Transseptal interforniceal endoscopic removal of superiorly recessed colloid cysts

Abstract

OBJECTIVE Transforaminal endoscopic colloid cyst resection is well described. However, some anatomical colloid cyst variants may warrant a modified approach. Rarely, colloid cysts separate the forniceal columns and grow superiorly within the leaflets of the septum pellucidum. Thus, the authors’ goal was to characterize the imaging features, clinical presentation, surgical strategy, and outcomes of patients with this superiorly recessed colloid cyst variant. METHODS A retrospective evaluation of patients who underwent endoscopic resection of colloid cysts from 1999 to 2020 was performed. The patients were dichotomized depending on whether the cyst was located predominately below the forniceal columns or was superiorly recessed (forniceal column separation with variable intraseptal extension). This comparative cohort study focused on clinical presentation, imaging features, operative technique, and patient outcome. RESULTS In total, 182 patients were identified. Seventeen patients had colloid cysts that were defined as superiorly recessed and underwent transseptal interforniceal removal, and 165 patients underwent a standard transforaminal approach. Patients had similar demographic characteristics. However, transseptal cysts were on average larger (17.8 mm vs 11.4 mm, p < 0.0001), and these patients had a greater frontal-occipital horn ratio (0.45 vs 0.41, p = 0.012). They were also more likely to have undergone a previous resection (p = 0.02). The two cohorts had similar surgical outcomes, with no differences in extent of resection, recurrence, or complications. CONCLUSIONS Superiorly recessed intraseptal colloid cysts are larger and tend to splay the bodies of the fornix, thus requiring a parasagittal transseptal interforniceal endoscopic approach. This achieves complete removal with comparatively negligible morbidity or rare recurrence (5.9%).

In Reply: Endoscopic Transseptal Approach for Removal of Colloid Cysts: 2-Dimensional Operative Video

“…We agree with Dr Uribe-Cardenas and Dr Souweidane that a complete capsule removal significantly reduces the risk of recurrence. 3 It is evident that we share the same enthusiasm in the use of the endoscopic technique for removal of colloid cysts. We think that the main differences between the 2 techniques depend mainly on the type of endoscope used to perform the procedure.…”

“…We agree with Dr Uribe-Cardenas and Dr Souweidane that a complete capsule removal significantly reduces the risk of recurrence. 3…”

Letter: Endoscopic Transseptal Approach for Removal of Colloid Cysts: 2-Dimensional Operative Video

“…We commend the authors for the use and dissemination of this minimally invasive technique, but we would like to put forth some thoughts based on our growing experience in the endoscopic treatment of these lesions (surpassing 200 cases), as well as our recent publication on this subtype in which we detailed the surgical nuances relevant to the transseptal technique. 2 The authors consider the risk of sudden death as part of the rationale for the procedure. This has been reported in the literature, but in our experience, it is uncommon.…”