Sudden Neurological Deterioration Research Articles

Adult-onset leukoencephalopathy with vanishing white matter with compound heterozygous EIF2B3 gene variants

BackgroundLeukoencephalopathy with vanishing white matter (VWM) is an autosomal recessive disorder affecting the white matter of the brain. It typically manifests during childhood, with clinical features including sudden and severe neurological deterioration triggered by stressors such as febrile illness, minor head trauma, or stressful events. Adult-onset cases of VWM are exceptionally uncommon.Case presentationIn this case, we present an adult patient who exhibited late-onset progressive VWM characterized by ataxia, postural instability, cognitive impairment, and emotional disturbances. Comprehensive screening for endocrine, metabolic, tumor, and immunologic disorders yielded normal or negative results. Brain imaging revealed diffuse and confluent hyperintensity in the white matter on T2-weighted images, along with periventricular cavitations. Genetic testing confirmed the diagnosis of VWM, identifying two heterozygous variants in the eukaryotic translation initiation factor 2B subunit γ (EIF2B3) gene: a pathogenic variant, c.1037 T > C (p.I346T), and a variant of undetermined significance, c.22A > T (p.M8L). Upon a 2-year follow-up, the patient's symptoms deteriorated rapidly following a COVID-19 infection.ConclusionsIn conclusion, we have presented a case of classical adult-onset VWM. Since there are no cures or definitive treatments for the disease, it's extremely important to focus on early diagnosis and the prevention of stressors to avoid acute deterioration.

A clinical study of patients with conservatively managed extra dural hematoma at a tertiary care hospital

Background: Head injury causes accumulation of blood between the rigid skull and the outer endosteal layer of the dura mater. If the volume of extradural hematoma is less than 30 ml volume, it may not require surgery based on neurological examination. Objectives: To study the various causes, factors influencing and outcome of conservatively management in Extra Dural Hematomas. Materials and Methods: A total of 23 Extra Dural Hematoma cases requiring conservative management were included in the study. All the patients were subjected to complete neurological examination including and various imaging techniques like CT brain and chest X-ray. The patients with volume<30ml, thickness<5 mm, midline shift<5 mm, GCS >8, were subjected to conservative management by admitting the patients in Intensive Care Units (ICU). Results: Among 23 EDH cases, 17 (74%) cases were males and 6(26%) cases were females. The mean age of patients was 26.7years. Road traffic accident was the common mode of injury in 47.8% (11 cases) of patients. Mean volume of hematoma was 20.5ml and GCS Score was mild to moderate group.The majority of the patients (34.7%) presented with frontal EDH. Among 23 cases, 91.3% of the patients were discharged with good recovery. Conclusion: Extra Dural Hematoma (EDH) with low volume can be considered for conservative therapy by close observation, yet a risk of sudden neurological deterioration. However, surgical evacuation is the definitive treatment of EDH but craniotomy can be avoided in many patients with keen observation and repeated neurological assessments.

A clinical study of patients with conservatively managed extra dural hematoma at a tertiary care hospital

Background: Head injury causes accumulation of blood between the rigid skull and the outer endosteal layer of the dura mater. If the volume of extradural hematoma is less than 30 ml volume, it may not require surgery based on neurological examination. Objectives: To study the various causes, factors influencing and outcome of conservatively management in Extra Dural Hematomas. Materials and Methods: A total of 23 Extra Dural Hematoma cases requiring conservative management were included in the study. All the patients were subjected to complete neurological examination including and various imaging techniques like CT brain and chest X-ray. The patients with volume<30ml, thickness<5 mm, midline shift<5 mm, GCS >8, were subjected to conservative management by admitting the patients in Intensive Care Units (ICU). Results: Among 23 EDH cases, 17 (74%) cases were males and 6(26%) cases were females. The mean age of patients was 26.7years. Road traffic accident was the common mode of injury in 47.8% (11 cases) of patients. Mean volume of hematoma was 20.5ml and GCS Score was mild to moderate group.The majority of the patients (34.7%) presented with frontal EDH. Among 23 cases, 91.3% of the patients were discharged with good recovery. Conclusion: Extra Dural Hematoma (EDH) with low volume can be considered for conservative therapy by close observation, yet a risk of sudden neurological deterioration. However, surgical evacuation is the definitive treatment of EDH but craniotomy can be avoided in many patients with keen observation and repeated neurological assessments.

A STUDY ON INCIDENCE, ETIOLOGY, CLINICAL PRESENTATION AND LOCATION OF CONSERVATIVELY MANAGED EXTRA DURAL HEMATOMA

Objectives: To study the incidence, etiology, clinical presentation and location of conservatively managed extra dural hematomas (EDHs). Methods: A total of 23 EDH cases requiring conservative management were included in the study. All the patients were subjected to complete neurological examination including and various imaging techniques like computed tomography brain and chest X-ray. The patients with hematoma volume <30 ml, thickness <5 mm, midline shift <5 mm, Glasgow Coma Scale >8, were subjected to conservative management by admitting the patients in intensive care units. Results: Among 23 EDH cases, 17 (74%) cases were males and 6 (26%) cases were females. A total of 8 patients were with age group of 10–20 years, 7 patients were with age group of 21–30 years and 8 patients were with age group of 31–40 years. The mean age of patients was 26.7 years. Road traffic accident was the common mode of injury in 47.8% (11 cases) of patients. The majority of the patients (34.7%) presented with frontal EDH. Conclusion: EDH with low volume can be considered for conservative therapy by close observation, yet a risk of sudden neurological deterioration. However, surgical evacuation is the definitive treatment of EDH but craniotomy can be avoided in many patients with keen observation and repeated neurological assessments.

Spontaneous intracerebral haemorrhage secondary to 5-ALA-induced thrombocytopaenia in a paediatric patient: case report and literature review

IntroductionThe primary objective of neurosurgical management of malignant gliomas is maximal safe resection of the tumour. One of the main obstacles in achieving this is the ability to accurately discriminate between tumour edges and the surrounding healthy brain tissue. The use of fluorescence-guided surgery utilising 5-aminolevulinic acid (5-ALA), first introduced more than 20 years ago, has become an invaluable adjunct in high-grade glioma surgery in adults. However, as 5-ALA is not licensed for use in paediatric patients, the safety profile for such use remains undetermined.Case reportWe describe the case of a 4-year-old boy who underwent 5-ALA-guided resection of a fourth ventricle anaplastic ependymoma. Although complete resection was achieved and the patient awoke from surgery well with no neurological deficits, the patient developed acute transaminitis, anaemia, thrombocytopaenia and coagulopathy postoperatively. The patient had a sudden neurological deterioration on postoperative day 2; imaging revealed that he had suffered a spontaneous right frontal intracerebral haemorrhage. The patient returned to theatre for surgical decompression and evacuation of the haematoma, and ultimately went on to make a full recovery.ConclusionThe use of 5-ALA in paediatric patients can be helpful in maximising surgical resection, but the associated safety profile remains undefined. Further research is urgently warranted in order to characterise the efficacy and risk of the use of 5-ALA in the paediatric population.

Cystic Glioblastoma of the Third Ventricle: Diagnostic Challenges and Poor Functional Outcome Related to Cystic Haemorrhage

<i>Background: </i>Glioblastoma multiforme (GBM) is the most common intra-axial primary brain tumour in adults, and prognosis is poor. Spontaneous haemorrhage is an uncommon but recognized initial presenting sign of primary brain tumour. Moreover, intra-cystic haemorrhage is frequent, further can affect functional outcome and even reducing survival duration. Most GBM tumours arise in the frontotemporal region, haemorrhagic cystic GBM arise in the third ventricle of the brain is very rare and create a diagnostic dilemma and surgical challenges. Third ventricular GBM can arise from structures on or near the third ventricle wall. Patients with massive intra-cystic haemorrhage can present with a wide spectrum of clinical signs and symptoms related to increased intracranial pressure (ICP), ranging from headache to sudden acute neurological deterioration, coma, and death. Acute deterioration frequently results from massive acute haemorrhage inside the cystic component leading to hydrocephalus, especially when the tumour mass obstructs the foramen of Monro. Due to high tumour-related mortality and sudden death related to acute hydrocephalus, A high index of suspicion is required to avoid misdiagnosis and delayed surgical treatment due to the atypical anatomic and radiologic presentation of cystic haemorrhagic GBM. This case presentation highlights the significant role of haemorrhage inside the GBM cystic component on both diagnosis and clinical course of the disease.

Hemorrhagic transformation in SARS-CoV-2 infected patients: case reports from Indonesia

Introduction:While initially suggested as a primary respiratory infection, there has been increasing proof that the novel coronavirus disease (COVID-19) also leads to severe neurological manifestation particularly ischemic stroke. The hypercoagulable state observed in COVID-19 patients is thought to contribute to this phenomenon although the exact pathophysiology is still unclear.Case: We are reporting two cases of hemorrhagic transformation after ischemic stroke in COVID-19 patients. Both patients were women presenting with ischemic stroke and bronchopneumonia due to COVID-19. They both experienced prolonged coagulation studies before sudden neurological deterioration. Evaluation CT scan demonstrated the hemorrhagic transformation of infarction. It is still unknown whether the coagulation disruption is primarily caused due to viral activity or secondary due to the inflammatory response. Hemorrhagic transformation is a complication of ischemic stroke, particularly in post-thrombolysis patients. However COVID-19 coagulopathy was thought to induce such event in COVID-19 patients presented with ischemic stroke.Conclusion: Although ischemic stroke has been widely reported in COVID-19 patients, there have been a few reports of hemorrhagic transformation events. This may lead to an increased understanding regarding COVID-19 pathophysiology and cerebrovascular disease.

A SILENT CASE OF LARGE CYSTIC MENINGIOMA

Meningiomas are the most common extra-axial neoplasms. Meningiomas, in general may be benign or malignant. Cystic meningiomas are one of the subtypes of meningioma, mimicking an intra-axial lesion radiologically and clinically. The common clinical manifestations may include but not limit to headache, vomiting, seizures &amp; focal neurological decits. The cystic component is an uncommon nding that makes it difcult to distinguish between a meningioma and a glial neoplasm radiologically. Here, we discuss a 54-year-old female patient who presented with subacute onset of transient memory disturbances and a sudden neurological deterioration who was found to have a cystic meningioma.

경추증성 척수증에 대한 수술에서 재관류손상의 수술중신경계감시

Neurologic deficit after cervical decompressive surgery for cervical spondylotic myelopathy is a rare but critical complication. Spinal cord reperfusion injury is one of the major causes of sudden neurologic deterioration associated with the surgery. If reperfusion injury occurs during the surgery, intraoperative neurophysiologic monitoring is essential for early diagnosis and intervention including surgical modification and maintaining proper mean blood pressure to reverse the neurologic damage. We review reperfusion injury in surgery for cervical spondylotic myelopathy.

CONSERVATIVE MANAGEMENT OF EXTRA DURAL HEMORRHAGE

Background: Extra Dural hematoma (EDH) is a blood clot that develops between the dura mater and the skull, found in 2.5% to 5% of head injured patients. Patient with small EDH may be treated conservatively through close observation is advised, yet sudden neurological deterioration may occur. Objective: To review the literature and to evaluate safety and efficacy of conservative management of extradural hematoma (EDH) in trauma patients with selected criteria. Patients and methods: This was a hospital based study which was done at the Department of neurosurgery at Al-Azhar University Hospitals and Luxor International Hospital during the period from September 2017 to September 2019. It was conducted on 15 patients with extradural hemorrhage who fulfilling the criteria (volume<30ml, thickness8), with exclusion of patients with extradural hematoma who needs surgical evacuation, patients with bleeding tendency and patients with temporal or occipital extradural hematoma. All cases records were reviewed and the pertinent data (clinical history, age, sex, mode of injury) analyzed. The patients were subjected to conservative treatment through Neurosurgery ICU admission and follow up CT Brain done at 6 hours, 12 hours, 24 hours and 48 hour after admission. Patients were given Analgesics, Antibiotics and Anti epleptics if needed .All patients stayed at ICU for 3 days until they had good conscious level then transferred to Neurosurgery ward for one day then discharged to home. Final CT Brain was done for all patients before discharge to ensure resolution of hemorrhage. Follow up of Patients continued for one month after discharge at clinic. Results: In our study of 15 patients, the conservative management of extradural hematoma continued in all patients (100%). This means that conservative management increased, and the mentioned protocol of conservative management gives successful results in the treatment of EDH. Conclusion: The conservative management gives successful results so we can avoid surgical evacuation in patients with selected criteria.

'White cord syndrome', a rare but disastrous complication of transient paralysis after posterior cervical decompression for severe cervical spondylotic myelopathy and spinal stenosis: A case report.

Transient paralysis following spinal decompression surgery is a rare but devastating postoperative complication. Spinal cord ischemia-reperfusion injury has been identified as one of the crucial pathogenic factors contributing to the sudden neurological deterioration associated with spinal decompression surgery. ‘White cord syndrome’ is a characteristic imaging manifestation of spinal cord ischemia-reperfusion injury, referring to high intramedullary signal changes in the sagittal T2-weighted MRI scan with unexplained neurological deficits following surgical decompression. The present study reported on the case of a 51-year old male patient who suffered from acute left limb hemiplegic paralysis following posterior cervical laminectomy decompression for severe cervical spondylotic myelopathy and spinal stenosis, which were caused by ossification of the posterior longitudinal ligament. The patient's neurological function gradually improved after the immediate administration of high-dose methylprednisolone therapy combined with mannitol and neurotrophic drugs. At the 2-month follow-up, the intensity of the spinal cord signal on MRI had almost returned to normal and the ‘white cord syndrome’ had disappeared. However, the patient complained of postoperative neck swelling pain caused by cerebrospinal fluid leakage; therefore, an additional cerebrospinal fluid leakage exploration and neoplasty were performed. At 2 weeks after the second surgery, the patient's neck swelling pain was relieved and the area of cerebrospinal fluid leakage was significantly reduced. Despite the low incidence rate, surgeons should be aware of this complication, particularly when treating chronic severe cervical spinal stenosis with anterior or posterior decompression. Once transient paralysis occurs, early diagnosis and interventions are essential to reverse the neurological deficit.

SAT-LB54 Acute Sterile Meningitis as a Primary Manifestation of Pituitary Apoplexy

Background: Pituitary apoplexy (PA) is a rare endocrinopathy that requires prompt diagnosis and treatment. Presentation with acute neutrophilic meningitis is uncommon.Clinical Case: A 67-year-old man presented to our hospital with a 2-week history of worsening bilateral frontal headache, nausea, and dry heaving. On admission, the patient was somnolent with a score of 13 on the GCS assessment (E2, V5, M6). The neurological exam was overall normal with normal ocular motion and intact cranial nerves, except for a left eye peripheral vision defect. Plain head CT revealed a well-circumscribed ovoid pituitary mass with suprasellar enlargement, consistent with a pituitary macroadenoma. Sellar MRI showed a pituitary mass, roughly 20 x 19 x 24 mm, bulging into the suprasellar cistern with optic chiasm elevation. Analysis of pituitary function revealed low ACTH concentration of 2.8 pg/mL (n = 7.2 - 63.3 pg/mL), a low random cortisol level of 1.7 ug/dL (n = 2.9 - 19.4 ug/dL), a low TSH of < 0.1 uIU/mL (n = 0.35 - 4.9 uIU/mL), a low free T4 level of 0.72 ng/dL (n = 0.77 - 1.48 ng/dL), a low LH of 0.8 IU/L (n = 1.7 - 8.6 IU/L) with a very low total testosterone level of < 3 ng/dL (n = 300 - 720 ng/dL) and normal prolactin, IGF-1 and GH levels. On hospital day 2, the patient had worsening encephalopathy with left eye ptosis and decreased vision. Repeat CT and MRI showed no interval change in the pituitary adenoma or evidence of bleeding. An immediate lumbar puncture was performed and CSF analysis revealed an increased leukocyte count of (1106/mm3) with 89% neutrophilic granulocytes, and increased total protein level of 138 mg/dL (n = 15 - 40 mg/dL), red blood cell count of 2040 without xanthochromia and glucose of 130 mg/dL (n = 40 - 70 mg/dL). Based on the laboratory results and new symptoms, empirical antibiotic (vancomycin, ceftriaxone, and ampicillin) therapy was started for suspected bacterial meningitis before the confirmation of the CSF culture study. CSF culture did not grow any organisms. Given the sudden visual impairment and neurological deterioration, the patient underwent transsphenoidal resection of the tumor with free nasal mucosal graft reconstruction. Histological examination revealed a necrotic pituitary adenoma with apoplexy and no evidence of hemorrhage. Postoperatively, his neurological exam greatly improved. His left pupil was reactive to light and the third palsy was improving.Conclusion: This case reinforces the importance of including PA in the differential diagnosis of acute headache, particularly in patients presenting with visual disturbances. Patients with PA often present with sterile meningitis due to increased debris and blood in the subarachnoid space which closely mimics acute bacterial meningitis. While MRI remains a sensitive imaging modality for the detection of PA, the latter remains a clinical diagnosis. Timely diagnosis with high clinical suspicion and treatment is essential.

Acute presentations of intradural lipomas: case reports and a review of the literature

BackgroundLumbosacral lipomas (LLs) may remain asymptomatic or lead to progressive neurological deterioration. However, sudden neurological deterioration is a rare and severe event. Herein, we report rare occurrences of sudden clinical deterioration in two previously asymptomatic children harbouring intradural LLs without dermal sinus tracts or signs of occult dysraphism. A review of the pertinent literature is also included.Case presentationOne child exhibited acute deterioration because of an epidural abscess associated with a filar lipoma without a sinus tract (probably caused by haematogenous spreading from a respiratory tract multiple infection), and the other child exhibited acute deterioration because of a very large, holocord syringomyelia-like cyst associated with a small conus lipoma. Both patients were 4 years old. In case #2, a previously undetected, severe tethered cord (conus at the S3-S4 level) was also present. A complete recovery was attained after an urgent surgical operation in both cases (in addition to targeted antibiotic therapy in case #1). All cases of deterioration in the literature were caused by abscess formation in dermal sinus tracts.ConclusionsProphylactic surgery may be indicated even in asymptomatic children that have tethered cord and surgically favourable LLs (small dorsal and filar LLs), especially if the conditions are associated with progressive syringomyelia. Similarly, intradural dermal sinus tracts should be regarded as surgery-indicated, even if the conus is in its normal position and the patient is asymptomatic because there is a consistent risk of severe, infection-related complications. Finally, asymptomatic patients with filar LLs and a normally located conus can be candidates for surgery or an accurate clinical and radiological follow-up.

Neuroimaging in emergency: a review of possible role of pineal gland disease.

The pineal gland can be involved in a variety of neoplastic and congenital masses and tumors. Pineal gland neoplasms occur more frequently in children, accounting for 3-8% of intracranial tumors in the pediatric population. Pineal cysts are small lesions usually asymptomatic and encountered incidentally. Pathologic processes involving the pineal region produce signs and symptoms related to the mass effect on the adjacent structures and invasion of surrounding structures. These include several acute symptoms, such as increased intracranial pressure syndrome from obstruction of the aqueduct and consequent hydrocephalus, and Parinaud syndrome. Pineal apoplexy is rare and refers to the sudden neurological deterioration following hemorrhage in the pineal gland, most commonly into a pineal cyst. Knowledge of the clinical presentation and imaging features of these lesions is essential to narrow the differential diagnosis, especially when presenting with acute onset.

Sudden neurological deterioration due to repeated intratumoral hemorrhage in a patient with a vestibular schwannoma

Vestibular schwannomas (VS) are the most common tumors involving the cerebellopontine angle (CPA) and the internal auditory canal (IAC). These tumors are usually slow-growing and commonly present with cranial nerve dysfunction such as hearing loss. Repeated intratumoral hemorrhage (ITH) is extremely rare with only four cases previously reported.We report the case of a 30 year old female with a right sided CP angle tumor who presented with vertigo and ataxia due to ITH. Her symptoms initially improved; however, three weeks later, she had acute onset of facial palsy and imaging confirmed rebleeding. Surgical pathology reported typical features of schwannoma.A literature review performed using the PubMed and EMBASE databases yielded four previous reports. A summary of these cases is presented and the features of ITH are discussed. Patients affected by repeated ITH present with sudden headache and ataxia. Rapid worsening of cranial nerve dysfunction such as hearing loss or facial nerve palsy is suggestive of ITH.

Sudden Neurological Deterioration Due to Repeated Intratumoral Hemorrhage in a Patient with a Vestibular Schwannoma

Abstract Vestibular schwannomas (VS) are the most common tumors involving the cerebellopontine angle (CPA) and the internal auditory canal (IAC). These tumors are usually slow-growing and commonly present with cranial nerve dysfunction such as hearing loss. Repeated intratumoral hemorrhage (ITH) is extremely rare with only four cases previously reported. We report the case of a 30 year old female with a right sided CP angle tumor who presented with vertigo and ataxia due to ITH. Her symptoms initially improved; however, three weeks later, she had acute onset of facial palsy and imaging confirmed rebleeding. Surgical pathology reported typical features of schwannoma. A literature review performed using the PubMed and EMBASE databases yielded four previous reports. A summary of these cases is presented and the features of ITH are discussed. Patients affected by repeated ITH present with sudden headache and ataxia. Rapid worsening of cranial nerve dysfunction such as hearing loss or facial nerve palsy is suggestive of ITH.

Study of predisposing risk factors and etiology of chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms – an institutional experience

AbstractIntroduction: Chronic subdural hematoma in clipped patients of unruptured intracranial aneurysms might lead to sudden neurological deterioration and may need emergency evacuation. We studied the effects of various factors in its etiology. Materials and methods: A retrospective study of 91operated clipped patients of unruptured aneurysms in the year 2014-2015 was taken. Various predisposing factors were studied. Results: Goreisan use was not associated with any reduction in post operative CSDH formation. Arachnoidoplasty and reduced post operative dead space contributed in a reduced formation of CSDH. Conclusion: Older male patients with aneurysms who had been treated with anticoagulant drugs should be considered candidates for additive ARP to prevent the development of postoperative CSDH.

Pathogenesis of An Intracranial Mycotic Aneurysm in An Immunocompromised Patient

Mycotic intracranial aneurysms are rare entities that can be rapidly fatal. The pathology of these lesions are usually due to bacterial infections however in exceptional cases such as immunocompromise, fungal agents are also found to be the cause. In this study, we present the case of a 43-year old, immunocompromised, male patient who suffered from a ruptured mycotic aneurysm after undergoing surgical evacuation of a basal ganglia brain abscess. Pathological analysis of the lesion showed that Aspergillus fumigatis was the causative agent. Since these types of lesions are rare, there are few clinical guidelines for treatment. We emphasize that in an immunocompromised patient with sudden neurological deterioration, mycotic intracranial aneurysm should be in the differential diagnosis.

Acute Cervical Disk Herniation Resulting in Sudden and Severe Neurologic Deterioration: A Case Series.

Objective Nontraumatic acute cervical disk herniation resulting in acute severe neurologic deficit is a rare entity described in a limited number of case reports. We describe the management and outcome in patients presenting with severe neurologic deterioration caused by acutely herniated cervical disks. Methods Four patients (mean age 39.5 years) presented to our tertiary care academic medical center from September 2012 to September 2013 with severe progressive neurologic deficits due to cervical disk herniation and were included in the series. Patients' surgical, medical, and imaging records were retrospectively reviewed under an Institutional Review Board waiver of informed consent. Results Patients in the series presented with acute neurologic deterioration, including paraparesis, Brown-Séquard syndrome, or quadriparesis deteriorating to quadriplegia. Emergent magnetic resonance imaging (MRI) scans and emergent decompression and fusion for acute soft disk herniation were performed in all cases. All patients recovered to excellent functional status with Frankel score improvement from B (one patient)/C (three patients) to E (three patients)/D (one patient). Conclusions Acute cervical disk herniation with acute neurologic deterioration is a medical emergency necessitating emergent MRI and surgical decompression. Clinical presentation varies. In patients with rapid-onset neurologic deterioration, a high level of suspicion for this rare entity is indicated.

Natural history of colloid cysts of the third ventricle.

OBJECTIVE Colloid cysts are rare, histologically benign lesions that may result in obstructive hydrocephalus and death. Understanding the natural history of colloid cysts has been challenging given their low incidence and the small number of cases in most reported series. This has complicated efforts to establish reliable prognostic factors and surgical indications, particularly for asymptomatic patients with incidental lesions. Risk factors for obstructive hydrocephalus in the setting of colloid cysts remain poorly defined, and there are no grading scales on which to develop standard management strategies. METHODS The authors performed a single-center retrospective review of all cases of colloid cysts of the third ventricle treated over nearly 2 decades at Washington University. Univariate analysis was used to identify clinical, imaging, and anatomical factors associated with 2 outcome variables: symptomatic clinical status and presentation with obstructive hydrocephalus. A risk-prediction model was defined using bootstrapped logistic regression. Predictive factors were then combined into a simple 5-point clinical scale referred to as the Colloid Cyst Risk Score (CCRS), and this was evaluated with receiver-operator characteristics. RESULTS The study included 163 colloid cysts, more than half of which were discovered incidentally. More than half of the incidental cysts (58%) were followed with surveillance neuroimaging (mean follow-up 5.1 years). Five patients with incidental cysts (8.8%) progressed and underwent resection. No patient with an incidental, asymptomatic colloid cyst experienced acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly half (46.2%) of symptomatic patients presented with hydrocephalus. Eight patients (12.3%) presented acutely, and there were 2 deaths due to obstructive hydrocephalus and herniation. The authors identified several factors that were strongly correlated with the 2 outcome variables and defined third ventricle risk zones where colloid cysts can cause obstructive hydrocephalus. No patient with a lesion outside these risk zones presented with obstructive hydrocephalus. The CCRS had significant predictive capacity for symptomatic clinical status (area under the curve [AUC] 0.917) and obstructive hydrocephalus (AUC 0.845). A CCRS ≥ 4 was significantly associated with obstructive hydrocephalus (p < 0.0001, RR 19.4). CONCLUSIONS Patients with incidentally discovered colloid cysts can experience both lesion enlargement and symptom progression or less commonly, contraction and symptom regression. Incidental lesions rarely cause acute obstructive hydrocephalus or sudden neurological deterioration in the absence of antecedent trauma. Nearly one-half of patients with symptomatic colloid cysts present with obstructive hydrocephalus, which has an associated 3.1% risk of death. The CCRS is a simple 5-point clinical tool that can be used to identify symptomatic lesions and stratify the risk of obstructive hydrocephalus. External validation of the CCRS will be necessary before objective surgical indications can be established. Surgical intervention should be considered for all patients with CCRS ≥ 4, as they represent the high-risk subgroup.