing colloid cysts as a substitute for open craniotomy. Cerebral vasospasm, a possible complication of the craniotomy procedure, has not been reported as a complication of endoscopic removal of colloid cysts. CASE DESCRIPTION: A 58-year-old man developed the worst headache of his life. The CT and MRI showed a 1.3 cm midline third ventricular cyst at the level of the foramen of Monro, consistent with a colloid cyst. The patient elected to undergo an endoscopic resection of the colloid cyst. The image-guided frameless stereotactic endoscopic colloid cyst resection proceeded without events. Postoperative MRI showed a gross total resection. The patient continued to improve until post-operative day #9 when he experienced an episode of slurred speech and several episodes of legs buckling. An MRI did not show a stroke. A CT angiogram showed diffuse vasospasm, including the basilar artery and bilateral middle cerebral arteries, when compared to the patient's preoperative MRA. The patient's antihypertensive medications were stopped. The patient was started on Nimodipine, 60 mg every 4 hours, and triple H therapy (Hypertension, Hypervolemia, and Hemodilution) was applied. His blood pressure rose and his neurologic exam improved over several days. The patient returned to his baseline in 14 days without any neurological deficits. To our knowledge, this is the first case report of a patient undergoing endoscopic colloid cyst resection that was complicated by diffuse cerebral vasospasm. CONCLUSIONS: We report the first case of acute, transient cerebral vasospasm following endoscopic resection of a colloid cyst.

Delayed hydrocephalus after excision of a colloid cyst: a case report.

BACKGROUND: In this case report we describe an unusual case of a patient who underwent resection of a colloid cyst and then presented 6 weeks postoperatively with obstructive hydrocephalus. There appear to be no prior reports of such a delayed complication after colloid cyst resection. CASE PRESENTATION: A 50-year-old Caucasian woman underwent resection of a colloid cyst with an uncomplicated perioperative course. Postoperative imaging demonstrated complete resection of the cyst. She was discharged home on postoperative day 4 but presented 6 weeks later with symptoms of obstructive hydrocephalus resulting in poor neurologic outcome and ultimately death. CONCLUSION: Patients presenting with symptoms of hydrocephalus after resection of a colloid cyst should be followed closely, and timely placement of an external ventricular drain may be critical.

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration.

OBJECTIVE: Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs. METHODS: A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome. RESULTS: One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3-15.4 years; 22% were < 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28). CONCLUSIONS: CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable.

Hemorrhagic colloid cyst of the third ventricle: A rare cause of colloid cyst growth and progressive hydrocephalus. Case report / Quiste coloide hemorrágico del tercer ventrículo: una causa rara de crecimiento de los quistes coloides e hidrocefalia progresiva. Reporte de un caso

Introduction Acute spontaneous bleeding within a colloid cyst of the third ventricle is extremely rare. Accordingly, is difficult to establish reliable prognostic factors, risk factors for obstructive hydrocephalus remain poorly defined, and there are no standard management strategies. Case presentation 19-Year-old man with a colloid cyst of the third ventricle causing obstructive hydrocephalus is described, initially treated with partial endoscopic removal and ventriculo-peritoneal shunt placement. Serial neuroimaging follow-up showed gradual growth of the cyst due to clinically silent intracystic recurrent hemorrhage. Microsurgical transcallosal approach was performed and the cyst was totally resected. Pathological examination demonstrated hemorrhages of varying ages within the tumor. Conclusion Bleeding within a colloid cyst must be considered when neuroimaging follow-up shows cyst growth, even with no clinical events associated. Hemorrhagic changes within the colloid cyst should be considered in the surgical indication and approach. Resumen Introducción El sangrado espontáneo agudo en un quiste coloide del tercer ventrículo es extremadamente raro. En consecuencia, es difícil establecer factores pronósticos fiables, los factores de riesgo asociados a hidrocefalia obstructiva permanecen mal definidos y no existen estrategias de manejo estandarizadas. Presentación del caso Varón de 19 años con un quiste coloide del tercer ventrículo e hidrocefalia obstructiva, inicialmente tratado mediante extirpación endoscópica parcial y derivación ventriculoperitoneal. Posteriormente se demostró el crecimiento gradual del quiste debido a hemorragias intraquísticas recurrentes, clínicamente silentes. Se realizó un abordaje microquirúrgico transcalloso con resección completa. El examen anatomopatológico demostró la presencia de hemorragias en diferentes estadios dentro del tumor (AU)

Colloid cysts are rare and benign intracranial tumors located in the third ventricle. Reliably defining the natural history of colloid cysts has been challenging due to their low incidence and the small number of cases in most reported series. They are a well-known cause of obstructive hydrocephalus, with occasional rapid clinical deterioration, and even sudden death.1 Acute spontaneous bleeding within a colloid cyst of the third ventricle is a rare event usually causing a sudden increase of the cyst size, that results in obstructive hydrocephalus and clinical deterioration. This complication has only been reported in a few cases of the scientific literature.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 For these reasons, risk factors for obstructive hydrocephalus in the setting of hemorrhagic colloid cysts remain poorly defined, there are no grading scales on which to develop standardized management strategies and is difficult to establish the reliable prognostic factors and surgical indications. We report a case of a colloid cyst of the third ventricle, that, after partial endoscopic removal developed progressive gradual growth due to recurrent and initially silent intracystic hemorrhages. The literature of this rare entity has been revised (AU)

Colloid cysts of the third ventricle in children.

OBJECTIVE: The rarity of colloid cysts in children makes it difficult to characterize this entity and offer meaningful advice on treatment. Infrequent case reports exist, but to date there has been no age-specific assessment. The purpose of this study was to define any differences between children and adults who are evaluated and treated for colloid cysts of the third ventricle. METHODS: Patients with colloid cysts were reviewed and stratified by age. Individuals ≤ 18 years of age were defined as pediatric patients and those > 18 years of age as adults. Clinical and radiographic data, treatment, and postoperative outcomes were compared between both groups. Bivariate analysis was conducted using the Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables. RESULTS: Of 132 endoscopic resections (121 primary, 10 secondary, and 1 tertiary) of a colloid cyst, 9 (6.8%) were performed in pediatric patients (mean age 14.1 years, range 9-18 years) and 123 (93.2%) were performed in adult patients (mean age 43.8 years, range 19-73 years). Cases were found incidentally more commonly in pediatric than adult patients (66.7% vs 37.4%, p > 0.05), and pediatric patients had lower rates of hydrocephalus than adult patients (11.1% vs 63.4%, p < 0.05). Acute decompensation at presentation was found in 8 adults (6.5%) but no children. Complete cyst removal (88.9% vs 90.2%, p > 0.05) and length of stay (1.6 days vs 2.9 days, p > 0.05) were not significantly different between the groups. Postoperative complications (6.5% in adults, 0% in children) and recurrence (2.4% in adults, 0% in children) were rare in both groups, and there were no treatment-related deaths. The mean postoperative radiological follow-up was longer in pediatric patients (45 months, range 4-89 months) than adults (44.1 months, range 1-171 months). CONCLUSIONS: While differences exist between children and adults regarding colloid cyst presentation, these are in keeping with the predicted evolution of a slow-growing lesion. Consistent with this observation, children had lower rates of hydrocephalus and a smaller mean maximal cyst diameter. Contrary to the published literature, however, sudden deterioration was not observed in pediatric patients but occurred in adult patients. In this limited pediatric sample size, the authors have not recorded any postoperative complications or recurrences to date. These encouraging results with endoscopic removal may positively impact future decisions related to children given their protracted life expectancy and projected rates of progression.

Endoscopic versus Open Microsurgical Excision of Colloid Cysts: A Comparative Analysis and State-of-the-Art Review of Neurosurgical Techniques.

BACKGROUND: The surgical approaches of colloid cysts commonly include endoscopy or open microsurgery. Each approach carries its own challenges, feasibility, and complications. The aim of the current study is to compare endoscopic versus open microsurgical excision of third ventricular colloid cysts. METHODS: A retrospective cohort study was conducted to compare the surgical outcomes of endoscopic versus open microsurgical (transcortical-transventricular and transcallosal approaches) excision of colloid cyst of the third ventricle at a tertiary-care medical institute. All patients with a neuroradiologic diagnosis of colloid cyst who subsequently underwent surgical management between January 2003 and June 2020 were included. The neurologic outcome was assessed at the last follow-up visit. RESULTS: A total of 32 patients with colloid cysts were included in the study. The mean age was 35.8 ± 18.3 years (range, 4-75 years). Female patients slightly outnumbered male patients (n = 17; 53.1%). A total of 21 patients (65.6%) underwent endoscopic resection of the colloid cyst. Complications were encountered in 7 patients (endoscopic, n = 3; microsurgery, n = 4; P = 0.151). Recurrence was identified in 4 patients (endoscopic, n = 3; microsurgery, n = 1; P = 0.673). Most patients improved neurologically on follow-up visits to the clinic (endoscopic, n = 19; microsurgery, n = 9; P = 0.482). CONCLUSIONS: Both endoscopic and microsurgical approaches provide favorable surgical outcomes in colloid cyst resection. The complication rates between both approaches is statistically insignificant. The optimal surgical approach for colloid cyst resection remains controversial.

Hemorrhagic colloid cyst of the third ventricle: A rare cause of colloid cyst growth and progressive hydrocephalus. Case report.

INTRODUCTION: Acute spontaneous bleeding within a colloid cyst of the third ventricle is extremely rare. Accordingly, is difficult to establish reliable prognostic factors, risk factors for obstructive hydrocephalus remain poorly defined, and there are no standard management strategies. CASE PRESENTATION: 19-Year-old man with a colloid cyst of the third ventricle causing obstructive hydrocephalus is described, initially treated with partial endoscopic removal and ventriculo-peritoneal shunt placement. Serial neuroimaging follow-up showed gradual growth of the cyst due to clinically silent intracystic recurrent hemorrhage. Microsurgical transcallosal approach was performed and the cyst was totally resected. Pathological examination demonstrated hemorrhages of varying ages within the tumor. CONCLUSION: Bleeding within a colloid cyst must be considered when neuroimaging follow-up shows cyst growth, even with no clinical events associated. Hemorrhagic changes within the colloid cyst should be considered in the surgical indication and approach.

Risk Analysis and Management of Third Ventricular Colloid Cysts.

OBJECTIVE: Colloid cysts (CCs) are histologically benign lesions that carry the risk of causing obstructive hydrocephalus. The indication for surgery for symptomatic cysts is unquestioned; however, the management of incidentally detected lesions has remained controversial. We independently evaluated the CC risk score (CCRS) as a useful risk stratification scheme. METHODS: The demographics, imaging characteristics, and clinical presentations of 103 patients with CC during a 10-year period were correlated with symptoms and the occurrence of hydrocephalus. The discriminate capacity of the CCRS was quantified and a decision algorithm formulated. RESULTS: The correlates of symptoms included age <65 years, diameter ≥7 mm, anterior location, hyperintensity on T2-weighted fluid-attenuated inversion recovery (FLAIR) and/or T2-weighted images, and headache at presentation without an alternative explanation. On multivariate analysis, age <65 years, diameter ≥7 mm, and headache at presentation predicted for symptomatic cysts. The CCRS was highly effective at identifying symptomatic patients and those with obstructive hydrocephalus. All patients with cyst growth and symptomatic progression had had an initial CCRS of ≥3 plus hyperintensity (preexisting or developing) on T2-weighted FLAIR images. CONCLUSIONS: The CCRS performed exceptionally well in distinguishing the highest risk patients. Closer follow-up is recommended for younger asymptomatic patients with cysts near the foramen of Monro. Hyperintensity on T2-weighted FLAIR images might indicate greater growth potential for small lesions.

Clinical and radiological characteristics in fatal third ventricle colloid cyst. Literature review.

BACKGROUND: Colloid cysts are a benign tumor that is almost exclusively found in the third ventricle and may cause hydrocephalus and rarely life-threatening acute deterioration and even sudden death. With very few cases of sudden death reported in literature not much is known about the patient and cyst characteristics in these patients. The authors present a review of 65 cases of colloid cyst attributed deaths in literature. MATERIALS AND METHODS: A literature search for sudden death with radiologically or pathologically identified colloid cyst was done on PubMed, google scholar, Medbase and clinicaltrials.org research drives. Patient demographics, symptoms and cyst characteristics were recorded and analyzed. A Bivaret Pearson correlationcoefficientwas used to analyze and compare the relationship between each antecedent symptom, cyst size, and, cyst hemorrhage in patients who subsequently succumbed and died in order to ascertain possible relation. RESULTS: Most patients had a history of sudden severe headaches (p = 0.01) with associated vomiting (p = 0.03). Radiologically, cyst associated ventriculomegaly was seen in 97% (P = 0.78) was a notable feature. Even more, the cyst size (p = 0.01) and associated hemorrhage (p = 0.02) were also major notable feature preceding sudden death in both gender group. CONCLUSION: Acute deterioration in colloid cysts is rare, but can be fatal. Associated symptoms include severe headache and vomiting. Seizures are commonly seen in patients in the first two decades. Given the risk of acute deterioration and mortality, headaches should be thoroughly investigated and all patients diagnosed with a colloid cyst > 1 cm should be offered surgical management regardless of symptom profile.

The Variable Appearance of Third Ventricular Colloid Cysts: Correlation with Histopathology and the Risk of Obstructive Ventriculomegaly.

BACKGROUND AND PURPOSE: While third ventricular colloid cysts may present as an incidental finding, they also harbor the potential to cause ventricular obstruction and sudden death. Herein we analyze the relationship between imaging appearance and the risk of obstructive ventriculomegaly. MATERIALS AND METHODS: This is a retrospective review of the MR imaging appearance of 64 patients with colloid cysts, 46 of whom also had a CT scan, obtained by a tertiary hospital imaging report data base search over a 10-year period. Cysts were categorized by appearance on T2-FLAIR and correlated with patient age, cyst size, and the risk of obstructive ventriculomegaly. Histopathologic correlation was available for 28 cases. RESULTS: The 64-patient cohort was 52% female, median age 50 years (range 10 to 99 years). Cysts hyperintense on T2-FLAIR (53.1%) were larger (P <.001), occurred in younger patients (P = .01), and had a higher risk of obstructive ventriculomegaly than homogeneously hypointense cysts (relative risk 6.18, 95% CI [2.04, 18.67]). Three patterns of T2 hyperintensity were identified: homogeneously hyperintense, hyperintense rim, and cysts with "dot sign." Although "dot sign" cysts were larger (P < .001), there was no significant difference in patient age or the risk of ventricular obstruction among T2 hyperintense cysts. Cyst wall histopathology did not vary with imaging appearance. CONCLUSIONS: Hyperintensity on T2-FLAIR, whether homogeneous, rim, or "dot sign," is associated with larger cyst size and younger patient age, and is an imaging risk factor for obstructive ventriculomegaly. The hyperintense rim does not represent a thickened cyst wall.

Genetics of Colloid Cyst in Monozygotic Twins: Case Report and Review of Literature.

BACKGROUND: Colloid cysts are rare developmental lesions, accounting for approximately 1% of intracranial tumors. Often, these benign lesions are asymptomatic, but they are associated with significant mortality as a result of acute hydrocephalus. This mortality in patients with vague or no symptoms dictates a need for better understanding of the etiology of colloid cysts to expedite diagnosis and management. We present a case of monozygotic twins with colloid cysts to propose a genetic etiology for colloid cyst. CASE DESCRIPTION: Previously healthy male monozygotic twins presented 4 years apart with headache secondary to hydrocephalus as a result of colloid cysts. Both patients underwent multiple surgeries and were doing well at last follow-up. CONCLUSIONS: The present case adds to a body of literature of familial colloid cysts, suggesting higher concordance in monozygotic compared with dizygotic twins. This may be due to high genetic load, shared intrauterine environment, epigenetic changes, or genetic mutation. This literature review suggests that given high morbidity and mortality of colloid cysts, screening may be beneficial. Even in the absence of a single, definitive genetic etiology, we recommend consideration of genetic screening or, at a minimum, screening with neuroimaging for monozygotic twins in cases where 1 twin is diagnosed with colloid cyst.