J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.10.1075 on 1 October 1984. Downloaded from Journal ofNeurology, Neurosurgery, and Psychiatry 1984;47:1075-1080 Behavioural manifestations of third ventricular colloid cysts JEFFREY M LOBOSKY,* JOHN C VANGILDER,* ANTONIO R DAMASIOt From the Department ofSurgery (Division ofNeurosurgery*), and Department ofNeurology (Divisioni of Behavioural Neurologyt), The University of Iowa College of Medicine, Iowa City, Iowa, USA SUMMARY Three patients with third ventricular colloid cysts manifested disturbances of memory, emotion and personality in the absence of hydrocephalus. All three patients demonstrated significant improvement following removal of the tumours. The symptoms and signs associated with these neoplasms may be attributed to compression or vascular compromise of the diencepha- lon with disorder of major limbic system structures. Tumour removal should be undertaken in patients with symptoms even in the absence of hydrocephalus, and ventricular shunting may be inadequate as a sole therapeutic measure. guest. Protected by copyright. Colloid cysts of the third ventricle are uncommon, less, headache is the most consistent complaint and comprising less than 1% of intracranial neoplasms. is usually related to accompanying hydrocephalus. Initially described by Wallmann' in 1858, they Venous distention secondary to compression of the remained no more than a pathologic curiosity until deep cerebral veins or their tributaries has also been Dandy's2 first successful operative removal of this postulated as a contributing cause of the cephal- tumour in 1921. These midline masses are benign gia.67 and lend themselves to complete removal with Less attention has been focused upon the abnor- minimal morbidity and mortality utilising micro- mal behavioural manifestations of this disorder and scopic surgical techniques. early authors-5I considered the neuropsychological Colloid tumours afflict males and females with disturbances to be a reflection of ventricular dilata- equal frequency. They have been reported between tion. Others' "12-'4 have noted a similarity between the age extremes of 2 months and 79 years but most the mental decline in patients with colloid cysts and become symptomatic between the third and fifth in those with normal pressure hydrocephalus. Thus, decades of life. The cysts range in size from 0-3 to 9 a causative relationship between the two has cm but the majority are found to be between 1 and 3 become accepted. The alternative possibility of cm in diameter. Sjovall3 initially postulated the diencephalic dysfunction from the tumour has been paraphysis as the site of origin of these tumours but largely ignored. this theory was later challenged by Kappers.4 Yenerman,'4 in his review of 54 patients with was Shuangshoti5 subsequently suggested that the cysts neuroepithelial cysts, agreed that hydrocephalus http://jnnp.bmj.com/ arise from infolding of the neuroepithelium which the most likely cause for the frequently observed lines the ventricular cavities thus accounting for dementia. He and others6" 14 added, however, that their occurrence in areas other than the anterior pressure effects from the tumour on diencephalic third ventricle. Most neuropathologists concur with structures might play a significant aetiologic role. In this latter theory of pathogenesis. this report we describe three patients with colloid The symptomatology of colloid cysts is protean cysts of the third ventricle whose findings may help and the classical history of positional headache with elucidate the role of diencephalic dysfunction in the intermittent apoplectic episodes is rare. Nonethe- generation of abnormal behavioUral symptoms. on September 27, 2021 by Address for reprint requests: Jeffrey M Lobosky, MD, Division of Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa Case reports City, Iowa 52242, USA. Case 1 Received 31 January 1984 In June, 1980. a 64-year-old housewife was investigated Accepted 10 March 1984 for a 3 year history of progressive gait difficulty and uri- 1075 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.10.1075 on 1 October 1984. Downloaded from 1076 Lobosky, VanGilder, Damasio Fig 1 (Case 1) A. Initial contrast enhanced CT scan revealing hydrocephalus. The level ofthis scan is above the third ventricle anid the tumour is not identified. B. Repeat CT scan 10 months after in.sertion of ventriculocaval shunt demonstrating resolving hydrocephlus and a colloid cyst. guest. Protected by copyright. nary incontinence. Neurological examination revealed revealed improvement in language and visuospatial severe dementia with marked disturbances of memory, abilities. The verbal I0 was 70, performance IQ 68 and her intellect and orientation associated with confabulations. memory quotient was 66. Currently she is at home and is There was a generalised increase in muscle tone, hyperac- maintaining an efficient household. tive muscle stretch reflexes, bilateral extensor plantar This patient exemplifies persistence of dementia after responses, an apractic gait and frontal lobe release signs treatment of her hydrocephalus and indicates the possibil- including snout, grasp and glabellar reflexes. Neuro- ity of an alternative aetiology. The improvement of her psychologic evaluation revealed severe impairment of all cognitive abilities after tumour removal suggests that cognitive functions. Verbal and performance IQs were diencephalic dysfunction could have been the cause of her measured at 62 and <50 respectively, and memory quo- behavioural disorder and underscores the inadequacy of tient was placed at 55. A computed tomographic scan (fig ventricular shunting as a sole therapeutic procedure in such la) showed marked hydrocephalus but an enhancing third cases. ventricular mass was not appreciated. The patient under- went intracranial pressure monitoring which revealed both Case 2 plateau and beta pressure waves greater than 25 mm Hg This 33-year-old insurance salesman was referred to Uni- and a right ventriculocaval shunt was inserted, following versity Hospitals in May, 1982 with an 8 year history of which the patient was discharged. In April, 1981, the intermittent anxiety attacks.' These episodes were patient was reevaluated. Her apractic gait and urinary characterised by severe agitation, chest pain, diaphoresis, incontinence had resolved and she no longer demonstrated tachypnoea, tachycardia and a sense of impending doom. long tract signs or frontal release phenomena. Her demen- These attacks had increased both in their frequency and tia, however, had progressed to such a degree that she severity, occurring up to 10 times daily and lasting from a required institutionalisation. The patient was markedly few seconds to several minutes with no associated abnor- http://jnnp.bmj.com/ confused and oriented only to her name. She was unable to mal motor movements or loss of consciousness. The recall even a single object one minute after its presentation patient underwent prolonged psychiatric treatment with- and she had lost all ability to calculate and reason. Formal out improvement. On occasion headaches accompanied psychometric evaluation could not even be obtained. A these episodes but no other physical or neurological com- second CT scan (fig lb) demonstrated improvement of the plaints were noted. The patient had a CT scan performed hydrocephalus and a prominent third ventricular mass which demonstrated a 2-0 cm mass in the anterior third which was apparent both on the enhanced and unenhanced ventricle without hydrocephalus. Because of the lack of studies. Retrospective review of the 1980 scan revealed the ventriculomegaly, this was interpreted as an asymptomatic on September 27, 2021 by mass to have been present at that time. A colloid cyst colloid cyst. The patient's general and neurological exami- estimated to be slightly greater than 2-0 cm in diameter nations were normal except for atrophy of the right calf was removed through a right frontal transventricular oper- secondary to childhood poliomyelitis. An electroence- ation. By the third post-operative day her mental status phalogram showed a non-specific right temporal dys- had improved dramatically and she was oriented to place, rhythmia and a normal neuropsychological profile. A sec- person and time with appropriate simple conversation. ond CT scan (fig 2) revealed the contrast enhancing, 2 0 Neuropsychological testing 16 months after surgery cm mass in the anterior third ventricle without hydro- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.47.10.1075 on 1 October 1984. Downloaded from Behavioural manifestations of third ventricular colloid cysts 1077 guest. Protected by copyright. - I~~~..-~ - -WI" Fig 2 (Case 2) Enhanced CT scan with an anterior third ventricular colloid cyst. There is no evidence ofsignificant Fig 3 (Case 3) CTscan after contrast infusion showing an anterior third ventricular mass without associated ventricular enlargement. hYdrocephalus. cephalus. The patient underwent a right frontal craniotomy paranoid schizophrenia. A second CT scan (fig 3) showed and a transcallosal removal of the colloid tumour. His persistence of the third ventricular tumour without hydro- postoperative course was complicated by 3 days of mutism cephalus. By a right transventricular operation a and several tonic-clonic seizures, the latter which were neuroepithelial cyst estmated at 2-0 cm in diameter was controlled with dilantin. After the mutism resolved the extirpated