Inchoate guidelines of endoscopic resection of colloid cysts

Brainstem death due to intracranial hypertension with hydrocephalus, produced by a third ventricular colloid cyst

We describe the clinical presentation and CT findings of a 10-year-old female patient about half an hour prior to cardiorespiratory arrest and subsequent death, resulting from brainstem compression and herniation caused by hydrocephalus and intracranial hypertension, produced by a previously undetected colloid cyst occluding foramina of Monro on both sides. While third ventricular colloid cysts are rare lesions, sudden unpredicted deaths have been attributed to undetected colloid cysts in many case reports, with some authors even considering that 10% of colloid cyst patients suffer such ends. However, there is still no conclusive or comprehensive guideline regarding how to prevent such situations. We make a short literature review and put forward a few recommendations or learning points to that end.

Third ventricle colloid cysts: An endoscopic case series emphasizing technical variations

Background

Colloid cyst treatment with purely endoscopic surgery is considered to be safe and effective. Complete capsule removal for gross total resection is usually recommended to prevent recurrence but may not always be safely feasible. Our objective was to assess the results of endoscopic surgery using mainly aspiration and coagulation without complete capsule resection and discuss the rationale for the procedure.

Methods

A retrospective review was conducted of 45 consecutive symptomatic patients with third ventricle colloid cysts that were surgically treated with purely endoscopic surgery from 1997 to 2018.

Results

Mean age was 35.4 years. Male-to-female ratio was 1:1. Clinical presentation included predominantly headache (80%). Transforaminal was the most used route (71.1%) followed by transeptal (24.5%) and interforniceal (4.4%). Capsule was intentionally not removed in 42 patients (93.3%) and cyst remnants were absent on postoperative MRI in 36 (85%). Mild complications occurred in 8 patients (17.8%). Surgery was statistically associated with cyst volume and ventricular size reduction. There were no serious complications, shunts or deaths. Follow-up did not show any recurrence or remnant growth that needed further treatment.

Conclusion

Gross total resection may not be the main objective for every situation. Subtotal resection without capsule removal seems to be safer while preserving good results, especially in a limited resource environment. Remnants left behind should be followed but tend to remain clinically asymptomatic for the most part. Surgical planning allows the surgeon to choose among the different resection routes and techniques available. Decisions are predominantly based on preoperative imaging and intraoperative findings.