Endoscopic resection of incidental colloid cysts

Abstract

Object Incidental colloid cysts are frequently managed with surveillance imaging rather than surgical excision. This approach is born out of their purported indolent growth pattern and the surgical morbidity associated with microsurgical removal. The advent of endoscopic colloid cyst removal may offer renewed assessment of these patients who carry a risk of acute neurological deterioration. An evidence-based recommendation should weigh the risks of operative treatment. Thus far, there has been no concentrated assessment of cyst removal in patients with incidental colloid cysts. The major objective in this study was to define the risks associated with the endoscopic surgical removal of incidentally diagnosed colloid cysts Methods A retrospective review of the medical records was performed to search for patients evaluated for a colloid cyst between the years 1996 and 2012. Eighty-seven patients underwent colloid cyst resection, and 34 were managed with nonoperative surveillance imaging. Microsurgical resections, endoscopic resections of residual or recurrent colloid cysts, and cases with unknown preoperative symptomatic status were excluded from further analysis. Seventy-seven cases of primary endoscopic resections were identified. Twenty resections were performed in patients with an incidental diagnosis and 57 in symptomatic individuals. Presenting characteristics and surgical outcomes were compared between the incidental and symptomatic groups. Results The mean age at surgery was 39.65 years for the incidental and 43.31 years for the symptomatic group (p = 0.36). The median maximal cyst diameter was 9.7 mm (range 3–31 mm) for the incidental and 12 mm (range 5–34 mm) for the symptomatic group. The mean frontal and occipital horn ratio was 0.3928 for the incidental and 0.4445 for the symptomatic group (p = 0.002). Total resection was achieved in 90% of the incidental and 82.3% of the symptomatic cases (p = 0.49). The median hospital stay was 1 day for incidental and 2 days for symptomatic cases (p = 0.006). There were no deaths. There was one case of aseptic meningitis in the incidental group. In the symptomatic group there were 3 complications: one patient with subjective memory impairment, one with transient short-term memory deterioration, and another with a superficial wound infection treated with operative debridement. Two patients from the symptomatic group needed a CSF diversion procedure, and no shunting was needed in the incidental group. There were two recurrences in the symptomatic group (78 and 133 months postoperatively) and none in the incidental group (p = 1). Conclusions Age and cyst diameter were not correlated with the absence or presence of symptoms in patients with a colloid cyst of the third ventricle. Operative results were highly favorable in both groups and did not reveal a higher risk of morbidity in the patient presenting with an incidental lesion. The results support endoscopic resection as a legitimate therapeutic option for patients with incidental colloid cysts. Generalization of the operative results should be cautiously made, since this is a limited series and the results may depend on the degree of neuroendoscopic experience.

Natural history of colloid cysts of the third ventricle

“…11 On the other hand, our data are in direct contrast to the recent study by Margetis et al that reported neither patient age nor cyst diameter was correlated with the absence or presence of symptoms in patients with colloid cysts. 12 Although the ages of our symptomatic cohorts were similar (37.9 ± 15.5 vs 43.3 ± 15.7 years), the incidental cohort was significantly older in the present study (54.2 ± 19.8 vs 39.7 ± 14.5 years), which may account for the significant difference in age that we observed. This discrepancy could be explained by differences in the demographics of the respective regions (St. Louis, Missouri vs New York City), differences in referral patterns, and the fact that our institution is a regional trauma center that serves both an urban and rural catchment area.…”

“…Estimates of the risk of rapid clinical deterioration due to acute hydrocephalus in patients with colloid cysts vary widely, from 3% to 35%, with an associated 5%-38% risk of death. 2,4,12,13,17 Historically, these patients were often described as having experienced "sudden deterioration and death," but several more recent studies using modern neuroimaging techniques have demonstrated that nearly all patients with acute obstructive hydrocephalus have progressive symptoms preceding precipitous clinical deterioration. Potential exceptions are the rare instances of acute intralesional hemorrhage or "cyst apoplexy."…”

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

“…Some studies have suggested that an incidental finding of colloid cyst should not result in a resection but rather in observation with serial imaging (8,27) while others have been more in favor of a surgical approach (28,29). Margetis et al compared surgical outcomes in 20 patients with incidental colloid cysts to 57 symptomatic patients with colloid cysts.…”

“…Margetis et al compared surgical outcomes in 20 patients with incidental colloid cysts to 57 symptomatic patients with colloid cysts. They found that there were no significant differences in postoperative morbidity and mortality (28). However, a major question that remains unanswered is whether there are any significant differences in benefits from such a procedure for patients with an incidental diagnosis.…”

Endoscopic versus open microsurgery for colloid cysts of the third ventricle

“…Colloid cysts have traditionally been operated through open microsurgery (OS), but advances with the endoscopic equipment and introduction of technical nuances to the endoscopic approach have made this approach the first-hand choice in several neurosurgical centers [8][9][10][11] . There is currently no consensus on the approach of choice that yields the most favourable results, in the treatment of patients with colloid cysts.…”