Our policy in intraventricular colloid cysts. Experience of 31 operated ...

A.V. Ciurea et alOur policy in intraventricular colloid cystsOur policy in intraventricular colloid cysts. Experience of 31operated cases.A.V. Ciurea, F.M. Brehar, Al. Tascu, A. Iliescu, D. Talianu, R. RizeaFirst Neurosurgical DepartmentEmergency Clinical Hospital “Bagdasar-Arseni”, BucharestAbstractThe colloid cyst of the third ventricle is abenign tumor situated in the anterior partof the third ventricle. This lesion representsless than 1% of the primary brain tumorbeing more common in young adults.Because of its particular location, thecolloid cyst can obstruct the Monroforamen, producing intermittentintracranian hypertension with headache,vomiting and visual disturbances. Thirtyonecases of colloid cysts have beenoperated using the microsurgical approachin the First Neurosurgical Department ofEmergency Clinical Hospital “Bagdasar-Arseni” between January 1995 andDecember 2008. The age of the patientswas between 17 and 46 years, with amedium age of 31 years. The follow-upperiod was between 9 months and 7 years.In three cases TTA approach has beenperformed. One of the cases developed avenous cerebral infarct after this procedure,but the patient had finally a good outcome.For 28 patients the transcortical approachhas been performed. In all cases the totalresection of the colloid cyst has beenperformed. Of all 31 cases, one casepresented a transitory hemiparesis, twocases showed negativist behavior, and threecases had transitory memory disturbances.There was no intraventricular hemorrhageafter colloid cyst resection in our series. Inconclusion, according to our policy, themicrosurgical approach is the besttreatment for third ventricular colloid cystsbecause of its main advantages comparedwith the endoscopic approach: thepossibility of total resection of the cyst, thegood control of the bleeding source duringthe procedure, and a better exposure of theanatomical landmarks.Keywords: colloid cyst, obstructivehydrocephalus, microsurgical approach,neuro-endoscopy.IntroductionColloid cysts are among the mostcommon benign tumors of the thirdventricle and represents, according withliteratury data, between 0.5 and 2% of allintracranial neoplasms (10, 11). Acharacteristic feature of the colloid cyst is itslocation at the anterior part of the thirdventricle, which may produce the occlusionof the foramina of Monro, resulting inbiventricular hydrocephalus (11). Thisparticular location reflects in a specificclinical picture which may include rapidneurological deterioration and even suddendeath. (9, 19). The vast majority of colloidcysts reported in the literature aresymptomatic and were therefore treated.The size of the cysts which is clinicallysignificant is more than 1,5 cm in diameter(Figure 1).

Romanian Neurosurgery (2011)Figure 1 MRI aspect of the colloid cyst of the thirdventricleFigure 2 CT scan showing colloid cyst located inthird ventricle with obstructive hydrocephalusThe main symptoms of the colloid cystsare: headache, gait disturbances, disturbedmentation, vomiting, blurred vision,incontinence and dizziness. The main signsare papilledema, gait disturbance,hyperreflexia, incoordination and nistagmus(10) The treatment of asymptomatic colloidcysts depends on individual characteristicsand patients’options (12, 13). The majorsymptoms depend of the size of the colloidcysts and are usually related to thesecondary hydrocephalus produced whenthey are large enough to occlude the Monroforamen (Figure 2). Signs and symptomsmay be also produced by compression ofthe nearby structures, like hypothalamusfloor and fornix. Sjovall et al postulated 100years ago, that episodic intracranialhypertension crises could be produces byintermitent obstruction of Monro foramen(20). Sudden increased in size of the colloidcyst due to intracystic hemmorhage couldbe another mechanism which explain theneurological deficits (1).Despite several cases which presentedseveral neurological deficits related to thesize of the cyst, sudden deterioration is rarefor the most patients with colloid cysts, andthe first symptoms are intermittent andnonspecific. (3). The cause of thesedeterioration is usually related to theobstruction of CSF outflow due toparticular location of the cyst. Otherauthors suggested that sudden death isrelated rather to local compression of thewall of the third ventricle, thuscompromising cardiovascular regulatorycenters in the hypothalamus, than withacute obstructive hydrocephalus (16).Probably, keeping in mind both hypothesismentioned above, the mechanism in suchcases is multifactorial (6). In cases withobstructive hydrocephalus, acute

deterioration might be provoked by lumbarpuncture, therefore a CT scan is mandatorybefore performing such a procedure (3). Inthe presence of associated obstructivehydrocephalus, there are two managemntoptions. If there is an acute symptomatichydrocephalus, a ventricular drainageshould be performed in emergency. If theventricular enlargment is not accompaniedby sings and symptoms of intracranialhypertension, the presence ofhydrocephalus ventricles could beadvantageous, offering to the surgeon anatural corridor and enough room to reachthe cyst and to remove the lesion. Thissituation is favorable for the transcorticalapproach. Contrary, if the transcallosalroute is chosen, one way is to implant aventricular drain in order to avoid excessiveretraction of the medial wall of the frontallobe (11). In this paper the authors presenttheir experience in 31 consecutive cases ofcolloid cysts operated using twomicrosurgical approaches.Materials and methodsThirty one cases of colloid cysts havebeen operated using the microsurgicalapproach in the First NeurosurgicalDepartment between January 1995 andDecember 2008. The age of the patientswas between 17 and 46 years, with amedium age of 31 years. There were 15males and 16 females. The main symptomswere: headache in 28 cases (90,3%), ataxiain12 cases (38,7%), VI-th nerve paresis in 9cases (29,1%), memory impairment in 14cases (45,2%), “ventricular seizures” in 18cases (58,1%). Other clinical signs consist ingatism in 4 cases (12,9%), nystagmus in 5cases (16,1%), bilateral dismetria in 4 cases(12,9%), epileptic seizures in 11 cases(35,5%), psychic impairment in 5 cases(16,1%). Twenty-eight cases (90,4%) havepreoperative hydrocephalus and 3 cases(9,6%) were without hydrocephalus Thefollow-up period was between 9 monthsand 7 years. One case died in theemergency room and diagnosis has beenestablished during necropsy (case nonincludedin our series). Another casepresented at the emergency room withintracranial hypertension syndrome. TheCT scan showed signs of acutehydrocephalus. VP shunt has beenperformed in emergency and the patient’ssymptoms improved significantly. The MRperformed after surgical procedureidentified a colloid cyst located in the thirdventricle which had produced theobstructive hydrocephalus.Treatment consisted in surgery in 31cases (100%), respectively in tumourremoval without VP shunt 29 cases(93,5%) and VP shunt (performed inemergency) and removal of the tumor in 2cases (6,50%). There was no case forobservation only.In three cases, TTA approach has beenperformed. One of the cases developed avenous cerebral infarct after this procedure,but the patient had finally a good outcome.For 28 patients, the transcorticalapproach has been performed. Theadvantages of this approach consist in theexcellent exposure of the cyst andsurrounding important anatomicallandmarks (internal cerebral vein, anteriorseptal vein, talamo-striate vein, choroidplexus, etc.), the resection of the cyst totallyinclusive the cyst’s capsule and a very goodcontrol of any bleeding point.Results and discussionsIn all cases total removal of the colloidcyst has been performed (Figure 3 andFigure 4).

Romanian Neurosurgery (2011)Figure 3AFigure 4AFigure 3A Colloid cyst of the third ventricle.B Postoperative aspectOf all 31 cases, one case presented atransitory hemiparesis, two cases showednegativist behavior, and three cases hadtransitory memory disturbances. There wasno intraventricular hemorrhage after colloidcyst resection in our series. Immediatecomplications consist in intracerebralhemorrhage 1 case (3,2%), epileptic seizuresin 11 cases (35,4%), of which partialseizures in 7 cases (22,5%) and generalizedseizures in 4 cases (12,9%).Figure 4A Colloid cyst of the third ventricle.B Postoperative MR image which shows totalresection of the cystLate complications were: obstructivehydrocephalus in 2 cases (6,4%), transitoryleft hemiparesis in 5 cases (16,1%), memorydisorder in 8 cases (25,8%), negativism,apathy in 4 cases (12,9%).Evolution of 31 cases operated werefavorable in 30 cases (96,7%), worse in 1case (3,3%) and no case of death (0 %).Microsurgical approach should be thefirst treatment option. Either transverstranscallosal approach (TTA), or

transcortical approach could be used toreach and resect the lesion totally.Both approaches are effective andusually safe, although neither is withoutcomplications. The initial steps of thetranscallosal are perhaps a bit more difficultand require meticulous microsurgicaltechniques. We do not prefer it, howeverthis is the procedure of choice if ventriclesare not enlarged. It allows a goodvisualization of the structures inside theventricular system. On the other hand thetrancortical approach have severaladvantages compared with transverstranscallosal approach.The minim invasive techniques consistin endoscopic, endoscope-assisted keyholeapproaches and, less frequently nowadays,stereotactic aspiration of the cyst. Colloidcysts, especially in patients with normalventricles after shunting, can be treatedwith simple stereotactic aspiration (2). Itshould be mentioned that the content couldbe too viscous and difficult to aspirate (15)and, furthermore, part of the capsule maybe left behind, causing recurrence of thelesion in an unacceptably high rate (8).More recently, endoscopic approachrepresents reasonable alternatives.However, there are many cases whenportions of the capsule are left behind sothe risk of recurrence still remains. Despiteof the technological advances, questionsstill remain regarding the advantages ofopen versus endoscopic in resection ofcolloid cysts. Comparing a series of a singleinstitution, Horn et al. showed that in theendoscopic group the rate of residual orrecurrent cysts was higher and the length ofstay was slightly shorter (7). This studyshowed also, that severe complications suchas hemiparesis and memory deficits can beassociated with this minimal invasiveapproach. Before the recent development ofmodern endoscopic technique, Kelly et alproposed another minimally invasiveapproach which consisted in placingstereotactically a tube retractor through afrontal burr hole. Other authors supportthe simultaneous approach of endoscopicand microsurgical strategies (4). Asmentioned above, ventricular enlargementcould be advantageous for the surgicalapproach, especially for transcorticalapproach. Contrary, if the transcallosalroute is chosen, a ventricular drain shouldbe used intra-operatively in order to avoidexcessive retraction of the medial wall ofthe frontal lobe (11). Several authors whosupport the microsurgical approach of thecolloid cyst of the third ventricle as the besttherapeutically option (5, 14, and 18). M.Sami consider also that third ventriclecolloid cyst has a perfect microsurgicalindication (17). In our opinion themicrosurgical approach is the besttreatment for third ventricular colloid cystsbecause it offers several advantagescompared with the endoscopic approach,such as the possibility of total resection ofthe cyst, the good control of the bleedingsource during the procedure, and a betterexposure of the anatomical landmarks. Ouroption is for the transcortical microsurgicalapproach because TTA has and importantrisk of memory deficit and could producedeep vein lesions.The advantages of this approach consistin the excellent exposure of the cyst andsurrounding important anatomicallandmarks (internal cerebral vein, anteriorseptal vein, talamo-striate vein, choroidplexus, etc.), the resection of the cyst totallyinclusive the cyst’s capsule and a very goodcontrol of any bleeding point.

Romanian Neurosurgery (2011)ConclusionColloid cysts are rare benign lesionslocated in the anterior part of the 3rdventricle in Monro area. The patognomonicfeatures are intracranial hypertensionattacks and so called “ventricular seizures”.The presence of intracranial hypertensionrequires surgery in emergency. Inconclusion, we think the microsurgicalapproach is the best treatment for thirdventricular colloid cysts because of its mainadvantages compared with the endoscopicapproach: the possibility of total resectionof the cyst, the good control of the bleedingsource during the procedure, and a betterexposure of the anatomical landmarks.Microsurgical approach should be the firsttreatment option. Either transverstranscallosal approach (TTA), ortrancortical approach could be used to reachand resect the lesion totally.e-mail: felixbrehar@yahoo.comtel: +40213343025AbbreviationsCSF: cerebro-spinal fluid; TTA:transvers transcallosal approach; VP:Ventriculo-peritonealReferences1. Beems T, Menovsky T, Lammens M (2006)Hemorrhagic colloid cyst. Case report and review of theliterature. Surg Neurol 65: 84-862. Bosch D A, Rahn T, Backlund E O: Treatment ofcolloid cyst of the third ventricle by stereotacticaspiration, Surg. Neurol. 9: 15-8, 19783. Buttner A, Winkler PA, Eisenmenger W, Weis W(1997) Colloid cyst of the third ventricle with fataloutcome: a report of two cases and review of theliterature. Int J Legal Med 110: 260-2664. Charampaki P, Filippi R, Welschehold S, et al. (2005)Tumors of the lateral and third ventricle: removal underendoscope – assisted keyhole conditions. Neurosurgery57 (ONS Suppl 4): ONS-302-ONS-3115. Ciurea A.V., Al. Tascu, F. Brehar, R. Rizea,Microsurgical procedures in intraventicular choloid cystin neuroendoscopy era, Al VI-lea Congres National alAsociatiei Romane de Chirurgie Endoscopica,Bucuresti, 11-14.11.2009.6. Hamlat A, Pasqualini E, Askar B (2004) Hypothesisabout the physiopathology of acute deterioration andsudden death caused by colloid cysts of the thirdventricle. Med Hypotheses 63: 1014-10177. Horn EM, Feiz-Erfan I, Bristol RE, et al. (2007)Treatment options for the third ventricular colloidcysts: comparison of open microsurgical versusendoscopic resection. Neurosurgery 60: 613-6208. Lobo-Antunes J, Louis KM, Ganti SR (1980) Colloidcysts of the third ventricle. Neurosurgery 7: 450-4559. Lobosky JM, Vangilder JC, Damasio AR (1984)Behavioural manifestations of third ventricular colloidcysts. J Neurol Neurosurg Psychiatry 47: 1075-108010. Mark S. Greenberg, Handbook of Neurosurgery,Thieme, 200611. Marc Sindou, Practical Handbook of Neurosurgery,Thieme, 200912. Pollock BE, Huston J (1999) Natural history ofasymptomatic colloid cysts of the third ventricle. JNeurosurg 91: 364-36913. Pollock BE, Shreiner SA, Huston (2000) A theoryon the natural history of colloid cysts of the thirdventricle. Neurosurgery 46: 1077-108314. R. L. Jeffree and M. Besser, Colloid cyst of the thirdventricle: a clinical review of 39 cases, Journal ofClinical Neuroscience, Volume 8, Issue 4, July 2001,Pages 328-33115. Rivas J J, Lobato R D: CT – assisted stereotacticaspiration of colloid cyst of the third ventricle. J.Neurosurg 62, 238 – 42, 198516. Ryder J W, Kleinschmidt B K, Keller T S, Suddendeterioration and death in patients with benign tumorsof the third ventricle area. J. Neurosurg. 64:216-23,198617. Sami M. et al. (2009), Microsurgical approach of thecolloid cyst of the third ventricle, RomanianNeurosurgical Conference with InternationalParticipation, Sibiu, 30.09-03.10.2009.18. Sampath, Raghuram MD; Vannemreddy, PrasadMD; Nanda, Anil MD (2010), Microsurgical Excisionof Colloid Cyst With Favorable Cognitive Outcomesand Short Operative Time and Hospital Stay: OperativeTechniques and Analyses of Outcomes With Review ofPrevious Studies, Neurosurgery: February 2010 -Volume 66 - Issue 2 - p 368–375; doi: 10.1227/01.NEU.0000363858.17782.8219. Shaktawat Sameer,Walid D Salman,Zuhair Twaij,and Abdul Al-Dawoud, Unexpected death afterheadache due to a colloid cyst of the third ventricle,World J Surg Oncol. 2006; 4: 4720. Sjovall E (1910) Über eine Ependymcysteembryonalen Charakters (Paraphyse?) im drittenHirnventrikel mit tödlichem Ausgang. Zugleich eineBeobachtung wahrer lipochromer Veränderungen mitAuftreten von Halbmondkörperchen. Beitr Pathol Anat47: 248-269