Acesso endoscópico transepto-interforniceal para cistos colóides: relato de caso

Abstract

RESUMO -A abordagem endoscópica de cistos colóides ainda é matéria controversa. As opções de tratamento são variadas: observação com exames seriados, tratamento da hidrocefalia, aspiração por estereotaxia, microcirurgia e endoscopia. O autor relata o caso de um paciente com cisto colóide do terceiro ventrículo, localizado em posição retroforaminal, no teto diencefálico, dissecando os dois fornices projetando-se supero-posteriormente em direção ao assoalho do ventrículo lateral, por dentro do cavum do septo pelúcido. A lesão foi alcançada com neuroendoscópio rígido, através de um orifício de trépano pré-coronal situado a 2,5 cm da linha média (ponto de Kocher). Seguindo por via transventricular, a lâmina direita do septo pelúcido foi aberta, posterior à veia septal. A lesão, muito endurecida, situada entre os dois fórnices, foi parcialmente ressecada através da via endoscópica transventricular transepto-interforniceal. Realizamos também septostomia e terceiro ventriculostomia endoscópicas neste paciente. Os diferentes tipos de procedimentos cirúrgicos das patologias situadas no terceiro ventrículo são discutidos com ênfase no papel da endoscopia.PALAVRAS-CHAVE: cisto colóide retroforaminal, abordagem endoscópica transepto-interforniceal. Endoscopic transepto-interforniceal approach to colloid cysts: case reportABSTRACT -The endoscopic treatment of colloid cysts of third ventricle is still controversial. Management of the patient can include observation and serial CT or MRI imaging only, ventriculo peritoneal shunt only, estereotactic aspiration, microsurgery and endoscopy. The author reports the case of a patient with colloid cyst of third ventricle located in a retroforaminal position, in the diencefalic roof, dissecting the raphe fornix, expanding supero-posteriorly, inside the cavum of the septum pellucidum, protruding on the floor of lateral ventricles. The cyst was approached with a rigid neuroendoscope, through a pre-coronal burr hole, 2.5 cm lateral to the midline (Kocher´s point). Following a transventricular route, the right leaf of the septum pellucidum was endoscopically opened with bipolar, posterior to the septal vein. A yellowish hard lesion was found and partially resected with biopsy forceps, between the two fornices, which were split apart by the uncommon expansion and location of the lesion, allowing a new endoscopic transventricular transepto-interforniceal approach. We also performed endoscopic septostomy and third ventriculostomy. The microsurgical approaches compared with endoscopic approaches, and the possibility of endoscopic alternative routes suitable for selected cases with superior expansion towards the fornix and septum pellucidum is discussed.KEY WORDS: retroforaminal colloid cyst, endoscopic transepto-interforniceal approach.O tratamento endoscópico de cistos colóides do terceiro ventrículo é matéria de controvérsia em neurocirurgia. A microcirurgia é considerada a técnica padrão para estes casos, porém a ressecção endoscópica com várias séries referindo ressecção total, quase compa...

Management of colloid cyst of third ventricle

“…The endoscopic transepto interforniceal approach can be used in colloid cysts of the third ventricle located in a retroforaminal position dissecting the raphe fornix and expanding superoposteriorly in the septum pellucidum (57). Rigid endoscopy affords good optical resolution, high magnification, and excellent illumination.…”

Treatment of colloid cysts of the third ventricle through neuroendoscopic Nd: YAG laser stereotaxis

“…Non-surgical treatment and control image sequence can be the right attitude in asymptomatic cases, when the colloid cyst is small and the foramen of Monro is wide and no hydrocephalus is present 5 . Shunting of cerebrospinal fluid, stereotactic aspiration of its content, microsurgical removal, stereotactic-guided endoscopy, neuroendoscopy, stereotactically-guided craniectomy and neuronavigationassisted endoscopy have been proposed for symptomatic patients [2][3][4][5][6][9][10][11][12][13] . Shunting is not recommended because the frequent problems related with the valves and the surgical procedures in the bilateral obstruction of the foramen of Monro requires bilateral ventricular shunting and it is not a curative treatment 5,7 .…”

“…This means that it can be indicated in patients with severe accompanying diseases 5 . In 1983, Pawer et al 3,12 reported the first successful endoscopy aspiration of a third ventricle colloid cyst and after that, other authors replaced the open surgical procedures by endoscopy 4,13,17 . The endoscopic removal is considered the therapy of choice, due to the satisfactory outcome [3][4][5]13,17 , minimal rate of complications, short hospitalization time 16 , earlier return to the work and the reduced costs 4,5,13,[17][18][19] .…”

“…The total removal of the colloid cysts was possible without mortality or any evidence of recurrence in an average follow-up period of 33 months. The complications reported were such as intraoperative hemorrhage, memory deficit, mutism, third cranial nerve palsy, ventriculitis, seizures, venous infarction, fornix and thalamus contusion, transient or permanent hemiparesis and subdural fluid accumulation 3,5,12,13,27,28 . In our series, only two patients presented transient morbidities that were easily treated: one had Diabetes insipidus that lasted for two days and was treated with a single dose of DDAVP, and another had chemical aseptic meningitis, probably due to the contact of the cyst content with the CSF.…”

“…Several therapeutic options have been proposed for its treatment: non-surgical treatment with control of sequential images, shunting of cerebrospinal fluid, stereotactic aspiration of its content, microsurgical removal, stereotactic guided endoscopy, neuroendoscopy, stereotactically-guided craniectomy and neuronavigation-assisted endoscopy [2][3][4][5][6][7][8][9][10][11][12][13] . Since 1960, CO 2 , Argon, Nd:YAG and Diode lasers have been used in neurosurgical procedures 1 .…”