Endoscopic trans-septal interforniceal approach for excision of colloid cysts of the third ventricle using the rotational technique.

Colloid cysts of the third ventricle are benign intracranial lesions that account for 0.5 to 2% of all brain tumors and are even rarer in pediatric population. Dandy was the first to successfully excise a colloid cyst of the third ventricle via a transcortical transventricular approach in 1921. For several decades to follow, the transcortical transventricular and transcallosal microsurgical approaches remained the cornerstone of surgical management of these lesions. With time and refinements in endoscopic equipment and techniques, endoscopic resection of colloid cysts evolved into a currently well-established and appealing minimally invasive alternative to microsurgery. Endoscopic endochannel techniques for colloid cysts of the third ventricle may either be transforaminal or trans-septal interforniceal, depending on the pathoanatomical features of the colloid cyst and its relation to the juxtaposed anatomical structures. The endoscopic trans-septal interforniceal approach is required to access the rare subset of colloid cysts that extend superior to the roof of the third ventricle between the two fornices insinuating themselves between the leaflets of the septum pellucidum. In this article, the surgical technique of the endochannel endoscopic trans-septal interforniceal approach is elaborated upon. A representative case is presented along with an operative video.

Endoscopic ultrasonic aspirator-assisted removal of a third ventricular colloid cyst.

BACKGROUND: Colloid cysts are benign tumors usually located on the roof of the third ventricle. Cyst removal is the treatment of choice. It can be accomplished microsurgically through a transcortical- or transcallosal approach, or endoscopically. There is a lack of consensus regarding the best strategy for cyst removal. One of the challenges of the traditional endoscopic technique is dealing with the cyst content density. Hyperdensity on computed tomography scan and low signal on T2-weighted magnetic resonance imaging (MRI) cyst are correlated with high viscosity cystic content. CASE REPORTS: We present a case of a colloid cyst of the third ventricle in a 15-year-old boy removed through a pure endoscopic transventricular approach. The cyst presented a low signal on T2 MRI; nevertheless, it was easily removed with the help of an endoscopic ultrasonic aspirator. DISCUSSION AND CONCLUSION: The colloid cyst of the third ventricle can be safely treated by a purely endoscopic approach. The rationale of the use of the ultrasonic aspirator relies on the facilitation of aspiration of the content even when the consistency is extremely firm.

Nonneoplastic and noninfective cysts of the central nervous system: A histopathological study.

Nonneoplastic epithelial cysts involving the central nervous system are diverse and are predominantly developmental in origin. This study represents a surgical series describing the histopathological features of 507 such epithelial cysts with clinical and imaging correlation. Age at surgery ranged from 7 months to 72 years (mean: 33 years) affecting 246 male and 261 female patients. Colloid cyst was the most frequently resected cyst, followed by epidermoid cyst, arachnoid cyst, Rathke cleft cyst, dermoid cyst, neurenteric cyst, Tarlov cyst, and choroid plexus cyst. Diagnosis was based on the location of the cysts and the nature of the lining epithelium. Rathke cleft cyst showed the highest propensity for squamous metaplasia, significant inflammation, and xanthogranulomatous reaction. Ulceration of lining epithelium and calcification were most frequent in dermoid cyst. Radiopathological concordance was maximal for colloid cyst, followed by epidermoid and arachnoid cysts. Epidermoid and dermoid cysts exhibited the highest propensity for local tumor progression, followed by Rathke cleft cyst.

Colloid cyst with hyphal-like structures: A rarity that mimics actinomycosis of athe third ventricle.

Colloid cysts are histologically well defined and consist of three main components, a capsule, with an underlying epithelial layer, and a mucinous heart. In our case, we present a 35-year-old female with acute deterioration of level of consciousness. An emergent CT scan showed a cystic lesion occluding the intraventricular foramen. The lesion was endoscopically excised through a transfrontal approach. Microscopic examination of the resected specimen revealed hyphal-like structures (HLS). This rare finding was first described by Dodds and Powers in 1977 and, in its microscopic nature, it mimics actinomyces of the third ventricle.

Xanthogranulomatous Colloid Cyst in a 13-Year-Old Boy: A Case Report and Surgical Implications.

INTRODUCTION: Colloid cysts are relatively uncommon lesions in the pediatric population. The xanthogranulomatous (XG) variant is very rare with less than 30 reported cases. CASE REPORT: In this report, the patient was a 13-year-old boy who presented with transient episodes of headache with blurring of vision. His MRI brain showed a T2 hyperintense well-defined cystic lesion, with an eccentrically located T2 hypointense partially enhancing nodule, at the foramen of Monro. He underwent middle frontal gyrus transcortical, transchoroidal gross total excision of the cyst. The histopathology of the lesion revealed an XG colloid cyst. The patient recovered well from the procedure and was relieved of the symptoms. CONCLUSION: XG colloid cyst may present with altered radiological features compared to the normal variant. This can pose a diagnostic dilemma, and it is important to differentiate it from a craniopharyngioma or a parasitic cyst, as in our case. When considered preoperatively, surgeons should be conscious to review their surgical strategies. Stereotactic aspiration of the XG cyst should be avoided as contents are thicker and heterogeneous than the usual. The spillage of cyst contents should be prevented. Also, the XG cysts are likely to have a poor cyst-fornix or -choroid plexus interface due to inflammation limiting complete resection.

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.

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.

Spontaneous Change in Density of Colloid Cyst: An Unusual Phenomenon.

BACKGROUND: Colloid cysts of the third ventricle are benign congenital lesions. They are at times totally asymptomatic or may be detected in the evaluation for headache, neurologic disturbances, or psychiatric disturbances. They may sometimes cause grave consequences such as coma or even sudden death. The radiologic appearance is unique and important for making decisions in the management. CASE DESCRIPTION: We report a patient with a colloid cyst who presented to us after sudden deterioration in consciouness. It was noted that he underwent brain computed tomography (CT) scan 10 months ago in the evaluation of headache. Compared with previous CT scan, there was a sudden change in the density and size of the colloid cyst with obstructive hydrocephalus. This unique change in the character of the colloid cyst occurred without any intervention. We discuss the possible etiologies behind this phenomenon along with a review of the literature. CONCLUSIONS: This case stands out remarkably because it is only the second case in literature with similar natural history.

Interrater and Intrarater Reliability of the Colloid Cyst Risk Score.

BACKGROUND: The Colloid Cyst Risk Score (CCRS) was developed to identify symptomatic patients and stratify risk of hydrocephalus among patients with colloid cysts. Its components consider patient age, cyst diameter, presence/absence of headache, fluid-attenuated inversion recovery (FLAIR) hyperintensity, and location within the third ventricle. OBJECTIVE: To independently evaluate the inter- and intrarater reliability of the CCRS. METHODS: Patients with a colloid cyst were identified from billing records and radiology archives. Three independent raters reviewed electronic medical records to determine age, presence/absence of headache, cyst diameter (mm), FLAIR hyperintensity, and risk zone location. Raters made 53 observations, including 5 repeat observations.Fleiss' generalized kappa (κ) was calculated for all of the nominal criteria, whereas Kendall's coefficient of concordance (W) and the intraclass correlation coefficient (ICC) were calculated for the overall score. RESULTS: Total CCRS score demonstrated extremely strong agreement (W = 0.83) using Kendall's W coefficient and good agreement (ICC = 0.74) using the ICC (P < .001). For interrater reliability of individual criteria, age (κ = 1.00) and FLAIR hyperintensity (κ = 0.89) demonstrated near perfect agreement. Axial diameter (κ = 0.63) demonstrated substantial agreement, whereas agreement was moderate for risk zone (κ = 0.51) and fair for headache (κ = 0.26). Intrarater reliability for total CCRS score was extremely strong using Kendall's W, good to excellent using ICC, and fair to substantial using weighted kappa. CONCLUSION: The CCRS has good inter- and intrarater reliability when tested in an independent sample of patients, though strength of agreement varies among individual criteria. The validity of the CCRS requires independent evaluation.

Inchoate guidelines of endoscopic resection of colloid cysts.

Colloid cyst are cystic lesions in the third ventricle and could render patients asymptomatic. However, there is an inherent risk of symptomatic progression, acute decompensation, and sudden death. Therefore, there is no clear consensus as how to observe or when to treat a newly diagnosed patient with a colloid cyst. The authors' objective is to identify the risk factors and then develop a risk stratification score to guide neurosurgeons during acute or chronic presentation. Radiological imaging characteristics have been outlined for the risk stratification as well preoperative evaluation. A baseline neuropsychological evaluation is helpful to obtain during an incidental presentation because history and neurological examination could be inconclusive in these cases. Radiological imaging with an MRI brain scan plays a vital role for the initial screening (determination of the cyst size, exact location, and the imaging characteristics) as well as for the preoperative planning. Stereotactic guidance is a high yield, followed by neuroendoscopic resection of the colloid cyst has been an established approach to resect these lesions. Modified colloid cyst risk scoring (mCCRS) system is robust and detailed for the optimal risk stratification of colloid cyst presentation. Stereotactic guided neuroendoscopic resection of the colloid cyst is a safe and efficacious approach to manage these lesions. The intended use, crucial steps involved, and the limitations of the technique have been discussed especially with a focus on the recurrence. Moreover, a comprehensive treatment algorithm has been presented.

Magnetic resonance characterization of the 'dot sign' in colloid cysts of the third ventricle.

PURPOSE: To determine the incidence of the 'dot sign' in patients with colloid cysts of the third ventricle and to characterise its MRI appearances. MATERIALS AND METHODS: Single institution retrospective analysis between January 2007 and October 2016 of all patients with either an imaging or imaging and histology-confirmed diagnosis of colloid cysts of the 3rd ventricle was undertaken. For all cases, MRI signal intensities of the cyst fluid component were graded by two independent radiologists relative to brain parenchyma. Presence of a dot, and if present, its size and relative position within the cyst were recorded. Signal intensities of the dot were then similarly assessed. RESULTS: 37 cases of colloid cyst were identified. Of these 37.8% (n = 14) demonstrated the dot sign. The majority (11 of 14) were observed inferiorly within the cyst; two cases were anteroinferior, and one other was posterior. All identified intracystic nodules displayed low signal intensity with respect to cyst fluid on T2 weighted sequences, and only two nodules were hypointense to fluid on T1-weighted imaging, with the remainder either iso- or hyperintense. CONCLUSIONS: An intracystic low T2 'dot' is a common MRI feature of colloid cysts of the third ventricle, and to our knowledge not previously systematically described. Presence of such a dot should not only not dissuade from a diagnosis of colloid cyst being made, but should in fact be used to strengthen the imaging diagnosis.

Hemorrhagic colloid cyst.

Colloid cysts are cystic lesions that are usually located in the anterior portion of the third ventricle near the foramen of Monro. Rarely, hemorrhagic cysts can lead to acute obstructive hydrocephalus or sudden death. We herein report 2 cases and a review literature. We examine a 47-year old male who presented with progressive headache and a 55-year old male who presented with progressive memory disturbance and unsteady gait. Both cases demonstrated typical imaging features of hemorrhagic colloid cyst, and were histopathologically confirmed. Total excision was achieved in both cases with good outcomes. Hemorrhagic colloid cysts are rare; however, bleeding tendencies should be carefully considered in patients with these cysts. The degree of rapidity with which clinical deterioration occurs may play a major role in the preferred treatment approach and subsequent outcomes.

Factors influencing outcome in patients with colloid cysts who present with acute neurological deterioration.

Colloid cysts have been associated with acute neurologic deterioration and sudden death. However, the low incidence of associated sudden deaths has meant that factors influencing outcome in patients who present with acute neurological deterioration have not been extensively published. A PubMed literature search was performed to identify reported patients who presented with acute neurological deterioration with radiographic or histopathologic diagnosis of a colloid cyst. Demographic data, presenting symptoms, physical exam, surgical interventions, and outcomes were recorded. Analysis included 140 patients. Mean cyst size was 2.12 cm in males and 1.59 cm in females (p = 0.155), and 1.64 cm in patients who survived and 2.05 cm in patients who died (p = 0.04). Minimum cyst size was 0.4 cm in females and 0.8 cm in males. All patients without surgical intervention died, versus 48% with surgical intervention (p < 0.0001). Patient age was not significantly associated with outcome. Patients with hydrocephalus who have symptomatic colloid cysts are at extremely high risk for acute neurological deterioration and sudden death. Larger cyst size was associated with higher mortality, regardless of intervention. Prompt surgical intervention in extremis can lead to survival in approximately half the patients. Females, even with smaller cyst sizes, may be more likely to die before any intervention and may therefore benefit from more aggressive treatment approaches.

Natural history of incidental colloid cysts of the third ventricle: A systematic review.

OBJECTIVE: Clinical significance and management of asymptomatic colloid cysts of the third ventricle is not well defined. The aim of this study was to investigate the risk of cyst progression necessitating surgical intervention during a surveillance period. METHODS: A systematic pooled analysis of the literature was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search (conducted in December 2017) in MEDLINE and EMBASE databases, identified eligible studies. Data related to demographic (sex, age, size), clinical (surgical intervention, acute neurological deterioration, cyst related mortality) and radiological outcomes (cyst stability, progression, regression) were extrapolated and analysed. RESULTS: Of the 134 manuscripts identified, only 4 retrospective studies (176 patients) met the inclusion criteria. The level of evidence provided by these studies was low. During a median follow up of 61.2 months (IQR 41.6-70.1), 11 patients (8.6%, 95% CI 4.7-14.9) required surgical intervention due to either clinical or radiological progression. One patient experienced an acute neurological decline (0.8%, 95% CI -0.3-4.7), which eventuated in death a few years later. There were no reported cases of sudden death during this period. On radiological follow up, 86.7% (95% CI 78.5-92.2) of cysts remained stable, 11.2% (95% CI 6.2-19.2) progressed, and 2.0% (95% CI 0.1-7.6) regressed in size. CONCLUSION: For incidental colloid cysts deemed appropriate for conservative management, there is a 5-15% risk of future progression necessitating operative intervention in the 5 years following diagnosis. The data presented supports the need for ongoing surveillance neuroimaging for asymptomatic colloid cysts.

Colloid cyst and multiple meningiomata in Gorlin syndrome.

A middle-aged man presented with syncope and confusion. Neuroimaging revealed a third ventricular mass with obstructive hydrocephalus and bilateral convexity meningiomata. The masses were excised and pathology showed a colloid cyst and WHO grade 1 meningiomata respectively. Multisystem workup confirmed Gorlin syndrome. To our knowledge, this is the fourth reported case of Gorlin syndrome associated with colloid cyst, and the first case where multiple meningiomata are also present.

Xanthogranulomatous colloid cyst of the third ventricle: Alter your surgical strategy.

Colloid cysts are the most common benign neoplasms of the anterior third ventricle, mostly located at the level of the foramen of Monro and can often manifest as sudden onset headache or loss of consciousness. These cysts often have a well-defined cyst wall, mucinous or watery intracystic fluid and have a fairly good plane with the surrounding parenchyma. Occasionally, intracystic haemorrhage can lead to xanthogranulomatous inflammatory changes within the cyst resulting in focal thickening of the cyst wall and adhesion to the surrounding structures. Here we describe a case of xanthogranulomatous colloid cyst which is a very rare variant of colloid cyst.

Tratamiento endoscópico de quistes coloideos del tercer ventrículo / Third ventricle colloid cysts endoscopic approach

Introducción: los quistes coloideos (QC) son tumores benignos de crecimiento lento, que comprenden menos del 1% de los tumores intracraneales. Se presentan en adultos jóvenes y se ubican más frecuentemente en el techo del tercer ventrículo. El objetivo de este trabajo es presentar una serie de pacientes con QC del tercer ventrículo operados por vía endoscópica, analizar la técnica quirúrgica, ventajas y desventajas. Desarrollo: se realizó una búsqueda retrospectiva de pacientes operados por vía endoscópica, en el Servicio de Neurocirugía del Hospital Italiano de Buenos Aires, de tumores del tercer ventrículo en un período de 2 años (2013-2015), con diagnóstico de QC confirmado por anatomía patológica . Se identificaron cinco pacientes, tres mujeres y dos hombres, cuyo promedio de edad fue de 50 años. No hubo complicaciones perioperatorias y ninguno mostró recidiva en el lapso de observación. Conclusión: la vía endoscópica es una vía técnicamente simple y con muy baja morbilidad. Si bien no siempre puede realizarse una exéresis completa, los trabajos prospectivos permitirán definir si esto resulta suficiente para el control de la enfermedad. (AU)

Colloid cysts are benign, slow-growing tumors, comprising less than 1% of intracranial tumors. They occur in young adults and are more frequently located on the roof of the third ventricle. The objective of this study is to present a series of patients with Colloid cysts operated endoscopically and analyze advantages and disadvantages of this surgical technique. We performed a retrospective review of Colloid Cysts operated on endoscopically, at the Neurosurgical Department of Hospital Italiano de Buenos Aires in a period of 2 years (2013-2015). Five patients were identified, three women and two men whose average age was 50 years. No perioperative complications were observed, with no recurrences during the follow up period. Conclusion: the endoscopic approach is technically simple and has very low morbidity. Although a complete excision can not always be performed, prospective studies will allow us to define whether if is sufficient to control the disease. (AU)

Infected colloid cyst.

INTRODUCTION: Colloid cysts are the most common pathologic lesions of the third ventricle. Although they are histologically benign, they may grow and can cause the hydrocephalus. A 5-year-old male patient underwent to surgery with the diagnosis of colloid cyst. In operation, after the anterior transcallosal approach, the cyst was punctured by syringe and obviously pus aspirated. CONCLUSION: Colloid cysts mostly remain silent and detected incidentally. Although it is rarely defined, rhinorrhea, hypopituitarism, diabetes insipidus, spasmodic torticollis, drop attack, aseptic meningitis, and coexistence with neurocysticercosis have been reported, but this is the first reported case of an infected colloid cyst.

Third-ventricle enterogenous cyst presentation mimicking a colloid cyst: uncommon presentation of a rare disease and literature review.

Enterogenous cysts (ECs) are endodermal lesions resulting from splitting anomalies in the neuroenteric canal. We report the case of a 64-year-old patient who presented with a sudden headache followed by collapse. Brain computed tomography revealed a hyperdense lesion in the anterior part of the third ventricle with obstructive hydrocephalus. A presumptive diagnosis of colloid cyst was made and he underwent a right transcortical approach for lesion resection. The histopathological examination revealed an EC. ECs are common lesions in the cervical-thoracic spine but rare in the supratentorial compartment with only two previously described cases occurring in the third ventricle.