Indications
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Symptomatic cysts
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Symptoms may range from visual obscurations and loss of consciousness to positional headache, sensory disturbance, and short-term memory decline.
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Symptoms of hydrocephalus, such as urinary incontinence, dementia, and ataxia, may also be present.
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Secondary hydrocephalus or unilateral ventriculomegaly
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Treatment is indicated whether or not symptoms are present.
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Incidental colloid cysts without secondary hydrocephalus
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Incidental cysts are a controversial indication for surgical intervention.
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The patient’s wishes, informed consent from the patient, and the surgeon’s level of comfort all are key factors when determining treatment.
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Contraindications
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A patient with an incidental colloid cyst and small ventricles presents a relative contraindication to surgery.
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Size of the cyst is another relative contraindication to the endoscopic approach. Given the limitations of current endoscopic instrumentation, large cysts containing tenacious material may take significantly longer to remove than by an open approach.
Planning and positioning
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It is prudent to have all patients assessed by a neurologist to ascertain absolutely that headaches are related to the cyst.
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Preoperative imaging should include data acquisition for frameless stereotactic intraoperative guidance, especially in the setting of small ventricles.
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The video monitor needs to be directly across from the surgeon, and it should be ensured that all components of the video chain are fully functional before making the skin incision.
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The patient is placed supine on the table with the head in three-point pin fixation. The head is flexed approximately 45 degrees to the horizontal plane without lateral flexion or rotation. The burr hole is placed 8 cm behind the nasion and 5 to 7 cm from the midline. We recommend approaching the cyst from the nondominant side, although if the ventricle of the dominant hemisphere is significantly more dilated, it is reasonable to approach the cyst from the side of the larger ventricle.
