title: Endoscopic approach to colloid cyst: what is the optimal entry point and trajectory?
abstract: OBJECTIVE
  An optimal entry point and trajectory for endoscopic colloid cyst (ECC) resection helps to protect important neurovascular structures. There is a large discrepancy in the entry point and trajectory in the neuroendoscopic literature.
  
  
  METHODS
  Trajectory views from MRI or CT scans used for cranial image guidance in 39 patients who had undergone ECC resection between July 2004 and July 2010 were retrospectively evaluated. A target point of the colloid cyst was extended out to the scalp through a trajectory carefully observed in a 3D model to ensure that important anatomical structures were not violated. The relation of the entry point to the midline and coronal sutures was established. Entry point and trajectory were correlated with the ventricular size.
  
  
  RESULTS
  The optimal entry point was situated 42.3 ± 11.7 mm away from the sagittal suture, ranging from 19.1 to 66.9 mm (median 41.4 mm) and 46.9 ± 5.7 mm anterior to the coronal suture, ranging from 36.4 to 60.5 mm (median 45.9 mm). The distance from the entry point to the target on the colloid cyst varied from 56.5 to 78.0 mm, with a mean value of 67.9 ± 4.8 mm (median 68.5 mm). Approximately 90% of the optimal entry points are located 40-60 mm in front of the coronal suture, whereas their perpendicular distance from the midline ranges from 19.1 to 66.9 mm. The location of the "ideal" entry points changes laterally from the midline as the ventricles change in size.
  
  
  CONCLUSIONS
  The results suggest that the optimal entry for ECC excision be located at 42.3 ± 11.7 mm perpendicular to the midline, and 46.9 ± 5.7 mm anterior to the coronal suture, but also that this point differs with the size of the ventricles. Intraoperative stereotactic navigation should be considered for all ECC procedures whenever it is available. The entry point should be estimated from the patient's own preoperative imaging studies if intraoperative neuronavigation is not available. An estimated entry point of 4 cm perpendicular to the midline and 4.5 cm anterior to the coronal suture is an acceptable alternative that can be used in patients with ventriculomegaly.
authors.affiliation: Division of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.
authors.forename: Leonardo
authors.initials: L
authors.lastname: Rangel-Castilla
authors.forename: Fangxiang
authors.initials: F
authors.lastname: Chen
authors.forename: Lawrence
authors.initials: L
authors.lastname: Choi
authors.forename: Justin C
authors.initials: JC
authors.lastname: Clark
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
mesh_terms: D002552:Cerebral Ventricles; D056364:Colloid Cysts / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D044583:Neuroendoscopy / Q000379:methods*; D012189:Retrospective Studies
keywords: ECC = endoscopic colloid cyst; FH = frontal horns; ID = internal distance; colloid cyst; endoscopy; entry point; hydrocephalus; image guidance; neuroendoscopy; surgical technique; trajectory