ORIGINAL PAPER/ARTYKU£ ORYGINALNY Endoscopic technique in the treatment of patients with colloid cysts of the third ventricle. Report based on over a decade of experience Technika endoskopowa w leczeniu pacjentów z torbiel¹ koloidow¹ komory III mózgu. Raport na podstawie ponaddziesiêcioletniego doœwiadczenia Stanis³aw Kwiek1, Damian Kocur1, Hanna Dole¿ych1, Krzysztof Suszyñski1,2, Sebastian Szajkowski1, Ryszard Sordyl1, Wojciech Œlusarczyk1,3, Wojciech Kukier1, Piotr Ba¿owski1 1Department of Neurosurgery, Medical University of Silesia, Katowice 2Department of Neurology, Medical University of Silesia, Katowice 3Department of Physiology, Medical University of Silesia, Katowice Neurologia i Neurochirurgia Polska 2012; 46, 3: 216-223 DOI: 10.5114/ninp.2012.29129 A bstr act Streszczenie Background and purpose: The aim of the work was a retro- Wstêp i cel pracy: Celem pracy by³a retrospektywna analiza spective analysis of the efficiency of endoscopic treatment of skutecznoœci operacyjnego leczenia pacjentów z torbiel¹ koloi - patients with colloid cysts of the third ventricle. dow¹ komory III mózgu z zastosowaniem techniki endosko- Material and methods: The analysis covered 17 patients. There powej. were 19 operations in total. The follow-up period ranged from Materia³ i metody: Analizie poddano 17 chorych z torbiel¹ 21 to 130 months. The effectiveness of the method was evalu- koloidow¹ komory III mózgu operowanych metod¹ endosko- ated by comparing neurological condition and magnetic reso- pow¹, u których wykonano ³¹cznie 19 zabiegów. Czas obser- nance imaging (MRI) before and after treatment. wacji chorych wynosi³ 21–130 miesiêcy. Skutecznoœæ metody Results: The mean duration of surgery was 81 minutes. oceniano, porównuj¹c stan neurologiczny i obraz radiologicz- The cyst was removed completely in 8 patients, subtotally ny mózgowia przed zabiegiem i po zabiegu. in 5, partially in 3, and in 1 case a biopsy was performed. No Wyniki: Œredni czas operacji wynosi³ 81 min. Torbiel usuniêto persistent intra- or postoperative complications or deaths ca³kowicie u 8, prawie ca³kowicie u 5, a czêœciowo u 3 pacjen- occurred. Immediately after the operation symptoms with- tów. W jednym przypadku wykonano biopsjê. Nie odnotowa- drew completely in 8 patients and partially in 9. In the long no zgonów oko³ooperacyjnych ani trwa³ych powik³añ. Bezpo- term follow-up pe riod, all symptoms receded completely in œrednio po operacji ust¹pienie wszystkich objawów choroby 11 pa tients and afurther 6 patients showed partial improve- stwierdzono u 8, a czêœciow¹ poprawê u 9 osób. W odleg³ym ment. MRI revealed the absence of the cyst in 8 patients, in okresie u 11 pacjentów ust¹pi³y wszystkie objawy kliniczne, 2 patients the tumor was smaller in size and in a further 7 pa - a u 6 nast¹pi³a czêœciowa poprawa. W badaniu za pomoc¹ rezo- tients some small parts of the walls of the cyst were present. nansu magnetycznego brak torbieli wykazano u 8 chorych, The width of the ventricle system returned to its normal size u 2 stwierdzono guz o mniejszych rozmiarach, a u 7 resztkow¹ in 8 patients, decreased in 8 patients and in 1 case remained at œcianê torbieli. Szerokoœæ uk³adu komorowego powróci³a do its initial size. In 2 pa tients temporary postoperative complica- normy u 8 pacjentów, zmniejszy³a siê u 8 osób, a pozosta³a tions occurred. The average hospitalization time was 9 days. w stanie wyjœciowym w 1 przypadku. U 2 pacjentów w okre- Correspondence address: Stanis³aw Kwiek, Klinika Neurochirurgii SP CSK ŒUM, ul. Medyków 14, 40-752 Katowice, phone/fax +48 32 789 45 02, e-mail: [email protected] Received: 3.04.2011; accepted: 25.01.2012 216 Neurologia i Neurochirurgia Polska 2012; 46, 3 Endoscopic removal of colloid cysts Conclusions: Recurrences of colloidal cysts after subtotal and sie bezpoœrednim wyst¹pi³y przejœciowe powik³ania operacji. partial removal do not occur very often, and the time of the Œredni czas hospitalizacji wynosi³ 9 dni. recurrence may either be very long or it may not happen at all. Wnioski: Wznowy torbieli koloidowych po prawie doszczêt- Although we recommend complete removal of the cyst, this nym lub czêœciowym usuniêciu nie wystêpuj¹ czêsto; czas do should not be pursued at the cost of incurring operative com- ich pojawienia siê po operacji mo¿e byæ bardzo d³ugi lub wzno- plications. wa mo¿e nie pojawiæ siê w ogóle. Autorzy rekomenduj¹ d¹¿enie do doszczêtnego usuniêcia torbieli, lecz nie kosztem wyst¹pie- Key words: colloid cyst of the third ventricle, neuroendoscopy, nia powik³añ operacyjnych. ventriculostomy, hydrocephalus. S³owa kluczowe: torbiel koloidowa komory III, neuroendo- skopia, wentrykulostomia, wodog³owie. Introduction Material and methods Although the colloid cyst of the third ventricle (TVCC) Seventeen patients (6 males and 11 females) were ana - is a benign tumour of neuroepithelial origin, it can be lysed. Mean age of patients was 44 (range 23-77). They potentially lethal [1-3]. There is also the risk of neurolo - were treated at the Neurosurgery Department of the Sile- gical deterioration or death due to hydrocephalus [4]. sian Medical University in Katowice, between 2000 and For more than 10 years the endoscopic technique has 2010, for third ventricle colloid cysts. Nineteen endo- been an alternative to microsurgical procedures [2,5-7]. scopic procedures in total were performed in those pa- On the other hand, with currently available endoscopic tients as well as ventriculostomy for obstructive hydro- technique, to obtain total resection of the cyst seems to cephalus resulting from TVCC. The diameter of the be more difficult than with ‘conventional’ microsurgi- tumours ranged from 5 mm to 23 mm (mean 15.75 mm). cal technique. A neurosurgeon who decides to perform Diagnoses were made on the basis of magnetic resonance an endoscopic TVCC resection faces a decision when to imaging (MRI) and computed tomography (CT) as well cease the surgery to decrease the probability of compli- as on the basis of postoperative histological examination. cations which can occur with this ‘minimally invasive’ Patients were operated on using a Storz neuroendoscope method. The majority of surgeons prefer the approach with a 5 lens via a standard third ventricle approach. In of ‘minimal complication rate’ to total endoscopic resec- the majority of cases (all except 1 patient) ventriculostomy tion of the cyst at all cost. Nevertheless, complete tumour was performed after the tumour removal. This technique, removal remains ‘a gold standard’ of surgery and accord- tools and approach were described in detail in our recent ing to some reports can be achieved nearly as frequent- papers [15,16]. None of the patients required microsur - ly as with microsurgery in specialized centres [1,5]. One gical removal of remnants of the tumour via cranioto- could even say that the endoscopic removal of TVCC has my. The radicality of TVCC removal has been assessed become a standard treatment in many medical centres. on the basis of the surgeon’s intraoperative report as well However, only a few centres prefer the endoscopic me - as MRI performed between the third and the sixth month thod, in spite of the fact that conventional microsurgi- of the postoperative period. In the postoperative period cal access usually contributes to a higher rate of com- all the patients had MRI once a year for a period of plications and often accounts for additional neurological 5 years, after which the imaging was repeated after 3 and deficits. 5 years. Clinical assessments were performed twice: In this report we summarize our over ten years of directly after the operation and in the long-term post- experience in endoscopic surgery of TVCC. Our inten- operative period. The patients were followed prospec- tion is to illustrate the problem from the perspective of tively (average 67.8 months, range 21-130 months). Cli - an average, non-specialized neurosurgical ward which nical symptoms before and after operations, the results routinely uses endoscopic technique. The objective of this of the operative procedure, radiological findings before contribution is to attempt to find and discuss an optimal and after the treatment and other details relating to the ‘trade-off’ between the desire to remove the tumour total- patients are presented in Table 1. ly and the risk of complications which can result from such a radical approach. Neurologia i Neurochirurgia Polska 2012; 46, 3 217 Stanis³aw Kwiek, Damian Kocur, Hanna Dole¿ych, KrzysztofSuszyñski,Sebast Stanis³aw Kwiek,DamianKocur,HannaDole¿ych, 218 Table 1. Clinical symptoms before and after surgery, completeness of third ventricle colloid cyst removal, radiological findings before and after surgery, complications and current neurological status of the patientsa Patient Age Symptoms CT/MRI findings Operative Compli- Follow-up CT/cine MRI control no. [years]/ at admission at admission procedure cations [months] examination sex 1. 30/M Headache, vomiting, diplopia Cyst size 15 mm, Subtotal cyst evacuation, No 81 Residual membrane, hydrocephalus ventriculostomy enlarged ventricular size 2. 23/F Acute headache, vomiting, Cyst size 18 mm, Subtotal cyst evacuation, No 50 Complete resection, memory deficits hydrocephalus ventriculostomy normal ventricular size 3. 77/F Mental status change, gait Cyst size 23 mm, Subtotal cyst evacuation, No 40 Residual membrane, disturbances, nystagmus, hydrocephalus ventriculostomy enlarged ventricular size lower limbs weakness 4. 53/M Acute headache, vegetative Cyst size 16 mm, Partial cyst evacuation, Transient 63 Small residual cyst, symptoms, mental status change hydrocephalus ventriculostomy CN III palsy normal ventricular size 5. 32/M Visual deficits Cyst size 17.5 mm, Total cyst evacuation, No 41 Complete resection, hydrocephalus ventriculostomy normal ventricular size ian Szajkowski,RyszardSordyl,WojciechŒlusarczyk, 6. 33/F Headache, vomiting, vertigo, Cyst size 13 mm, Total cyst evacuation, No 41 Complete resection, somnolence, depression, visual hydrocephalus ventriculostomy normal ventricular size deficits, numbness, pyramidal signs 7. 34/F Nystagmus, tremor Cyst size 8 mm, Subtotal cyst evacuation, No 80 Residual membrane, hydrocephalus ventriculostomy normal ventricular size 8.