Early recurrence from stereotactic aspiration ofa colloid cyst of the third ventricle

Early recurrence from stereotactic aspiration ofa colloid cyst of the third ventricle

JOCN-188.QXD 10/13/01 5:32 PM Page 570 570 Skirving, Pell REFERENCES 1. Angelopoulos M, Gupta SR, Azat Kia B. Primary intraventricular hemorrhage ...

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REFERENCES 1. Angelopoulos M, Gupta SR, Azat Kia B. Primary intraventricular hemorrhage in adults: clinical features, risk factors, and outcome. Surg Neurol 1995; 44: 433–436. 2. Miyasaka Y, Yada K, Ohwada T, Morii S, Kitahara T, Kurata A, Tanaka R. Choroid plexus arteriovenous malformations. Neurol Med Chir 1992; 32: 201–206. 3. Nomura S, Orita T, Tsurutani T, Kajiwara K, Izumihara A. Transient hydrocephalus due to movement of a clot plugging the aqueduct. Comput Med Imaging Graph 1997; 21: 351–353. 4. Kadowaki C, Hara M, Numoto M, Takeuchi K, Saito I. Cine magnetic resonance imaging of aqueductal stenosis. Childs Nerv Syst 1995; 11: 107–111. 5. Quencer RM. Intracranial CSF flow in pediatric hydrocephalus: evaluation with cine-MR imaging. AJNR: Am J Neuroradiol 1992; 13: 601–608.

Fig. 1 Magnetic resonance imaging performed 2 years previously (left) and in a few months before admission (right). The deep occipital malformation decreased with treatment, but a nidus remained.

Early recurrence from stereotactic aspiration of a colloid cyst of the third ventricle D. J. Skirving MBBS, M. F. Pell FRACS Concord General Repatriation Hospital, Sydney, Australia

Summary The case of a 66 year old woman who underwent successful stereotactic aspiration of a symptomatic colloid cyst of the third ventricle, but who had recurrence after only 5 weeks, is presented. Stereotactic aspiration is a well established technique for the treatment of colloid cysts, however disagreement exists regarding its efficacy. Two factors, both from pre-operative CT, help to predict success from aspiration: the cyst’s density and size. The literature reports that recurrence after successful stereotactic aspiration should not occur for many years. © 2001 Harcourt Publishers Ltd Fig. 2 Computed tomography initially showed intraventricular hemorrhage in the right lateral ventricle as well as the enlargement of third and lateral ventricles (upper panel). The aqueduct was blocked with high-density material believed to be a clot. Seven hours later hydrocephalus had completely resolved with disappearance of the high density at the aqueduct (lower panel).

ventricular drainage was planned. After obtaining parental consent for surgery and making urgent preparations for operation, we deferred the procedure just prior to head shaving when all symptoms suddenly and completely resolved 7 h after their onset.CT demonstrated complete resolution of hydrocephalus with disappearance of the high density from the aqueduct (Fig. 2, lower panel). DISCUSSION Obstructive hydrocephalus is frequently seen in cases of IVH. The obstruction often occurs at the aqueduct, usually from clots. Hypertension and AVMs are common causes of IVH; indeed, most cases of IVH with unknown etiology are believed to result from rupture of a cryptic AVM involving the choroid plexus.1,2 On the other hand, spontaneous resolution of obstructive hydrocephalus caused by IVH is rarely seen in the early acute phase.3 However, cerebrospinal fluid flow (CSF) tends to be hyperdynamic, and pressure at the aqueduct increases in obstructive hydrocephalus.4,5 In this manner, CSF flow can dislodge the clot from the aqueduct. In a case with obstructive hydrocephalus caused by a small amount of IVH, the possibility of spontaneous resolution in the period of preparation for operation should be kept in mind during close clinical monitoring. Journal of Clinical Neuroscience (2001) 8(6)

Journal of Clinical Neuroscience (2001) 8(6), 570–571 © 2001 Harcourt Publishers Ltd DOI: 10.1054/jocn.2000.0847, available online at http://www.idealibrary.com on

Keywords: colloid cyst, recurrence, stereotaxy Received 6 June 2000 Accepted 27 September 2000 Correspondence to: M F Pell, St. Vincent’s Clinic, Suite 705 A, 438 Victoria Street, Darlinghurst 2010, Sydney, Australia. Tel.: ;61 (02) 8382 6766; Fax: ;61 (02) 8382 6770

INTRODUCTION Colloid cysts of the third ventricle are rare, benign intracranial tumours.8,10 On plain computed tomography, these lesions appear rounded at the level of the foramen of Munro and are usually hyperdense and homogenous, enhancing mildly with contrast material. However, their appearance can be variable, appearing hypodense or isodense and heterogenous.10 The optimal treatment for these lesions is controversial.1,5,6,8,10 CASE STUDY A 66 year old woman presented with 2 months of periorbital headaches. She had a left lower lobe lobectomy 4 years earlier, for adenocarcinoma of the lung. General and neurological examination was normal. CT revealed a hyperdense mass, which enhanced mildly with contrast, in the anterior third ventricle and there was no associated hydrocephalus (Fig. 1A). A differential diagnosis of a colloid cyst, or less likely a secondary deposit from © 2001 Harcourt Publishers Ltd


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Fig. 1 (A) CT at presentation (B) CT after first stereotactic aspiration

Fig. 2 (A) CT at presentation of recurrent cyst (B) CT after second stereotactic aspiration

lung carcinoma, was made. The patient underwent framed stereotactic biopsy using the Cosman-Roberts-Wells (CRW Radionics) stereotactic system. Aspiration using a right frontal approach and Sudan-Nashold biopsy needle was performed. Four mls of mucoid fluid was aspirated. Histopathology confirmed this to be a colloid cyst. Follow-up CT scan 4 days later showed a small residual cyst consisting of the remaining cyst wall plus a small volume of colloid (Fig. 1B), and the patient was discharged home. She represented 5 weeks later with headaches on bending forward. Repeat CT scan revealed re-accumulaion of the colloid cyst (Fig. 2A). The patient underwent a second stereotactic aspiration through the old burr hole. Again, 4 mls of mucoid fluid was aspirated. Follow up CT 4 days later showed complete disappearance of the cyst (Fig. 2B).

was radiological ‘radical cyst aspiration’ achieved. Two of these were not followed as they required early ventriculoperitoneal shunts for persistent hydrocephalus. The remaining three did not have recurrent cysts detected until 74, 89 and 84 months after the initial procedure. They found that when aspiration was incomplete, on radiological examination, recurrence was high and often early. These, however, were not strictly recurrences but represented failed initial treatment.10 Kondziolka and Lunsford5 reported a series of 22 patients with colloid cysts of the anterior third ventricle, and found that stereotactically guided aspiration alone was successful in half of these. A successful aspiration was described as one in which postoperative CT demonstrated complete disappearance of the cyst or evidence of a small residual consisting of the remaining cyst wall plus a small volume of colloid. A mere decrease in size of the cyst post aspiration did not equate with success. Two factors were identified, both from preoperative CT, which helped to predict success from aspiration: the viscosity of the cystic contents and the size of the colloid cyst. Firstly, a preoperative CT scan appearance of a hypodense or isodense cyst predicted that the cyst contents were of low viscosity, and aspiration was successful in six of eight cases of a hypodense or isodense cyst. On the other hand, hyperdense cysts predicted high viscosity of cyst contents and failure of aspiration occurred in 13 of 14 patients with hyperdense cysts. This difference was statistically significant. Secondly, when cysts were less than 1.0ml in volume the rate of unsuccessful aspirations was higher. Reasons cited included the high viscosity of the contents of small cysts and technical difficulties such as deviation of small cysts away from the biopsy needle. These factors have been consistent in subsequent unreported cases by the same authors.6 They concluded that when aspiration is reserved for this subgroup of patients, success from aspiration is high, and because of its low risk should still be offered as the initial procedure of choice. Despite MRI contributing much to the diagnosis of colloid cysts and providing excellent pre-operative anatomical definition, it was not possible to correlate successful aspiration with cyst appearance on MRI images with short or long relaxation time sequences.5,10 In this case, despite the pre-operative CT scan revealing a hyperdense cyst, aspiration was successful. However, the cyst recurred after 5 weeks. In the literature, recurrence after only 5 weeks has not been reported after a successful aspiration. Interestingly, the recurrent cyst was isodense, not hyperdense, perhaps suggesting that colloid cysts become hyperdense over time. REFERENCES

DISCUSSION The literature suggests that colloid cysts of the third ventricle fit into two broad groups: those that are asymptomatic and found incidentally, and those that have produced symptoms.11 Patients in whom asymptomatic colloid cysts are diagnosed can be observed with serial imaging.11 If a cyst starts to cause symptoms, enlarges or hydrocephalus develops, surgical intervention is indicated.11 Early attempts at open surgery for these lesions gave poor results.2,8,9 With the aim of reducing this morbidity and mortality, simple cyst aspiration,3 followed by stereotactic guided aspiration,1 were developed. Currently, disagreement exists in the literature as to the efficacy of stereotactic guided aspiration, especially regarding its long term results.1,5,6,8 Some claim recurrence rates are high,8 while others state that recurrence rates are acceptable in selected patients.5,6 Bosch et al.1 had no recurrences in their four cases for up to 7 years. Jeeves et al.4 reported on one case which had not recurred after 10 years. Mathiesen et al.8 reported a series of 16 patients and concluded that this technique fails to offer a permanent treatment. However, in only five patients © 2001 Harcourt Publishers Ltd


Bosch DA, Rahn T, Backlund EO. Treatment of colloid cysts of the third ventricle by stereotactic aspiration. Surg Neurol 1978; 9: 15–18. 2. Dandy WE. Benign Tumours of the Third Ventricle of the Brain: Diagnosis and Treatment. Springfield, 111: Charles C Thomas, 1933: 171. 3. Gutierrez-Lara F, Patino R, Hakim S. Treatment of tumours of the third ventricle: a new and simple technique. Surg Neurol 1975; 3: 323–325. 4. Jeeves MA, Simpson DA, Geffen G. Functional consequences of the transcallosal removal of intraventricular tumours. J Neurol Neurosurg Psychiatry 1979; 42: 134–142. 5. Kondziolka D, Lunsford LD. Stereotactic management of colloid cysts: factors predicting success. J Neurosurg 1991; 75: 45–51. 6. Kondziolka D, Lunsford LD. Aspiration of colloid cyst. J Neurosurg 1993; 79(6): 965–6. 7. Little JR, MacCarty CS. Colloid cysts of the third ventricle. J Neurosurg 1974; 40: 230–235. 8. Mathiesen T, et al. High recurrence rate following aspiration of colloid cysts in the third ventricle. J Neurosurg 1993; 78: 748–752. 9. McKissock W. The surgical treatment of colloid cysts of the third ventricle. A report based upon twenty-one personal cases. Brain 1951; 74: 1–9. 10. Pell MF, Steel TR, Thomas DGT. Stereotactic biopsy in special areas. In: Pell MF, Thomas DGT (eds.) Handbook of Stereotaxy Using the CRW Apparatus, 1st ed. Baltimore: Williams and Williams, 1994: 129–148. 11. Pollock B, Huston J. III. Natural History of asymptomatic colloid cysts of the third ventricle. J Neurosurg 1999; 91: 364–369.

Journal of Clinical Neuroscience (2001) 8(6)