Extruded contents of colloid cysts after endoscopic removal

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OBJECTIVE

Mineralized or desiccated colloid cysts pose some unique challenges to endoscopic removal. The extrusion of the solid matrix into the intraventricular compartment has not been previously reported and, as such, no guidance exists regarding its predilection, prevention, and fate.

METHODS

Postoperative imaging studies in a registry of patients undergoing endoscopic removal of colloid cyst were reviewed to detect any solid matrix within the ventricular compartment. Preoperative images and operative notes were used to determine if any features were predictive. Serial postoperative images and clinical notes were used to characterize the implications of these findings.

RESULTS

From a review of 94 patients, 10 (10.6%) patients had evidence of an extruded intraventricular solid fragment (median follow-up 4 months; range 0.5–115 months). Of the evaluable patients, 7 of 9 patients had T1-weighted hyperintense and T2-weighted hypointense cysts on preoperative scans. Seventy-eight percent of the extrusions were on the same side as the endoscopic entry. Three patients demonstrated early fragment migration, but not after 8 months of radiological follow-up. All evaluable patients demonstrated improvement in their hydrocephalus, and none suffered a complication attributable to the intraventricular extruded fragments.

CONCLUSIONS

Intraventricular extruded colloid fragments can occur after endoscopic resection, with the possible risk demonstrated as cyst hypointensity on preoperative T2-weighted images. The finding does not seem to result in any clinical morbidity, and radiographic involution is the rule. Migratory capacity, however, does exist and justifies a more frequent imaging surveillance schedule and consideration for removal.

ABBREVIATIONSFOHR = frontal occipital horn ratio.

Article Information

INCLUDE WHEN CITING Published online January 8, 2016; DOI: 10.3171/2015.6.JNS142676.

Correspondence Mark M. Souweidane, Department of Neurological Surgery, NewYork-Presbyterian Hospital, Weill Medical College, Cornell University, 525 E. 68th St., Box 99, New York, NY 10065. email: mmsouwei@med.cornell.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Patient 9. Left: Sagittal T2-weighted MR image showing a large anterior third ventricular colloid cyst with hyperintense signaling and a focal area with T2-weighted signal drop-out (arrowhead), indicating more solid or mineralized contents that are prone to extrusion with endoscopic extirpation. Right: Postoperative axial T2-weighted MR image showing an extruded hypointense fragment in the right occipital horn (arrowhead), with another axial cut showing that the frontal horns were clean at that time.

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    Patient 9. Postoperative scans obtained as follow-up of the extruded colloid fragment. A: CT scans obtained 12 days postoperatively showing that the fragment has moved from the right occipital horn to the right frontal horn (arrowhead). Note in the slice on the right that both occipital horns are devoid of fragments. B: CT scans obtained 4 weeks postoperatively, showing the fragment has moved to the left occipital horn (arrowhead) with clean frontal horns at the same time in the slice on the right. C: MR image obtained 4 months postoperatively, showing that the fragment was still in the left occipital horn (arrowhead).

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    Patient 2. Eight-month postoperative dynamic CT scan of the right lateral (left) and left lateral (right) decubitus positions used to evaluate the movement of the fragment seen in the left frontal horn (arrowhead).

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    Patient 7. This patient had the longest follow-up period. Preoperative T2-weighted (A) and T1-weighted (B) MR images showing the isointense and hyperintense signals of the colloid cyst. C and D: T2-weighted MR image (C) obtained 7 days postoperatively, showing an extruded fragment in the right occipital horn (arrow), which retained its general position, size, and signal characteristics at 2 months postoperatively (D). E: Gradient-echo T2*-weighted MR image obtained 24 months postoperatively, showing the susceptibility of the fragment in same position. F–H: T2-weighted MR images obtained at 48 months (F), 84 months (G), and 120 months postoperatively (H) showing the same fragment position.

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