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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 5  |  Page : 557-558

Giant colloid cyst of third ventricle with microhemorrhages causing neurological deterioration: A very rare presentation


Post Graduate Institute of Neurological Surgery (PGINS), Dr A. Lakshmipathi Neurosurgical Centre, VHS Hospital, Chennai, India

Date of Web Publication3-Nov-2012

Correspondence Address:
Ravindranath Kapu
Post Graduate Institute of Neurological Surgery (PGINS), Dr A. Lakshmipathi Neurosurgical Centre, VHS Hospital, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.103226

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How to cite this article:
Kapu R, Pande A, Vasudevan MC, Ramamurthi R. Giant colloid cyst of third ventricle with microhemorrhages causing neurological deterioration: A very rare presentation. Neurol India 2012;60:557-8

How to cite this URL:
Kapu R, Pande A, Vasudevan MC, Ramamurthi R. Giant colloid cyst of third ventricle with microhemorrhages causing neurological deterioration: A very rare presentation. Neurol India [serial online] 2012 [cited 2019 Oct 22];60:557-8. Available from: http://www.neurologyindia.com/text.asp?2012/60/5/557/103226


Sir,

A 28-year-old male was admitted with severe headache and multiple episodes of vomiting of one-day duration. He had occasional headaches for the past 6 months with occasional memory lapses. He was diagnosed to have colloid cyst with unilateral hydrocephalus 8 years back for which right ventriculo-peritoneal shunt was done. On examination that he reluctantly obeyed, ocular fundi showed bilateral papilloedema and no other neurologic deficits. Blood investigations, cerebrospinal fluid (CSF) analysis and endocrine profile were within normal range. Shunt reservoir was aspirated and patency confirmed. Computed tomography (CT scan) of the brain [Figure 1]a and b showed an isodense lesion (6 Χ 6 cm) in the anterior part of third ventricle with multiple foci of hyperdensities (40-65 Hounsefield units). Magnetic resonance imaging (MRI) [Figure 2]a and b showed a large cystic lesion, hyperintense on both T1- and T2-weighted images, with multiple foci of hypointensities in the cyst wall. Right frontal craniotomy was done, and through anterior interhemispheric, transcallosal-transventricular approach, lateral ventricles were reached. There was a large bluish cystic lesion in the right lateral ventricle arising from ipsilateral foramen of Monro. Xanthochromic hemorrhagic fluid was aspirated from the cyst and it was decompressed. Cyst cavity was entered and hemosiderin deposits were identified along the cyst wall suggestive of old hemorrhages. With careful dissection and gentle separation, cyst wall was completely excised. External ventricular drainage was kept for 3 days. His postoperative period was uneventful. Postoperative CT scan showed complete excision of the lesion [Figure 3]a and b. Histopathology confirmed the diagnosis of colloid cyst with hemorrhages and cyst fluid as hemorrhagic fluid [Figure 4]a and b. At one-year follow-up, he has no fresh neurological deficits and has relief from headache.
Figure 1: (a) CT scan brain plain study showing a 6×6 cm isodense lesion with areas of hyperdensities. (b) Post-contrast CT scan showing isodense lesion with mild peripheral rim enhancement. Areas of hyperdensities seen in the cyst wall and ventriculo-peritoneal shunt tip is seen in situ

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Figure 2: MRI scan of (a) T1-weighted FLAIR image and (b) T2- weighted images showing hyperintense lesion with multiple areas of hypointensities suggestive of bleeds

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Figure 3: Postoperative CT scan brain plain study (a) and contrast study (b) showing complete excision of the lesion with resolving hydrocephalus

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Figure 4: (a) Colloid cyst lining epithelium is tall columnar with few goblet cells. Note the vascular wall with thin walled venous channels. (b) Large zone showing xanthogranulomatous response with cholesterol clefts and brownish hemosiderin deposits reflecting old hemorrhage [a, b: H and E stain, magnification - scale bar]

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Colloid cysts generally range from 0.3-40 cm in size. [1] Cysts larger than 3 cm called "giant colloid cysts" (GCC) are very rare. [2],[3] These cysts present with features of raised intracranial pressure due to obstructive hydrocephalus. Our patient presented with headache and multiple episodes of vomiting, in spite of having a functioning ventriculo-peritoneal shunt. Bleeding in colloid cyst has rarely been reported. [4],[5] Zeitlin and colleagues [6] were the first persons to document bleeding into a colloid cyst in a 47-year-old male. Systemic hypertension and coagulation disorders were considered as risk factors for bleeding, which were not present in our patient. The cause of micro bleeds as seen in our patient can be attributed to long-standing hydrocephalus causing rupture of cyst wall vessels. The basic pathophysiology is yet to be investigated.

Imaging features of colloid cysts are quite variable. [7] In our patient, the cyst was isodense to brain with specks of hyperdensities (40-60 Hounsfield unit) suggestive of hemorrhage. On MRI, colloid cysts generally appear hyperintense on T1-weighted images, hypointense on T2-weighted images with minimal or absent contrast enhancement. Presence of hyperintensity in both T1- and T2-weighted images could be due to hemorrhages. [2] In our patient, the lesion was hyperintense on T1 and T2 images with areas of hypointensities along the wall suggestive of bleed, which was confirmed both intraoperatively and on histopathology. There is only one case report of hemorrhage into a giant colloid cyst. [2] Though very rare, colloid cyst does bleed and causes rapid deterioration in neurological status; timely surgical intervention can give gratifying results.

 
 » References Top

1.Mamourian AC, Cromwell LD, Harbaugh RE. Colloid cyst of the third ventricle: Sometimes more conspicuous on CT than MR. AJNR Am J Neuroradiol 1998;19:875-8.  Back to cited text no. 1
    
2.Kasliwal MK, Kiran S, Agrawal D, Sharma BS. Giant colloid cyst in a child. Pediatr Neurosurg 2007;43:442-3.  Back to cited text no. 2
    
3.Yamanaka K, Iwai Y, Nakajima H, Kobayashi Y, Inoue T. Multiple remote brain hemorrhages after removal of a giant colloid cyst of the third ventricle-case report. Neurol Med Chir (Tokyo) 1998;38:24-7.  Back to cited text no. 3
    
4.Farooq MU, Bhatt A, Chang HT. Hemorrhagic colloid cyst in a 9-year-old girl. Pediatr Neurol 2008;38:443-4.  Back to cited text no. 4
    
5.Malik GM, Horoupian DS, Boulos RS. Hemorrhagic (colloid) cyst of the third ventricle and episodic neurologic deficits. Surg Neurol 1980;13:73-7.  Back to cited text no. 5
    
6.Zeitlin H, Lichtenstein BW. Cystic tumor of the third ventricle containing colloid material. Arch Neurol Psychiatry 1937;38:268-87.  Back to cited text no. 6
    
7.Maeder PP, Holtas SL, Basibuyuk LN, Salford LG, Tapper UA, Brun A. Colloid cysts of the third ventricle: Correlation of MR and CT findings with histology and chemical analysis. AJNR Am J Neuroradiol 1990;11:575-81.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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