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Konstantinos Margetis, Paul J. Christos and Mark Souweidane

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.

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Konstantinos Margetis and Mark M. Souweidane

Endoscopic resection of colloid cyst in patients with normal-sized ventricular system is challenging, because the limited intraventricular space increases the risk of injuring eloquent nervous structures and critical blood vessels. The utilization of frameless stereotaxy and tissue shaving device facilitates the procedure. An important operative step is the ventricular insufflation that allows for an endoscope introduction without causing inadvertent injury to the caudate nucleus. The attached clip shows the basic operative steps of the procedure. In this clip the solid colloid cyst contents necessitated an en-block colloid cyst resection, in lieu of initially aspirating the cyst contents and subsequently removing the cyst walls.

The video can be found here: http://youtu.be/zzYYZEsd-uk.

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Alberto Feletti and Pierluigi Longatti

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Konstantinos Margetis, Prajwal Rajappa, William Cope, David Pisapia and Mark M. Souweidane

A 21-year-old man presented with triventricular hydrocephalus due to a tectal mass. He underwent an endoscopic third ventriculostomy, and multiple nodules were identified at the floor of the third ventricle intraoperatively. Surgical pathology of one of these lesions demonstrated that the tissue represented a low-grade astrocytoma. The case highlights the existing potential of neuroendoscopy to reveal neuroimaging-occult lesions, in spite of the significant advances of MRI. Furthermore, the combination of the age of the patient, the nonenhancing MRI appearance, and the multifocality of the lesions constitutes a rare and interesting neoplastic presentation within the brain. The constellation of findings likely represents dissemination of a low-grade tectal glioma via the CSF compartment.

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Konstantinos Margetis, Prajwal Rajappa, Apostolos John Tsiouris, Jeffrey P. Greenfield and Theodore H. Schwartz

OBJECT

A critical goal in neurosurgical oncology is maximizing the extent of tumor resection while minimizing the risk to normal white matter tracts. Frameless stereotaxy and white matter mapping are indispensable tools in this effort, but deep tumor margins may not be accurately defined because of the “brain shift” at the end of the operation. The authors investigated the safety and efficacy of a technique for marking the deep margins of intraaxial tumors with stereotactic injection of Indigo Carmine dye.

METHODS

Investigational New Drug study approval for a prospective study in adult patients with gliomas was obtained from the FDA (Investigational New Drug no. 112680). At surgery, 1–3 stereotactic injections of 0.01 ml of Indigo Carmine dye were performed through the initial bur holes into the deep tumor margins before elevation of the bone flap. White light microscopic resection was conducted in standard fashion by using frameless stereotactic navigation until the injected margins were identified. The resection of the injected tumor margins and the extent of resection of the whole tumor volume were determined by using postoperative volumetric MRI.

RESULTS

In total 17 injections were performed in 10 enrolled patients (6 male, 4 female), whose mean age was 49 years. For all patients, the injection points were identified intraoperatively and tumor was resected at these points. The staining pattern was reproducible; it was a sphere of stained tissue approximately 5 mm in diameter. A halo of stained tissue and a backflow of dye through the needle tract were also noted, but these were clearly distinct from the staining pattern of the injection point, which was vividly colored and demarcated. Postoperative MR images verified the resection of all injection points. The mean extent of resection of the tumor as a whole was 97.1%. For 1 patient, a brain abscess developed on postoperative Day 16 and needed additional surgical treatment.

CONCLUSIONS

Stereotactic injection of Indigo Carmine dye can be used to demarcate multiple deep tumor margins, which can be readily identified intraoperatively by using standard white light microscopy. This technique may enhance the accuracy of frameless stereotactic navigation and increase the extent of resection of intraaxial tumors.

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Prajwal Rajappa, Konstantinos Margetis, Dimitri Sigounas, Vijay Anand, Theodore H. Schwartz and Jeffrey P. Greenfield

The authors report a case of a recurrent pediatric ventral pontine ependymoma that they resected through an endonasal endoscopic transclival approach. Regarding the options for a surgical approach to ventral pontine tumors, traditional far-lateral approaches are associated with considerable morbidity due to the required muscle mobilization, brain retraction, and in-line obstruction of cranial nerves before reaching the target. The endoscopic endonasal transclival approach was made appealing by eliminating all of these concerns. The patient's fully pneumatized sphenoid sinus, laterally displaced basilar artery, and the direct ventral location of the bulky disease all further supported this unconventional choice of surgical corridor to achieve a palliative brainstem decompression of an incurable recurrence.