A 41-year-old gentleman presented to the eye clinic complaining of seeing floaters before both eyes since 2 weeks. On questioning, he admitted getting intermittent dull headache of mild to moderate intensity and dizziness on and off while walking since 2 months. There was no associated nausea or vomiting or other neurological symptoms. He was detected to be a hypertensive few months ago and was on treatment with lisinopril 5-mg daily.\nOcular examination revealed a best-corrected Snellen's visual acuity of 6/6 p in both eyes. Anterior segment examination showed exotropia of about 45° in left eye that was alternating. Rest of anterior segment examination including intraocular pressure was normal. Fundoscopy of the right eye revealed early vitreous hemorrhage. The disc showed slight blurring of margins associated with peripapillary retinal hemorrhages []. Fundus examination of the left eye showed early vitreous hemorrhage and blurring of disc margin. There was a small area of preretinal hemorrhage inferior to the disc []. B scan ultrasound also confirmed early vitreous hemorrhage.\nA diagnosis of bilateral early disc edema with mild vitreous hemorrhage was made, and he was investigated. Contrast-enhanced CT scan of brain showed a well-defined oval nonenhancing hyperdense lesion measuring 2 × 1.9 × 2.3 cm at the anterosuperior aspect of third ventricle bulging through the right foramen of Monro and compressing the left foramen of Monro causing dilatation of both lateral ventricles with cerebrospinal fluid (CSF) seepage []. Fourth ventricle appeared normal. Moderate 0.8-cm midline shift was also seen to the left side.\nA presumptive diagnosis of colloid cyst causing moderate obstructive hydrocephalus was made, and he was referred urgently to the department of neurosurgery. He underwent emergency craniotomy and cyst excision. Histopathological examination of the excised tissue showed cyst contents lined by cyst wall lined by ciliated cuboidal epithelium resting on fibrocollagenous tissue consistent with colloid cyst. Postoperative CT scan showed pneumocephalus and subdural collection in the right frontotemporal region that resolved spontaneously after few days.\nThe patient improved symptomatically following surgery. On follow-up after 1 month, he reported complete resolution of floaters and headache.\nFundus evaluation showed resolving vitreous hemorrhage and disc edema. Follow-up after 3 months showed complete resolution of disc edema and vitreous hemorrhage [Figure and ]. He is being followed up closely for recurrence of symptoms. He has remained asymptomatic for the last 18 months after the intervention.
A 20-year-old male patient presented to our outpatient services with complaints of neck pain for 4 months and intermittent vomiting for 2 months duration. General physical examination was unremarkable. Neurological examination revealed left upper limb weakness (power 4+/5, Medical Research Council grading). Rest of the examination was normal.\nGadolinium-enhanced magnetic resonance imaging (MRI) revealed a well-defined lobulated lesion in the ventral cervicomedullary region from medulla to upper border of C2 vertebra. The lesion was heterogeneous in appearance; the anterior part measured 2.8 × 1.6 cm and was hypointense and hyperintense on T1- and T2-weighted images, respectively; while the 1.7 × 1.1 cm sized posterior part was iso to mildly hyperintense on T1 and heterogeneously hyper intense on T2-weighted sequences [Figure and ]. The anterior part of the lesion was isointense, whereas the posterior part was hyperintense on fluid attenuation and inversion recovery (FLAIR) sequences. There was mild restriction on diffusion-weighted sequences. On post-contrast study, rim enhancement was evident in the posterior part of the lesion []. Preoperative diagnosis was neurenteric cyst. Surgery was performed in prone position. A midline suboccipital craniectomy (with bone removal more on left side), left-sided C1 posterior arch removal, and partial C2 hemilaminectomy were performed. Intraoperatively, there was a well-defined, intradural, extra-medullary encapsulated, relatively avascular, lobulated lesion containing easily suckable, cheesy material located anterior to medulla extending up to C2 vertebral level. Vertebral artery, lower cranial nerves, and posterior inferior cerebellar artery were well visualized and preserved. Tumor decompression was followed by near total excision of the cyst wall in view of adherence of the cyst wall focally to surrounding vital structures. Postoperative course was uneventful and he was discharged on 7th postoperative day and is currently on regular follow-up. At the last follow-up of 3 months, patient was well with no deficits. Postoperative MRI showed a very small residual lesion [].\nHematoxylin and eosin photomicrographs showed epithelial lining thrown into folds along with irregular bundles of collagen. Higher magnification images show a prominent columnar epithelial lining with goblet cells focally thrown into papillary formations (×100), pseudostratification, and absence of cilia (×400). Overall features were consistent with an endodermal (neurenteric) cyst of Hind-gut type [Figure and ].