COLLOID CYST OF THE THIRD VENTRICLE .PPTX

Ahmed Adel Farag
Ahmed Adel FaragNeurosurgeon um king Abdullah medical city
COLLOID CYST OF THE 3RD VENTRICLE
AHMED ADEL, M.Sc, MRCSI, CG-FNE, FEBNS, M.D
OVERVIEW
EPIDEMIOLOGY
• About 0.5–1% of all intracranial tumors.
• Usual age of diagnosis: 20–50 yrs.
• Children ????????
• Most commonly found in the third ventricle in the region of the
foramina of Monro, but may be seen elsewhere, e.g. in septum
pellucidum.
PATHOLOGY
Pathogenesis origin: unknown, abnormal folding of the primitive
neuroepithelium (the paraphysis elements)
Pathology: Comprised of a fibrous epithelial-lined wall filled with
either mucoid or dense hyloid substance, occationally old blood
(hemosiderin).
Microscopic: These cysts are lined by a single layer of columnar
epithelium which produces mucin
CLINICAL PRESENTATION:
•“Asymptomatic” > 50 % incidental.
•Headache is the most common presentation.
•Patients may start to have headaches once diagnosed.
•Careful evaluation of headache aetiology.
•Non specific presentation.
•Memory affection> subclin.
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
MOCA TEST: PRE AND POSTOP
NATURAL HISTORY
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Kamc female 84 yrs (2 yrs fu)
august 2020
July 2021
1 March 2022
8 march
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Risk of Acute Deterioration 34% in Symptomatic Colloid Cyst
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
• 163 colloid cysts,
• more 50% were discovered incidentally.
• 8.8% progressed and underwent resection (FU 5yrs).
• In another study 8% in 10 yrs.
• No patient with an incidental, asymptomatic colloid cyst
experienced acute obstructive hydrocephalus or sudden
neurological deterioration in the absence of antecedent trauma.
• 46.2% of symptomatic patients presented with hydrocephalus.
• 12.3% presented acutely.
• About 3 % risk of death of the symptomatic group.
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
A CCRS ≥ 4 was significantly associated
with obstructive hydrocephalus
Female pt 51 yrs old , 5yrs compensation
SUDDEN DEATH
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
• Ranges from 3% to 5% of patients.
• MECHANISM:
• Colloid cysts are mobile and thus could shift position and acutely
block CSF flow with resultant herniation.
• Progressive obstruction from tumor growth does often produce
chronic hydrocephalus, and it is possible that at some point the
brain may decompensate in some cases.
• Changes in CSF dynamics resulting from procedures (LP,
ventriculography, trauma) may have also contributed.
• Disturbance of hypothalamic-mediated cardiovascular reflex
control.
• CYST APOPLEXY.
Don’t …until you do….
Radiology
Radiologically
• MRI: usually the optimal imaging technique. However, there are cases
where cysts are isointense on MRI and CT is superior
• MRI appearance: variable. Usually hyperintense on T1WI,
hypointense on T2WI. Some data suggests that symptomatic patients
are more likely to display T2 hyperintense cysts on MRI, indicating
higher water content which may reflect a propensity for continued
cyst expansion.
• Enhancement: minimal, sometimes involving only capsule.
• CT scan: findings are variable. Most are hyperdense (however, iso-
and hypodense colloid cysts occur), and about half enhance slightly.
Density may correlate with viscosity of contents; hyperdense cysts
were harder to drain percutaneously.
• These tumors rarely calcify.
CT
Size
Giant > 5cm
MRI
MRI Signal Correlation With The Content
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
DDX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Rare DDX: It is a spot dx
• Basilar artery aneurysms
• Calcified meningioma
• Blood in the region of the FM
• Neurocysticercosis
• Hamartomas
• Primary or secondary neoplasm
• Xanthogranulomas
• Pilocytic astrocytoma
DON’T FORGET
•T2 BLACK HOLE SIGN
•T2 HYPERINTENSITY
•FLAIR HYPERINTENSITY
•HGIC COLLOID CYST
Management
•OBSERVATION
•SHUNTING
•SURGICAL RESECTION
Shunt dependency.
Tumor progression>> compress
Hypothalamus.
Symptomatic progression in
asymptomatic cysts 8% in
10 years
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
`
5-10%
2.7%
CHOICE BETWEEN TRANSCORTICAL OR TRANSCALLOSAL
• Degree of dilatation of the lateral ventricles.
• Venous anatomy of the frontal cortex.
• Thickness of cortical mantle.
• Specific location and extent of the colloid cyst in the third ventricle.
• Patient presentation (Acutely decompensated) and preoperative
cognitive function.
Which approach is the best?
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
VENTRICULOSCOPIC RESECTION
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
THE BEST OUTCOME = LOW MORBIDITY + GTR
GOOD OUTCOME REQUIRE:
• PROPER PT SELECTION
• SUITABLE EQUIPMENT
• GOOD PLANNING OF ENTRY POINT
• BIMANUAL TECHNIQUE
• SHARP DISSECTION AVOID MUCH PULLING
• RETRACTION WITH ENDOSCOPIC TROCAR
• PROPER HAEMOSTASIS
• SCIT
• DRY FIELD TECHNIQUE
PROPER PT SELECTION
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
SUITABLE EQUIPMENT
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Always be ready
PLANNING OF ENTRY POINT
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
BIMANUAL TECHNIQUE
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
RETRACTION WITH ENDOSCOPIC SHEATH
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
HAEMOSTASIS
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
SCIT
SCIT
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
MULTIFUNCTIONAL SUCTION CANNULA
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
CASES
CASE 1
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case # 2: T2 black dot sign
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case # 3: Small FM
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case # 4
Case # 5:
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case 6
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case #7: Subchoriodal approach
Case # 8:
Case 9: male pt 29 yrs endoscopic 2019
Residual 2020
2021
2022
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Case # 10:
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
Pt Headache did not improve
Meticulous studying of the MRI image is important to
choose the proper approach.
 Proper pt selection and skillful endoscopic techniques can
help to achieve GTR WITHOUT complication.
Always be ready for any intraop. event.
Don’t be forced by the pt to do unnecessary surgery.
HOME MESSAGE
BEFORE WE END
COLLOID CYST OF THE THIRD VENTRICLE .PPTX
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COLLOID CYST OF THE THIRD VENTRICLE .PPTX

  • 1. COLLOID CYST OF THE 3RD VENTRICLE AHMED ADEL, M.Sc, MRCSI, CG-FNE, FEBNS, M.D
  • 3. EPIDEMIOLOGY • About 0.5–1% of all intracranial tumors. • Usual age of diagnosis: 20–50 yrs. • Children ???????? • Most commonly found in the third ventricle in the region of the foramina of Monro, but may be seen elsewhere, e.g. in septum pellucidum.
  • 4. PATHOLOGY Pathogenesis origin: unknown, abnormal folding of the primitive neuroepithelium (the paraphysis elements) Pathology: Comprised of a fibrous epithelial-lined wall filled with either mucoid or dense hyloid substance, occationally old blood (hemosiderin). Microscopic: These cysts are lined by a single layer of columnar epithelium which produces mucin
  • 5. CLINICAL PRESENTATION: •“Asymptomatic” > 50 % incidental. •Headache is the most common presentation. •Patients may start to have headaches once diagnosed. •Careful evaluation of headache aetiology. •Non specific presentation. •Memory affection> subclin.
  • 7. MOCA TEST: PRE AND POSTOP
  • 11. Kamc female 84 yrs (2 yrs fu) august 2020
  • 13. 1 March 2022 8 march
  • 16. Risk of Acute Deterioration 34% in Symptomatic Colloid Cyst
  • 18. • 163 colloid cysts, • more 50% were discovered incidentally. • 8.8% progressed and underwent resection (FU 5yrs). • In another study 8% in 10 yrs. • No patient with an incidental, asymptomatic colloid cyst experienced acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. • 46.2% of symptomatic patients presented with hydrocephalus. • 12.3% presented acutely. • About 3 % risk of death of the symptomatic group.
  • 20. A CCRS ≥ 4 was significantly associated with obstructive hydrocephalus
  • 21. Female pt 51 yrs old , 5yrs compensation
  • 24. • Ranges from 3% to 5% of patients. • MECHANISM: • Colloid cysts are mobile and thus could shift position and acutely block CSF flow with resultant herniation. • Progressive obstruction from tumor growth does often produce chronic hydrocephalus, and it is possible that at some point the brain may decompensate in some cases. • Changes in CSF dynamics resulting from procedures (LP, ventriculography, trauma) may have also contributed. • Disturbance of hypothalamic-mediated cardiovascular reflex control. • CYST APOPLEXY.
  • 27. Radiologically • MRI: usually the optimal imaging technique. However, there are cases where cysts are isointense on MRI and CT is superior • MRI appearance: variable. Usually hyperintense on T1WI, hypointense on T2WI. Some data suggests that symptomatic patients are more likely to display T2 hyperintense cysts on MRI, indicating higher water content which may reflect a propensity for continued cyst expansion. • Enhancement: minimal, sometimes involving only capsule. • CT scan: findings are variable. Most are hyperdense (however, iso- and hypodense colloid cysts occur), and about half enhance slightly. Density may correlate with viscosity of contents; hyperdense cysts were harder to drain percutaneously. • These tumors rarely calcify.
  • 28. CT
  • 29. Size
  • 31. MRI
  • 32. MRI Signal Correlation With The Content
  • 35. DDX
  • 37. Rare DDX: It is a spot dx • Basilar artery aneurysms • Calcified meningioma • Blood in the region of the FM • Neurocysticercosis • Hamartomas • Primary or secondary neoplasm • Xanthogranulomas • Pilocytic astrocytoma
  • 38. DON’T FORGET •T2 BLACK HOLE SIGN •T2 HYPERINTENSITY •FLAIR HYPERINTENSITY •HGIC COLLOID CYST
  • 40. •OBSERVATION •SHUNTING •SURGICAL RESECTION Shunt dependency. Tumor progression>> compress Hypothalamus. Symptomatic progression in asymptomatic cysts 8% in 10 years
  • 44. `
  • 46. CHOICE BETWEEN TRANSCORTICAL OR TRANSCALLOSAL • Degree of dilatation of the lateral ventricles. • Venous anatomy of the frontal cortex. • Thickness of cortical mantle. • Specific location and extent of the colloid cyst in the third ventricle. • Patient presentation (Acutely decompensated) and preoperative cognitive function.
  • 47. Which approach is the best?
  • 54. THE BEST OUTCOME = LOW MORBIDITY + GTR
  • 55. GOOD OUTCOME REQUIRE: • PROPER PT SELECTION • SUITABLE EQUIPMENT • GOOD PLANNING OF ENTRY POINT • BIMANUAL TECHNIQUE • SHARP DISSECTION AVOID MUCH PULLING • RETRACTION WITH ENDOSCOPIC TROCAR • PROPER HAEMOSTASIS • SCIT • DRY FIELD TECHNIQUE
  • 73. SCIT
  • 74. SCIT
  • 79. CASES
  • 82. Case # 2: T2 black dot sign
  • 84. Case # 3: Small FM
  • 93. Case 9: male pt 29 yrs endoscopic 2019
  • 95. 2021
  • 96. 2022
  • 100. Pt Headache did not improve
  • 101. Meticulous studying of the MRI image is important to choose the proper approach.  Proper pt selection and skillful endoscopic techniques can help to achieve GTR WITHOUT complication. Always be ready for any intraop. event. Don’t be forced by the pt to do unnecessary surgery. HOME MESSAGE