Paired Colloid Cysts in the Third Ventricle

Paired Colloid Cysts in the Third Ventricle

Case Report Paired Colloid Cysts in the Third Ventricle Amit Kumar Thotakura1, Venkata Srinivasa Rao Nooti2, Sudhakar Ghanta3 Key words Colloid cyst...

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Case Report

Paired Colloid Cysts in the Third Ventricle Amit Kumar Thotakura1, Venkata Srinivasa Rao Nooti2, Sudhakar Ghanta3

Key words Colloid cyst - Paired - Third ventricle -

Abbreviations and Acronyms MRI: Magnetic resonance imaging T1W: T1-weighted image T2W: T2-weighted image From the 1Department of Neurosurgery, NRI Medical College, Mangalagiri, Guntur; and Departments of 2 Neurosurgery and 3Pathology, Metro Superspeciality Hospitals, Vijayawada, Andhra Pradesh, India To whom correspondence should be addressed: Venkata Srinivasa Rao Nooti, M.Ch. [E-mail: [email protected]] Citation: World Neurosurg. (2016) 93:485.e7-485.e9. http://dx.doi.org/10.1016/j.wneu.2016.07.034 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

INTRODUCTION Colloid cyst is the most common neoplastic lesion of the third ventricle. It presents with varied presentations, and its intensities are various on magnetic resonance imaging (MRI). It is treated by surgical excision, either microscopic or endoscopic. The occurrence of 2 colloid cysts in the ventricular system is rare. We present a case with paired colloid cysts of the third ventricle in a patient who presented with obstructive hydrocephalus.

CASE REPORT A 35-year-old female patient presented with history of headache of 2 months duration not associated with vomiting. She had 2 episodes of generalized tonic-clonic seizures. Higher mental functions, cranial nerves, and musculoskeletal system examination were normal. Her MRI brain showed evidence of a 14- to 16-mm, round to oval, well-defined area of altered signal intensity in the roof of the third ventricle adjacent to the foramen of Monro. The lesion is isointense on T1-weighted (T1W) image, hyperintense on T2-weighted (T2W)

- BACKGROUND:

Colloid cyst is the most common neoplastic lesion of the third ventricle, and the occurrence of 2 colloid cysts in the ventricular system is rare.

- CASE

REPORT: We present a 35 year old female patient with paired colloid cysts of the third ventricle who presented with obstructive hydrocephalus and were treated surgically with the transcallosal interhemispheric transforaminal approach. Until now only 3 patients of dual or paired colloid cysts of different ventricles were reported. To the best of our knowledge, this is the first case with both the colloid cysts present in the third ventricle.

- CONCLUSION:

This report illustrates the importance of proper radiologic study in a case of colloid cyst and preparing preoperatively and excision of both the colloid cyst whenever present, to prevent the recurrence.

image and flair imaging with central hypointensity. Another small hypointense lesion adjacent to this lesion is seen in the T2W images suggestive of paired colloid cysts with obstructive hydrocephalus and periventricular seepage (Figure 1). Our preferred surgical option to colloid cyst is the interhemispheric transcallosal approach. The patient was positioned supine with her neck slightly flexed. Her head was fixed on 4-pin clamp. A 6-cm right frontoparietal parasagittal craniotomy was done extending across the midline, 4 cm anterior to the coronal suture and 2 cm posterior to the coronal suture. The dura was opened based on the superior sagittal sinus. We retracted the frontal lobe, preserving the bridging veins. Arachnoid dissection was done next. The 2 distal anterior cerebral arteries were noted, and the corpus callosum was exposed. A 2-cm callosotomy was done anteriorly, slightly onto the left side of the midline. We then entered the left lateral ventricle. The colloid cyst was seen obstructing the foramen of Monro, and a vein was noted traversing the colloid cyst on the foramen. We dissected and preserved the vein. The cyst was decompressed. Initially, soft mucoid material was aspirated followed by thick inspissated material present at the depth of the lesion. The cyst wall was dissected from all around and excised. Another small cyst was noted at midline

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slightly on to the right side. Septostomy was done, and the right foramen of Monro was noted to be free. Again, the left lateral ventricle was entered and the second cyst was dissected and excised in toto. Hemostasis was achieved. We closed the dura and replaced the bone flap. A suction drain was inserted, and the skin was closed in layers. Postoperatively the patient was extubated, and her recovery was smooth. She had no added deficits and was discharged on fifth postoperative day. Histopathologic examination of both cysts showed that the cyst wall was lined by flattened cuboidal epithelial cells along with loose stroma and sparsely inflammatory cells suggestive of colloid cysts (Figure 2). DISCUSSION Colloid cyst is commonly a single lesion that arises on the roof of the third ventricle at the anterosuperior aspect of the third ventricle near the foramen of Monro. Various theories relating to the origin of the colloid cyst have been proposed. Most of the authors believe that the neuroepithelial sources like choroidal epithelium, ependyma, and paraphysis are the source of origin.1,2 Some authors have suggested the endodermal source as the origin of a colloid cyst.3-5 A review of the literature yields 3 reports of paired colloid cysts in a single patient,

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CASE REPORT AMIT KUMAR THOTAKURA ET AL.

PAIRED COLLOID CYST

Table 1. List of Earlier Case Reports with Paired Colloid Cysts in Ventricular System

Author

Figure 1. Magnetic resonance image of brain showed evidence of 14- to 16-mm, round to oval, well-defined area of altered signal intensity in the roof of the third ventricle adjacent to the foramen of Monro. It is isointense on T1-weighted imaging (left), hyperintense on T2-weighted imaging (right) and with central hypointensity. Another small hypointense lesion adjacent to this lesion is seen in the T1-weighted image (left) and T2-weighted image (right) (red arrow).

the details of which are tabulated in Table 1. None of these reports had paired colloid cysts in the third ventricle. Our case appears to be the first one with both the colloid cysts in the third ventricle. There are reports of a third ventricular colloid cyst associated with another lesion, xanthogranuloma.9,10 The other lesion need to be differentiated from colloid cyst radiologically yet be prepared preoperatively for excision of both lesions. The colloid cyst on MRI is generally seen as a heterogenous lesion on T1W and T2W images. In our case, the larger lesion shows heterogenous intensity on T2WMRI, hyperintense lesion with central

hypointensity on T2W imaging. As per El Khoury et al.,11 the consistency of the lesion correlates with the intensity on a T2W image. The hyperintensity represents more soft fluid, whereas hypointensity suggests nonsuckable, thick, inspissated material. The smaller lesion is homogenously hypointense on T2W imaging. The intensity of the lesions corresponds to the operative findings in our case. The symptoms are generally due to the obstruction of the foramen of Monro by the enlarging colloid cyst. As seen in the 2 reports of paired colloid cysts (1 in the lateral ventricle), the symptomatic one was in the third ventricle. So it is important to

Location of Colloid Cysts

Gender and Age of Patient (in years)

1. Parkinson and Childe, 19526

Both in fourth ventricle

Male, 28

2. MauriceWilliams and Wadely, 19987

1 in lateral ventricle, symptomatic in third ventricle

Male, 27

3. Dahdaleh et al., 20128

1 in lateral ventricle, symptomatic in third ventricle

Female, 31

Both in third ventricle

Female, 35

4. Present study

study the imaging properly and plan for surgery. Otherwise, if any small lesion is missed, it may increase in size and cause the recurrence of symptoms. CONCLUSION This is a rare occurrence of paired colloid cysts in the third ventricle. Careful preoperative planning and surgical excision are required in these cases to prevent the recurrence of symptoms. REFERENCES 1. Coxe WS, Luse SA. Colloid cyst of third ventricle. An electron microscopic study. J Neuropathol Exp Neurol. 1964;23:431-445. 2. Greenwood J Jr. Paraphysial cysts of the third ventricle with report of eight cases. J Neurosurg. 1949;6:153-159. 3. Hirano A, Ghatak NR. The fine structure of colloid cysts of the third ventricle. J Neuropathol Exp Neurol. 1974;33:333-341. 4. Ho KL, Garcia JH. Colloid cysts of the third ventricle: ultrastructural features are compatible with endodermal derivation. Acta Neuropathol. 1992;83:605-612. 5. Lach B, Scheithauer BW. Colloid cyst of the third ventricle: a comparative ultrastructural study of neuraxis cysts and choroid plexus epithelium. Ultrastruct Pathol. 1992;16:331-349.

Figure 2. Histopathologic examination (hematoxylin-eosin stain, high power [40]) of both cysts [(A) larger cyst, (B) smaller cyst] showed a cyst wall lined by flattened cuboidal epithelial cells along with loose stroma and sparsely inflammatory cells suggestive of colloid cysts.

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6. Parkinson D, Childe AE. Colloid cyst of the fourth ventricle; report of a case of 2 colloid cysts of the fourth ventricle. J Neurosurg. 1952;9:404-409.

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CASE REPORT AMIT KUMAR THOTAKURA ET AL.

7. Maurice-Williams RS, Wadley JP. Paired colloid cysts of the third and lateral ventricles. Br J Neurosurg. 1998;12:47-50. 8. Dahdaleh NS, Dlouhy BJ, Kirby PA, Greenlee JD. Unusual “double density” colloid cysts. J Clin Neurosci. 2012;19:612-614. 9. Matsushima T, Fukui M, Kitamura K, Soejima T, Ohta M, Okano H. Mixed colloid cystxanthogranuloma of the third ventricle. A light and electron microscopic study. Surg Neurol. 1985; 24:457-462.

PAIRED COLLOID CYST

10. Shuangshoti S, Phonprasert C, Suwanwela N, Netsky MG. Combined neuroepithelial (colloid) cyst and xanthogranuloma (xanthoma) in the third ventricle. Neurology. 1975;25:547-552. 11. El Khoury C, Brugières P, Decq P, CossonStanescu R, Combes C, Ricolfi F, et al. Colloid cysts of the third ventricle: are MR imaging patterns predictive of difficulty with percutaneous treatment? Am J Neuroradiol. 2000;21:489-492.

relationships that could be construed as a potential conflict of interest. Received 3 June 2016; accepted 11 July 2016 Citation: World Neurosurg. (2016) 93:485.e7-485.e9. http://dx.doi.org/10.1016/j.wneu.2016.07.034 Journal homepage: www.WORLDNEUROSURGERY.org Available online: www.sciencedirect.com 1878-8750/$ - see front matter ª 2016 Elsevier Inc. All rights reserved.

Conflict of interest statement: The article content was composed in the absence of any commercial or financial

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