Colloid cysts of the third ventricle with fatal outcome: a report of two cases and review of the literature

Diagnostic Methods in Forensic Pathology: Autoptic Findings and Immunohistochemical Study in Cases of Sudden Death Due to a Colloid Cyst of the Third Ventricle

The colloid cyst is a non-malignant tumor growth made of a gelatinous material covered by a membrane of epithelial tissue. It is usually located posterior to the foramen of Monro, in the anterior aspect of the third ventricle of the brain. Due to its location, it can cause obstructive hydrocephalus, increased intracranial pressure, and sudden cardiac death, catecholamine-mediated, through hypothalamus compression. All the mechanisms are still controversial, but the role of catecholamine has been confirmed with histological findings that highlighted myocardial injury (coagulative myocytolysis and contraction band necrosis, CBN). This study presents a case of sudden death in a previously healthy 22-year-old male due to a colloid cyst of the third ventricle. A complete autopsy was performed, highlighting in the brain an abundant quantity of cerebrospinal fluid (CSF) and a 2 cm pale grayish-green rounded cyst formation partially filling and distending the third ventricle. The diagnosis was confirmed through immunohistochemical investigation: positivity for Periodic acid-Schiff (PAS) staining and CK7 expression. In cases such as the one reported here, a combined approach of autopsy, histology, and immunohistochemistry is mandatory in order to identify the neoformation's location and morpho-structural characteristics for a correct differential diagnosis, as well as to identify the cause of death.

Rate of Missed Intracranial Colloid Cysts on MRI and CT

BACKGROUND AND PURPOSE

Intracranial colloid cysts of the third ventricle are rare; however, they may be symptomatic. They can create a mass effect on the foramina of Monro, resulting in acute hydrocephalus. Colloid cysts are detectable on CT and MRI but are commonly missed. In this paper, we investigate the rate of missed colloid cysts on MRI and/or CT imaging within our multihospital metropolitan medical group.

MATERIALS AND METHODS

A retrospective, institutional review board-approved search of the network-wide picture archiving and communication system (PACS) from January 1, 2010, to October 31, 2020, was performed to identify reports including a "colloid cyst" in MRI brain or CT head imaging. Results without imaging and/or surgical confirmation of intracranial colloid cysts were excluded, rendering 229 cases. A PACS review of these cases was performed by two neuroradiologists to determine instances where the cyst had previously been imaged but not diagnosed on either CT or MRI.

RESULTS

Two hundred twenty-nine subjects had confirmed colloid cysts through imaging and/or surgical reports. Of these, 46 had prior imaging depicting a colloid cyst either on CT and/or MRI without mention on the interpretative report, resulting in a non-detection rate of 20.1%.

CONCLUSION

Intracranial colloid cysts can be missed at a considerably high rate, which is concerning given their clinically unpredictable nature and ability to cause significant morbidity and mortality. As such, it is important to take a proactive approach to searching for these cysts as part of a regular imaging search pattern and to continue to determine new methods of increasing detection sensitivity.

Intraventricular sizeable colloid cyst with atypical radiological features: A case report and evidence-based review

Colloid cysts are benign intracranial lesions, typically located in the anterior portion of the third ventricle near the interventricular foramina of Monro. The cysts usually consist of an epithelial lining filled with viscous gelatinous material of various components. Colloid cysts are generally asymptomatic, but once symptomatic, they can present in a variety of ways, including headaches, vomiting, visual and memory problems, and vertigo. Colloid cysts present classically on imaging as a well-delineated hyperattenuating lesion on unenhanced radiological modalities. Herein, we report a case of a patient who presented with hydrocephalus caused by a sizeable colloid cyst which demonstrated atypical imaging findings in the form of hypodensity on CT and hyperintensity on T2WI, making them difficult to identify and easy to miss. Although this atypical imaging appearance is uncommon with yet unknown true incidence, it is prudent to be aware of it because early management of colloid cysts has a favorable outcome, in contrast to untreated cysts that are associated with higher rates of morbidity and mortality. Additionally, we provide a comprehensive, evidence-based review of the medical entity of intracranial colloid cysts with highlights of current postulated pathological theories and management algorithms.

Sudden cardiac death in the young: A consensus statement on recommended practices for cardiac examination by pathologists from the Society for Cardiovascular Pathology

Sudden cardiac death is, by definition, an unexpected, untimely death caused by a cardiac condition in a person with known or unknown heart disease. This major international public health problem accounts for approximately 15-20% of all deaths. Typically more common in older adults with acquired heart disease, SCD also can occur in the young where the cause is more likely to be a genetically transmitted process. As these inherited disease processes can affect multiple family members, it is critical that these deaths are appropriately and thoroughly investigated. Across the United States, SCD cases in those less than 40 years of age will often fall under medical examiner/coroner jurisdiction resulting in scene investigation, review of available medical records and a complete autopsy including toxicological and histological studies. To date, there have not been consistent or uniform guidelines for cardiac examination in these cases. In addition, many medical examiner/coroner offices are understaffed and/or underfunded, both of which may hamper specialized examinations or studies (e.g., molecular testing). Use of such guidelines by pathologists in cases of SCD in decedents aged 1-39 years of age could result in life-saving medical intervention for other family members. These recommendations also may provide support for underfunded offices to argue for the significance of this specialized testing. As cardiac examinations in the setting of SCD in the young fall under ME/C jurisdiction, this consensus paper has been developed with members of the Society of Cardiovascular Pathology working with cardiovascular pathology-trained, practicing forensic pathologists.

A case of recurrent flight-induced cerebrospinal fluid shunt overdrainage

Shunted patients often complain of headaches after flights. The effect of air travel on shunt systems is unknown. We describe the case of a patient with longstanding hydrocephalus, who suffered flight-induced clinical deterioration and shunt overdrainage in two independent occasions. The patient, clinically stable for 1.5 and 5 years before each episode, reported severe headaches starting during the descent stages of the air travel. On both occasions, brain MRI imaging demonstrated pronounced ventricular size reduction. This case suggests that flight-induced shunt overdrainage can occur and should be suspected in patients with prolonged headaches and/or clinical deterioration triggered by air travel.

Delayed hydrocephalus after excision of a colloid cyst: a case report

Background

In this case report we describe an unusual case of a patient who underwent resection of a colloid cyst and then presented 6 weeks postoperatively with obstructive hydrocephalus. There appear to be no prior reports of such a delayed complication after colloid cyst resection.

Case presentation

A 50-year-old Caucasian woman underwent resection of a colloid cyst with an uncomplicated perioperative course. Postoperative imaging demonstrated complete resection of the cyst. She was discharged home on postoperative day 4 but presented 6 weeks later with symptoms of obstructive hydrocephalus resulting in poor neurologic outcome and ultimately death.

Conclusion

Patients presenting with symptoms of hydrocephalus after resection of a colloid cyst should be followed closely, and timely placement of an external ventricular drain may be critical.

Retrospective evaluation of endoscopic treatment in colloid cyst of the third ventricle

Introduction

Endoscopic methods have gained a well-established position in surgical treatment of colloid cysts of third ventricle. However, the possibility of total tumor removal with this method and the long-term effectiveness of treatment are being questioned.

Aim

Personal twenty years’ experience in treatment of third ventricle colloid cysts is presented on the basis of retrospective analysis.

Material and methods

The study group included 58 patients diagnosed by neuroimaging (head CT/MRI) with third ventricle colloid cyst. Post-hospital follow-up ranged from 18 to 42 months. Long-term follow-up head CT/MRI was performed in 39 patients.

Results

The colloid cyst was removed totally in 47 (81%) patients. In 11 cases, the colloid cyst’s wall was tightly adherent to the roof of the third ventricle, which limited the radicality of the procedure. Sixteen patients demonstrated memory impairments, 4 patients epilepsy and another 2 akinetic mutism in the direct postoperative course. One patient died as a result of complications unrelated to the procedure. The average hospitalization was 5 days. In the late period after surgery, remission of the most, previously, reported ailments and symptoms has been reported. Surgical treatment for hydrocephalus was needed in 7 patients. In 3 cases cyst recurrence was diagnosed which required reoperation.

Conclusions

The endoscopic methods allow the total removal of a third ventricle colloid cyst in most patients. Leaving a small coagulated fragment of the cyst rarely results in its recurrence. This method results in effective treatment with a low complications rate, shortens hospitalization time and brings the patient a high level of satisfaction with a quick recovery.

Colloid cysts of the third ventricle in children

OBJECTIVE

The rarity of colloid cysts in children makes it difficult to characterize this entity and offer meaningful advice on treatment. Infrequent case reports exist, but to date there has been no age-specific assessment. The purpose of this study was to define any differences between children and adults who are evaluated and treated for colloid cysts of the third ventricle.

METHODS

Patients with colloid cysts were reviewed and stratified by age. Individuals ≤ 18 years of age were defined as pediatric patients and those > 18 years of age as adults. Clinical and radiographic data, treatment, and postoperative outcomes were compared between both groups. Bivariate analysis was conducted using the Fisher exact test for categorical variables and Mann-Whitney U-test for continuous variables.

RESULTS

Of 132 endoscopic resections (121 primary, 10 secondary, and 1 tertiary) of a colloid cyst, 9 (6.8%) were performed in pediatric patients (mean age 14.1 years, range 9-18 years) and 123 (93.2%) were performed in adult patients (mean age 43.8 years, range 19-73 years). Cases were found incidentally more commonly in pediatric than adult patients (66.7% vs 37.4%, p > 0.05), and pediatric patients had lower rates of hydrocephalus than adult patients (11.1% vs 63.4%, p < 0.05). Acute decompensation at presentation was found in 8 adults (6.5%) but no children. Complete cyst removal (88.9% vs 90.2%, p > 0.05) and length of stay (1.6 days vs 2.9 days, p > 0.05) were not significantly different between the groups. Postoperative complications (6.5% in adults, 0% in children) and recurrence (2.4% in adults, 0% in children) were rare in both groups, and there were no treatment-related deaths. The mean postoperative radiological follow-up was longer in pediatric patients (45 months, range 4-89 months) than adults (44.1 months, range 1-171 months).

CONCLUSIONS

While differences exist between children and adults regarding colloid cyst presentation, these are in keeping with the predicted evolution of a slow-growing lesion. Consistent with this observation, children had lower rates of hydrocephalus and a smaller mean maximal cyst diameter. Contrary to the published literature, however, sudden deterioration was not observed in pediatric patients but occurred in adult patients. In this limited pediatric sample size, the authors have not recorded any postoperative complications or recurrences to date. These encouraging results with endoscopic removal may positively impact future decisions related to children given their protracted life expectancy and projected rates of progression.

Rare large colloid cyst obstructing the posterior third ventricle: illustrative case

BACKGROUND

Colloid cysts of the posterior third ventricle are exceedingly rare. This location is a high-risk zone for colloid cysts because of potential obstruction of the cerebral aqueduct.

OBSERVATIONS

The authors report a case of a 57-year-old man who presented with a 6-month history of progressive headache, short-term memory loss, visual blurring, and an episode of double vision. Magnetic resonance imaging (MRI) revealed a colloid cyst, 22 mm in diameter, attached to the roof of the posterior third ventricle. The posterior third ventricle was obstructed, but both foramina of Monro were patent. The entirety of the cyst was resected via a right frontal parasagittal, interhemispheric, transventricular approach through the foramen of Monro. It was not contained within the velum interpositum. The patient did not experience any postoperative deficits.

LESSONS

This case supports the theoretical evidence that colloid cysts in the posterior zone of the third ventricle pose a risk for obstructive hydrocephalus. This report of a large cyst in a rare location describes a unique lesion and provides the first published MRI description.

A 3rd ventricular colloid cyst causing acute hydrocephalus with stunned myocardium: A case report

Background: Third ventricular colloid cysts are benign but may cause acute hydrocephalus, raised intracranial pressure, decreased consciousness level, and sudden death. These ventricular colloid cysts associated with stunned myocardium are rarely reported in the literature. This study reported a case of a third ventricular colloid cyst presented as acute hydrocephalus complicated with severe neurogenic pulmonary edema, stunned myocardium, and heart failure, which survived at the end.

Case presentation: A 29-year-old woman presented to the emergency department with one day history of headache, vomiting, and altered consciousness level. Early brain imaging showed a cyst in the third ventricle. The patient rapidly deteriorated neurologically and developed severe pulmonary edema and heart failure requiring immediate external ventricular drain and heart failure management. Once stabilized, she underwent endoscopic excision of the ventricular cyst. Histopathology confirmed the diagnosis of colloidal cyst. She survived all these acute life-threatening events, improved, and stabilized, and was discharged home. She was followed up in outpatient clinics after 6 months of discharge with no symptoms or neurological deficit.

Conclusion: A third ventricular colloid cyst can cause acute hydrocephalus leading to stunned myocardium requiring immediate surgical intervention, advanced hemodynamic monitoring, and acute heart failure management.

Risk Analysis and Management of Third Ventricular Colloid Cysts

OBJECTIVE

Colloid cysts (CCs) are histologically benign lesions that carry the risk of causing obstructive hydrocephalus. The indication for surgery for symptomatic cysts is unquestioned; however, the management of incidentally detected lesions has remained controversial. We independently evaluated the CC risk score (CCRS) as a useful risk stratification scheme.

METHODS

The demographics, imaging characteristics, and clinical presentations of 103 patients with CC during a 10-year period were correlated with symptoms and the occurrence of hydrocephalus. The discriminate capacity of the CCRS was quantified and a decision algorithm formulated.

RESULTS

The correlates of symptoms included age <65 years, diameter ≥7 mm, anterior location, hyperintensity on T2-weighted fluid-attenuated inversion recovery (FLAIR) and/or T2-weighted images, and headache at presentation without an alternative explanation. On multivariate analysis, age <65 years, diameter ≥7 mm, and headache at presentation predicted for symptomatic cysts. The CCRS was highly effective at identifying symptomatic patients and those with obstructive hydrocephalus. All patients with cyst growth and symptomatic progression had had an initial CCRS of ≥3 plus hyperintensity (preexisting or developing) on T2-weighted FLAIR images.

CONCLUSIONS

The CCRS performed exceptionally well in distinguishing the highest risk patients. Closer follow-up is recommended for younger asymptomatic patients with cysts near the foramen of Monro. Hyperintensity on T2-weighted FLAIR images might indicate greater growth potential for small lesions.

Clinical and radiological characteristics in fatal third ventricle colloid cyst. Literature review

BACKGROUND

Colloid cysts are a benign tumor that is almost exclusively found in the third ventricle and may cause hydrocephalus and rarely life-threatening acute deterioration and even sudden death. With very few cases of sudden death reported in literature not much is known about the patient and cyst characteristics in these patients. The authors present a review of 65 cases of colloid cyst attributed deaths in literature.

MATERIALS AND METHODS

A literature search for sudden death with radiologically or pathologically identified colloid cyst was done on PubMed, google scholar, Medbase and clinicaltrials.org research drives. Patient demographics, symptoms and cyst characteristics were recorded and analyzed. A Bivaret Pearson correlationcoefficientwas used to analyze and compare the relationship between each antecedent symptom, cyst size, and, cyst hemorrhage in patients who subsequently succumbed and died in order to ascertain possible relation.

RESULTS

Most patients had a history of sudden severe headaches (p = 0.01) with associated vomiting (p = 0.03). Radiologically, cyst associated ventriculomegaly was seen in 97% (P = 0.78) was a notable feature. Even more, the cyst size (p = 0.01) and associated hemorrhage (p = 0.02) were also major notable feature preceding sudden death in both gender group.

CONCLUSION

Acute deterioration in colloid cysts is rare, but can be fatal. Associated symptoms include severe headache and vomiting. Seizures are commonly seen in patients in the first two decades. Given the risk of acute deterioration and mortality, headaches should be thoroughly investigated and all patients diagnosed with a colloid cyst > 1 cm should be offered surgical management regardless of symptom profile.

Interrater and Intrarater Reliability of the Colloid Cyst Risk Score

BACKGROUND

The Colloid Cyst Risk Score (CCRS) was developed to identify symptomatic patients and stratify risk of hydrocephalus among patients with colloid cysts. Its components consider patient age, cyst diameter, presence/absence of headache, fluid-attenuated inversion recovery (FLAIR) hyperintensity, and location within the third ventricle.

OBJECTIVE

To independently evaluate the inter- and intrarater reliability of the CCRS.

METHODS

Patients with a colloid cyst were identified from billing records and radiology archives. Three independent raters reviewed electronic medical records to determine age, presence/absence of headache, cyst diameter (mm), FLAIR hyperintensity, and risk zone location. Raters made 53 observations, including 5 repeat observations.Fleiss' generalized kappa (κ) was calculated for all of the nominal criteria, whereas Kendall's coefficient of concordance (W) and the intraclass correlation coefficient (ICC) were calculated for the overall score.

RESULTS

Total CCRS score demonstrated extremely strong agreement (W = 0.83) using Kendall's W coefficient and good agreement (ICC = 0.74) using the ICC (P < .001). For interrater reliability of individual criteria, age (κ = 1.00) and FLAIR hyperintensity (κ = 0.89) demonstrated near perfect agreement. Axial diameter (κ = 0.63) demonstrated substantial agreement, whereas agreement was moderate for risk zone (κ = 0.51) and fair for headache (κ = 0.26). Intrarater reliability for total CCRS score was extremely strong using Kendall's W, good to excellent using ICC, and fair to substantial using weighted kappa.

CONCLUSION

The CCRS has good inter- and intrarater reliability when tested in an independent sample of patients, though strength of agreement varies among individual criteria. The validity of the CCRS requires independent evaluation.

Paroxysmal Lower Limb Tremor as a Rare Presentation of Colloid Cyst of the Third Ventricle: A Case Report and Literature Review

Objective:

Colloid cysts of the third ventricle are benign intracranial tumors. They are most commonly presented with signs of intracranial hypertension due to obstructive hydrocephalus, including headache, nausea/vomiting and vision disturbances, whereas extrapyramidal symptoms such as tremor are very rare. Sudden death, due to abruptly developed hydrocephalus, can be also observed. Although paroxysmal symptomatology attributed to the intermittent obstruction of the foramen of Monro is considered the “classical” clinical presentation, it is rather the exception in clinical practice.

Case Report:

A 42-year-old woman with no medical history was admitted to the neurology department as suffering from a potential demyelinating disease due to episodes of paroxysmal tremor of her right lower limb and persistent mild gait instability, which presented 15 days prior to her arrival. She also complained of episodes of partially position-dependent bilateral headache over the last 10 years, as well as episodes of vertigo over the last 4 years. On arrival, her gait was shuffling and mildly wide-based and an intermittent tremor of her right lower limb was observed in supine and sitting positions, but not in a prone position. Brain magnetic resonance imaging (MRI) demonstrated a round cystic lesion of the third ventricle, accompanied by hydrocephalus with enlargement of lateral ventricles. MRI findings were highly indicative of a colloid cyst. The patient underwent resection of the mass and the tremor resolved after surgery.

Conclusion:

Given the greatly heterogeneous clinical presentation of colloid cysts, our case highlights the significance of the prompt diagnosis of this rare but potentially fatal cause of paroxysmal limb tremor.

Flying with Colloid Cyst: A Cautionary Note

BACKGROUND

Colloid cysts are benign and rare tumors of the brain. The growth rates of these tumors are unpredictable. These cysts can increase in size and obstruct the cerebrospinal fluid pathways producing obstructive hydrocephalus. Consequently, this can manifest as acute severe headaches followed by deterioration in consciousness, or even sudden death in patients. Such remarkable episodes occurring in patients during air travel have been reported sparsely in the literature.

CASE DESCRIPTION

In this report, we narrate the ordeal of a patient who had severe headache followed by loss of consciousness during his air travel. After his arrival, he was taken to a referral center where the diagnosis of a colloid cyst obstructing the cerebrospinal fluid pathway resulting in acute obstructive hydrocephalus was revealed. We analyze the physiologic effects of cabin pressure and high altitude on the intracranial pressure and present a brief review of the literature.

CONCLUSIONS

Changes in cabin pressure during flight may play a role in worsening of intracranial pressure in patients with colloid cyst with marginal brain compliance.

Feasibility and Challenges of Microsurgical Resection of Colloid Cysts in Patients with Preexisting Ventriculoperitoneal Shunts

BACKGROUND

Colloid cysts are the most common third ventricular tumor and may present with symptoms related to obstructive hydrocephalus. Although definitive endoscopic or microsurgical resection is the standard of care, patients may receive temporizing ventriculoperitoneal shunts when definitive management is deferred. Subsequent definitive treatment can be challenging because of the ventricular collapse and narrowing of the operative corridor. There is currently no literature evaluating the feasibility of definitive colloid cyst resection in patients with preexisting ventriculoperitoneal shunts.

METHODS

We retrospectively reviewed records for patients undergoing colloid cyst resection between 2009 and 2019 to identify patients with preexisting shunts prior to surgery.

RESULTS

Three patients had preexisting ventriculoperitoneal shunts. Two patients had been shunted at outside institutions where microsurgical or endoscopic resection was not available. One patient received a shunt from an outside surgeon when she was deemed a poor surgical candidate because of cardiac instability. All 3 patients underwent successful gross total colloid cyst resection via the transcallosal approach without recurrences during a mean follow-up of 4.2 years. All patients had intact cognitive and memory function and returned to work.

CONCLUSIONS

Surgical resection of colloid cysts is possible despite a preexisting ventriculoperitoneal shunt. Because the ventricular space may be collapsed postoperatively because of cerebrospinal fluid diversion, a transcortical route (either endoscopic or microscopic) can be complicated by a small operative corridor with reduced visibility. The transcallosal approach was safe and feasible in these cases for providing midline access with adequate visualization for complete resection despite ventricular collapse.

Surgical management of colloid cysts in children: experience at a tertiary care center

INTRODUCTION

Colloid cysts are uncommon lesions in the pediatric age group, which most commonly occur in the fourth through fifth decades. The authors hereby report a series of 36 patients with colloid cysts in the pediatric age group.

MATERIAL AND METHOD

A retrospective chart review was conducted on all patients with colloid cyst who underwent surgery in our institute between November 2003 and December 2016 (13 years). Patients above the age of 18 were excluded from the study. They were analyzed based on clinical presentation, radiological findings, surgical approaches, and outcome.

RESULTS

There were 36 pediatric patients selected for the study. Age ranged from 8 to 18 years. The male-to-female ratio was 3.5:1. Headache and vomiting were the most common symptoms, and papilledema is the most common clinical sign. The mean duration of symptoms was 9 months (range 1 day to 5 years), but 27 (75%) of the children had precipitous symptoms just before presentation. Preoperative CT showed a hyperdense non-enhancing lesion in the majority of cases. Endoscopic excision was done in 13; 5 patients underwent transcortical transventricular excision, while transcallosal approach was opted for in 17 patients. In one patient, the colloid cyst could not be removed endoscopically and had to be converted to transcortical transventricular approach. Postoperatively, five patients developed CSF leak. They were successfully managed conservatively. One patient had operative site extra dural hematoma and underwent re-exploration, and two patients had transient hemiparesis which improved spontaneously. The median follow-up period was 9 months in the 30 available patients. Though no formal neuropsychological testing was done at follow-up, all children appeared to be doing well without memory disturbances.

CONCLUSION

Pediatric colloid cysts are less common and may show rapid deterioration. Timely surgery results in a permanent cure with minimum morbidity. The results of either micro neurosurgical or endoscopic operative excision of colloid cysts in children are excellent. All children who are symptomatic with raised intracranial pressure due to a third ventricular colloid cyst should undergo definitive surgery. There were no major permanent deficits in memory or disconnection syndromes observed with the limited anterior colostomy.

Fatal Colloid Cysts: A Systematic Review

OBJECTIVE

To accurately describe patient characteristics and the clinical presentation of fatal colloid cysts.

METHODS

A systematic literature search of 3 popular databases was performed. Inclusion criteria were individuals with sudden-onset death and colloid cysts identified on imaging and/or autopsy. The cause of death must have been ascribed to the colloid cyst to be eligible for data extraction. Deaths precipitated by lumbar puncture were excluded. Clinical data were extracted and descriptive statistics were ascertained. Subgroup analyses were performed to compare adults with pediatric patients.

RESULTS

A total of 107 patients were included in the quantitative synthesis. The mean age was 28.5 years (standard deviation 13.3, range 6-79 years). Male and female patients were affected equally. Headache was the most frequent symptom (n = 86, 80%). There were 6 patients (5 adults and 1 child) who reported positional headaches. The mean duration of signs and symptoms was shorter in adults versus pediatric patients (2.1 days vs. 6.5 days, P = 0.02), and more adults presented with signs and symptoms for less than 24 hours than did pediatric patients (38% vs. 6%, P = 0.01). Colloid cyst mean diameter was 2.0 cm (standard deviation 1.1, range 0.5-7.9 cm) and 96% measured 1 cm or larger.

CONCLUSIONS

Our data suggests that the prodrome preceding sudden death in the setting of a colloid cyst may be shorter in adults. Also, most fatal colloid cysts measured 1 cm or larger.

Microsurgical Treatment of Colloid Cysts of the Third Ventricle

BACKGROUND

This study analyzes the results of surgical treatment in 377 patients with colloid cysts (CCs) of the third ventricle who were treated at the Burdenko Neurosurgery Institute from 1981 to 2015. Operations were performed by a single surgeon (the first author of the article).

METHODS

The transcallosal approach was used to remove CCs in 97% of cases. Total cyst removal was performed in 96% of cases (in 4% of cases, a small cyst capsule fragment was left on the veins and fornix); in 3 cases, the cyst recurred, which required its repeated removal.

RESULTS

Hydrocephalus symptoms regressed in 98% of patients. The most frequent complications in the early postoperative period were memory impairments of varying severity, with a tendency to regress by the time of discharge. Two patients had an intraventricular hematoma, which required operative exploration in 1 patient. There were 4 cases of meningitis (including 1 shunt-associated meningitis) and 5 cases of transient pyramidal insufficiency.

CONCLUSIONS

We made a preliminary assessment of the reasonability of the infratentorial supracerebellar approach for removal of CCs in 10 cases.

Natural history of colloid cysts of the third ventricle

OBJECTIVE Colloid cysts are rare, histologically benign lesions that may result in obstructive hydrocephalus and death. Understanding the natural history of colloid cysts has been challenging given their low incidence and the small number of cases in most reported series. This has complicated efforts to establish reliable prognostic factors and surgical indications, particularly for asymptomatic patients with incidental lesions. Risk factors for obstructive hydrocephalus in the setting of colloid cysts remain poorly defined, and there are no grading scales on which to develop standard management strategies. METHODS The authors performed a single-center retrospective review of all cases of colloid cysts of the third ventricle treated over nearly 2 decades at Washington University. Univariate analysis was used to identify clinical, imaging, and anatomical factors associated with 2 outcome variables: symptomatic clinical status and presentation with obstructive hydrocephalus. A risk-prediction model was defined using bootstrapped logistic regression. Predictive factors were then combined into a simple 5-point clinical scale referred to as the Colloid Cyst Risk Score (CCRS), and this was evaluated with receiver-operator characteristics. RESULTS The study included 163 colloid cysts, more than half of which were discovered incidentally. More than half of the incidental cysts (58%) were followed with surveillance neuroimaging (mean follow-up 5.1 years). Five patients with incidental cysts (8.8%) progressed and underwent resection. No patient with an incidental, asymptomatic colloid cyst experienced acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly half (46.2%) of symptomatic patients presented with hydrocephalus. Eight patients (12.3%) presented acutely, and there were 2 deaths due to obstructive hydrocephalus and herniation. The authors identified several factors that were strongly correlated with the 2 outcome variables and defined third ventricle risk zones where colloid cysts can cause obstructive hydrocephalus. No patient with a lesion outside these risk zones presented with obstructive hydrocephalus. The CCRS had significant predictive capacity for symptomatic clinical status (area under the curve [AUC] 0.917) and obstructive hydrocephalus (AUC 0.845). A CCRS ≥ 4 was significantly associated with obstructive hydrocephalus (p < 0.0001, RR 19.4). CONCLUSIONS Patients with incidentally discovered colloid cysts can experience both lesion enlargement and symptom progression or less commonly, contraction and symptom regression. Incidental lesions rarely cause acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly one-half of patients with symptomatic colloid cysts present with obstructive hydrocephalus, which has an associated 3.1% risk of death. The CCRS is a simple 5-point clinical tool that can be used to identify symptomatic lesions and stratify the risk of obstructive hydrocephalus. External validation of the CCRS will be necessary before objective surgical indications can be established. Surgical intervention should be considered for all patients with CCRS ≥ 4, as they represent the high-risk subgroup.

A systematic review of causes of sudden and severe headache (Thunderclap Headache): should lists be evidence based?

Background

There are many potential causes of sudden and severe headache (thunderclap headache), the most important of which is aneurysmal subarachnoid haemorrhage. Published academic reviews report a wide range of causes. We sought to create a definitive list of causes, other than aneurysmal subarachnoid haemorrhage, using a systematic review.

Methods

Systematic Review of EMBASE and MEDLINE databases using pre-defined search criteria up to September 2009. We extracted data from any original research paper or case report describing a case of someone presenting with a sudden and severe headache, and summarized the published causes.

Results

Our search identified over 21,000 titles, of which 1224 articles were scrutinized in full. 213 articles described 2345 people with sudden and severe headache, and we identified 6 English language academic review articles. A total of 119 causes were identified, of which 46 (38%) were not mentioned in published academic review articles. Using capture-recapture analysis, we estimate that our search was 98% complete. There is only one population-based estimate of the incidence of sudden and severe headache at 43 cases per 100,000. In cohort studies, the most common causes identified were primary headaches or headaches of uncertain cause. Vasoconstriction syndromes are commonly mentioned in case reports or case series. The most common cause not mentioned in academic reviews was pneumocephalus. 70 non-English language articles were identified but these did not contain additional causes.

Conclusions

There are over 100 different published causes of sudden and severe headache, other than aneurysmal subarachnoid haemorrhage. We have now made a definitive list of causes for future reference which we intend to maintain. There is a need for an up to date population based description of cause of sudden and severe headache as the modern epidemiology of thunderclap headache may require updating in the light of research on cerebral vasoconstriction syndromes.

Endoscopic resection of incidental colloid cysts

OBJECT

Incidental colloid cysts are frequently managed with surveillance imaging rather than surgical excision. This approach is born out of their purported indolent growth pattern and the surgical morbidity associated with microsurgical removal. The advent of endoscopic colloid cyst removal may offer renewed assessment of these patients who carry a risk of acute neurological deterioration. An evidence-based recommendation should weigh the risks of operative treatment. Thus far, there has been no concentrated assessment of cyst removal in patients with incidental colloid cysts. The major objective in this study was to define the risks associated with the endoscopic surgical removal of incidentally diagnosed colloid cysts.

METHODS

A retrospective review of the medical records was performed to search for patients evaluated for a colloid cyst between the years 1996 and 2012. Eighty-seven patients underwent colloid cyst resection, and 34 were managed with nonoperative surveillance imaging. Microsurgical resections, endoscopic resections of residual or recurrent colloid cysts, and cases with unknown preoperative symptomatic status were excluded from further analysis. Seventy-seven cases of primary endoscopic resections were identified. Twenty resections were performed in patients with an incidental diagnosis and 57 in symptomatic individuals. Presenting characteristics and surgical outcomes were compared between the incidental and symptomatic groups.

RESULTS

The mean age at surgery was 39.65 years for the incidental and 43.31 years for the symptomatic group (p = 0.36). The median maximal cyst diameter was 9.7 mm (range 3-31 mm) for the incidental and 12 mm (range 5-34 mm) for the symptomatic group. The mean frontal and occipital horn ratio was 0.3928 for the incidental and 0.4445 for the symptomatic group (p = 0.002). Total resection was achieved in 90% of the incidental and 82.3% of the symptomatic cases (p = 0.49). The median hospital stay was 1 day for incidental and 2 days for symptomatic cases (p = 0.006). There were no deaths. There was one case of aseptic meningitis in the incidental group. In the symptomatic group there were 3 complications: one patient with subjective memory impairment, one with transient short-term memory deterioration, and another with a superficial wound infection treated with operative debridement. Two patients from the symptomatic group needed a CSF diversion procedure, and no shunting was needed in the incidental group. There were two recurrences in the symptomatic group (78 and 133 months postoperatively) and none in the incidental group (p = 1).

CONCLUSIONS

Age and cyst diameter were not correlated with the absence or presence of symptoms in patients with a colloid cyst of the third ventricle. Operative results were highly favorable in both groups and did not reveal a higher risk of morbidity in the patient presenting with an incidental lesion. The results support endoscopic resection as a legitimate therapeutic option for patients with incidental colloid cysts. Generalization of the operative results should be cautiously made, since this is a limited series and the results may depend on the degree of neuroendoscopic experience.

Hemorrhagic colloid cyst: Case report and review of the literature

Colloid cysts are cystic lesions located at the anterior part of third ventricle, close to foramen of Monro and contain colloid material. Hemorrhage in a colloid cyst is very rare. On literature review, we found only six cases of hemorrgic colloid cyst; among them, four were diagnosed at postmortem examination. We report a rare case of a hemorrhagic colloid cyst in a young lady who presented with sudden onset severe headache and vomiting. Computed tomography (CT) scan showed isodense lesion located at foramen of Monro with hyperdense areas suggestive of hemorrhage with foraminal obstruction. The lesion was not enhancing on contrast. Magnetic resonance imaging (MRI) brain revealed a well-defined cystic mass lesion located at the foramen of Monro which was hyperintense on T1 and hypointense on T2-weighted images. Excision of the colloid cyst was performed which revealed hemorrhagic clot instead of colloid material. Histopathological examination revealed a colloid cyst with hemorrhage. We believe that this is the first such reported case of successful clinical outcome following early diagnosis and excision of a hemorrhagic colloid cyst in an adult.

Full scope of options

OBJECTIVE

The purpose of Clinical Problem Solving articles is to present management challenges to give practicing neurosurgeons insight into how field leaders address these dilemmas. This illustration is accompanied by a brief review of the literature on the topic.

PRESENTATION

The case of a 16-year-old boy presenting with headaches is presented. The patient is found to have a typical colloid cyst at the foramen of Monro. Bilateral ventriculoperitoneal shunt placement had been performed as an initial treatment of the patient before presentation.

RESULTS

Surgeons experienced in open and endoscopic surgery discuss their individual approaches to colloid cysts, in the context of previous shunting, providing a varied perspective on the clinical challenges posed by these lesions.

CONCLUSION

Both open and endoscopic options remain viable for excision of a colloid cyst. Each has associated potential complications, as illustrated by the current case.

Colloid cyst of the third ventricle, hypothalamus, and heart: a dangerous link for sudden death

Colloid cysts are rare congenital, intracranial neoplasms, commonly located in the third ventricle. Colloid cysts are endodermal congenital malformations. The cysts commonly range in size from 1-2 cm in diameter, although large cysts >3 cm in size have been reported. The components of the cyst include an outer fibrous capsule over an inner epithelium. The epithelium is usually a single layer of mucin-producing or ciliated cells. Such cysts contain mucoid and gelatinous material, which is positive for both Periodic acid Schiff (PAS) and mucicarmen staining. Although colloid cysts usually represent histopathologically benign neoplasms, they can result in sudden, unexpected and potentially lethal complications. The mechanism(s) of death is still a controversial subject and several mechanisms have been postulated to explain the sudden onset of severe symptoms and of fatal rapid deterioration in patients with colloid cysts. In this case, macroscopic and histological findings addressed the diagnosis of colloid cyst of the third ventricle with diffuse myocardial injury (coagulative myocytolysis or contraction band necrosis, CBN) and led us to conclude that acute cardiac arrest due to hypothalamus stimulation in the context of colloid cyst of the third ventricle was the cause of death. As the hypothalamic structures which are involved in neuroendocrine and autonomic regulation playing a key role in cardiovascular control are located close to the walls of the third ventricle which is the most frequent anatomical site of colloid cyst, this may suggest that reflex cardiac effects due to the compression of the hypothalamic cardiovascular regulatory centers by the cyst explain the sudden death in patients harboring a colloid cyst when signs of hydrocephalus or brain herniation are lacking.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/4915842848034158.

Acute hemorrhage in a colloid cyst of the third ventricle: A rare cause of sudden deterioration

Background:

Acute neurological deterioration and death in a patient harboring a colloid cyst of the third ventricle remains a poorly understood phenomenon. Sudden neurological derangement caused by spontaneous bleeding within a colloid cyst is a rare and potentially fatal event, usually requiring immediate diagnosis and emergency surgical treatment.

Case Description:

A 47-year-old male presented with acute right-sided hemiparesis and speech impediment, followed by rapid deterioration of consciousness. Neuroimaging studies showed a rounded mass at the roof of the anterior third ventricle, causing biventricular hydrocephalus along with a left-sided basal ganglia hematoma. The lesion showed scattered foci of a recent hemorrhage which extended into the left lateral ventricle. Surgical treatment involved emergency external ventricular drainage followed by the prompt elective total resection of the lesion via a transcallosal route. Pathological findings confirmed the diagnosis of a colloid cyst with focal areas of vascular congestion and blood extravasation within its wall.

Conclusions:

Spontaneous bleeding into a colloid cyst of the third ventricle may cause acute obstructive hydrocephalus and intracranial hypertension due to rapid enlargement of the lesion. This event may account for the sudden neurological deterioration and/or death observed in a previously asymptomatic patient. The diagnosis of hemorrhagic phenomena within a colloid cyst represents a challenge due to the variable signal usually displayed by these lesions on computed tomography (CT) and magnetic resonance imaging (MRI). Emergency ventricular drainage followed by elective tumoral removal constitutes a valid and safe treatment strategy.

Complete endoscopic removal of colloid cyst using a nitinol basket retriever

Neuroendoscopic treatment of colloid cysts is limited by the reach and flexibility of the instruments that can be passed through the working channels of the rigid neuroendoscope. The authors describe a case of a third ventricular colloid cyst where a large solid colloid fragment was recovered using a nitinol stone retrieval basket as a flexible wall-guided atraumatic salvage instrument. A flexible nitinol stone retrieval basket was successfully used through an endoscopic working channel to retrieve a large portion of the colloid cyst from the occipital horn of the lateral ventricle in a 70-year-old man who presented with progressive memory loss, urinary incontinence, and slowness of gait. A flexible nitinol stone retrieval basket can be safely and effectively maneuvered in the ventricular system, using the ventricular wall for deflection, and can be used to retrieve colloid cyst fragments as a salvage technique. Remaining free-floating large colloid cyst fragments in the ventricular system do not necessarily require a second craniotomy or bur hole for access but may be retrieved using a nitinol stone retrieval basket.

Pediatric colloid cysts of the third ventricle: management considerations

PURPOSE

Pediatric colloid cysts (CC) have a congenital origin, and yet, there are very few studies focussing exclusively on their occurrence in the pediatric population. Pediatric CC has been associated with more aggressive clinical and radiological patterns than their adult counterparts. In this study, undertaken on children with anterior third ventricular CC, excised using the interhemispheric transcallosal approach, the characteristic clinicoradiological features and management options are studied.

METHODS

Five pediatric patients (aged 16 years or less; mean age 13.8 years; mean duration of symptoms:7.6 months) out of 38 patients with CC operated between 1995 to 2009 were included. The clinical manifestations included those of raised intracranial pressure (n = 4); exacerbation of occipital headache on reading (n = 1); secondary optic atrophy (n = 3); and, drop attacks (n = 1). On computed tomography scan, the cyst was hyperdense, enhancing in two patients and not enhancing in three patients. All had bilateral lateral ventricular dilatation with periventricular lucency. On magnetic resonance imaging (n = 3), the cyst was T1 hypointense and T2 isointense in one, hyperintense on both T1 and T2 with a hypointense capsule and nonenhancing on contrast in one (with a giant colloid cyst), and T1 hyperintense and T2 hypointense in one patient. An interhemispheric, transcallosal trajectory combined with transforminal approach (n = 3); combined transforminal and subchoroidal approaches (n = 1); and, interforniceal approach (n = 1) were used.

RESULTS

Total excision was performed in four patients. In one patient, a small part of capsule was left attached to thalamostriate vein. Symptoms of raised intracranial pressure showed improvement in all the patients with resolution of hydrocephalus. There was no tumor recurrence at follow-up.

CONCLUSIONS

Pediatric colloid cysts are rarer than their adult counterparts due to their late detection only after manifestations of raised intracranial pressure, visual or cognitive dysfunction or drop attacks occur. Their radiological appearance varies depending upon the amount of mucoid content, cholesterol, proteins, and water content. The fast development of clinical manifestations in children may be related to rapid enlargement of cyst due to higher water content within them. The transcallosal approach is the "gold standard" of surgery and usually ensures gratifying and lasting results.

Sudden adult death

In the investigation of sudden death in adults, channelopathies, such as long QT syndrome, have risen to the fore in the minds of forensic pathologists in recent years. Examples of these disorders are touched upon in this review as an absence of abnormal findings at postmortem examination is characteristic and the importance of considering the diagnosis lies in the heritable nature of these conditions. Typically, a diagnosis of a possible channelopathy is evoked as an explanation for a 'negative autopsy' in a case of apparent sudden natural death. However, the one potential adverse effect of this approach is that subtle causes of sudden death may be overlooked. The intention of this article is to review and discuss potential causes of sudden adult death (mostly natural) that should be considered before resorting to a diagnosis of possible channelopathy. Nonetheless, it becomes apparent that many of the potential causes of sudden death can have a genetic basis. Thus, it becomes an important consideration that there may be a genetic basis to sudden death that extends beyond the negative autopsy.

Familial colloid cyst of the third ventricle

We describe the cases of a mother and son who presented one year apart with a colloid cyst of the third ventricle. The mother was symptomatic and had complete resolution of her symptoms after surgical intervention. Her son was asymptomatic. There have been several reported instances of a familial association of colloid cysts of the third ventricle. The probability of a colloid cyst occurring in the same family coincidentally is possible, but highly unlikely (1 x 10(10)). The increasing number of reports of the familial incidence of colloid cysts would suggest the possibility of an autosomal dominant inheritance pattern, but to date, a familial pattern of inheritance has not been recognised. If there is a potential genetic link, then screening of asymptomatic relatives may be indicated. With non-invasive imaging techniques, such as computed tomography and magnetic resonance imaging scanning, accurate diagnosis and effective elective treatment is possible. This may result in preventing future complications as a result of hydrocephalus or sudden unexpected death, and also reduce morbidity as surgery can be done electively rather than as an emergency procedure.

Sudden death due to undiagnosed intracranial hemangiopericytoma

A previously healthy 9-year-old Japanese boy with a 4-day history of vomiting and headache died suddenly and unexpectedly. An external examination revealed no abnormalities other than foam around the mouth and nose. An internal examination revealed severe pulmonary edema and hemorrhagic hemangiopericytoma arising from the choroid plexus of the right lateral ventricle. The cause of death was thought to be neurogenic pulmonary edema caused by the rapid growth of a hemangiopericytoma, with intratumoral hemorrhage.

Hemorrhagic colloid cyst in a 9-year-old girl

Colloid cysts of the third ventricle are benign intracranial tumors that usually become symptomatic in adults, rather than in children. Rare hemorrhages in these cysts can cause acute obstructive hydrocephalus and sudden death. We report a novel pediatric case of hemorrhagic colloid cyst in a 9-year-old girl who presented with headaches, nausea, and had sudden deterioration of her mental status. The patient underwent emergent ventriculostomy and then craniotomy to resect the colloid cyst; she had an excellent recovery.

Barometric changes in patients with intracranial lesions: can they dive and fly?

BACKGROUND

People who harbor a neurosurgical lesion or who have just been operated on raise doubts to their physician about the possible risks related to transcontinental flights or practicing some sports (eg, diving, climbing) characterized by sudden barometric changes.

CASE DESCRIPTION

A young male patient harboring a high-grade cerebral glioma presented the first symptoms after a diving expedition and subsequent transatlantic flight.

CONCLUSIONS

This case hinted the authors to review the literature on this controversial topic where there is lack of scientific evidence, trying to define the possible risks and making a general recommendation.

TREATMENT OPTIONS FOR THIRD VENTRICULAR COLLOID CYSTS

OBJECTIVE

We retrospectively reviewed our experience treating third ventricular colloid cysts to compare the efficacy of endoscopic and transcallosal approaches.

METHODS

Between September 1994 and March 2004, 55 patients underwent third ventricular colloid cyst resection. The transcallosal approach was used in 27 patients; the endoscopic approach was used in 28 patients. Age, sex, cyst diameter, and presence of hydrocephalus were similar between the two groups.

RESULTS

The operating time and hospital stay were significantly longer in the transcallosal craniotomy group compared with the endoscopic group. Both approaches led to reoperations in three patients. The endoscopic group had two subsequent craniotomies for residual cysts and one repeat endoscopic procedure because of equipment malfunction. The transcallosal craniotomy group had two reoperations for fractured drainage catheters and one operation for epidural hematoma evacuation. The transcallosal craniotomy group had a higher rate of patients requiring a ventriculoperitoneal shunt (five versus two) and a higher infection rate (five versus none). Intermediate follow-up demonstrated more small residual cysts in the endoscopic group than in the transcallosal craniotomy group (seven versus one). Overall neurological outcomes, however, were similar in the two groups.

CONCLUSION

Compared with transcallosal craniotomy, neuroendoscopy is a safe and effective approach for removal of colloid cysts in the third ventricle. The endoscope can be considered a first-line treatment for these lesions, with the understanding that a small number of these patients may need an open craniotomy to remove residual cysts.

Colloid Cyst: Diffusion MR Imaging Findings

Colloid cysts usually have viscid gelatinous material or denser content. In an adult patient with a colloid cyst, diffusion magnetic resonance (MR) imaging was applied to detect its features with this sequence that if its viscous content may lead to a hyperintense appearance (decreased diffusion pattern) on b= 1000 sec/mm(2) images similar to epidermoids. The colloid cyst had hypointense signal on the b= 1000 sec/mm(2) image. The ADC map had more information that the ADC value of the cyst was 1.58 x 10(-3) mm(2)/sec. This value was apparently higher than that of normal cerebral parenchyma, and was apparently lower than that of CSF. These diffusion MR imaging features of the colloid cyst are consistent with an elevated diffusion pattern in contrast to epidermoids.

Colloid cysts in children, a clinical and radiological study

INTRODUCTION

Colloid cysts are uncommon in children. They occur more frequently in young adults.

METHODOLOGY

This is a retrospective study on all pediatric patients (<or=18 years) with colloid cysts treated surgically in our institute between 1977 and 2005.

RESULTS

A total of 43 patients with colloid cyst were treated surgically. Seven pediatric patients (16% of the total number of patients) were identified. Patients' ages ranged from 6 to 18 years (mean of 14.1+/-4.67). They all presented clinically with symptoms and signs of increased intracranial pressure. Radiologically, the cyst size ranged from 10 to 25 mm (mean of 16.1+/-5.2). All patients had either diagnostic computed tomography (CT) or magnetic resonance imaging (MRI), or both. The colloid cysts appeared hyperdense on CT in five patients (83%) and isodense in one (six available studies). On MRI, all (five available studies) lesions were hyperintense on T2-weighted images. All seven patients had complete cyst resection. Either transcortical (five patients) or transcallosal approaches (two patients) was used in the surgical resection. There was no mortality. One patient developed a delayed cerebrospinal fluid leak related to hydrocephalus, and another patient developed a delayed postoperative seizure. The radiological findings supported the aggressive clinical scenario of these lesions in the pediatric group of patients.

CONCLUSION

In conclusion, colloid cysts can occur in children. They are associated with more aggressive clinical and radiological patterns. Early surgical intervention is highly recommended.

Hemorrhagic colloid cyst

Colloid cysts are benign tumors situated in and connected to the roof of the third ventricle. The clinical presentation is diverse, varying from incidentally found cysts to acute death. This presentation is explained by an acute hydrocephalus due to an obstruction of the cerebrospinal fluid (CSF) flow at the level of the foramina of Monro. Why these lesions cause a sudden obstruction is not clear in most cases. Possible explanations of a sudden deterioration are shifts of the cysts after lumbar puncture or CSF flow obstruction after shunt dysfunction. We add an explanation for the acute deterioration of patients with colloid cysts (ie, hemorrhagic changes in the cysts). This complication has been published only 4 times before, all diagnosed at postmortem examination. A young patient is presented with a recently diagnosed and symptomatic colloid cyst who deteriorated the night before surgery because of intracystic hemorrhage. Despite emergent CSF diversion, our patient remained in a poor clinical condition. We review the literature about this topic and discuss the consequences for the neurosurgical practice.