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"textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Endoscopic treatment is nowadays the treatment of choice for third ventricle colloid cysts removal.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The frequency of complications ranges from 6% to 11%, usually related to memory disturbances.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Terson’s syndrome as a complication of a neuroendoscopic procedure is extremely unusual, being only one case reported before this one in the literature.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The case and the surgical procedure are described, as well as the possible mechanisms for its development.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case description</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 55-year-old female was diagnosed incidentally of a third ventricle colloid cyst five years ago. On follow up, an evident enlargement of lateral ventricles was detected so surgical removal was recommended to avoid the development of a symptomatic hydrocephalus.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The MRI showed a round lesion in left foramen of Monro, isointense in T1 and hypointense in T2, with asymmetric ventricular enlargement, being left side bigger than right one. In CT scan the lesion was hyperdense (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The colloid cyst was removed endoscopically through a left frontal burr hole. After puncture of the cyst and removal of its contents the cyst could be mobilized and subsequently removed completely. During the procedure no hemodynamic or other problems were noted. Rinsing by a pressure system was used during the procedure, keeping outflow channel continuously open. The removal of the cyst was laborious, and the duration of the surgery was 90<span class="elsevierStyleHsp" style=""></span>min. A preventive ventricular drain was placed after the surgery.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The day after surgery a CT were done (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), and no complications were reported, so the ventricular drain was removed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">On ward, patient complained of visual loss, especially in left eye. Ophthalmologic examination revealed bilateral retinal and right vitreous haemorrhages, predominantly in left eye where macula was affected (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Patient was operated on vitreous haemorrhage one month after and six months after surgery visual deficit had improved partially.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Complications after endoscopic colloid cyst removal are reported in a range from 6 to 11%. Most often, they are memory disturbances, related to the manipulation of fornix during surgery. It happens in around 6,4% of the cases and most of the times symptoms are transient (4,9%). Meningitis is another frequent complication, usually aseptic (4,1%) due to the liberation of the cyst content into de ventricular system. Less often meningitis is bacterial (1,5%). Hemiparesis due to injury of the internal capsule is not common and usually related to unproper trajectories (1,5%).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Terson’ syndrome was initially described as vitreous haemorrhage associated to an intracranial subarachnoid haemorrhage. Nowadays comprises any kind of intraocular haemorrhage (vitreous, retinal or subhyaloideal) associated with rising of intracranial pressure. It is supposed that elevation of intracranial pressure is transmitted along the optic nerve sheath to preretinal space increasing the venous pressure, leading to venous stasis and haemorrhages.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Terson’s syndrome is an extremely rare complication of intraventricular endoscopic surgery and in literature there are only three cases described in literature related to intraventricular endoscopy and only two related to endoscopic treatment of colloid cysts described before the present case.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> In one case,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> the debut was a subarachnoid haemorrhage and some weeks after the episode, waiting for a MRI, the patient developed an acute hydrocephalus, needing emergent ventricular drainage. The authors also describe that during the surgery ventricles tended to collapse so energic rinsing was necessary to keep them open. Authors supposed that rinsing during surgery associated with intermittent obstruction of the outflow channel could lead to high intracranial pressure, that could cause the haemorrhages. The second case described in relation to a colloid cyst was related to an intraoperative sudden raise of intracranial pressure, with hypertension and bradycardia that forced to stop the surgery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The case related to third ventriculostomy was also related to a surgical complication with elevated intracranial pressure that caused severe arterial hypertension and bradycardia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The Terson’s syndrome has also been described in relation to endoscopic spinal procedures where continuous irrigation is used to keep the field clean and make space to work.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> The fluid could press the spinal duramater inducing elevation of intracranial pressure, leading to intraocular haemorrhages.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Endoscopic surgery of colloid cysts needs continuous infusion of fluid into the ventricles to maintain them open. Irrigation is also used to clean the cerebrospinal fluid from blood and sometimes to control bleeding. In the present case, irrigation was done using a pressure system, keeping open the outflow channel all the time. Preoperative ventricular dilatation provided enough space to work but sometimes vigorous rinsing was needed to control bleeding. Maybe the length of the procedure and the rinsing could have led to a rise of intracranial pressure that could cause the development of the intraocular haemorrhages. In this case, no signs of intracranial hypertension (arterial hypertension and bradycardia) were noted at any moment during the procedure so intracranial pressure monitoring could be useful in these surgeries. A flexible sensor in the epidural space, introduced through the same burr hole used for the endoscopy, could be helpful to monitor the intracranial pressure during the surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0060" class="elsevierStylePara elsevierViewall">Terson’s syndrome is a very unusual but possible complication after an intraventricular endoscopic procedure, and it could be developed without subarachnoid haemorrhage. The elevation of intracranial pressure during the procedure is the most likely cause of the intraocular haemorrhages so monitoring of this parameter during surgery could help to prevent them.</p></span></span>"
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