Endoscopic resection of the third ventricular epidermoid cysts: A case review and review of literature
- Departments of Neurosurgery, Kaiser Permanente Fontana Medical Center, Fontana, United States.
- Departments of Neurosurgery, Riverside University Health System, Riverside, California, United States.
Departments of Neurosurgery, Kaiser Permanente Fontana Medical Center, Fontana, United States.
DOI:10.25259/SNI-233-2019Copyright: © 2019 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Samir Kashyap, Bhagat Cheema, Vaninder Chhabra. Endoscopic resection of the third ventricular epidermoid cysts: A case review and review of literature. 07-Jun-2019;10:98
How to cite this URL: Samir Kashyap, Bhagat Cheema, Vaninder Chhabra. Endoscopic resection of the third ventricular epidermoid cysts: A case review and review of literature. 07-Jun-2019;10:98. Available from: http://surgicalneurologyint.com/surgicalint-articles/9349/
Background:Epidermoid cysts are benign, congenital lesions that originate from ectodermal cells, they are most commonly found in the cerebellopontine angle, but rarely in the ventricular system. There is limited literature regarding the different microsurgical techniques utilized to approach these lesions.
Methods:A 63-year-old female with a recurrent third ventricular epidermoid cyst underwent gross total resection utilizing an endoscopic technique. We also reviewed the various endoscopic/microsurgical approaches and outcomes reported in literature.
Results:We identified 15 cases, including our own. Nine of these were managed using microsurgical techniques, while six cases (including ours) were treated endoscopically; gross total resection was achieved in 10/15 cases (67%). Most commonly, surgeons utilized the interhemispheric transcallosal approach (five cases). Tumor recurrence was seen in two cases. Complications attributed to these resections included: disorders of the hypothalamic-pituitary axis (3) – diabetes insipidus, galactorrhea, and hypopituitarism; tumor recurrence (2); aseptic meningitis (1); and a transient Korsakoff syndrome (1).
Conclusion:Epidermoid cysts of the third ventricle are exceedingly rare, and surgical resection is generally well tolerated. Microsurgical transcortical, transcallosal, and endoscopic approaches each have advantages and disadvantages, and are associated with unique procedure-specific complications. Continuing technological improvement would favor endoscopic approaches for resection of tumors of the third ventricle in the future.
Keywords: Epidermoid cyst, Neuroendoscopy, Third ventricle
Epidermoid cysts are benign, congenital lesions that originate from ectodermal cells.[
A 63-year-old female presented with several days of confusion/altered level of consciousness. She had a Glasgow Coma Score of 14, was lethargic, and demonstrated a left homonymous hemianopsia. In 2015, she had undergone a craniotomy for subtotal resection of an epidermoid cyst. Now, the computed tomography (CT) scan revealed a large mixed-density suprasellar mass effacing the third ventricle, with a notable increase in the size of the cyst [
Preoperative – *(a) Noncontrast computed tomography head demonstrating epidermoid cysts of the third ventricle. (b) Axial T2 sequence showing the cystic and solid components of the tumor. (c) Diffusion-weighted imaging showing the characteristic diffusion restriction associated with epidermoid cysts. (d) T1 postcontrast axial sequence showing enhancement of the solid component of the cyst with minimal enhancement within the cystic component. (e) T1 postcontrast sagittal sequence showing occupation of the third ventricle by the tumor.
Through a small, elliptical right frontal craniotomy and corticectomy, the third ventricle was entered using an 11.5 mm Thoracoport with the assistance of stereotactic navigation. An endoscope was placed down the port and through the foramen of Monroe; tumor was identified as adherent to the floor of the third ventricle. An Angiocath, attached to a syringe, was utilized to drain the cyst. Pulsatile bacitracin/normal saline irrigation was then utilized to flush the ventricular system, and the cyst contents were gently suctioned and removed. Liliequist’s membrane was identified, and additional tumor was noted to be deep to the membrane. When it was opened, keratin fragments were mobilized with pulsatile irrigation. Endoscopic biopsy instruments then afforded removal of more adherent tissue. The remaining fragments that had settled in the occipital horn were also mobilized and removed. A ventricular catheter was then left in place as the Thoracoport was removed. Postoperatively, the patient exhibited a left gaze preference (without a residual field cut) that persisted. Imaging consistant with gross total resection [
Review of literature
A review of literature, including our case, yielded 15 cases undergoing resection of the third ventricular epidermoid cysts [
Anatomy and pathophysiology of epidermoid tumors
Epidermoid cysts are slow-growing, benign lesions that comprise 0.2%–1.8% of all intracranial tumors.[
Clinical, radiographic diagnosis, and treatment of the third ventricular epidermoid tumors
These lesions are typically incidental findings on CT, but magnetic resonance imaging is often the optimal confirmatory test.[
Surgical approaches to the third ventricle
There are three essential approaches to the third ventricle: transcortical, transcallosal, and endoscopic. The transcortical approach traditionally utilizes entry to the ventricle through a right frontal trajectory. There are, however, three variations of this approach utilizing a frontal, parietal, or middle temporal gyrus trajectory.[
There are various microsurgical and endoscopic techniques for approaching epidermoid cysts/tumors in the third ventricle. The aim is to limit disruption of normal tissue and injury to the limbic system, while still providing adequate surgical exposure. In our case and reviewing the literature, we noted gross total resection of these lesions could be achieved in 83% of endoscopic cases (5/6), compared to 3/5 utilizing the interhemispheric approach. Further, advances in endoscopy may eventually establish this technique as the new standard of care for the surgical management of the third ventricular epidermoid cysts.
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
There are no conflicts of interest.
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