Endoscopic treatment of third ventricular colloid cysts: a review including ten personal cases

Revisiting the Endoscopic vs. Microscopic colloid cysts resection battle with emphasis on endoscope assisted technique

Introduction

Colloid cysts are challenging regarding their location. Surgical resection remains the therapeutic option of choice for symptomatic cysts. However, choosing the optimal surgical approach is still a subject of debate.

Research question

The aim of the study is to compare three surgical approaches; Pure endoscopic (PE), pure microscopic (PM) and endoscope assisted microsurgical (EA).

Material and methods

Retrospective data extraction from our database was done and we included patients who underwent surgical resection for colloid cysts since 2008. Patients were categorized into three groups based on the forementioned surgical techniques. Outcome measures assessed included extent of resection (EOR), morbidity using modified Rankin Scale (mRS), hospital stay duration (HSD), and complications.

Results

41 patients met our inclusion criteria and were divided as follows; PM 13 patients (31.7%), PE 19 patients (46.3%) and EA with 9 patients (22.0%). Mean age (SD) was 37.4 ± 12.2. Male: Female is 1:1.05 and average follow-up was 3.9 ± 2.8 years. Gross total resection(GTR) reached 92.3% (12/13) using PM, 78.9% (15/19) with PE and 100% (9/9) under EA. Morbidity was 15.4%, 10.5% and 0% respectively (mRS >2). Hospital stay duration was significantly shorter in PE and EA (p = 0.012).

Discussion and conclusion

EA excision of colloid cysts is safe and effective. When compared to PE and PM approaches, it can combine the advantages of both tools utilizing the microscope and endoscope to achieve a safe, gross total resection while minimizing hospitalization duration. The choice of surgical approach, however, should be individualized based on the cyst's location, size, and the surgeon's expertise and preference.

Terson's syndrome after endoscopic removal of a colloid cyst

An extremely rare complication of endoscopic colloid cyst removal is presented. Terson's syndrome related to endoscopic resection of a colloid cyst has been reported only twice before in the literature and it could be explained by intracranial hypertension related to rinsing during the procedure. The case is described and the complications in the neuroendoscopic removal of colloid cyst are reviewed from the literature.

Endoscopic ultrasonic aspirator-assisted removal of a third ventricular colloid cyst

BACKGROUND

Colloid cysts are benign tumors usually located on the roof of the third ventricle. Cyst removal is the treatment of choice. It can be accomplished microsurgically through a transcortical- or transcallosal approach, or endoscopically. There is a lack of consensus regarding the best strategy for cyst removal. One of the challenges of the traditional endoscopic technique is dealing with the cyst content density. Hyperdensity on computed tomography scan and low signal on T2-weighted magnetic resonance imaging (MRI) cyst are correlated with high viscosity cystic content.

CASE REPORTS

We present a case of a colloid cyst of the third ventricle in a 15-year-old boy removed through a pure endoscopic transventricular approach. The cyst presented a low signal on T2 MRI; nevertheless, it was easily removed with the help of an endoscopic ultrasonic aspirator.

DISCUSSION AND CONCLUSION

The colloid cyst of the third ventricle can be safely treated by a purely endoscopic approach. The rationale of the use of the ultrasonic aspirator relies on the facilitation of aspiration of the content even when the consistency is extremely firm.

Neuroendoscopy: intraventricular and skull base tumor resection in children

During the last 30 years, the neurosurgeons have witnessed a revolution in the practice of interventricular surgery. The advent of neuroendoscopy at the end of the 1980s has allowed a minimally invasive management of a very large series of pathologies in pediatric neurosurgery ranging from hydrocephalus to arachnoid cyst to intraventricular tumors. The progresses in the management of hydrocephalus, intracranial cyst, and the fluid filled collection nevertheless has been more rapid and radical due to the simpler equipment that is necessary to perform this kind of surgery. The intraventricular tumors instead have been addressed in a slower way, and for many years, the only endoscopic procedure that was allowed on interventricular tumors was a biopsy associated with the management of hydrocephalus. Only very small tumors have been considered operable for complete removal during many years due to the limitations of the neuroendoscopic equipment and to the small calibers of the working channel. More recently, the advent of new devices and new surgical techniques are offering new perspectives on the possibility of intraventricular tumor surgery in children. In this review, we describe the historical perspective of the learning curve of intraventricular tumor surgery under neuroendoscopic control and try to offer a view of the future perspective in the removal of larger intraventricular tumors, analyzing the main indications for intraventricular endoscopic tumor surgery. We offer as well an historical perspective of the evolution of skull base surgery and endonasal transsphenoidal approach for skull-based tumors in children. This kind of surgery that has acquired widespread acceptance for many pathologies in adult age has diffused more slowly in pediatric neurosurgery due to the anatomical limitation observed in these age range. Also in this field, the slow evolution of the technique and of the technology available to neurosurgeons has allowed a very significant expansion of indication for the minimally invasive removal of skull base tumors in children.

Isolated entrapment of the lateral ventricle after neuroendoscopic resection of colloid cysts: single - center experience and management

BACKGROUND

A minimally invasive option of colloid cyst surgical treatment is endoscopic resection, well validated in various reports and clinical practice. A rare complication of the surgical treatment, previously reported only once in literature, is the entrapment of the lateral ventricle. In this study we aim to outline our experience in the management of this occurrence, hypothesizing possible etiopathogenetic causes.

METHODS

Among patients who underwent neuroendoscopic resection for a colloid cysts at our Institution between 2013 and 2022, cases who developed a postoperative lateral ventricle entrapment were retrospectively reviewed and included. Clinical history, imaging and treatment were reported.

RESULTS

Among 34 patients treated for a colloid cysts, two (5.9 %) patients developed an ipsilateral ventricular entrapment with dilation from two to five months after the resection. Both patients were substantially asymptomatic and neurologically intact, and therefore treated conservatively. One case underwent complete spontaneous radiological resolution one month later, and the other one has remained neurological asymptomatic at follow-up.

CONCLUSIONS

Isolated asymptomatic ventricular entrapment with significant dilation after endoscopic colloid cyst resection is a rare occurrence which can be plausibly caused by scar tissue at the level of the foramen of Monro. Because they can have an indolent course with spontaneous resolution, conservative treatment is a viable option, with strict radiological and clinical follow - up. Given the rarity of the occurrence, further studies with larger cohorts are warranted to confirm the etiopathogenetic hypothesis and validate the clinical management.

Endoscopic treatment of intracranial cysts in infants: personal experience and review of literature

BACKGROUND

A wide variety of intracranial cysts is known to occur in infants. If symptomatic, they require treatment; the ideal surgical treatment and indications of surgery are yet a matter of discussion. Traditional treatment is either by cystoperitoneal shunting, or microsurgical fenestration. Endoscopic treatment is an alternative procedure that avoids the invasiveness of open craniotomy and the complications caused by shunting.

METHODS

This article reviews the endoscopic treatment of intracranial cysts in infants. The author presents personal experience by reviewing the results of endoscopic treatment in different subgroups among his series of pediatric patients extending over 20 years.

RESULTS

Different types of intracranial cysts in infants were discussed and the role of endoscopy in the management of these patients was reviewed. The author also presented the results of endoscopic treatment of a personal series including 87 infants with intracranial cysts operated by the endoscopic procedure.

CONCLUSIONS

It has been recommended to use the endoscopic procedure in the treatment of intracranial cysts in infants, because it is effective, simple, minimally invasive, and associated with low morbidity and mortality rates. However, an important prerequisite is the presence of an area of contiguity with the subarachnoid cisterns and/or the ventricular system.

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.

Neurocognitive Complications after Ventricular Neuroendoscopy: A Systematic Review

In recent years, neuroendoscopic treatment of hydrocephalus and various ventricular pathologies has become increasingly popular. It is considered by many as the first-choice treatment for the majority of these cases. However, neurocognitive complications following ventricular neuroendoscopic procedures may occur leading mostly to amnesia, which might have a grave effect on the patient's quality of life. Studies assessing neurocognitive complications after ventricular neuroendoscopic procedures are sparse. Therefore, we conducted a systematic review assessing the available literature of neurocognitive complications and outcome after ventricular neuroendoscopy. Of 1216 articles screened, 46 were included in this systematic review. Transient and permanent neurocognitive complications in 2804 ventricular neuroendoscopic procedures occurred in 2.0% (n = 55) and 1.04% (n = 28) of the patients, respectively. Most complications described are memory impairment, followed by psychiatric symptoms (psychosyndrome), cognitive impairment not further specified, declined executive function, and confusion. However, only in 20% of the series describing neurocognitive complications or outcome (n = 40) was neurocognition assessed by a trained neuropsychologist in a systematic manner. While in most of these series only a part of the included patients underwent neuropsychological testing, neurocognitive assessment was seldom done pre- and postoperatively, long-term follow up was rare, and patient's cohorts were small. A paucity of studies analyzing neurocognitive complications and outcome, through systematic neuropsychological testing, and the correlation with intraoperative lesions of neuronal structures (e.g., fornix) exists in the literature. Therefore, the neurocognitive and emotional morbidity after ventricular neuroendoscopic procedures might be underestimated and warrants further research.

Neuroendoscopic resection of intraventricular tumors: a systematic outcomes analysis

Introduction. Though traditional microsurgical techniques are the gold standard for intraventricular tumor resection, the morbidity and invasiveness of microsurgical approaches to the ventricular system have galvanized interest in neuroendoscopic resection. We present a systematic review of the literature to provide a better understanding of the virtues and limitations of endoscopic tumor resection. Materials and Methods. 40 articles describing 668 endoscopic tumor resections were selected from the Pubmed database and reviewed. Results. Complete or near-complete resection was achieved in 75.0% of the patients. 9.9% of resected tumors recurred during the follow-up period, and procedure-related complications occurred in 20.8% of the procedures. Tumor size ≤ 2cm (P = 0.00146), the presence of a cystic tumor component (P < 0.0001), and the use of navigation or stereotactic tools during the procedure (P = 0.0003) were each independently associated with a greater likelihood of complete or near-complete tumor resection. Additionally, the complication rate was significantly higher for noncystic masses than for cystic ones (P < 0.0001). Discussion. Neuroendoscopic outcomes for intraventricular tumor resection are significantly better when performed on small, cystic tumors and when neural navigation or stereotaxy is used. Conclusion. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors of a particular morphology.

The Significance of Cyst Remnants After Endoscopic Colloid Cyst Resection

BACKGROUND:

Controversy surrounds the fate of cyst remnants after endoscopic colloid cyst resection.

OBJECTIVE:

Our study evaluated recurrence rates in patients with total endoscopic resection of colloid cysts vs those with coagulated cyst remnants.

METHODS:

Sixty-five consecutive patients and 67 procedures for endoscopic resection of colloid cysts from 1995 to 2011 were reviewed. Degree of resection was based on intraoperative assessment and postoperative magnetic resonance imaging (MRI). Recurrence rates were compared between patients with complete resection those with coagulated cyst remnants.

RESULTS:

Data analysis was performed of 56 patients and 58 procedures, with no follow-up in 9 patients. All patients had MRI-defined complete resection. On intraoperative assessment, 9 procedures had coagulated remnants and 45 procedures had complete resection (4 data unknown). The overall recurrence rate was 6.89% (4/58), 33.3% (3/9) with cyst remnants, and 2.2% (1/45) with total resection (P = .0124). Maximum follow-up was 144 months (mean, 40.4 months). Mean follow-up was 66.0 months for cyst remnant cases, and 33.5 months for totally resected cases. There was no mortality or permanent morbidity. Transient morbidity included memory deficit (n = 2), aseptic meningitis (n = 1), and local wound infection (n = 1).

CONCLUSION:

Endoscopic colloid cyst resection results in a low overall recurrence rate. Immediate postoperative MRI was insufficient for assessing degree of resection and was a poor predictor of recurrence. Ablation of cyst remnants rather than total removal is associated with a significantly higher rate of recurrence. The primary goal of endoscopic surgery should, therefore, be removal of all cyst contents and wall remnants.

Supraorbital endoscopic approach to colloid cysts

BACKGROUND

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.