Accepted Manuscript

Colloid Cyst of Third Ventricle: Long-term Results of Endoscopic Management in a

Series of 112 Cases

Mohammad Samadian, Kaveh Ebrahimzadeh, Ehsan Nazari Maloumeh, Armin Jafari,

Guive Sharifi, Sepideh Shiravand, Hadi Digaleh, Omidvar Rezaei

PII: S1878-8750(17)32209-X
DOI: 10.1016/j.wneu.2017.12.093
Reference: WNEU 7106

To appear in: World Neurosurgery

Received Date: 6 October 2017

Revised Date: 13 December 2017
Accepted Date: 14 December 2017

Please cite this article as: Samadian M, Ebrahimzadeh K, Nazari Maloumeh E, Jafari A, Sharifi G,
Shiravand S, Digaleh H, Rezaei O, Colloid Cyst of Third Ventricle: Long-term Results of Endoscopic
Management in a Series of 112 Cases, World Neurosurgery (2018), doi: 10.1016/j.wneu.2017.12.093.

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 ACCEPTED MANUSCRIPT

Colloid Cyst of Third Ventricle: Long-term Results of Endoscopic

Management in a Series of 112 Cases

Mohammad Samadian1, Kaveh Ebrahimzadeh1, Ehsan Nazari Maloumeh1*, Armin Jafari1, Guive

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Sharifi1, Sepideh Shiravand1, Hadi Digaleh2, Omidvar Rezaei1

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1
Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical

Sciences, Tehran, Iran Telephone number: +982151025182 Fax number: +982155416130

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2
Neurobiology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran,

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Telephone number: +982122429765, Fax number: +982122432047
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Mohammad Samadian, MD [email protected]
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Kaveh Ebrahimzadeh [email protected]

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*Ehsan Nazari Maloumeh, MD [email protected]

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Armin Jafari, MD [email protected]

Guive Sharifi [email protected]

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Sepideh Shiravand, MD [email protected]

Hadi Digaleh, MD [email protected]

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Omidvar Rezaei [email protected]

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*Corresponding author: Ehsan Nazari Maloumeh

Key words: Colloid cyst, Endoscopic approach, Third ventricle

Abbreviation: EAM: Endoscope-Assisted Microsurgery/ IVH: Intraventricular hemorrhage

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Introduction

Colloid cysts are benign intracranial lesions accounting for 0.5 to 2% of brain tumors. They are
1, 2
most often located at the roof of the third ventricle near the foramen of Monro . Although

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colloid cysts typically present with progressive headaches due to obstructive hydrocephalus , a

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few patients present with sudden death caused by severe obstructive hydrocephalus . There have

been several approaches to treat third ventricular colloid cysts. Traditionally, a transcortical or

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transcallosal craniotomy approach has been primarily employed to treat colloid cysts of the third
4-9
ventricle . Other alternative options include conservative observation, isolated

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ventriculoperitoneal shunting, infratentorial supracerebellar approaches and a stereotatically

3,11,12
transventricular approach .Since the evolution and description of endoscopic approach to
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treat third ventricular colloid cysts in 1983, the use of endoscopy for removing colloid cysts of

third ventricle has gained popularity, so that several studies have evidenced the efficacy and
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2, 13- 16, 18
safety of endoscopic resection of colloid cysts .
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The aim of this retrospective study was to report the results of endoscopic approach to resect
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third ventricular colloid cyst of 112 cases presenting between the years of 2003 to 2015.
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Material and Methods

Patients’ data. We conducted a retrospective review of 112 cases with colloid cyst between 2003

and 2015, who underwent endoscopic surgeries with suspicion of colloid cyst at the Loghman

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Hospital. All patients had preoperative computed tomography (CT) scan, magnetic resonance

imaging (MRI) and detailed clinical history on admission, the data from medication documents,

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nursing and doctors’ notes, and discharge summaries. The diagnosis was based on histological

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confirmation and the following clinical data were collected for each patient: age, gender, main

symptom that prompted the diagnosis, presence of hydrocephalus pre- and postoperatively, pre-

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and postoperative neurologic deficits, need for ventriculoperitoneal shunt placement and
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infection rate. Radiographic variables evaluated included preoperative ventriculomegaly,

maximum diameter of lesion on MRI, signal intensity of cyst content on T1- and T2-weighted
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sequences, cyst density on computed tomography (CT) scan, presence of radiographic residual

immediately after surgery and at follow-up, and cyst recurrence at follow-up. All data were
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collected and analyzed jointly by two neurosurgeons in our department.

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Endoscopic technique. Each patient was intubated under general anesthesia with the head in a
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neutral, flexed position and held in a three-point Mayfield head fixation frame. A preoperative

stereotactic brain magnetic resonance imaging (MRI) and computed tomography was registered
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to the patient’s head. A rigid endoscope with a main and a side working channel and 0º viewing
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angle by Storz® GAAB (Tuttlingen, Germany) was used. In the beginning, a single 3-cm frontal

precoronal burr hole was made traditionally 3 cm from the midline until 2010. From 2010

onwards we determined the accurate location of Burr hole and also the optimized trajectory to

access third ventricular colloid cyst employing MR-navigation (Figure1).

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In case of thick cranium, the Burr hole edge was trimmed to change the direction of working

sheet trajectory. After the operation, the cortical hole of brain was plugged with Gelfoam and the

cranial defect was covered with bone dust and/or titanium Burr hole plate. In most patients the

right side was chosen as this provided the most correct approach to the lesion, depending on

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asymmetries in ventricular size or lateralization of the colloid cyst toward the foramen of Monro.

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In 10 patients the cyst had to be tackled from the left side due to asymmetry of ventricles

accompanied by a more dilated left ventricle and also cysts which were not in the middle line

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and more lateralized toward the left side (based on MR findings particularly coronal MRI) could

be more easily resected from the left foramen of Monro, thus we preferred left side Burr hole to

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resect these 10 cysts. The endoscope was stabilized manually by an assistant and holder. Periodic
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irrigation within the procedure was performed with isothermic Ringer’s lactate solution. Holder

was present during all surgeries (Figure2); however we had to use holder only in patients in
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whom the cyst had a large size and also in case of type 2 colloid cyst (Table 2). Holder was also
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used when occurring bleeding during the surgery leading to poor visibility of the cyst.
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In 4 cases we had to convert to EAM (Endoscope-Assisted Microsurgery) due to uncontrollable

IVH in 3 cases and a large solid type 2 colloid cyst in 1 case.

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The following endoscopic technique was employed in our series to resect third ventricular

colloid cyst (Figure3):

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1. At first we coagulated both choroid plexus in proximity of colloid cyst and the cyst wall with
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bipolar electrocautery.

2. We opened the cyst wall applying microscissor and then aspirated the contents of the cyst

using suction aspirator. In order to suction the invisible contents of the cyst we applied also a

specific side-cutting suction tube in such a way that, at first an open-end suction aspirator was
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applied. Then a side hole was created if necessary at 3-mm end of suction aspirator using 3-mm

kerrison rongeuer to aspirate the invisible contents of the cyst (Side-cutting suction tube). By

doing this the contents could be aspirated by the created side hole even if the end hole of suction

aspirator was blocked by the cyst wall. Also by rotating the suction aspirator around inside the

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cyst, all invisible contents could be aspirated.

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In this series, 19 of colloid cysts (17%) (Type 2 colloid cyst) (Table2) had much viscid contents

which could not be aspirated completely by suction aspirator. Thus, we had to use grasping

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forceps to evacuate completely the contents of these 19 colloid cysts (Figure3.f).

3. After evacuation of the cyst content we began to dissect the cyst wall from third ventricular

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roof, veins and choroid plexus. A flexible forceps was applied along the side working channel to
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twist the cyst wall (Twisting maneuver) in order to lose the junction of cyst wall and third

ventricle. Then, we pulled gently the cyst wall toward the either right or left lateral ventricle
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depending on the location of Burr hole (right or left side Burr hole) and simultaneously the
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pedicle of the cyst comprising small vessels was coagulated using bipolar coagulator along the
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main working channel.

After dissecting the cyst wall and coagulating the cyst pedicle we cut the pedicle with
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microscissor and removed the whole cyst wall en bloc. In some cases (8%) the cyst wall was

removed partially owing to firm adherence of the cyst wall to veins and vital structures. In these
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cases the remained part of the cyst wall was coagulated to decrease the rate of recurrence.
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Results

In this study, the results of endoscopic resection of 112 cases were evaluated with a diagnosis of

colloid cyst of third ventricle. 76 cases were male with an average age of 37.6 years and 36

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females with average age of 34.45 years. Patients were mean age 36.2 years old, the youngest

was six months old and the oldest was 87 years old (table1).

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Patients complained of headache (84.1%), vomiting (42.2%) and impaired vision (36.3%). Other

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symptoms included: loss of consciousness (11%), urinary incontinence (8.3%), memory deficits

(13.9%), gait instability (23%) and hemiparesis (9 %) were also studied in patients (table 1). On

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CT scan of patients, most lesions were in the middle line and all in third ventricle of the brain.
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During surgery we met two types of cyst being different in consistency of content. Most of the

Cysts with soft consistency of content were easily suctioned completely by suction aspirator
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during the operation, thus we made decision to term them “Type 1 colloid cyst” and those with
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much viscid contents which were difficult to be suctioned completely by suction aspirator were
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described as “Type 2 colloid cyst”. We applied grasping forceps to evacuate contents of this type

of cysts completely. The rate of type 1 colloid cysts was much higher (83%) than type 2 (table
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2).

All 112 patients had computed tomography (CT) scan (Table3). In 63 patients (56%) the cyst
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was hyperdense, 49 of these patients had “Type 1 colloid cyst” and 14 of them had “Type 2
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colloid cyst”. In 37 patients (33%) the cyst was hypodense, 36 of these patients had “Type 1

colloid cyst” and 1 of them had “Type 2 colloid cyst”. In 12 patients (11%) the cyst was

isodense, 8 of these patients had “Type 1 colloid cyst” and 4 of them had “Type 2 colloid cyst”

(Table3).
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All 112 patients had MRI (Table4). In 17 patients (15%) the cyst had a hyperintense appearance

on T1-weighted- and a hypointense appearance on T2-weighted MRI, 3 out of these patients had

“Type 1 colloid cyst” and 14 of them had “Type 2 colloid cyst” (Figure4).

In 21 patients (19%) the cyst had a hyperintense appearance on T1-weighted MRI and an

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isointense appearance on T2-weighed MRI, 20 of these patients had “Type 1 colloid cyst” and 1

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of them had “Type 2 colloid cyst”. In 48 patients (43%) the cyst was hypointense on T1-

weighted MRI and hyperintense on T2-weighted MRI, 47 of these patients had “Type 1 colloid

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cyst” and 1 of them had “Type 2 colloid cyst” (Figure4). In 13 patients (12%) the cyst was

isointense on both T1- and T2-weighted MRI, 12 of these patients had “Type 1 colloid cyst” and

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one of them had “Type 2 colloid cyst”. In 10 patients (8%) the cyst had an isointense appearance
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on T1-weighted MRI and a hyperintense appearance on T2-weighted MRI, 9 of these patients

had “Type 1 colloid cyst” and one of them had “Type 1 colloid cyst”. In 3 patients (3%) the cyst
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was isointense on T1-weighted MRI and hypointense on T2-weighted MRI, 2 of these patients
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had “Type 1 colloid cyst” and 1 of them had “Type 2 colloid cyst” (Table4).
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The average duration of surgery was between 1 hour and 25 minutes to 2 hours and 50 minutes.

There was a mortality of 1.7% (2 cases). Fulminant meningitis was the cause of death in these 2
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cases. (Table5).

Standard for recovery was the normalization of ICP, which was less than 15 cmH2o. In 83 cases,
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within 48 hours, the ICP reached normal levels, and in others it took maximum 10 days until the
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ICP was in normal ranges.

Complete resection was reported in 103 cases (92%) and partial in 9 cases (8%) (Table5). 4 cases

(3.5%) presented with recurrence of the cyst and they all were patients with residual cyst;

however none of them needed resurgical procedure (Table5).

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Postoperative complications included 9 cases of meningitis (8%), 5 cases of memory deficit (4%)

and 4 cases of hemiparesis (3%) (Table5).

EVD was placed in 68 cases (60%) which was discontinued 48 hours after normalization of ICP.

8 cases (6%) presented with a decreased level of consciousness occurring and worsening during

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3 days. Initially, EVD was placed in these patients and then the cyst was resected with an

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endoscopic approach. In one case, the patient had a ventriculoperitoneal shunt for 20 years

referred with malfunction of shunt. The shunt was removed and then the patient underwent

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endoscopic resection of the cyst. Permanent ventriculoperitoneal shunt was placed in 4 cases

(3.5%) (Table5).

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Discussion

Colloid cysts are rare benign lesions typically located in the third ventricle and represent 0.5%-
1, 2
2% of all intracranial tumors . Traditionally, the patients have been treated surgically by

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6, 8
utilizing transcortical or transcallosal microsurgical approaches for colloid cyst resection .

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Nevertheless, less invasive endoscopic approaches are exerted increasingly to minimize
13, 14, 19, 20
perioperative morbidity . Here, our data suggested that the most common presenting

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features in patients with third ventricular colloid cyst are headache, vomiting and impaired

vision. Complete resection was achieved in majority of patients (92%).

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Meningitis, hemiparesis, and memory deficits occurred most commonly as postoperative
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complications.
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76 cases (63%) were male with an average age of 37.6 years and 44 cases (37%) were female

with an average age of 34.45 years. Third ventricular colloid cyst seems to be more common in
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21-23
males than in females . However, there are some reports in which the majority of patients are
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25 24
female or the proportion of males and females is relatively the same . In our series the most

common symptoms were headache (84.1%), vomiting (42.2%), impaired vision (36.3%),gait
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21, 25
instability (23%) and memory disorder (13.9%). This is in line with recent studies .
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Obstruction of CSF flow results in increased intracranial pressure which is the commonly
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referenced mechanism for symptom production. However, this mechanism is not in line with the

results of a study in which some symptomatic patients had no hydrocephalus and some patients
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with incidental cysts had concomitant ventriculomegaly . It has been proposed that intermittent

obstruction or a noncompliant ventricular system can lead to symptoms without hydrocephalus.

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Respectively, compensated hydrocephalus could be likely considered to explain asymptomatic

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ventriculomegaly in incidental cysts .

It has been established that colloid cysts found hypodense on CT scan may be aspirated more
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successfully . This claim is evidenced by our study as well. According to CT findings in our

series, in all patients with a hypodense cyst, except in one, the cyst was easily suctioned

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completely (Type 1 colloid cyst) (Table3), therefore it could be concluded that colloid cysts with

a hypodense appearance on CT scan would have much greater chance to be easily suctioned

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completely during surgery (Type 1 colloid cyst) (Table3). Most of colloid cysts have been

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reported to be hyperdense on CT scan . Similarly the number of hyperdense cysts was higher
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(56%) in our series (Table3).

17 of patients had a cyst with a hyperintense appearance on T1-weighted- and hypointense

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appearance on T2-weighted MRI (Table4) (Figure4). Only in 3 out of these patients (18%) the

cyst was easily suctioned completely (Type 1 colloid cyst) while in 14 of them (82%) the cyst
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was difficult to be aspirated completely (Type 2 colloid cyst). It is likely that cysts found
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hyperintense on T1-weighted- and hypointense on T2-weighted MRI would be much more

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difficult to be suctioned completely by suction aspirator. Additionally 20 patients had a

hypointense cyst on T2-weighted MRI irrespective of T1-weighted MR images. 15 of these cysts

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(75%) were difficult to be suctioned during surgery (Type 2 colloid cyst) (Table4). This is in line
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29
with another study in which it has been suggested that a hypointense appearance on T2-

weighted MR images may predict a difficult aspiration.

The mortality rate in our series was 1.7% (2 cases). Fulminant meningitis was the cause of death

in these 2 cases. This is consistent with the surgical mortality in other series, ranging from 0% to
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4% 6, 8, 23, 25,30. It seems likely that there is no significant difference in mortality rates between the
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endoscopic and the microsurgical approaches .

112 patients were treated surgically with an endoscopic resection of cyst. Based on the findings

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reported by the main surgeon during the operation (Figure3-i) evidenced by post-operative

imaging (Figure5), total resection was achieved in 103 (92%) cases and in 9 patients (8%) the

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cyst was resected partially. One of the reasons that, this high rate of complete resection was

achieved in our series could be the high rate of cysts which were easily suctioned completely

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during the operation (83%) (Type 1 colloid cyst). This suggests that, type 1 third ventricular

colloid cysts could increase the probability of total resection. This is consistent with another
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recent study . However, this should be assessed in further studies.

Although one criticism of the endoscopic approach is that the rate of partial resected cysts is
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higher in this approach compared with open approaches 6, 13, 17, 19, 24, 31 , in our experience, a high
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rate of complete cyst resection has been possible. This is in line with some other series .
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Actually, the extent of resection varies widely from series to series. In one series, the majority of
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patients treated endoscopically had residual cysts. Only one patient however, needed a
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reoperation for recurrence 1 year after endoscopic treatment . Likewise, in another study, the

proportion of partial resection was much higher than complete resection, but none needed
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13
reoperation .
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One another study demonstrated also a high rate of residual cysts (9 out of 21 cysts), however,
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only two of them needed a reoperation for recurrence .

In contrast with studies mentioned above, in a large series, the complete resection of the cyst was

achieved in 80% of the patients treated via the endoscope. None of the patients with either total
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or subtotal resection presented with recurrence of the cyst during an average follow-up period of
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2 years .

Consistently, in our series, the rate of complete resection of the cyst was much higher than partial

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cyst resection, so that in 92% of the patients the cyst was completely resected. This should be

noted that 4 cases (3.5%) presented with recurrence of the lesion. All of them were patients with

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residual cyst; however none of these patients needed reoperation.

Thus, a high rate of complete resection could be achieved in an endoscopic approach. These

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findings of different studies mentioned above demonstrate, first; an incomplete resection could

be acceptable, nevertheless it may be needed to follow up the patients by serial imaging for a

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long time. Second, even if we assume that the rate of incomplete resection would be higher in
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patients treated with an endoscopic approach, the rate of recurrence of the cyst is not necessarily
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higher in the patients with residual cyst, as the potential for regrowth of residual cyst is obscure.

In our series the postoperative complications included meningitis (8%), hemiparesis (3%), and
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memory deficits (4%). Although endoscopy is a minimally invasive surgical approach to treat
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third ventricular colloid cysts, complications such as hemiparesis and memory deficits, can occur
6, 15
. Nevertheless, it is believed that endoscopic approaches offer effective treatment of colloid
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33, 14, 19,32

cysts with low morbidity . New-onset seizures occurred in none of our cases. However,
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they have been associated with the open surgical approach .
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25 32
In two recent studies the rate of EVD placement has been reported 45% and 77% . Here, we

had eight patients (6%) presenting with loss of consciousness occurring and deteriorating during

three days before admission. In these patients single or bilateral EVDs were placed emergently

and after the recovery of their general condition, the cyst was resected completely. EVD was

placed in 68 cases (60%) postoperatively. Two days after the normalization of intracranial
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pressure, EVD of the patients was removed. One other case (0.8%) had a ventriculoperitoneal

shunt placed at an outside hospital prior to transfer. He presented with malfunction of the shunt.

He underwent surgical treatment. The shunt was removed and the cyst was completely resected.

Four patients (3.5%) needed a permanent ventriculoperitoneal shunt. This is in line with previous

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reports 6, 8, 23, 25.

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The length of hospitalization is shorter in the patients treated endoscopically. This may evidence

that endoscopic approach could be a more cost-effective treatment than open microsurgical

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24
approaches .

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Conclusion

In this retrospective study we assessed the results of endoscopic resection of third ventricular

colloid cyst in 112 symptomatic cases. Patients with incidental (asymptomatic) colloid cysts

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were not included. Although several other studies, like our study, have demonstrated the efficacy

and safety of endoscopic surgical approach to treat third ventricular colloid cysts, more exclusive

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prospective studies are needed to prove this claim.

In this series it was demonstrated that endoscopic resection of third ventricular colloid cysts is a

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minimally invasive approach to achieve high percentage of total cyst removal with a low risk of

recurrence and low surgical morbidity and mortality.

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Acknowledgements

“The authors would like to thank the Clinical Research Development Unit (CRDU) of

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Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran,

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Iran for their support, cooperation and assistance throughout the period of study.”

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Figure legends

Figure1. Coronal (left) and sagittal (middle) view of applying MR-navigation to determine the most

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accurate trajectory to access the third ventricular colloid cyst. It is defined by determining a line
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from calvarium toward the target to provide the most appropriate access to the cyst in order to
prevent damage to the adjucent neuronal structures particularly the head of caudate nucleus and
fornices. Post-operative axial CT scan (right) demonstrates the endoscope tract. The optimized trajectory
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to access third ventricular colloid cysts has 3 characteristics including perpendicular to the roof of third
ventricle, lateral enough to prevent damage to the fornix and medial enough to avoid damage to the head
of caudate nucleus.
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Figure2. View of a multiarm endoscopic holder applied in case of type 2 colloid cyst, in patients in whom
the cyst had an unusual large size and also in cases in whom bleeding occurred during the endoscopic
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procedure resulting in poor visibility of the cyst.

Figure3. View of a third ventricular colloid cyst and choroid plexus (a). Coagulation of both cyst wall
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and choroid plexus (b) & (c). Aspiration of the cyst content with an open-end suction aspirator (d).
Aspiration of invisible contents of the cyst with the side hole of suction aspirator (side-cutting suction
tube) (e). Removal of the viscid contents of a type 2 colloid cyst with a grasping forceps (f). Applying a
flexible forceps along the side working channel to twist the cyst wall (Twisting maneuver) and
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coagulating the pedicle of the cyst simultaneously along the main working channel (g). Removal of the
entire cyst wall en bloc (h). View of a colloid cyst of third ventricle resected completely during the
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endoscopic procedure (i).

Figure3. (Upper) View of a third ventricular colloid cyst with a hypointense appearance on T1-
weighted axial MRI (left) and a hyperintense appearance on T2-weighted axial MRI (right).
(Lower) View of a hyperintense colloid cyst on T1-weighted axial MRI (left) and a hypointense colloid
cyst on T2-weighted axial MRI (right).

Figure4. T1-weighted sagittal MRI reveals a hyperintense colloid cyst of third ventricle (left). Post-
operative T1-weighted sagittal MRI demonstrates complete resection of the cyst (right).
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23. Sheikh AB, Mendelson ZS, Liu JK. Endoscopic versus microsurgical resection of colloid cysts: a
systematic review and meta-analysis of 1278 patients. World Neurosurg.2014;82:1187–1197.
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24. Horn EM, Feiz-Erfan I, Bristol RE, Lekovic GP, Goslar PW, Smith KA, et al: Treatment options for
third ventricular colloid cysts: comparison of open microsurgical versus endoscopic resection.
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25. Brostigen, C. S., Meling, T. R., Marthinsen, P. B., Scheie, D., Aarhus, M. Helseth, E: Surgical
management of colloid cyst of the third ventricle. ActaNeurologicaScandinavica .2016;1-4.
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neurosurgery.2014;120:1259-67.
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27. Kondziolka D, Lunsford LD. Factors predicting successful stereotactic aspiration of colloid cysts.
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ventricle: correlation of MR and CT findings with histology and chemical analysis. AJNR Am J
Neuroradiol.1990;11:575–581

29. Armao D, Castillo M, Chen H, Kwock L. Colloid cyst of the third ventricle: imaging-pathologic
correlation. American journal of neuroradiology. 2000 Sep 1; 21(8):1470-7.
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recraniotomy in 2630 consecutive craniotomies for intracranial tumors. Neurosurgery.2011;68:1259-
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Stereotactically guided endoscopic port surgery for intraventricular tumor and colloid cyst resection.
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32. Wilson DA, Fusco DJ, Wait SD, Nakaji P. Endoscopic resection of colloid cysts: use of a dual-
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33. Sharifi G, Bakhtevari MH, Samadian M, Alavi E, Rezaei O. Endoscopic surgery in
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neurosurgery.2015;84:398-404.

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Table1. Preoperative Demographic data

Gender Frequency %
Male 67.8

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Female 32.2
Average age
Male 37.6

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Female 34.4
Clinical presentation
Headache 84.1

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Vomiting 42.2
Impaired vision 36.3
Gait instability 23

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Memory deficits 13.9
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loss of consciousness 11
Urinary incontinency 8.3
Hemiparesis 9
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Table2. Third ventricular colloid cysts classification

Classification of cysts Frequency %

Type 1 colloid cyst *
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83
Type 2 colloid cyst ** 17
* Cysts which were easily suctioned completely by suction aspirator.
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** Cysts which were difficult to be suctioned completely by suction aspirator, thus grasping forceps was applied to
evacuate the cyst content completely.
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Table3. Imaging features of third ventricular colloid cyst on CT scan of patients.

Imaging feature Number of patients Percentage

/ Number of total patients

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Hyperdense 63 / 112 56
*
Patients with “Type 1 colloid cyst” 49 / 93 53

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Patients with “Type 2 colloid cyst”
** 14 / 19 74

Hypodense 37 / 112 33

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*
Patients with “Type 1 colloid cyst” 36 / 93 39
Patients with “Type 2 colloid cyst”
** 1 / 19 5

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Isodense 12 / 112 11
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Patients with “Type 1 colloid cyst” 8 / 93 8
** 4 / 19 21
Patients with “Type 2 colloid cyst”
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* Cysts which were easily suctioned completely by suction aspirator.

** Cysts which were difficult to be suctioned completely by suction aspirator, thus grasping forceps was applied to
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Table4. MRI findings of third ventricular colloid cyst.

T1 intensity T2 intensity Number of patients Percentage

/ Number of total
patients
Hyperintense Hypointense 17 / 112 15

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Patients with “Type 1 3 / 93 3
colloid cyst” *
Patients with “Type 2 14 / 19 74

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colloid cyst” **
Hyperintense Isointense 21 / 112 19

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Patients with “Type 1 20 / 93 21
colloid cyst” *
Patients with “Type 2 1 / 19 5
colloid cyst” **

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Hypointense Hyperintense 48 / 112 43
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Patients with “Type 1 47 / 93 51
colloid cyst” *
Patients with “Type 2 1 / 19 5
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colloid cyst” **

Isointense Isointense 13 / 112 12

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Patients with “Type 1 12 / 93 13

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colloid cyst” *
Patients with “Type 2 1 / 19 5
colloid cyst” **
Isointense Hyperintense 10 / 112 8
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Patients with “Type 1 9 / 93 9

colloid cyst” *
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Patients with “Type 2 1 / 19 5

colloid cyst” **
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Isointense Hypointense 3 / 112 3

Patients with “Type 1 2 / 93 3

colloid cyst” *
Patients with “Type 2 1 / 19 5
colloid cyst” **
* Cysts which were easily suctioned completely by suction aspirator.

** Cysts which were difficult to be suctioned completely by suction aspirator, thus grasping forceps was applied to
evacuate the cyst content completely.
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Table5. Results
Result Frequency %

Complete Resection 92
Partial Resection 8
Recurrence 3.5

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Mortality 1.7
EVD 60
Permanent VP Shunt 3.5

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Post-operative Complications
Meningitis 8
Memory deficit 4

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Hemiparesis 3

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Figure1.
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Figure 2.
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Figure 3.
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Figure5.
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Highlights

1. Endoscopic resection of third ventricular colloid cysts is a minimally invasive approach to achieve high

percentage of total cyst removal.

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2. Endoscopic resection of third ventricular colloid cysts is associated with a low risk of

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recurrence.

3. Endoscopic resection of third ventricular colloid cysts is a minimally invasive approach

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associated with low surgical morbidity and mortality.

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