A 45-year old patient with headache

DEPARTMENT OF RADIOLOGY, 28-05-2013

M. Torfs, AZ Middelheim

Patient presentation [1]

45-year old Caucasian male

Past medical history:- glaucoma

Patient presentation [2]

History of present condition:- fall on his forehead 12 days before admission, while doing push-ups- headache since a few days after the fall- since three days aggravation of the pain, especially when bending forward- temporary loss of sight (10 minutes)

Clinical examination:- normal orientation, normal consciousness- symmetric reflexes

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

NECT (15/03/2013)

Diagnosis?

NECT CECT Supratentorial obstructive hydrocephalus (with periventricular edema)

Isodense/slightly hyperdense mass 3th ventricle, no enhancement

Diagnosis

Supratentorial hydrocephalus, caused by a colloid cyst

MRI (18/03/2013)

FLAIR, AX T2-WI, AXT2-WI, COR

Colloid cyst: epidemiology

Incidence: 1/1.000.000 (person-years)- account for 0.5%-1.0% of all intracranial tumors- represent 15%-20% of intraventricular masses

Most become symptomatic between the 3rd and 5th decades of life

M/F 1:1

Rare in children (only 1%-2% occur under 10y)

Colloid cyst: etiology and APD Etiology not well understood

Leading theory: ectopic endodermal elements migrate into the velum interpositum during CNS embryonic development

Cyst wall is lined with a mixed array of epithelial and goblet cells secreting proteinaceous mucinous fluid (may be responsible for the increase of size)

Cyst cavities may be filled with blood degradation products such as cholesterol crystals

http://www.pathology.vcu.edu/WirSelfInst/neuro_medStudents/tumor-2.html

Colloid cyst: clinical features

Symptoms of intermittent or prolonged increased intracranial pressure

Most common symptoms:- headache- vertigo- memory deficits- behavioral disturbances- diplopia

Sudden interruption of CSF circulation with coma and death have been reported

Malignant degeneration does not occur

Colloid cyst: imaging features [CT] 2/3 of colloid cysts are homogeneously

hyperdense, 1/3 are isodense (to brain) well-delineated, round or ovoid, noncalcified located anterior in the 3rd ventricle (wedged

in foramen of Monro) enhancement: usually absent, sometimes thin

rim of enhancement

Colloid cyst: imaging features [MRI] Wide variation of signal characterisation

Most common: hyperintense on T1-WI, hypointense on T2-WI

Rim enhancement in some cases

! CSF flow artefacts can mimic colloid cysts ! (clue = location)

Colloid cyst: imaging features [MRI]

Patient 1

Patient 2

Colloid cyst: differential diagnosis

Normally pathognomonic

CSF flow artefacts!! (MR pseudocyst) Intraventricular meningioma Neurocysticus cyst Subependymoma Choroid plexus papilloma

Colloid cyst: treatment

Surgery:- transcortical approach- interhemisperic transcallosal approach- endoscopic approach

Colloid cyst: complication

Quick progressive supratentorial hydrocephalus with transtentorial herniation

Colloid cyst: take home messages

Adults 20-40 years

Variation in density (CT) and signal features (MRI), located anterior in the 3rd ventricle (wedged in foramen of Monro)

Associated with sudden death

References

Osborn A, Diagnostic Neuroradiology

Emedicine

Radiopaedia.org

de Witt Hamer PC, Verstegen MJ, De Haan RJ, Vandertop WP, Thomeer RT, Mooij JJ, van Furth WR. High risk of acute deterioration in patients harboring symptomatic colloid cysts of the third ventricle. J Neurosurg. 2002 Jun;96(6):1041-5