Surgical management of colloid cysts of the third ventricle: a single-institution comparison of endoscopic and microsurgical resection

J Neurosurg 137:905–913, 2022

Colloid cysts of the third ventricle are histologically benign lesions that can cause obstructive hydrocephalus and death. Historically, colloid cysts have been removed by open microsurgical approaches. More recently, minimally invasive endoscopic and port-based techniques have offered decreased complications and length of stay, with improved patient satisfaction.

METHODS A single-center retrospective analysis of patients with colloid cysts who underwent surgery at a large tertiary care hospital was performed. The cohort was assessed based on the surgical approach, comparing endoscopic resection to open microsurgical resection. The primary endpoint was rate of perioperative complications. Univariate analysis was used to assess several procedure-related variables and the cost of treatment. Multivariate analysis was used to assess predictors of perioperative complications. Total inpatient cost for each case was extracted from the health system financial database.

RESULTS The study included 78 patients with colloid cysts who underwent resection either via an endoscopic approach (n = 33) or through a craniotomy (n = 45) with an interhemispheric-transcallosal or transcortical-transventricular approach. Nearly all patients were symptomatic, and half had obstructive hydrocephalus. Endoscopic resection was associated with reduced operative time (3.2 vs 4.9 hours, p < 0.001); lower complication rate (6.1% vs 33.1%, p = 0.009); reduced length of stay (4.1 vs 8.9 days, p < 0.001); and improved discharge to home (100% vs 75.6%, p = 0.008) compared to microsurgical resection. Coagulated residual cyst wall remnants were more common after endoscopic resection (63.6% vs 19.0%, p < 0.001) although this was not associated with a significantly increased rate of reoperation for recurrence. The mean follow-up was longer in the microsurgical resection group (3.1 vs 4.9 years, p = 0.016). The total inpatient cost of endoscopic resection was, on average, one-half (47%) that of microsurgical resection. When complications were encountered, the total inpatient cost of microsurgical resection was 4 times greater than that of endoscopic resection where no major complications were observed. The increased cost-effectiveness of endoscopic resection remained during reoperation.

CONCLUSIONS Endoscopic resection of colloid cysts of the third ventricle offers a significant reduction in perioperative complications when compared to microsurgical resection. Endoscopic resection optimizes nearly all procedure-related variables compared to microsurgical resection, and reduces total inpatient cost by > 50%. However, endoscopic resection is associated with a significantly increased likelihood of residual coagulated cyst wall remnants that could increase the rate of reoperation for recurrence. Taken together, endoscopic resection represents a safe and effective minimally invasive approach for removal of colloid cysts.

Transseptal interforniceal endoscopic removal of superiorly recessed colloid cysts

J Neurosurg 137:813–819, 2022

Transforaminal endoscopic colloid cyst resection is well described. However, some anatomical colloid cyst variants may warrant a modified approach. Rarely, colloid cysts separate the forniceal columns and grow superiorly within the leaflets of the septum pellucidum. Thus, the authors’ goal was to characterize the imaging features, clinical presentation, surgical strategy, and outcomes of patients with this superiorly recessed colloid cyst variant.

METHODS A retrospective evaluation of patients who underwent endoscopic resection of colloid cysts from 1999 to 2020 was performed. The patients were dichotomized depending on whether the cyst was located predominately below the forniceal columns or was superiorly recessed (forniceal column separation with variable intraseptal extension). This comparative cohort study focused on clinical presentation, imaging features, operative technique, and patient outcome.

RESULTS In total, 182 patients were identified. Seventeen patients had colloid cysts that were defined as superiorly recessed and underwent transseptal interforniceal removal, and 165 patients underwent a standard transforaminal approach. Patients had similar demographic characteristics. However, transseptal cysts were on average larger (17.8 mm vs 11.4 mm, p < 0.0001), and these patients had a greater frontal-occipital horn ratio (0.45 vs 0.41, p = 0.012). They were also more likely to have undergone a previous resection (p = 0.02). The two cohorts had similar surgical outcomes, with no differences in extent of resection, recurrence, or complications.

CONCLUSIONS Superiorly recessed intraseptal colloid cysts are larger and tend to splay the bodies of the fornix, thus requiring a parasagittal transseptal interforniceal endoscopic approach. This achieves complete removal with comparatively negligible morbidity or rare recurrence (5.9%).

Anterior trans-frontal endoscopic resection of third-ventricle colloid cyst

Acta Neurochir (2017) 159:1049–1052

The endoscopic technique has been recognised as a viable and safe alternative to microsurgery for the treatment of third-ventricle colloid cyst. However, the standard precoronal endoscopic approach does not always provide an adequate visualisation of the attachment of the cyst to the velum interpositum. Using a more anterior approach, it is easier to reach the roof of the cyst and its possible adherences with the tela choroidea.

Method The authors describe step by step the anterior transfrontal endoscopic approach for management of third ventricle colloid cyst.

Conclusions The described approach has shown to be safe, quick and effective for the treatment of third-ventricle colloid cyst.

Natural history of colloid cysts of the third ventricle

J Neurosurg 125:1420–1430, 2016

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.

Endoscopic Removal of Third Ventricular Colloid Cyst: Experience of 90 Cases

Endoscopic Removal of Third Ventricular Colloid Cyst- Experience of 90 Cases-1

Neurosurg Q 2015;25:46–50

Third ventricular colloid cysts are benign lesions originating in the roof of the anterior third ventricle. They constitute around 1% of all intracranial tumors. The optimal surgical management of colloid cysts continues to be a matter of debate.

Objective: This study was perfomed to assess the efficacy and safety of the endoscopic technique in treatment of 90 patients with colloid cysts.

Methods: During the period from June 2001 to October 2011, 90 patients with third ventricular colloid cyst were operated by the endoscopic single burr hole approach. The age ranged between 16 and 67 years (mean 40.3 years). Fifty-eight were females. The cyst size ranged between 8 and 35 mm. In computed tomography (CT) scan, the cyst was hyperdense in 74 cases and isodense in 16 cases. The standard Kocher burr hole was used in 63 and a more both anterior and lateral burr hole was used in 27 cases. Total cyst removal was achieved in 79 patients. Cyst content evacuation and capsule coagulation was done in 10 cases; whereas partial cyst excision was made in 1 case. All patients were followed by a CT scan at 1 and 6 months time from the surgery and then at 2-year interval. The follow-up period ranged from 6 to 120 months with a mean of 62 months.

Results: The operative time ranged between 60 and 175 minutes with a mean of 84 minutes. Ventriculostomy tube and prophylactic antiepileptics were not used for any of the cases. One patient needed ventricular shunting 5 months after the procedure. There was no reported mortality related to the endoscopic colloid cyst removal. The reported morbidities were hemiparesis in 2 cases, transient memory deficit in 7 patients, superficial wound infection in 5 patients, and CSF leakage from the wound in 3 cases. No recurrence was found in our series.

Conclusions: Being a burr hole technique, endoscopy offers a real safe and effective minimally invasive tool for treating third ventricular colloids. It offers superior illumination, greater magnification, and enhanced visualizations of the ventricular anatomy. There is no doubt that the mortality, morbidity, and operative costs are less with endoscopy when compared with other combating therapeutic modalities. In our opinion, if the endless argument considering the point of tumor recurrence is brought apart, endoscopy should be the first-line treatment for third ventricular colloid cysts.

Key Words: colloid cyst, third ventricle, endoscopic, surgical removal.

Optimal entry point for endoscopic colloid cyst resection

Endoscopic approach to colloid cysts

J Neurosurg 121:790–796, 2014

An optimal entry point and trajectory for endoscopic colloid cyst (ECC) resection helps to protect important neurovascular structures. There is a large discrepancy in the entry point and trajectory in the neuroendoscopic literature.

Methods. Trajectory views from MRI or CT scans used for cranial image guidance in 39 patients who had undergone ECC resection between July 2004 and July 2010 were retrospectively evaluated. A target point of the colloid cyst was extended out to the scalp through a trajectory carefully observed in a 3D model to ensure that important anatomical structures were not violated. The relation of the entry point to the midline and coronal sutures was established. Entry point and trajectory were correlated with the ventricular size.

Results. The optimal entry point was situated 42.3 ± 11.7 mm away from the sagittal suture, ranging from 19.1 to 66.9 mm (median 41.4 mm) and 46.9 ± 5.7 mm anterior to the coronal suture, ranging from 36.4 to 60.5 mm (median 45.9 mm). The distance from the entry point to the target on the colloid cyst varied from 56.5 to 78.0 mm, with a mean value of 67.9 ± 4.8 mm (median 68.5 mm). Approximately 90% of the optimal entry points are located 40–60 mm in front of the coronal suture, whereas their perpendicular distance from the midline ranges from 19.1 to 66.9 mm. The location of the “ideal” entry points changes laterally from the midline as the ventricles change in size.

Conclusions. The results suggest that the optimal entry for ECC excision be located at 42.3 ± 11.7 mm perpendicular to the midline, and 46.9 ± 5.7 mm anterior to the coronal suture, but also that this point differs with the size of the ventricles. Intraoperative stereotactic navigation should be considered for all ECC procedures whenever it is available. The entry point should be estimated from the patient’s own preoperative imaging studies if intraoperative neuronavigation is not available. An estimated entry point of 4 cm perpendicular to the midline and 4.5 cm anterior to the coronal suture is an acceptable alternative that can be used in patients with ventriculomegaly.

Anterior trans-frontal endoscopic management of colloid cyst

Endoscopic trans-frontal approach colloid cysts

Neurosurg Rev (2014) 37:235–241

Different management options are available for the treatment of colloid cysts. Goals of those procedures are to achieve a complete resection avoiding potential long-term recurrence along with CSF pathways restoration with minimal morbidity and mortality.

The two main surgical options are endoscopic resection or direct removal by either transfrontal or transcallosal approach. The efficacy of endoscopic technique to achieve gross total colloid cyst excision has been well documented.

In the present study, authors describe a series of 29 patients who underwent surgery by a variation of the standard worldwide implemented endoscopic technique. Using a more anterior approach, it is easier to reach the roof of the cyst, its possible adherences with the tela choroidea, plexus, and the internal cerebral veins. The described approach has shown to be safe, quick, and very effective with a total cyst removal rate of 86.2 %.

Endoscopic transchoroidal and transforaminal approaches for resection of third ventricular colloid cysts

Endoscopic resection IIIrd ventricular colloid cysts

Neurosurg Rev (2014) 37:227–234

To review our experience over 10 years in endoscopic resection of third ventricular colloid cysts, describing the details of the transventricular–transchoroidal approach used in selected patients.

This series included 24 patients with colloid cysts of the third ventricle treated in our department between October 2001 and January 2013 using an endoscopic approach. Clinical presentation, preoperative radiological findings, endoscopic technique employed, and complications were assessed in all patients.

The mean length of patient follow-up was 5.16 years. The most common symptom was headache (75 %). The average size of the resected colloid cysts was 16.25 mm, the maximum diameter measured in cranial magnetic resonance imaging. Resection was transforaminal in 16 cases (66.7 %), transchoroidal in 7 (29.17 %), and transseptal in 1; macroscopically complete resection was achieved in 23 of 24 procedures (95.8 %).

Complications included three intraventricular hemorrhages, four memory deficits (two of them transient), one case of temporary potomania, two soft tissue infections, and one meningitis. There were no statistically significant differences between the route of resection and number of complications.The Glasgow Outcome Scale at 1 year after surgery was 5 in 82.6 % of the patients.

A transventricular endoscopic approach allows macroscopically complete resection of third ventricle colloid cysts in most cases. The option of opening the choroidal fissure (transventricular–transchoroidal approach) during the procedure can address third ventricle colloid cysts that do not emerge sufficiently through the foramen of Monro without increasing procedure-related morbidity.

Supraorbital Endoscopic Approach to Colloid Cysts

Neurosurgery 69[ONS Suppl 2]:ons176–ons183, 2011 DOI: 10.1227/NEU.0b013e318219563c

Surgical approaches to colloid cysts of the third ventricle have evolved over time. In recent years, endoscopy has been recognized as an effective alternative to open surgery. The disadvantage of endoscopic treatment is the difficulty in controlling the adhesion of the cyst to the roof of the third ventricle and in obtaining complete removal of the cyst.

OBJECTIVE: To design and carry out a supraorbital approach to obtain a better viewing angle of the cyst and better control of the adhesion of the cyst to the roof of the third ventricle.

METHODS: From September 2005 to February 2008, we operated on 7 consecutive patients with colloid cysts in the third ventricle. All procedures were performed with the endoscopic supraorbital approach. The endoscopic procedure was performed with a rigid STORZ endoscope with 3 working channels. In 4 patients, the surgical supraorbital trajectory was planned with the help of a navigator.

RESULTS: The procedures lasted between 60 and 110 minutes, including the registration on the navigation system. Near-total removal of the cyst was achieved in 6 patients. All patients were discharged within 6 days.

CONCLUSION: Endoscopic treatment may be an effective and safe alternative to open surgical craniotomy. Our series shows that the endoscopic supraorbital endoscopic resection is a valuable approach to colloid cysts of the third ventricle.

Long-term Results of the Neuroendoscopic Management of Colloid Cysts of the Third Ventricle: A Series of 90 Cases

Neurosurgery 68:179–187, 2011 DOI: 10.1227/NEU.0b013e3181ffae71

The endoscopic removal of third ventricular colloid cysts has been developed as an alternative to microsurgical transcortical-transventricular and transcallosal approaches.

OBJECTIVE: To examine the value of endoscopic technique by reviewing the large number of endoscopically treated patients with long-term follow-up in 2 neurosurgical centers.

METHODS: A retrospective chart review was conducted for all patients admitted for resection of a third ventricular colloid cyst to the Radboud University Nijmegen Medical Centre (Nijmegen, the Netherlands) and the Hoˆ pital Henri Mondor (Paris, France) between 1994 and 2007. Both clinical and radiological symptoms and operative results were evaluated.

RESULTS: Postdischarge clinical follow-up was available for 85 patients over a mean period of 4 years 3 months. Permanent morbidity occurred in 1 patient (persisting preoperative memory deficit). Follow-up imaging of 80 evaluable patients showed that total or nearly total cyst removal was possible in 46 individuals (57.5%). Residual cyst was present in 34 patients (42.5%), and 6 required repeated endoscopic surgery for symptomatic regrowth. Recurrent cysts were mainly seen within the first 2 years after surgery.

CONCLUSION: It is debatable whether the higher numbers of recurrent or residual cysts can be justified by the slightly lower complication rates achieved with endoscopic removal. However, results have been improving over the years. Moreover, the modifications observed on control magnetic resonance images justify the need for regular control imaging for at least the first 2 years postoperatively.

Colloid Cysts of the Third Ventricle: Endoscopic Versus Microsurgical Removal

Neurosurg Q 2010;20:142–145

Study Design: A comparative randomized prospective clinical study.

Background and Purpose: The endoscopic approach to colloid cysts of the third ventricle is receiving increasing interest. However, its effectiveness is a matter of discussion. The aim of the study was to present a direct and long-term outcome after endoscopy of a colloid cyst versus microsurgery.

Materials and Methods: Ten patients with colloid cysts were prospectively analyzed. Group A consisted of 5 patients treated endoscopically, whereas 5 patients treated using a transcorticaltransventricular approach comprised group B. Clinically, symptoms of raised intracranial pressure were predominant. All patients had hydrocephalus. Tumor diameter ranged from 10 to 27 mm. The mean follow-up period was 22 months.

Results: The mean surgery time was 122 minutes in group A and 201 minutes in group B. Hospital stay was 1.5 days in the intensive care unit and 2.5 days in the ward in group A as compared with 3.5 days in the intensive care unit and 7 days in the ward in group B.

Postoperative complications in group A were in the form of 1 transient hemiparesis and 1 transient short-term memory loss. Two patients in group B suffered transient short-term memory loss postoperatively and 1 patient suffered from transient hemiparesis. Clinically, the preoperative symptoms resolved in all the patients. One patient who underwent microsurgery required a ventriculoperitoneal shunt postoperatively. All patients who underwent endoscopy remained shunt independent.

Conclusions: The endoscopic approach to colloid cysts of the third ventricle is safe, effective, and carries a low complication rate. Endoscopy may be recommended as a treatment option.

Microsurgical Excision of Colloid Cyst With Favorable Cognitive Outcomes and Short Operative Time and Hospital Stay: Operative Techniques and Analyses of Outcomes With Review of Previous Studies

Neurosurgery: February 2010 – Volume 66 – Issue 2 – p 368–375. doi: 10.1227/01.NEU.0000363858.17782.82

Microsurgical and endoscopic colloid cyst excision differ with regard to operative time, length of hospital stay, and extent of resection.

METHODS: A retrospective review of a single surgeon’s microsurgical colloid cyst resection in 10 consecutive patients was performed. Cyst size, hydrocephalus, symptoms, operative time, postoperative stay, complications, and objective testing of memory, concentration, calculation, and attention (cognition), along with performance at job, were noted.

RESULTS: All 10 patients had complete excision. Mean cyst size, mean operative time, and median postoperative stay were 1.6 cm, 124 minutes, and 3.5 days respectively. The mean operative time from cyst visualization to complete excision was 18 minutes. Follow-up ranged from 6 to 111 months (mean, 49.5 months). There were no recurrences; symptoms (headache, visual and balance problems) improved significantly in 70%. Postoperative cognitive performance, including memory, was the same in 8 patients (5 of whom had preoperative memory problems) and worse in 2 patients who had no preoperative memory problems. The bone flap was removed in 1 patient for wound dehiscence. Hemiparesis in another patient, seen immediately after surgery, completely resolved before discharge. One patient with loculated ventricles and multiple previous shunt revisions had unresolved hydrocephalus after cyst excision.

CONCLUSION: We report the very short operative times and postoperative stay for microsurgery, which are comparable to some endoscopic series. We also report results of objective tests of cognitive performance. With adoption of a callosal incision of 1 cm or less, meticulous dissection around the fornix, and complete excision, acceptable long-term cognitive function and functional performance were achieved. Our results support the microsurgical approach. A larger sample size can more conclusively establish whether it should be chosen over the endoscopic technique.

Endoscopic treatment of third ventricular colloid cysts

Neurosurg Rev (2009) 32:395–402. DOI 10.1007/s10143-009-0208-2

The surgical treatment of colloid cysts has been traditionally difficult with high rate of postoperative complications. The variety of surgical options reflects the technical difficulty in removing these benign lesions with low morbidity. Microsurgical removal has for years been considered the “gold standard” of treatment, with the use of either a transcortical–transventricular or a transcallosal approach. Neuroendoscopic management is emerging as a safe, effective alternative to microsurgery. The present review discusses the role

of endoscopy in the surgical treatment of third ventricular colloid cysts focusing on some factors, which might influence the outcome. The results have been presented from the literature and supplemented by the results of treating ten personal cases of third ventricular colloid cysts who were operated endoscopically in the Neurosurgical Department, Cairo University. This study aims at evaluating the endoscopic approach as a surgical line of treatment in the management of third ventricular colloid cysts and to see if it has already become superior over microsurgery.

Conclusions: Endoscopic approach to third ventricular colloid cysts is a minimally invasive procedure, which achieves both total evacuation of the cyst and at least near-total resection of the cyst wall with a low surgical morbidity. The available results document less radical excisions as compared to microsurgical group; this is counterbalanced by the lower incidence of complications and shorter operative, hospitalization, and rehabilitation time in the endoscopic group. This conclusion makes endoscopy an alternative and not a better choice than microsurgery. Consequently, the ongoing debate between both procedures remains unresolved. This dispute will become resolved only when long-term studies (mean follow-up for 10 years or greater) are available for a substantial number of patients who have undergone endoscopic resection.