<<

Neurosurgical Review (2019) 42:127–132 https://doi.org/10.1007/s10143-018-0956-y

ORIGINAL ARTICLE

Endoscopic management of third ventricular colloid cysts in mildly dilated lateral ventricles

Mohamed A. Eshra1

Received: 16 December 2017 /Revised: 15 January 2018 /Accepted: 6 February 2018 /Published online: 12 March 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract Colloid cysts of the are considered as benign lesions. The clinical manifestations are not clear in most of cases. Many treatment options are available and endoscopic removal of the cysts proves to be a very successful method especially if the lateral ventricles are moderately or severely dilated. Sometimes, we faced cases with non- or mildly dilated ventricles which may add more risks to the operation, limit the radicality of removal, or abort the procedure entirely. Sixteen cases of colloid cyst with mildly dilated ventricles were operated upon between 2008 and 2016 using the rigid endoscopic system. Twelve were female and four were male. Their ages were between 17 and 40 years old. and epileptic fits were the presenting symptoms in 13 cases and 2 cases respectively. One case was asymptomatic. The patients were followed up from 1 to 4 years. Total removal in 12 cases and evacuation of the contents and partial removal in 4 cases. Mild transient complications occurred in the form of fever in seven cases, vomiting in four cases or short-term recent memory loss in three cases. No deaths occurred due to the procedures. Working endoscopically in enlarged ventricles is very effective and easy; however, small sized ventricles do not prevent safe and effective complete removal of colloid cysts. Cases with residual cyst wall do not suffer from recurrence.

Keywords Colloid cyst . Neuroendoscopy . Third ventricle .

Introduction coma or sudden deaths which sometimes occur in conjunction with colloid cysts [3, 5, 6]. The third ventricle is a small slit-like space between the two The surgical treatment strategies for colloid cyst are multiple thalami. It may harbor a colloid cyst which is considered as a with advantages and disadvantages for each tool. Recently, the benign lesion representing less than 1% of brain tumors and evolution and advances occurred in the neuroendoscopy attached to the tela choroidea and may occlude one or both allowed the endoscopic intervention for colloid cysts to be used foramina of Monro. The cysts contain a viscid gelatinous ma- by most of craniosurgeons for its safety and efficacy [7, 8]. terial of variable density and, accordingly, their density in CT Many studies reported very good results in using endosco- or MRI varies greatly [1]. py to remove colloid cysts in moderately or hugely dilated The behavior of the cyst and its impact on the surrounding lateral ventricles. In this study, we try to investigate the safety, structures are clearly understood. The cyst presents itself by efficacy, and outcome of endoscopic removal of colloids with multiple variable and nonspecific symptoms differing greatly mildly dilated ventricles without neuronavigation or if the ventricles are moderately or hugely dilated, causing stereotaxy. , vomiting, blurred vision, and ataxia [2–5]. If the cyst is asymptomatic or discovered accidently, its management options are controversial. Some opinions tend Patients and methods to manage every case in spite of absent symptoms for fear of Sixteen cases with colloid cysts with mildly dilated ventricles (Evans ratio from 30 to 42%, which has a high interobserver * Mohamed A. Eshra [email protected] reliability [9]) were operated upon between June 2008 and December 2016 using the rigid endoscopic system. Twelve 1 Department of , Faculty of Medicine, Alexandria were female and four were male. Their ages were between University, Champillion St., Elazaritta, Alexandria, Egypt 17 and 40 years old. Headaches and epileptic fits were the 128 Neurosurg Rev (2019) 42:127–132

Table 1 Summary of clinical and operative data No. Sex Presentation Colloid size Removal Operative Complications (mm) time (min)

1 23/F Headache 11 Partial 100 Fever 2 35/F Asymptomatic 5 Total 60 Fever/vomiting 3 28/F Headache 12 Total 77 4 25/F Headache 12 Total 84 – 5 17/F Headache 9 Total 90 Fever/vomiting 6 37/F Headache 8 Total 95 Fever 7 19/F Epilepsy 11 Total 90 – 8 39/M Headache 14 Partial 100 Fever 9 34/F Headache 7 Total 80 – 10 27/F Epilepsy 15 Partial 95 Amnesia 11 36/M Headache 11 Partial 100 – 12 22/M Headache 15 Total 70 – 13 40/F Headache 8 Total 84 – 14 23/F Headache 14 Total 100 Fever/amnesia 15 37/F Headache 10 Total 65 – 16 34/M Headache 13 Total 80 Fever/vomiting presenting symptoms in 13 cases and 2 cases respectively. coagulation of the adherent wall in addition to septal perfora- One case was asymptomatic. The patients were followed up tion in all cases just in case if anyone needs CSF diversion from 1 to 4 years. Summary of the clinical data of the cases is post-operatively. We used the rigid GAAB system in all cases. demonstrated in Table 1. Regarding the size of the tumor Using general anesthesia in all cases, patients were in su- measured from the radiological investigations, it varied from pine and their neck flexed 30–45°. The benefit of head eleva- 5 to 15 mm. Right-sided approach was used in all patients. tion was to minimize the CSF leakage from the endoscope Informed consent was obtained from all individual partici- during the procedure. To make the operative work on the pants included in the study. colloid easy and to minimize the torque on the cortex or intra- ventricular structures, we put the burr hole 1 cm anterior to the coronal suture and 3 cm away from the midline. Opening the Methods dura in a cruciate pattern was done followed by bipolar coag- ulation of the arachnoid—brain surface. The lateral ventricle Our pre-operative plan was total removal of the cyst or at least was tapped using the standard brain cannula, and the distance evacuation of its content, partial removal of its wall, and from the skull surface till perforation of the ependyma of the ventricle was measured using the graduation on the surface of the cannula. We observed that the opening pressure was not dangerously high like cases with mega-sized ventricles.

Fig. 1 Endoscopic view of colloid cyst occupying the third ventricle and partially occluding the foramen of Monro with minor vascularity over its Fig. 2 Endoscopic view of colloid cyst occupying the third ventricle with surface a considerable vascularity over its surface Neurosurg Rev (2019) 42:127–132 129

Tapping was successful from the first time in ten cases, second Results time in four cases, and third time in two cases. While the cannula was inside the ventricle, where the The surgical goals planned pre-operatively were drainage of pulsating CSF comes from, we introduced the endoscopic cyst content and total or partial resection of the capsule. These sheath with 6.5 mm diameter, barely touching the lateral goals were achieved in all cases without the need to abort the side of the cannula and moving it slowly until it has the procedure or to shift to open craniotomy. The follow-up peri- same distance as the cannula. The trochar of the sheath od was from 1 to 4 years. In all cases, we observed that the (obturator) was removed. Making sure that the sheath was partial occlusion of the foramen of Monro as the colloid was intraventricular and CSF came out, we removed the brain attached to the roof of the third ventricle leaving the antero- cannula. The rode-lens system was inserted in the sheath inferior part of the foramen un-occluded and this observation and locked. We navigated inside the ventricle to identify explains the small sizes of ventricles of cases encountered in its landmarks and to visualize the colloid occupying the this study. We succeeded in total removal in 12 cases and foramen of Monro. Any surface vessel over the colloid evacuation of the contents and partial removal in 4 cases. was coagulated. The colloid was punctured using endo- Looking at the colloid capsules after its removal, we found scopic bipolar cautery and endoscopic scissor if the cap- the hole made in the capsule and remnants of colloid material sule was thick. Evacuation of its content by suction using inside. Venous bleeding was encountered in six cases, which 6F catheter was done. Complete evacuation of the colloid was cleared by thorough irrigation only in three cases and by content will lead to collapse and redundancy of the cap- combination of balloon tamponade at the foramen edge and sule which would be coagulated numerous times. Very irrigation in three cases. The time of procedure was between gentle traction would be applied to peel off the capsule 60 and 100 min with a mean of 74 min. We used antiepileptic from the roof of the third ventricle using endoscopic for- drugs pre- and post-operatively in two cases only. Post- ceps making sure that no vessels were attached to the operative ICU admission for 1 day was done only for four capsule which may rupture casing minor hemorrhage cases. Headache improved in all 13 cases 1 day after opera- which can be easily controlled by transient tamponading tion. Follow-up CT was done for all patients after 1 and using the inflated endoscopic balloon and washed out by 2 weeks then at 3-month intervals. The four cases with partial thorough irrigation by warmed lactated Ringer’s solution. removal were followed up by MRI after 6 months, 1 year, and When the field was clear, the tumor bed was re-inspected 2 years with no evidence of recurrence (Figs.1, 2, 3, 4, 5, 6, 7, for any venous ooze or residual capsule. Perforation of the and 8). septum lucidum (septostomy) was done for all cases. Mild transient post-operative complications occurred in the Finally, the endoscope was removed from the brain. The form of fever in seven cases and vomiting in four cases. The cortical track was sealed by small tube of gel foam fever was treated by cold foments and antipyretics. Recent followed by closure of the scalp wound. memory loss was encountered in three cases that was tempo- All patients were followed up clinically and radiologically rary and improved within 1 week. This memory loss may be shortly after operation for 1 month then later followed up at due to edema of the that was resolved within days. No regular intervals of 3 months for 1 to 4 years. The patients deaths occurred due to the procedures. Ten patients were stayed in hospital for 1–3days. discharged from the hospital after 1 day, five patients after

Fig. 3 Pre-operative MRI of colloid cyst of the third ventricle with small-sized ventricles 130 Neurosurg Rev (2019) 42:127–132

Fig. 6 Post-operative MRI with complete removal of the colloid cyst

Fig. 4 Post-operative CT with complete removal of the colloid cyst drawbacks of being bilateral shunting, not a definitive way of therapy and leaving a growing tumor untouched with its neuro- 2 days, and one patient after 3 days. Summary of the clinical logical complications and risk of sudden death in some patients data of the cases is demonstrated in Table 1. [12]. Stereotactic cyst aspiration has the advantage of being a min- imally invasive procedure with no complications of open surgery Discussion and has a high degree of accuracy but the estimated coordinates may change after ventricular tapping. However, it has a higher Colloid cysts in spite of being benign tumors, there are a lot of failure rate with hyper dense or small cysts and may be compli- debates about their evolution, location, natural history, and cated by hemorrhage, infection, or amnesia. Finally, it leaves the management. Colloid cysts were managed by different modal- cyst capsule as it is leading to high risk of recurrences [1, 13]. ities along the past decades and these management techniques Total resection may be achieved by open craniotomy with ranged from just ventricular decompression and content aspi- its different approaches or by endoscopic removal. Open cra- ration to complete tumor resection [10–12]. niotomy although being the definitive radical surgical option Ventricular CSF decompression by shunting may alleviate to treat colloid cysts, it carries considerable risks of morbidity some or the whole manifestations; however, it has several and mortality [14].

Fig. 5 Pre-operative MRI of colloid cyst of the third ventricle with small-sized ventricles Neurosurg Rev (2019) 42:127–132 131

Fig. 7 Pre-operative CT of colloid cyst of the third ventricle with small- Fig. 8 Post-operative CT with complete removal of the colloid cyst sized ventricles

Peri-operative complications which may occur with endo- Many old and recent trials at endoscopic resection of the scopic cystectomy in small ventricles are minor and transient colloid cyst have been reported. Nowadays, the standard goal in most of the studies in the form of minor venous bleeding, of endoscopic colloid cystectomy is not just the evacuation of transient short-term memory loss, and CSF leakage [19–22]. the content or coagulation of the wall but also the total or at More severe complications were reported as forniceal injury, least partial removal of the cyst capsule and these were made injury to the deep venous system, chemical meningitis, com- easier by improvements in endoscopic technology, good an- municating hydrocephalus, and heterotopic colloid tissue im- esthesia, and advancing learning curves. Endoscopic plantation in the ventricular system. The contraindications for cystectomy may be hindered by recurrent cases, non-dilated the endoscopic approach are posteriorly located cysts and re- ventricles, micro-foramen of Monro, or posteriorly located current cases [23, 24]. colloids [15–17]. Along the follow-up period, no increase in the ventric- Ventricular tapping is the corner stone in successful ular size was observed. So, none of our patients needed endoscopic cystectomy in small ventricles. We started en- any type of CSF diversion. All our cases were followed doscopic surgery on colloid cysts in small ventricles after up for 1–4 years with no evidence of recurrences. In many 8 years of experience in ventricular tapping and endo- studies, the recurrence rate was minor and ranged from 0 scopic surgery for endoscopic third ventriculostomy, to 11% [25]. The endoscopic cystectomy may have some foraminoplasty, septostomy, aqueductoplasty, or endo- advantages over the microsurgical approach. From these scopic biopsy. Thus, we have acquired adequate training are the good illumination, superior magnification, better and good experience in tapping such small ventricles. visualization of the ventricular anatomy, and possibility to Introducing the endoscopic sheath touching the wall of visualize the roof of the third ventricle where the colloid the brain cannula makes the insertion of the endoscope cyst is attached with angled endoscope. Visualization of intraventricular easy. Endoscopic manipulation inside the roof of the third ventricle could be achieved by mi- small ventricles is not difficult as long as the scope is croscopic interforniceal approach but with high risk of directly facing the foramen of Monro and this is accom- bilateral forniceal injury. Post-operative seizures are sig- plishedbyproperlocalizationoftheburrhole[18–20]. nificantly lower in endoscopic cystectomy than the 132 Neurosurg Rev (2019) 42:127–132 microsurgical resection. Finally, endoscopic colloid 8. Qiao L, Souweidane MM (2011) Purely endoscopic removal of cystectomy has shorter operative times and hospital stay intraventricular brain tumors: a consensus opinion and update. Minim Invasive Neurosurg 54:149–154 [14, 20, 23, 25, 26]. 9. O’Hayon BB, Drake JM, Ossip MG, Tuli S, Clarke M Frontal and occipital horn ratio: a linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatr Neurosurg Conclusion 29:245–249 10. Phillippe D, Caroline LG, Pierre B (1998) Endoscopic management of colloid cyst. Neurosurgery 42:1288–1294 Mildly dilated ventricles do not preclude successful endoscop- 11. Pollok BE, Huston J (1999) The natural history of asymptomatic ic management of third ventricular colloid cysts even without cyst of the third ventricle. J Neurosurg 91:364–369 stereotactic guidance or neuro-navigation. Post-operative 12. Rodziewcz GS, Mark V (2000) Endoscopic colloid cyst surgery. complications are minor and transient. Very good experience Neurosurgery 46:655–662 in ventricular tapping is mandatory for successful endoscopic 13. Mathiesen T, Grane P, Linggren L (1998) Third ventricular colloid cyst: a consecutive 12-year series. J Neurosurg 1997 86:5–12 cystectomy. Longer periods of follow-up would be beneficial 14. Lewis AL, Crone KR, Taha J (1994) Surgical resection of third to patients and surgeons. ventricular colloid cyst: preliminary results comparing transcallosal microsurgery with endoscopy. J Neurosurg 81:174–178 Compliance with ethical standards 15. Charalampaki P, Filippi R, Welschehold S, Perneczky A (2006) Endoscope-assisted removal of colloid cysts of the third ventricle. Neurosurg Rev 29:72–79 Ethical approval All procedures performed in this study involving hu- 16. Powell MP, Torrens MJ, Thompson JLG (1983) Isodense colloid man participants were in accordance with the ethical standards of the cyst of the third ventricle: a diagnostic and therapeutic problem national research committee and with the 1964 Helsinki declaration and solved by ventriculoscopy. Neurosurgery 13:234–237 its later amendments or comparable ethical standards. 17. Wesley A, Uttman JS, Frazee GR (1999) Endoscopic resection of colloid cysts: surgical consideration using the rigid endoscope. Informed consent Informed consent was obtained from all individual Neurosurgery 44:1103–1109 participants included in the study. 18. Margetis K, Souweidane MM. (2013): Endoscopic resection of colloid cyst in normal-sized ventricular system. Neurosurg Focus Conflict of interest The author declares that he has no conflict of 34(1 Suppl): Video 8 interest. 19. Tirakotai W, Schulte DM, Bauer BL, Bertalanffy H, Hellwig D. (2004): Neuroendoscopic surgery of intracranial cysts in adults. Childs Nerv Syst 20:842–851 References 20. Wait SD, Gazzeri R, Wilson DA, Abla AA, Nakaji P,Teo C. (2013): Endoscopic colloid cyst resection in the absence of . Neurosurgery 73(1 Suppl Operative) 1. Kondziolka D, Lunsford D (1991) Stereotactic management of col- 21. Bouras T, Sgouros S (2012) Complications of endoscopic third – loid cysts: factors predicting success. J Neurosurg 75:45 45 ventriculostomy. Acta Neurochir Suppl 113:149–153 2. Desai KI, Nadkarni TD, Muzumdar DP, Goel AH (2002) Surgical 22. Zohdi A, El Kheshin S (2006) Endoscopic approach to colloid management of colloid cyst of the third ventricle—a study of 105 cysts. Minim Invasive Neurosurg 49:263–268 cases. Surg Neurol 57:295–304 23. Sheikh AB, Mendelson ZS, Liu JK (2014) Endoscopic versus mi- 3. Grondin RT, Hader W, MacRae ME, Hamilton MG (2007) crosurgical resection of colloid cysts: a systematic review and meta- Endoscopic versus microsurgical resection of third ventricle colloid analysis of 1,278 patients. World Neurosurg 82:1187–1197 cysts. Can J Neurol Sci 34:197–207 4. Hernesniemi J, Leivo S (1996) Management outcome in third ven- 24. Zabihyan S, Etemadrezaie H, Baharvahdat H, Baradaran A, tricular colloid cysts in a defined population: a series of 40 patients Ganjeefar B, Bohl MA, Nakaji P (2015) Remote transplantation treated mainly by transcallosal microsurgery. Surg Neurol 45:2–14 of a third ventricle colloid cyst: case report. J Neurosurg 122: – 5. Horn EM, Feiz-Erfan I, Bristol RE, Lekovic GP, Goslar PW, Smith 1406 1410 KA, Nakaji P, Spetzler RF (2007) Treatment options for third ven- 25. Shapiro S, Rodgers R, Shah M, Fulkerson D, Campbell RL (2009) tricular colloid cysts: comparison of open microsurgical versus en- Interhemispheric transcallosal subchoroidal fornix-sparing craniot- doscopic resection. Neurosurgery 60:613–620 omy for total resection of colloid cysts of the third ventricle. – 6. Carrasco R, Pascual JM, Medina-López D, Burdaspal-Moratilla A Clinical article. J Neurosurg 110:112 115 (2012) Acute hemorrhage in a colloid cyst of the third ventricle: a 26. Weston J, Greenhalgh J, Marson AG (2015) Antiepileptic drugs as rare cause of sudden deterioration. Surg Neurol Int 3:24 prophylaxis for post-craniotomy seizures. Cochrane Database Syst 7. Delitala A, Brunori A, Russo N (2011) Supraorbital endoscopic Rev 3(2):CD007286. https://doi.org/10.1002/14651858. approach to colloid cysts. Neurosurgery 69(2 Suppl Operative): CD007286.pub3 ons176–ons183