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Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 5  |  Page : 1164-1167

Hemorrhagic colloid cyst


Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Web Publication6-Sep-2017

Correspondence Address:
Lakshman I Kongwad
Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_909_16

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How to cite this article:
Menon G, Kongwad LI, Nair RP, Kumar V. Hemorrhagic colloid cyst. Neurol India 2017;65:1164-7

How to cite this URL:
Menon G, Kongwad LI, Nair RP, Kumar V. Hemorrhagic colloid cyst. Neurol India [serial online] 2017 [cited 2019 Aug 23];65:1164-7. Available from: http://www.neurologyindia.com/text.asp?2017/65/5/1164/214098




Sir,

Colloid cysts are benign cystic lesions located in the third ventricle close to the foramina of Monro and carry a good prognosis following surgery. Hemorrhage within a colloid cyst is an extremely rare cause for sudden deterioration, with potentially fatal complications. We report the case of a 60-year-old lady who presented with a hemorrhagic colloid cyst. The patient was managed successfully by microsurgery.

A 69-year old lady presented with a history of headache and vomiting of 1-week duration. She gave no history of any other symptom and her past history was unremarkable. On examination, she was fully conscious and alert and had evidence of raised intracranial pressure in the form of bradycardia and papilledema. Computed tomography (CT) scans and magnetic resonance imaging (MRI) revealed the presence of a third ventricular lesion with intraventricular bleed and moderate hydrocephalus [Figure 1], [Figure 2], [Figure 3]. She underwent a right pericoronal parasagittal craniotomy and an interhemispheric transcallosal approach. Cerebrospinal fluid (CSF) was under pressure. A reddish-brown mass was seen occupying the whole of the foramen of Monro [Figure 4]. Needle aspiration was attempted but was unsuccessful. The cyst wall was then opened and brownish organized clots were removed piecemeal. After cyst decompression, the cyst wall was excised completely [Figure 4], [Figure 5], [Figure 6]. Pathological examination confirmed hemorrhage within the colloid cyst. She had an uneventful post-operative course and recovered well.
Figure 1: A CT scan showing a well-defined heterogeneously hyperdense lesion along the left lateral wall of the third ventricle close to the left foramen of Monro with another hyperdense focus at the outlet of the third ventricle causing obstructive hydrocephalus. This is diagnostic of a colloid cyst with hemorrhage

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Figure 2: A well-defined T1 (a and b) and FLAIR (c) hyperintense lesion measuring ~15 × 16 × 15 mm which shows heterogeneous signal intensity on T2 weighted images (d and e) that is seen in the anterior part of the roof of third ventricle, abutting and compressing the foramen of Monro predominantly on the left side, causing resultant obstructive hydrocephalus. Heterogeneous hyperintensity seen in the third ventricle on FLAIR image is suggestive of hemorrhage (c). Post-contrast image (f) shows no enhancement of the lesion

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Figure 3: Blooming is seen in the third ventricle and dependent position of occipital horns of bilateral lateral ventricles – likely intraventricular extension of the hemorrhage. The central area shows diffusion restriction (a) and blooming in susceptibility weighted imaging (b) suggestive of hemorrhage

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Figure 4: Intraoperative color plate showing the hemorrhagic lesion at the foramen of Monroe

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Figure 5: Post-excision (intraoperative color plate) image of the lesion showing the opened out foramen of Monro with cerebrospinal fluid flow across it

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Figure 6: Postoperative CT scans showing complete resection of the cyst and reduction in the ventricle size

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Colloid cysts are benign cystic lesions located on the roof of the third ventricle close to the foramina of Monro and account for 0.5% to 1% of all intracranial tumors and 15–20% of intraventricular neoplasms. They are congenital tumors of uncertain origin. They are believed to originate either from ectopic endodermal elements, diencephalic ependymoma, or invagination of neuroepithelium of the ventricle. The cysts are lined by cuboidal, columnar, or pseudostratified epithelial lining with interspersed mucosal goblet cells which secrete amorphous and protein-rich material. Colloid cysts may remain asymptomatic and usually manifest with clinical symptoms in young adulthood. The growing cyst can obstruct the foramen of Monro and result in symptoms of raised intracranial pressure due to obstructive hydrocephalus. Long standing cysts with chronic hydrocephalus may also manifest as dementia, gait disturbances, and urinary incontinence in some patients. The cyst may also directly compress the adjacent diencephalic nuclei, the fornix or the limbic pathway, and result in emotional, behavioral, and memory disturbances.

Rarely, colloid cysts can be a cause of sudden death due to acute hydrocephalus. The exact cause for such acute attacks is not known. Hemorrhage within the cyst is an extremely rare cause and the incidence is limited to anecdotal case reports numbering a little over ten.[1],[2],[3],[4],[5],[6] Four of these cases were diagnosed during autopsy studies.[1] Sudden death in these cases is probably due to venous infarction or to a rapid compression of the third ventricle walls, producing a reflex irritation of the hypothalamic cardiovascular regulatory centers.

Beems et al., were the first to report a case of hemorrhagic colloid cyst; however, the patient had a stormy course.[4] All the other clinical cases reported so far presented with progressive worsening of clinical status due to acute obstructive hydrocephalus requiring emergency ventricular drainage.[1],[2],[3],[4],[5],[6] Our patient, however, was stable at presentation and we could manage with direct excision of the cysts without an external ventricular drainage. Radiological diagnosis of the bleed is often difficult as colloid cyst tend to be hyperdense on plain CT scan. On MRI, all hemorrhagic colloid cysts described so far displayed a high intensity signal on T1-weighted images and a low intensity signal in T2-weighted images. Bleed is best diagnosed if there is spillover of blood into the ventricles, as was seen in our case. In other cases, with a pure intracystic bleed, the diagnosis can be challenging. Xanthogranuloma of the third ventricle is a close and important differential diagnosis.[7] Quite often, these lesions coexist and the exact pathological correlation between a colloid cyst and a xanthogranuloma remains controversial. It is believed by some that xanthogranulomas arise as a result of hemorrhage into the walls of small colloid cysts. A tabulation of all the hemorrhagic colloid cyst cases, reported in literature, have been made to demonstrate the improved survival rates [Table 1].[11],[12],[13],[14],[15],[16],[17],[18]
Table 1: Cases of hemorrhagic colloid cyst reported in literature in chronological order

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The cause for intracystic bleed is unknown. Hypertension and coagulation disorders have been suggested as possible etiological factors but have not been proven in most cases. In one case report, the bleed within the cyst was associated with a coincidental basal ganglia hematoma.[8] In all the other cases including ours, the etiology remains unknown.

Rapid alleviation of hydrocephalus by external ventricular drainage followed by an elective excision of the cyst has given satisfactory results in most of the reports. In patients who are stable, direct cyst excision without emergency ventricular drainage is an option, as was done in our case. Surgical excision may be carried out either microscopically or endoscopically;[9],[10] however, we preferred microscopy because aspiration of thick clots through the endoscope port can at times be difficult. During microsurgery, the dense thrombus-like clots mandate piece-meal decompression akin to a tumor to avoid damage to the surrounding vital structures. In conclusion, intracystic bleed can be a rare cause for sudden deterioration in patients with colloid cysts. Preoperative radiological diagnosis can be challenging. Microsurgical excision is preferable over endoscopic removal in such patients and early surgery and cyst decompression yield satisfactory results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tamura Y, Uesugi T, Tucker A, Ukita T, Tsuji M, Miyake H, et al. Hemorrhagic colloid cyst with intraventricular extension J Neurosurg 2013;118:498-501.  Back to cited text no. 1
    
2.
Diyora B, Nayak N, Kukreja S, Sharma A. Hemorrhagic colloid cyst: Case report and review of the literature. Asian J Neurosurg 2013;8:162.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Coce N, Pavliša G, Nanković S, Jakovčević A, Seronja-Kuhar M, Pavliša G. Large hemorrhagic colloid cyst in a 35-year-old male. Turk Neurosurg 2012;22:783-4.  Back to cited text no. 3
    
4.
Beems T, Menovsky T, Lammens M. Hemorrhagic colloid cyst: Case report and review of the literature. Surg Neurol 2006;65:84-6.  Back to cited text no. 4
[PUBMED]    
5.
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. 5
[PUBMED]    
6.
Godano U, Ferrai R, Meleddu V, Bellinzona M. Hemorrhagic colloid cyst with sudden coma. Minim Invasive Neurosurg 2010;53:273-4.  Back to cited text no. 6
[PUBMED]    
7.
Tomita H, Tamaki N, Korosue K, Kokunai T. Xanthogranuloma with massive hematoma in the third ventricle: Case report. Neurosurgery 1996;39:591-4.  Back to cited text no. 7
[PUBMED]    
8.
Carrasco R, Pascual JM, Medina-López D, Burdaspal-Moratilla A. Acute hemorrhage in a colloid cyst of the third ventricle: A rare cause of sudden deterioration. Surg Neurol Int 2012;3:24.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Symss NP, Ramamurthi R, Rao SM, Vasudevan MC, Jain PK, Pande A. Management outcome of the transcallosal, transforaminal approach to colloid cysts of the anterior third ventricle: An analysis of 78 cases. Neurol India 2011;59:542-7.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Deopujari CE, Mohanty CB. Anatomic variations of the fornix and its clinical implications. Neurol India 2016;64:947-9.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
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. 11
    
12.
Shuangshoti S, Roberts MP, Netsky MG. Neuroepithelial (Colloid) Cysts: Pathogenesis and relation to choroid plexus and ependyma. Arch Pathol 1965;80:214-24.  Back to cited text no. 12
[PUBMED]    
13.
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. 13
[PUBMED]    
14.
Hadar EJ, Schmunk GA, Salamat MS. Hemorrhagic colloid cyst in a patient with leukemia. Case illustration. J Neurosurg 1999;91:516.  Back to cited text no. 14
[PUBMED]    
15.
Coce N, Pavlisa G, Nankovic S, Jakovcevic A, Seronja-Kuhar M, Pavlisa G. Large hemorrhagic colloid cyst in a 35-year old male. Turkish Neursurg. DOI: 10.5137/1019-5149.JTN.4162-11.1.  Back to cited text no. 15
    
16.
Ogbodo E, Kaliaperumal C, Bermingham N, O'Sullivan M. Spontaneous haemorrhage and rupture of third ventricular colloid cyst. BMJ Case Reports. 2012;2012:bcr2012006863. doi: 10.1136/bcr-2012-006863.  Back to cited text no. 16
    
17.
Tamura Y, Uesugi T, Tucker A, Ukita T, Tsuji M, Miyake H, Kuroiwa T. Hemorrhagic colloid cyst with intraventricular extension. J Neurosurg 2013;118:498-501.  Back to cited text no. 17
[PUBMED]    
18.
Diyora B, Nayak N, Kukreja S, Sharma A. Hemorrhagic colloid cyst. Case report and review of the literature. Asian J Neurosurg 2013;8:162.  Back to cited text no. 18
[PUBMED]  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
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