Sudden death due to a colloid cyst of the third ventricle: Report of three cases with a special sign at autopsy

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.

Pediatric colloid cysts: a multinational, multicenter study. An IFNE-ISPN-ESPN collaboration

OBJECTIVE

Colloid cysts (CCs) are rare at all ages, and particularly among children. The current literature on pediatric CC is limited, and often included in mixed adult/pediatric series. The goal of this multinational, multicenter study was to combine forces among centers and investigate the clinical course of pediatric CCs.

METHODS

A multinational, multicenter retrospective study was performed to attain a large sample size, focusing on CC diagnosis in patients younger than 18 years of age. Collected data included clinical presentation, radiological characteristics, treatment, and outcome.

RESULTS

One hundred thirty-four children with CCs were included. Patient age at diagnosis ranged from 2.4 to 18 years (mean 12.8 ± 3.4 years, median 13.2 years, interquartile range 10.3-15.4 years; 22% were < 10 years of age). Twenty-two cases (16%) were diagnosed incidentally, including 48% of those younger than 10 years of age. Most of the other patients had symptoms related to increased intracranial pressure and hydrocephalus. The average follow-up duration for the entire group was 49.5 ± 45.8 months. Fifty-nine patients were initially followed, of whom 28 were eventually operated on at a mean of 19 ± 32 months later due to cyst growth, increasing hydrocephalus, and/or new symptoms. There was a clear correlation between larger cysts and symptomatology, acuteness of symptoms, hydrocephalus, and need for surgery. Older age was also associated with the need for surgery. One hundred three children (77%) underwent cyst resection, 60% using a purely endoscopic approach. There was 1 death related to acute hydrocephalus at presentation. Ten percent of operated patients had some form of complication, and 7.7% of operated cases required a shunt at some point during follow-up. Functional outcome was good; however, the need for immediate surgery was associated with educational limitations. Twenty operated cases (20%) experienced a recurrence of their CC at a mean of 38 ± 46 months after the primary surgery. The CC recurrence rate was 24% following endoscopic resection and 15% following open resections (p = 0.28).

CONCLUSIONS

CCs may present in all pediatric age groups, although most that are symptomatic present after the age of 10 years. Incidentally discovered cysts should be closely followed, as many may grow, leading to hydrocephalus and other new symptoms. Presentation of CC may be acute and may cause life-threatening conditions related to hydrocephalus, necessitating urgent treatment. The outcome of treated children with CCs is favorable.

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.

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.

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.

The impact of surgical resection on headache disability and quality of life in patients with colloid cyst

Introduction Colloid cysts are histologically benign but can present with a broad spectrum of symptoms. A systematic review of the literature did not reveal any patient-centered data on the headache disability and quality of life (QoL) of these patients. Methods This is a retrospective cohort study of 187 colloid cyst patients from the Colloid Cyst Survival Group who completed a survey that included demographic data, clinical data, a modified QoL survey (SF36v2), and a headache disability inventory or index (HDI). Results Using multivariable linear regressions, we confirmed that the physical (PCS) and mental (MCS) components of SF-36 were significantly increased in the surgery group after adjustment for various baseline characteristics ( p = 0.025; p = 0.006). Self-reported headache disability was significantly decreased with surgery when adjusted for the same baseline characteristics ( p = 0.02). Finally, patients with an incidental diagnosis of colloid cyst reported similar benefits from surgery in PCS, MCS and HDI. Conclusion Our results suggest that colloid cyst patients who underwent a surgical resection self-report a better QoL and less headache disability compared with patients who did not undergo surgery. Future prospective studies with baseline measures of QoL are indicated to confirm our findings.

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.

Colloid cyst mimicking intracranial hemorrhage after head trauma

Trauma patients consist vast majority of the patients who admit to emergency department, and most of them have a head trauma. A 58-year-old patient was taken to emergency department with head trauma, and a hyperdense lesion neighboring to third ventricle was detected. A diagnosis of colloid cyst was made in the patient who was being followed up for hemorrhage. In patients with head trauma, colloid cyst may easly be confused with intracranial hemorrhage due to hyperdensity. The aim of this report is to emphasize the importance of clinical thinking in the differential diagnosis of hyperdense lesion on computed tomography imaging of a patient with head injury.

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.

Sudden intraaqueductal dislocation of a third ventricle ependymoma causing acute decompensation of hydrocephalus

The authors report an unusual sudden intraaqueductal dislocation of a third ventricle ependymoma causing acute loss of consciousness, and they detail its neuroendoscopic treatment. This case is unique and has never been described in the literature before. The patient suffered from headache and recurrent nausea. Admission MR images revealed a contrast-enhancing lesion within the posterior part of the third ventricle. During the course of the day of admission, the patient suddenly became comatose. Emergency MR imaging demonstrated a deeply intraaqueductal dislocation of the pedicled tumor, with complete obstruction of the aqueduct and ventricular dilation. Immediate surgical intervention with endoscopic third ventriculostomy and complete tumor removal was performed. After surgery, the patient made a rapid recovery. In this case, the authors presume a sudden intraaqueductal dislocation of the ependymoma caused by aspiration of the tumor as a result of the caudal CSF flow.