A 20-year-old lady presented with a 6 months history of progressive headache and memory disturbances. Few days prior to presentation, she had three episodes of generalized tonic clonic seizures. She also had gait disturbances and severe giddiness. Higher mental function examination revealed impaired recent memory. Fundoscopic examination showed bilateral papilloedema. Cranial nerve examination, motor and sensory examination was normal. Plantar reflexes were extensor on both sides and Romberg's sign was positive. Computed tomography (CT) scan of the brain showed isodense lesion located at foramen of Monro with hyperdense areas suggestive of hemorrhage with foraminal obstruction. The lesion was not enhancing on contrast []. Magnetic resonance imaging (MRI) brain revealed obstructive hydrocephalus due to a large lesion in the third ventricle which was homogenously hyperintense on T1-weighted images and homogenously hypointense on T2-weighted images [].\nRight lateral ventricle was entered via right frontoparietal craniotomy and an interhemispheric transcallosal approach. A grayish red, well-defined, soft to firm lesion was reached through the interforniceal approach. Needle aspiration was attempted but was unsuccessful. The surface of the cyst was vascular, so it was coagulated. The cyst wall was thickened and its separation from surrounding tissue was difficult. On opening the cyst, there was no colloid material, but a brownish yellow organized clot was found which was removed piecemeal. The clot was easily separated from the inner cyst wall. After almost complete evacuation of cyst content, the thick wall was held with biopsy forceps with one hand and with the other hand it was dissected from the surrounding parenchymal tissue. A complete excision of the cyst was ensured. Both internal cerebral veins were seen and found intact. Pathological examination confirmed hemorrhage within the colloid cyst. Microscopic examination also showed blood clots containing hemosiderin laden macrophages and many rhomboid cholesterol crystals and chronic inflammatory cells []. Post-operatively she had no seizures. Her memory function completely improved over a 3 week period.
A 77-year-old white woman presented to the emergency room with complaints of headaches, memory loss, and abnormal gait for the past 4 months. She had a 10-year history of a controlled type 2 diabetes mellitus and hypertension. At neurological examination, she was awake, partially oriented, with pupils equal round and reactive to light, without papilledema, perceived strength, eumetric intention tremor, no frontal release signs, and ataxia of gait.\nA magnetic resonance imaging (MRI) revealed a hyperintense T1WI solid cystic lesion measuring 3.0 cm×2.8 cm×2.9 cm located inside the anterior portion of the third ventricle causing obstructive hydrocephalus. The posterior portion of the lesion was predominantly solid and hypointense on T2WI and on gradient echo (GRE) T2WI, and the anterior portion was predominantly cystic with both hyper- and hypointense areas on T1WI and T2WI, with no suppression on fluid- attenuated inversion recovery (FLAIR) and no restriction to diffusion. The solid portion was hypointense on T1WI and demonstrated heterogeneous areas of enhancement after gadolinium contrast agent administration; there were also some peripheral sparse areas of enhancement in the cystic portion of the lesion. These heterogeneous peripheral enhancements and hypointensity on GRE TW2I are consistent with either hemosiderin or calcifications, raising concern for an atypical colloid cyst or a cystic craniopharyngioma [].\nA left frontal craniotomy with pterional approach and a transfrontal route using endoscopic visualization and stereotactic guidance were performed, and the intraventricular lesion was removed microsurgically. The solid part of the lesion was excised, and most of the capsules were removed except for the part densely adherent to the floor of the third ventricle. About 3–4 ml of “machine-like oil” fluid was also drained.\nIn the intraoperative view, the lesion was solid cystic located in the third ventricle near the foramen of Monro. The specimen received and fixed in 10% buffered formalin, displayed a nodular appearance, measured 2.5 cm×2.0 cm×2.0 cm, and weighed 7.0 g. It was surrounded by a delicate irregular membrane, with a yellowish color and friable areas. The solid part was firm, grayish-black in color, and avascular [].\nIn the intraoperative histological examination, a diagnosis of craniopharyngioma was made, but the definitive histopathological examination of the excised specimen revealed a colloid cyst lined by a single layer of cuboidal, partially flattened nonciliated and ciliated epithelial cells. There was a high prevalence of macrophages and epithelioid cells, many of which included refractile material and hemosiderin. In addition, cholesterol clefts and lymphocytes were seen in focal sets. Polymorphonuclear leukocytes were diffusely spread out throughout the granuloma []. The final diagnosis of a xanthogranulomatous colloid cyst with hemosiderosis was made. The immediate post-operative MRI demonstrated an almost complete reduction of the cystic lesion, with some sparse areas of contrast agent enhancement, and normalization in the lateral ventricle size []. Clinically, the patient evolved with the gradual improvement of the condition; she was discharged and followed-up conservatively with serial neuroimaging.