Endoscopic Surgery in Nonhydrocephalous Third Ventricular Colloid Cysts: A Feasibility Study

Endoscopic versus Microsurgical Resection of Third Ventricle Colloid Cysts: A Single-Center Case Series of 140 Consecutive Patients

BACKGROUND

Both endoscopic and microsurgery transcortical resection methods are used for colloid cysts of the third ventricle but they have not been compared regarding benefits and pitfalls.

METHODS

Data of patients who underwent surgical resection of third ventricle colloid cyst via either endoscopic or microsurgery approach by a single surgeon from 2005 to 2020 were retrospectively collected. After administration of criteria, 140 records were retrieved (60 patients through endoscopic resection and 80 patients by a transcranial microsurgery approach). Clinical and surgical measures were compared between the 2 types of surgery after adjustment for confounders.

RESULTS

Length of hospital stay, postoperative meningitis, operation time, cyst size, and baseline comorbidities were similar between two groups. Gross total resection (GTR) was achieved for all patients in the microsurgery group, whereas in the endoscopic group, resection was lower (90% vs. 100%; P = 0.005). Intraoperative hemorrhage occurred in 14 endoscopic patients (23.3%), whereas for the microscopic group, it was zero (P < 0.001). Postoperative shunt was required for 2 patients (one in the endoscopic group and the other in the microscopic group). Two patients had tumor recurrence, both of whom were in the endoscopic group. No mortality was detected in either group. Multivariate analyses were insignificant for confounding effects of clinical and demographic factors in occurrence of worse surgical outcomes (non-GTR and hemorrhage).

CONCLUSIONS

In our series, the rate of intraoperative hemorrhage was higher with the endoscopic method and GTR was lower, even after adjustment for other factors. This situation could be caused by technological shortcomings and limited space for resection maneuvers and management of complications.

Endoscopic bimanual sharp dissection technique for gross-total resection of colloid cysts: technical note

Neuroendoscopic resection of colloid cysts has gained tremendous popularity over the last 2 decades because of good clinical outcomes and a low complication profile. However, in comparison to microsurgical resections, endoscopic resection has a lower rate of gross-total resection, which leaves the patient at risk for cyst recurrence. At present, there is still ongoing debate as to the best surgical approach for colloid cysts. Endoscopic resection as a technique has to compete with the good outcomes of microsurgical resections with respect to a long-term recurrence-free outcome. It is the authors' belief that gross-total resection should be the aim of endoscopic cyst resection. In this technical note, they describe their surgical technique for achieving safe gross-total resection of colloid cysts by using a ventriculoscopic system. The surgical technique includes a far anterolateral entry point, navigational guidance, bimanual sharp dissection, use of the endoscopic sheath as a retractor, the small-chamber irrigation technique, and the dry-field technique for hemostasis.

Long-Term Outcomes of Endoscopic Third Ventricle Colloid Cyst Resection: Case Series With a Proposed Grading System

BACKGROUND

Endoscopic resection of colloid cysts has gained recent widespread practice. However, reported complication and recurrence rates are variable, possibly, in part, because of a lack of consistency with reporting of the extent of cyst capsule removal.

OBJECTIVE

To present the long-term outcomes of endoscopic resection of third ventricle colloid cysts without complete capsule removal and propose a grading system to allow consistent description of surgical outcomes.

METHODS

A retrospective review of 74 patients who underwent endoscopic resection of symptomatic third ventricle colloid cysts between 1995 and 2018 was performed. Kaplan-Meier analyses were used to assess recurrence-free survival rates.

RESULTS

Median patient age and cyst diameter were 48.0 (13.0-80.0) yr and 12.0 (5.0-27.0) mm, respectively. Complete emptying of cyst contents with capsule coagulation was achieved in 73 (98.6%) patients. All patients improved or remained stable postoperatively, with a median follow-up duration of 10.3 (0.3-23.7) yr. Radiographic recurrence occurred in 6 (8.1%) patients after their initial surgery, 5 (6.8%) of whom underwent redo endoscopic resection. No major complications or mortality was encountered at primary or recurrence surgery.

CONCLUSION

Endoscopic resection of third ventricle colloid cysts without emphasizing complete capsule removal is a viable option for successfully treating colloid cysts of the third ventricle. Long-term follow-up demonstrates that it is associated with low risks of complications, morbidity, mortality, and recurrence. The proposed extent of the resection grading scheme will permit comparison between the different surgical approaches and facilitate the establishment of treatment guidelines for colloid cysts.

Endoscopic Versus Microscopic Transcallosal Excision of Colloid Cysts: A Systematic Review in the Era of Complete Endoscopic Excision

OBJECTIVE

Transcallosal microscopic and endoscopic excisions are both well established approaches to colloid cyst resection; however, there has been no clear consensus regarding the favored approach. We performed a systematic review comparing the transcallosal microscopic and endoscopic transcortical approaches for colloid cyst excision.

METHODS

We performed a systematic review from 2000-2018 of patients undergoing colloid cyst excision via a microscopic transcallosal or endoscopic transcortical approach where the surgical intent was gross total resection. Studies that included multiple approaches were included if the reported results were stratified by approach.

RESULTS

The microsurgical transcallosal approach had a higher rate of gross total resection when compared with endoscopic excision (96% for transcallosal vs. 78.5% endoscopic; P < 0.0001). There was also a lower recurrence rate with the transcallosal approach (0.98% vs. 2.16%; P = 0.0036); however, there was no difference in reoperation rates with similar length of follow-up (0.33% transcallosal, 0.61% endoscopic; P = 1.000). Endoscopy had lower overall morbidity when compared with transcallosal approaches (8.7% vs. 18.6%; P = 0.0001), including statistically significant lower rates of infection, infarct, and seizures in the endoscopic cohort. Rates of permanent memory deficit were similar (6.55% transcallosal vs. 4.5% endoscopic; P = 0.52). Shunt dependency was 9.8% after transcallosal excision versus 3.5% after endoscopic excision (P = 0.0002).

CONCLUSIONS

Modern series of colloid cyst excision continue to favor transcallosal approaches in achieving gross total resection. Nevertheless, endoscopic techniques have significantly reduced morbidity compared to transcallosal approaches, including lower rates of infection, infarct, and seizure. Endoscopic approaches also have a statistically significant decreased rate of shunt dependency-arguably the most important primary endpoint of surgery. With improving endoscopic technology and mastery of the technique, endoscopic excision is maturing into a standard first-line approach for colloid cyst excision.

Colloid Cysts: Evolution of Surgical Approach Preference and Management of Recurrent Cysts

BACKGROUND

Optimal management of third ventricular colloid cysts remains debated. While microsurgery offers greater resection rates and lower recurrences, endoscopy offers a perceived less invasive option.

OBJECTIVE

To describe the evolution of our practice to favor microsurgery and determine the optimal management of recurrent colloid cysts

METHODS

Any patient having undergone surgery for a colloid cyst by the senior author was identified and included in the study cohort. Clinical, radiographic, and operative records were reviewed, with attention paid to those patients requiring recurrent surgery.

RESULTS

Thirty-three patients were treated for intracranial colloid cysts between 1995 and 2017. Two patients had initial surgical treatment at an outside institution prior to presentation at our institution. Microsurgery was used in 15/31 initial cases, endoscopy in 13 cases, and ventriculoperitoneal shunting in 3 cases. Between 1995 and 2005, 89% of colloid cysts (8/9 cases) were resected endoscopically, whereas 74% of colloid cysts (14/19 cases) were resected by microsurgery after 2005. Of the 13 patients treated endoscopically, 6 (46%) required surgery for recurrent cysts. Incomplete cyst wall resection at the initial operation increased the recurrence rate to 55%. There were no recurrences in the microsurgery cohort.

CONCLUSION

Surgical resection of recurrent colloid cysts should focus on complete removal of the cyst wall to minimize the chance of recurrence. Microsurgery has been shown to provide the highest success rates for cyst wall resection and lowest rates of recurrence and is therefore recommended for patients undergoing surgery for primary and recurrent colloid cysts.

Nerve-Sheath-Risen Neuroglial Cyst: A Case Report and Review of the Literature

BACKGROUND

Neuroglial cysts are rare intracranial lesions that are believed to originate from the sequestration of neural tube lining during embryogenesis. They can present anywhere within the neuraxis; however, their most common location is the frontal lobe. Cerebellopontine angle (CPA) neuroglial cysts are extremely rare and to the best of authors' knowledge, there are no previous reports of a neuroglial cyst arising from cranial nerves.

CASE DESCRIPTION

The current study presented a male adolescent with the reoccurrence of an intracranial cyst with symptoms of diplopia and facial numbness primarily treated as CPA arachnoid cyst with fenestration of the cyst 12 months prior to admission to our center. Different magnetic resonance imaging (MRI) sequences showed a thin-walled extra-axial cyst at the right CPA without gadolinium (Gd)-enhancement. Direct visualization of the lesion revealed a cyst arising from the 5th cranial nerve sheath compressing the surrounding structures. The cyst was fenestrated and a biopsy was taken from the cyst wall. The pathological analysis along with specified histological markers indicated the neuroglial nature of the cyst.

CONCLUSION

The rising of a neuroglial cyst from the nerve sheath is a finding that brings other possible origins of neuroglial cysts into consideration.

Nonspecific Headache Diagnosed as a Brain Colloid Cyst with Hydrocephalus

A 29-year-old male presented to our emergency department with complaints of a left frontal headache, similar to his prior headaches. He also reported about 30 minutes of facial and tongue numbness, left arm weakness, slurred speech and changes in hearing that had resolved prior to his arrival. Despite the short duration of the other neurologic symptoms, he also endorsed persistent “dizziness.” Despite his history of recurrent headaches, he had never had any neuroimaging. This, as well as his reports of new neurological symptoms, prompted his care team to obtain a non-contrast brain computed tomography. The findings were consistent with a mass with mild hydrocephalus. Patient underwent neurosurgical resection of the mass at a tertiary center. He did well after surgery and was discharged on postop day 6 with a diagnosis of colloid cyst.

Combination of Neuroendoscopic and Stereotactic Procedures for Total Resection of Colloid Cysts with Favorable Neurological and Cognitive Outcomes

BACKGROUND

Despite a wide range of surgical procedures, an unresolved debate remains regarding which attempt is optimal for the treatment of colloid cysts in the third ventricle. In this article, we present a new combination of stereotactic and endoscopic techniques.

METHODS

This prospective study includes 27 consecutive patients with symptomatic primary and recurrent colloid cysts. All cysts were removed via a neuroendoscope through a rostral transfrontal, transforaminal approach. The endoscope was supported by an additional cannula fixed in the stereotactic frame. Both tools were inserted into one lateral ventricle through two separate burr holes using stereotactic guidance.

RESULTS

The median operating time was 135 minutes. All cysts were removed completely, and no mortality or permanent complications related to surgery occurred. The mean time of observation was 43.5 months (range, 3-78 months), and no clinical or radiologic recurrences were observed. One patient with a history of an infected ventriculoperitoneal shunt did not improve after cyst removal, but improved after subsequent reimplantation of the shunt. In all other cases, symptoms resolved (67%) or decreased (30%). Cognitive functions improved or remained unchanged in all 10 elective cases examined neuropsychologically before and after surgery.

CONCLUSIONS

The techniques we describe for removal of colloid cysts are safe and effective, even for recurrent cases, and they provide 100% total resection, favorable cognitive outcomes, low risk of recurrence, and low risk of morbidity. The disadvantages of this method are a longer time for surgery and the need for more complex instrumentation compared with conventional endoscopic resection.