Combined endoscopic transforaminal-transchoroidal approach for the treatment of third ventricle colloid cysts

Abstract

Colloid cysts are histologically benign lesions whose primary goal of treatment should be complete resection to avoid recurrence and sudden death. Open surgery is traditionally considered the standard approach, but, recently, the endoscopic technique has been recognized as a viable and safe alternative to microsurgery. The endoscopic approach to colloid cysts of the third ventricle is usually performed through the foramen of Monro. However, this route does not provide adequate visualization of the cyst attachment on the tela choroidea. The combined endoscopic transforaminal-transchoroidal approach (ETTA), providing exposure of the entire cyst and a better visualization of the tela choroidea, could increase the chances of achieving a complete cyst resection. Between April 2005 and February 2011, 19 patients with symptomatic colloid cyst of the third ventricle underwent an endoscopic transfrontal-transforaminal approach. Five of these patients, harboring a cyst firmly adherent to the tela choroidea or attached to the middle/posterior roof of the third ventricle, required a combined ETTA. Postoperative MRI documented a gross-total resection in all 5 cases. There were no major complications and only 1 patient experienced a transient worsening of the memory deficit. To date, no cyst recurrence has been observed. An ETTA is a minimally invasive procedure that can allow for a safe and complete resection of third ventricle colloid cysts, even in cases in which the lesions are firmly attached to the tela choroidea or located in the middle/posterior roof of the third ventricle.

Transcortical removal of third ventricular colloid cysts: a comparison of conventional, guided microsurgical and endoscopic approaches and a review of the literature

“…Although colloid cysts are benign tumors, they may continue to enlarge to occlude the foramen of Monro and are known to lead to sudden death (9,21,39).Standard surgical approaches for the removal of CC traverse either the corpus callosum or the frontal cortex. …”

“…Cortical incision and parenchymal dissection were minimized by the use of stereotactically guided cylindrical retractor (4,6,25). Cortical injury was further reduced by the introduction of the neuroendoscope (14,18,21,22,28,30,46).…”

Transcortical Endoscopic Surgery for Intraventricular Lesions

“…Wait et al54) demonstrated 15 successful cyst removals in cases without ventriculomegaly using a rigid, 6 mm, 30-degree endoscope under the usual irrigation to prevent ventricular collapse. Care must be taken during this approach, to avoid or minimize injury to the fornix and bleeding from the choroid plexus and venous structures22,26,54). Iacoangeli et al26) proposed the TTA approach.…”

“…Care must be taken during this approach, to avoid or minimize injury to the fornix and bleeding from the choroid plexus and venous structures22,26,54). Iacoangeli et al26) proposed the TTA approach. TA may not allow for adequate control of the cyst, especially when it is located in the posterior third ventricle, resulting in residual and recurrent cysts after endoscopic removal29).…”

“…The introduction of new instruments, including rod lens Hopkins optics, high-resolution cameras, and frameless stereotaxy, has led to a tremendous increase in the number of neuroendoscopic procedures performed since the early 1990s. Recently, the application of endoscopic surgery has extended into various diseases relevant to the neurosurgical field, including transcortical intraventricular lesions, such as arachnoid cyst intraventricular extensions17,40), colloid cysts22,26,54), and intraventricular cysticercosis24,53). New applications include biopsies13,39,44,49,52) and intraventricular brain tumor removal6,50).…”