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 third ventricle 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. Headaches 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 . Hydrocephalus 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. headache, 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 neurosurgery, 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 Amnesia 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.