Dr. Ali Niyaf
MBBS, MS, MCh (neurosurgery)
Head of Department of Neurosurgery
ADK Hospital, Male'

 

Chandra Prakash Limbu, Ram Kumar Shrestha, Ibrahim Moomin

Colloid cyst of the third ventricle is a rare but challenging intraventricular benign epithelium-lined cystic tumor. These lesions comprise 2% of all intracranial tumors. Traditionally, surgical excision is carried out by transcallosal or transcortical transventricular approaches. Currently, endoscopic management of these lesions is growing due to numerous advantages. We share our preliminary experience of six (6) cases of colloid cysts treated using neuro-endoscopy.

We performed a retrospective review of medical records of patients who underwent surgical treatment colloid cyst who had been operated endoscopically in our department from 2015-2018. We use a LOTTA system for intracranial Neuroendoscopy. A single surgeon in all of the cases performed surgery. Surgical technique included devascularization of the cyst wall, aspiration of the colloid content and gross total resection of the cyst attaining cerebrospinal fluid flow pathway. Inadvertent hemorrhage was attended by thorough continuous irrigation. Follow up was done in all case with clinical assessment, fundoscopy, and MRI imaging studies.

Patients were predominantly males and age ranged from 25-68 years. The prevailing clinical symptoms were headache, dizziness, vomiting, gradual progressive visual blurring and transient limb weakness. Brain MRI clearly delineated this largely third ventricular cystic lesion with or without hydrocephalus. The operative duration varied with a steep learning curve ranging from 180 to 50mins. Intraoperative early landmark misidentification due to poor orientation occurred in one case. Two cases of intraoperative intraventricular hemorrhage was observed, which was dealt with continuous irrigation and bipolar coagulation, among which one case required placement of a safety EDV. The outcome was favorable in all six patients with length of hospital stay of 3-5 days. We observed one case of postoperative aseptic meningitis due to ventricular bleed. We had no new onset neurological deficit or mortality following cyst resection. Histopathology revealed colloid material and cyst wall consistent with colloid cyst in all cases. Follow up MRI brain was done at 3-month interval in all cases. None of the patients revealed ventriculomegaly. Residual cyst wall was identified in one (1) case with no signs of CSF flow obstruction.

Neuroendoscopic resection of colloid cysts is time efficient, safe surgical technique, minimally invasive and least traumatic to approach to the ventricular colloid cysts. Landmark disorientation is a challenge in patients with minimal hydrocephalus; hence guidance utilizing Neuronavigation is an essential adjuct in such cases. Intraventricular hemorrhage could be challenging but can be dealt by efficient of irrigation system and meticulous use of bipolar. Our preliminary results of endoscopic resection of colloid cysts were encouraging and can be considered as first line of treatment in their management.

Neuroendoscopy, Third ventricular Colloid Cyst