Penetration of an Optic Nerve by a Sellar/Suprasellar Arachnoid Cyst

Endoscopic transnasal transsphenoidal management of sellar/suprasellar arachnoid cyst: A case report and literature review

Background

Arachnoid cysts (ACs) are collections of cerebrospinal fluids (CSFs) that develop within the arachnoid layer of the meninges. Sellar ACs are comparatively rare. In general, ACs account for approximately 1% of all intracranial mass lesions, and sellar ACs are 3% of all intracranial ACs. An endoscopic transnasal transsphenoidal approach for the treatment of ACs by fenestrating the cyst's wall and connecting with the subarachnoid space is the most optimal option.

Case Description

A 74-year-old woman whose sellar AC was diagnosed on magnetic resonance imaging a year ago was admitted to our hospital with complaints of bitemporal hemianopia and diminished visual acuity in the past 2 months. Sellar AC was diagnosed based on the clinical history and presentation, as well as neurologic, endocrinologic, and ophthalmologic examinations, including visual acuity and visual field examination, and additional imaging findings. The patient with a sellar/suprasellar AC was treated by an endoscopic transnasal transsphenoidal approach with cyst drainage and perforation of the lamina terminalis. Postoperatively, the visual disturbances improved markedly. No surgery-related complications occurred.

Conclusion

The endoscopic transnasal transsphenoidal approach remains a minimally invasive and preferred approach for the treatment of sellar/suprasellar ACs. Hermetically reconstructing the sellar floor is an effective method to prevent CSF leakage.

Oculomotor nerve root split: incidental finding on MRI-case report and literature review

BACKGROUND

The oculomotor nerve (OMN) innervates the pupil, ciliary body, upper eyelid, and extraocular muscles through two divisions: a superior division that innervates the levator palpebrae superioris (LPS) and superior rectus (SR), and an inferior division that supplies the medial rectus (MR), inferior rectus (IR), inferior oblique (IO), and parasympathetic fibers to the pupil and ciliary body. We present a case of complete splitting of the cisternal segment of bilateral OMNs that was discovered incidentally on magnetic resonance imaging (MRI) in a patient who had no ocular complaints.

CASE REPORT

A 69-year-old patient was found to have bilateral splitting of the cisternal segments of OMNs during an MRI for trigeminal neuralgia workup. Both nerves sprang from the midbrain as distinct roots. They were symmetric on the right and minimally asymmetric on the left. On both sides, the medial root was slightly inferiorly situated. The patient had no visual problems and continued to function normally. A review of the literature for similar cases identified no such variants; however, it did identify eight examples of OMN fenestrations produced by aneurysms (AN), six of which had no OMN palsy symptoms.

CONCLUSION

An anatomic variant of split bilateral OMN cisternal segments is described. The superior and inferior divisions may have different brainstem origins. Although this variant is an anatomic curiosity, it may have clinical significance and explain the various presentation of compressive OMN palsies.

The efficacy of cystoperitoneal shunting for the surgical management of intracranial arachnoid cysts in the elderly: A systematic review of the literature

Background:

Intracranial arachnoid cysts (AC) are benign, cerebrospinal fluid filled spaces within the arachnoid layer of the meninges. Neurosurgical intervention in children and young adults has been extensively studied, but the optimal strategy in the elderly remains unclear. Therefore, we performed a single center retrospective study combined with a systematic review of the literature to compare cystoperitoneal (CP) shunting with other surgical approaches in the elderly cohort.

Methods:

Retrospective neurosurgical database search between January 2005 and December 2018, and systematic review of the literature using PRISMA guidelines were performed. Inclusion criteria: Age 60 years or older, radiological diagnosis of intracranial AC, neurosurgical intervention, and neuroradiological (NOG score)/clinical outcome (COG score). Data from both sources were pooled and statistically analyzed.

Results:

Our literature search yielded 12 studies (34 patients), which were pooled with our institutional data (13 patients). CP shunts (7 patients; 15%), cyst fenestration (28 patients; 60%) and cyst marsupialisation/resection (10 patients; 21%) were the commonest approaches. Average duration of follow-up was 23.6, 26.9, and 9.5 months for each approach, respectively. There was no statistically significant association between choice of surgical intervention and NOG score (P = 0.417), COG score (P = 0.601), or complication rate (P = 0.955). However, CP shunting had the lowest complication rate, with only one patient developing chronic subdural haematoma.

Conclusion:

CP shunting is a safe and effective surgical treatment strategy for ACs in the elderly. It has similar clinical and radiological outcomes but superior risk profile when compared with other approaches. We advocate CP shunting as first line neurosurgical intervention for the management of intracranial ACs in the elderly.

Spontaneous Resolution of Asymptomatic Pediatric Suprasellar Arachnoid Cysts: Report of 2 Cases and Review of the Literature

INTRODUCTION

Sellar/suprasellar arachnoid cysts are infrequent nonneoplastic cystic lesions that account for approximately 1% of all arachnoid cysts. While various surgical treatment options have been proposed for symptomatic lesions, treatment guidelines regarding the management of asymptomatic sellar/suprasellar arachnoid cysts remain to be elucidated. This case series aims to provide a better insight into the management and outcomes of such lesions.

CASE PRESENTATION

We discuss 2 pediatric patients diagnosed with sellar/suprasellar arachnoid cysts who remained asymptomatic and demonstrated spontaneous gradual resolution of their arachnoid cysts on subsequent imaging studies.

CONCLUSION

Review of the literature identified only a handful of previously reported cases of spontaneously disappearing suprasellar arachnoid cysts. There might be a role for conservative management of sellar/suprasellar arachnoid cysts in certain patients who remain asymptomatic.