We present the case of a patient who underwent craniotomy for resection of a colloid cyst and then presented 6 weeks later with obstructive hydrocephalus. A 50-year-old Caucasian woman with past medical history otherwise significant only for hypothyroidism presented with symptoms of intermittent headaches and unsteadiness. Imaging revealed a colloid cyst (7 × 9 × 8 mm3), and the patient elected to undergo craniotomy for resection (Fig. 1).
The patient underwent transcortical microscopic resection of her colloid cyst with intraoperative computed tomography (CT) image guidance and placement of external ventricular drain. Intraoperatively, the intracranial pressure (ICP) was noted to be mildly elevated upon entering the dura. The cyst, which appeared to be most densely adherent to the choroid plexus of the roof of the third ventricle, was successfully resected. The patient’s intraoperative course was unremarkable, and she was extubated in the operating room (OR) prior to transfer to the neurosurgical intensive care unit (NSICU). Postoperative imaging was read as consistent with complete resection of the cyst with some mild ventriculomegaly and small-volume intraventricular hemorrhage (Fig. 2).
Her postoperative course was largely unremarkable as well, although she did report some short-term memory impairment prior to discharge. At her follow-up visit 2 weeks after the surgery, she reported that she was doing well with rehabilitation, although she continued to report memory issues. She had another follow-up visit a few weeks later, at which she again expressed concern about memory issues, as well as difficulty with spelling, anxiety, and insomnia.
She presented to the emergency department (ED) 6.5 weeks postoperatively after falling with complaints of headache and nausea/vomiting. On initial examination, the patient was drowsy but oriented and able to follow commands. Head CT showed worsening hydrocephalus (Fig. 3), and the patient was admitted for external ventricular drain (EVD) placement and intracranial pressure (ICP) monitoring. While awaiting transfer to the NSICU, the patient became acutely obtunded with decerebrate posturing and dilated pupils. The patient was intubated and stabilized, and an EVD was placed in the ED prior to transfer to the NSICU. She returned to the OR for a ventriculoperitoneal shunt (VPS) several days later, which was uneventful from an anesthetic and surgical perspective. Unfortunately, the patient’s neurologic prognosis remained poor, with imaging of the brain consistent with ischemic hypoxic encephalopathy. She was transferred to a skilled nursing facility and subsequently died.