Colloid Cysts Workup

  • Author: Lawrence S Chin, MD, FACS; Chief Editor: Allen R Wyler, MD   more...
 
Updated: Jun 24, 2010
 

Laboratory Studies

Routine preoperative studies, including a CBC count, chemistry panel, and coagulation studies are performed in addition to various imaging modalities.

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Imaging Studies

CT scan

Colloid cysts appear homogenous, with two thirds of them appearing hyperdense to the surrounding parenchyma and one third appearing isodense to the surrounding parenchyma. The lesions are well delineated and are usually round or ovoid. Occasionally, the lesions have a thin rim of enhancement after contrast injection, but they are typically nonenhancing and are not calcified. The size of these cysts varies, but most are 5-25 mm.

Axial CT scan that shows a colloid cyst with assocAxial CT scan that shows a colloid cyst with associated hydrocephalus.

The CT scan is an important preoperative study because the viscosity of the cyst contents correlates more closely to the radiodensity visible on a CT scan than to the density visible on MRI. The viscosity of cyst contents determines the most appropriate surgical approach. A hyperdense cyst is more likely to have solid contents and is more difficult to drain. Hyperdensity may also correlate with a reduced capacity to enlarge over time.

MRI

The appearances of colloid cysts on MRIs are variable. The most common appearance is hyperintensity on T1 and hypointensity on T2. The amount of rim enhancement is variable. The variable MRI signals do not correlate with the fluid density of cyst contents, although a MRI is valuable in differentiating a colloid cyst from a basilar tip aneurysm, which may a have similar appearance on a CT scan.

Additionally, recognizing that a CSF flow artifact at the Monro foramen can mimic the appearance of a colloid cyst through MRI is important. Finally, the Constructive Interference in the Steady State (CISS) sequence of a MRI can delineate an abnormal contour of the ventricular system and intraventricular septa, from which essential information for surgical planning, including endoscopic surgery can be obtained. Postoperative CISS images can also be used, demonstrating not only regression of hydrocephalus but also the patency of small fenestrations.

In a retrospective study of 19 patients who underwent endoscopic management of colloid cysts of the third ventricle, El-Khoury et al found that 100% of lesions with low signal intensity on T2 weighted images had a higher intracystic viscosity contents that translated to an increased difficulty in aspiration of the contents.[3] In contrast, 63% of patients with high-signal lesions were easy to aspirate. This differentiation may be useful in preoperative planning and management.

Coronal MRI shows a colloid cyst in the roof of thCoronal MRI shows a colloid cyst in the roof of the third ventricle. The patient has mild hydrocephalus. Intraoperative photograph through the operating miIntraoperative photograph through the operating microscope shows a colloid cyst in the Monro foramen. Choroid plexus is observed overlying the cyst, and the thalamostriate vein is along the inferior border. Intraoperative photograph that shows removal of thIntraoperative photograph that shows removal of the cyst, leaving a dilated Monro foramen. The third ventricle can be seen through the opening.
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Other Tests

Ophthalmologic evaluation may be useful if diplopia (seen in 10% of patients) is a presenting complaint or if papilledema (seen in 50% of patients) is found during the examination. Neuropsychological evaluation may be useful if memory loss or behavior change (found in 35-40% of patients) is a presentation.

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Diagnostic Procedures

Lumbar puncture

Lumbar puncture is absolutely contraindicated in patients with these lesions because of a risk of cerebral herniation.

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Histologic Findings

Colloid cysts are lined with simple or pseudostratified epithelial cells. Their shape is either flattened cuboidal or low columnar, and they rest on a thin capsule of collagen and fibroblasts. The cysts are mucin secreting and ciliated. Cells are Periodic Acid-Schiff (PAS) and S100 positive, while Glial Fibrillary Acidic Protein (GFAP), vimentin, and neurofilament are negative. The stromal wall stains positively for vimentin. Contents of the cyst are usually greenish and of variable viscosity.

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Contributor Information and Disclosures
Author

Lawrence S Chin, MD, FACS  Professor and Chairman, Department of Neurosurgery, State University of New York Upstate Medical University

Lawrence S Chin, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association for Cancer Research, American Association for the Advancement of Science, American Association of Neurological Surgeons, American College of Surgeons, Children's Oncology Group, Congress of Neurological Surgeons, Phi Beta Kappa, and Society for Neuro-Oncology

Disclosure: Nothing to disclose.

Coauthor(s)

Mayur Jayarao, MD  Fellow, Department of Neurosurgery, Boston Medical Center

Mayur Jayarao, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, and Medical Council of India

Disclosure: Nothing to disclose.

Specialty Editor Board

Scott C Dulebohn, MD  Neurological Surgeon, Appalachian Neurosurgical

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Ryszard M Pluta, MD, PhD  Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences at Warsaw, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA, Chicago ,IL

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Congress of Neurological Surgeons and Polish Society of Neurosurgeons

Disclosure: Nothing to disclose.

Paolo Zamboni, MD  Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

Allen R Wyler, MD  Former Medical Director, Northstar Neuroscience, Inc

Allen R Wyler, MD is a member of the following medical societies: American Academy of Neurological and Orthopaedic Surgeons, American Association of Neurological Surgeons, and Society of Neurological Surgeons

Disclosure: Nothing to disclose.

References

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Axial CT scan that shows a colloid cyst with associated hydrocephalus.
Coronal MRI shows a colloid cyst in the roof of the third ventricle. The patient has mild hydrocephalus.
Intraoperative photograph through the operating microscope shows a colloid cyst in the Monro foramen. Choroid plexus is observed overlying the cyst, and the thalamostriate vein is along the inferior border.
Intraoperative photograph that shows removal of the cyst, leaving a dilated Monro foramen. The third ventricle can be seen through the opening.
 
 
 
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