Suprasellar cysts: clinical presentation, surgical indications, and optimal surgical treatment

Arachnoid Cyst of the Cerebellopontine Angle: A Systematic Literature Review

OBJECTIVE

The role of surgical management of arachnoid cyst (AC) of the cerebellopontine angle (CPA) is uncertain. This topic has remained controversial with varying contradictory recommendations in the literature, which is limited to mostly case reports. We aimed to provide a comprehensive summary and analysis of symptoms, operative techniques, outcomes, and recurrence of all available surgical cases of AC of the CPA to date.

METHODS

A systematic literature search was performed in May 2022 querying several scientific databases. Inclusion criteria specified all studies and case reports of patients with AC located at the CPA for which any relevant surgical procedures were performed.

RESULTS

A total of 55 patients from the literature and 5 treated at our institution were included. Mean patient age was 29 years (range, 0.08-79 years), with nearly twice (1.7×) as many female as male patients (37 female, 22 male). Headaches (35%), hearing loss (30%), vertigo (22%), and ataxia (22%) were the most common presentations. Following surgery, 95% experienced symptom improvement, with complete resolution in 64%. Of patients with hearing loss, 44% reported a return to normal. The rate of mortality was 1.69%, and 10% of tumors recurred (mean follow-up 2.3 years [range, 0-15 years].

CONCLUSIONS

Symptomatic AC of the CPA is rare. It exhibits a proclivity for females and commonly manifests with headache, hearing loss, vertigo, and ataxia. While careful selection for surgical candidacy is needed and intervention should be reserved for patients with severe symptoms, surgical decompression is an effective tool for symptom alleviation and recovery.

Intracranial arachnoid cysts

PURPOSE

The purpose of this review article is to outline the natural history, pathogenesis, anatomic considerations and surgical decision-making in caring for patients with intracranial arachnoid cysts.

METHODS

A review of the literature for intracranial arachnoid cysts was performed using Embase, PubMed, and Web of Science databases, including review of the bibliographies of eligible articles and the author's own experience.

RESULTS

Among those reviewed, 59 relevant original articles were included as well as illustrative cases from the authors own experience.

CONCLUSIONS

Arachnoid cysts are congenital lesions characterized by split arachnoid membrane, thick collagen in the cyst wall, absent traversing trabecular processes within the cyst, and hyperplastic arachnoid cells in the cyst wall. The underlying etiology is not entirely known, and they occur in greater proportion in males and in greater incidence with various genetic conditions including Down syndrome, mucopolysaccharidosis, schizencephaly, neurofibromatosis, autosomal dominant polycystic kidney disease (ADPKD), acrocallosal syndrome, and Aicardi syndrome. Most intracranial arachnoid cysts are incidentally found and occur in the middle cranial fossa, with the remaining occurring in the cerebellopontine angle, suprasellar cistern, quadrigeminal cistern, convexity, and posterior fossa/cisterna magna. The current article outlines the natural history, prevalence, demographic factors, and treatment decisions in managing patients with intracranial arachnoid cysts.

Surgical indications in pediatric arachnoid cysts

INTRODUCTION

Arachnoid cysts are developmental lesions consisting of CSF collections within the subarachnoid space. There are many theories and hypotheses about their pathogenesis and histopathology and this may also explain the diversities seen in clinical behaviors of these cysts, their natural history and consequently their management where there is a great controversy about selecting patients for surgical intervention. The most common location in pediatrics is the Sylvian or middle cranial fossa and this made it gain more concern and greater debate about its management where its diagnosis is often accidently or associated with nonspecific symptoms.

AIM

Our aim in this article was to review the main surgical indications for pediatric arachnoid cysts in the literature.

CONCLUSION

We concluded that the decision for surgical intervention for pediatric arachnoid cysts is not a simple one and highly debatable and should be taken cautiously especially with sylvian arachnoid cysts that may reach a large size without symptoms. However, there is a consensus that the occurrence of symptoms definitely correlated to the presence of these cysts or their rupture with consequent subdural hematoma or hygroma are indications for surgical intervention. Large cysts in locations compressing CSF pathways causing hydrocephalus are also candidates for surgical fenestration. The surgical gain from prophylactic surgery is questionable particularly when asymptomatic.

Arachnoid Cyst: An Asymptomatic Exuberance

A 66-year-old man presented to the emergency department with sudden onset of dysarthria, left central facial palsy, and left hemihypesthesia involving the tongue. The patient was hemodynamically stable (blood pressure of 153/84 mmHg and heart rate of 80 bpm) and normoglycemic, without a history of trauma or toxic exposure. Assuming an acute stroke, the patient immediately underwent a brain CT scan that revealed a large left-sided fronto-parieto-temporal arachnoid cyst, with approximately 9.5 x 5.1 cm of maximum diameters (anteroposterior and transversal), compressing the brain parenchyma and the ventricular system, with a right deviation of the median structures by about 5 mm. The patient had a complete spontaneous resolution of the initial symptoms while in the emergency department. He declined admission to the ward for observation and further investigation, choosing to be discharged against medical advice. Lately, the patient represented to the ED with a new episode, this time with worsening symptoms, and consented to a cystoperitoneal shunt insertion. The procedure was well tolerated, and the patient has been asymptomatic since surgery.

A case of hydrocephalus confounded by suprasellar arachnoid cyst and concomitant reversible cerebral vasoconstriction syndrome

Background:

Obstructive hydrocephalus is a neurologic condition that has varied clinical and imaging presentations, as well as a multitude of congenital etiologies including aqueductal stenosis and less commonly arachnoid cysts. Aqueductal stenosis is a physical limitation to cerebrospinal fluid flow along the course of the aqueduct, which results in enlargement of the third and lateral ventricles. Arachnoid cysts are thin walled and fluid filled central nervous system lesions that can result in mass effect on adjacent structures. While arachnoid cysts are mostly asymptomatic, they may present with neurological symptoms that vary depending on the location of the lesion. Suprasellar cysts in particular may cause obstructive hydrocephalus as well as endocrine dysfunction. Reversible cerebral vasoconstriction syndrome (RCVS) is an unusual condition caused by cerebral arterial vasoconstriction that often presents initially with a thunderclap headache. Frequently, there is some environmental trigger associated with this condition. RCVS more commonly affects women and can induce stroke.

Case Description:

A 57-year-old female presented to the emergency department with progressive headache and visual changes. Initial workup suggested the patient’s symptoms where related to RCVS but subsequent surgical management of what was presumed to be long standing, compensated hydrocephalus resulted in resolution of the patient’s symptoms.

Conclusion:

We report, to the best of our knowledge, the first case of aquedutal stenosis and suprasellar arachnoid cyst with concomitant RCVS. The presence of multiple pathologies found on radiologic imaging illustrates the challenges presented by incidental findings and subsequent anchoring bias in medical diagnosis.

Frame-based stereotactic implantation of cystoventricular shunts for treating acquired intracerebral cysts

OBJECTIVE

The treatment of symptomatic, progressive or recurrent acquired intracerebral cysts is challenging, especially when they are localized in eloquent structures. In addition to resection, endoscopic fenestration, or stereotactic puncture, the implantation of a cystoventricular shunt by stereotactic guidance (SCVS) has been reported as a minimally invasive procedure; however, only scarce data are available regarding its feasibility and efficacy. Here, the authors evaluated the feasibility and efficacy of frame-based SCVS in patients with acquired intracranial cysts.

METHODS

In this single-center retrospective analysis, the authors included all patients with acquired intracerebral cysts treated by SCVS following a standardized prospective protocol between 2012 and 2020. They analyzed clinical symptoms, complications, and radiological outcome with regard to cyst volume reduction by 3D volumetry.

RESULTS

Thirty-four patients (17 females and 17 males; median age 44 years, range 5-77 years) were identified. The median initial cyst volume was 11.5 cm3 (range 1.6-71.6 cm3), and the mean follow-up was 20 months (range 1-82 months). At the last follow-up, 27 of 34 patients (79%) showed a cyst volume reduction of more than 50%. Initial symptoms improved or resolved in 74% (n = 25) and remained stable in 24% (n = 8). No permanent clinical deterioration after treatment was observed. The total complication rate was 5.9%, comprising transient neurological deterioration (n = 1) and ventriculitis (n = 1). There were no deaths. The overall recurrence rate was 11.8%.

CONCLUSIONS

In this study, SCVS proved to be a safe, minimally invasive, and effective treatment with reliable long-term volume reduction, resulting in clinical improvement and a minor complication rate.

A Neuronavigation-Assisted Endoscopic Ventriculocystocisternostomy of a Suprasellar Arachnoid Cyst: A 2D Video Case Presentation

Background and Importance: Suprasellar arachnoid cysts are insidious and progressive ventricular cysts that cause hydrocephalus, ataxia, optic, and endocrinological symptoms. These cysts can be successfully treated via an endoscopic ventriculocystocisterostomy (VCC).

Clinical Presentation: A three-year-old patient presented with emesis and bobble-head doll syndrome with a suprasellar arachnoid cyst. Through our video, we present our neuronavigation-assisted endoscopic VCC without cautery and the relevant neuroanatomy.

Conclusion: Neuroendoscopic fenestration is a preferred approach over resection or shunting for a suprasellar arachnoid cyst. In addition, VCC has decreased recurrence and increased radiologic improvement over a ventriculocystostomy (VC).

Paediatric arachnoid cysts: Surgical outcomes from a Singapore children's hospital

Arachnoid cysts (AC) are reported to have a prevalence of up to 2.6% in children. Most AC remain indolent, but others may expand or rupture to cause life-threatening symptoms of raised intracranial pressure. Currently, there are 2 controversial topics with regards to the management of ACs: the indications for surgery and the choice of surgical procedure. We therein report our institution's neurosurgical experience for symptomatic AC over a 22-year period and corroborate our results with published literature. This is a single institution, retrospective study conducted at KK Women's and Children's Hospital from 01 January 1998 to 31 December 2019. A total of 38 patients with ACs that required surgery were recruited. The 3 most common anatomical locations were in the middle cranial fossa (40.5%), posterior fossa (24.3%) and interhemispheric (13.5%). Typical clinical presentations included symptoms of raised intracranial pressure (34.2%), obstructive hydrocephalus (28.9%) and AC rupture (21.1%). Surgical approaches included 17 craniotomy-based procedures, 7 endoscopic fenestrations, 11 cystoperitoneal shunts, 2 burrhole drainage operations and 1 excision of spinal AC. Thirteen patients (34.2%) underwent either another operation due to the lack of resolution of their AC-related symptoms or secondary to complications directly related to their initial surgery. Average length of followup from time of first operation was 84.1 months. Overall, our results demonstrate similarities in epidemiology, clinical presentation and surgical experience, in comparison to larger cohort studies. We advocate collaborative efforts to better understanding of the pathophysiology of paediatric ACs, particularly for deciding between the various surgical treatment modalities.

Suprasellar arachnoid cysts: systematic analysis of 247 cases with long-term follow-up

At present, limited data exists to discuss the characteristics of suprasellar arachnoid cysts (SACs). The aim of this study is to elucidate the relationship between characteristics of cysts and outcomes, quantitatively analyze improvement in hydrocephalus, and evaluate the risk factors for the prognosis of SACs treated by endoscope. From June 2002 to 2017 December, 247 cases of SACs treated by endoscope in Beijing Tiantan Hospital were included in this study. The severity of hydrocephalus was evaluated by Evans' index (EI). The results showed that the slit-valve and the transparent/thin membrane were noted in 86.2% and 76.5% of overall patients, respectively, and the distribution differences among age-groups were statistically significant (p < 0.01). After a mean follow-up duration of 73.1 months, 18 patients underwent a reoperation. Ventriculocystostomy (VC) (hazard ratio (HR), 3.37; 95% confidence interval (CI), 1.2-9.47; p = 0.024) and history of treatment (HR, 3.98; 95% CI, 1.31-12.31; p = 0.015) were adverse factors for reoperation rate. MRI at 1-year follow-up revealed mean decreases of 78.4% and 9.13% in cyst size and EI. No paraventricular edema was an adverse factor associated with the improvement in hydrocephalus (HR, 11.22; 95% CI, 5.43-23.18; p < 0.01). These results indicated that ventriculocystocisternostomy (VCC) and no history of treatment is favorable factors for prognosis of SACs treated by endoscope. If feasible, VCC is the optimal choice for SACs. Slit-valve phenomenon and transparent/thin membrane are correlated with age but did not influence the outcomes of endoscopic fenestration. The mechanism for the expansion of cysts may be different between child and adult patients. Paraventricular edema is a favorable factor for the improvement in hydrocephalus after endoscopic surgery.

Experience with Management of Intracranial Arachnoid Cysts

OBJECTIVES

 The aim of this study was to analyze the demographics, clinical presentation, and surgical outcome of intracranial arachnoid cysts and to review the surgical options.

METHODS

 This is a retrospective observational study of 56 cases of symptomatic arachnoid cysts among all age groups treated between 2004 and 2020 at the Bombay Hospital, Mumbai. Endoscopic fenestration, microsurgical cyst excision, and shunt insertion were the interventions performed. Clinical presentation, cyst reduction post-intervention, and complications were studied. The follow-up period varied from 1 month to 16 years. Statistical analysis was done for 43 patients with a minimum of 3 years' follow-up.

RESULTS

 In all, 75% of patients were <18 years of age. Of these, the majority were between the age of 1 and 10 years. There were 14 cases of temporal, 13 cases of retrocerebellar, 10 cases of quadrigeminal cistern, and 7 cases each of interhemispheric and suprasellar arachnoid cysts. The most common clinical presentation was headache and vomiting. Concomitant hydrocephalus was seen on imaging in 24 cases. Endoscopic fenestration of cyst was the most routinely performed procedure (35 cases). Four patients of endoscopic fenestration underwent a redo endoscopic procedure on follow-up. Post-operative reduction in cyst size was found to be significantly better after endoscopic fenestration (p < 0.05).

CONCLUSION

 Though the best available treatment for arachnoid cysts remains controversial, surgery has been found to be beneficial in symptomatic cases. Endoscopic fenestration is considered the first-line surgical option and it may be followed by shunt, if necessary. Shunts may be preferred in very young children where there is associated hydrocephalus/macrocephaly.

A Review of Common Endoscopic Intracranial Approaches

With the evolution of surgical techniques, endoscopy has emerged as a suitable alternative to many instances of more invasive methods. In this review article, we aim to discuss the endoscopic advancements, procedural details, indications, and outcomes of the most commonly practiced neuroendoscopic procedures. We have also summarized the uses, techniques, and challenges of neuroendoscopy in select neurosurgical pathologies.

Suprasellar arachnoid cysts in adults: clinical presentations, radiological features, and treatment outcomes

A tendency for suprasellar arachnoid cysts (SACs) to occur in young children is known. Data of adult SACs were rare in previous reports. The aim of this study is to discuss their clinical presentations, radiological features, and treatment outcomes based on 23 adult patients who underwent endoscopic fenestration in our hospital between January 2003 and December 2018. Preoperative cyst volume ranged from 12.3 to 72.5 cm³ (mean 39.8 ± 19.8). Endocrine disorders occurred in 7 (30.4%) patients. Hydrocephalus was observed in 20 patients. In the patients with hydrocephalus, the mean preoperative Evans' index (EI) (%) and frontooccipital horn ratio (FOHR) (%) were 44.8 (ranged 32.2-63.4) and 49.6 (ranged 36.7-59.8), respectively. A bivariate correlation showed significant positive association between preoperative cyst volume and preoperative EI or FOHR (Pearson correlation, r = 0.607, p = 0.005; r = 0.583, p = 0.007). The slit-valve phenomenon was observed in 13 (56.5%) patients. Pale/tenacious cyst walls were observed in 12 (52.2%) patients. Postoperatively, all patients achieved the improvement in clinical symptoms and a decrease in cyst size. The mean decreases in cyst volume, EI, and FOHR were 64.7%, 7.89%, and 5.8%, respectively. A bivariate correlation indicated the irrelevance between the postoperative cyst volume and postoperative EI or FOHR (Pearson correlation: r = 0.37, p = 0.11; r = 0.43, p = 0.054). These results reveal that there are a few differences in several aspects between adult patients and child patients. The severity of hydrocephalus is correlated with cyst size in adult patients. Additionally, the excellent outcomes in adult SACs can be obtained by endoscopic fenestration.

Management of Suprasellar Arachnoid Cysts in Children: A Systematic Literature Review Highlighting Modern Endoscopic Approaches

OBJECTIVE

Suprasellar arachnoid cysts are a rare but important pediatric neurosurgical pathology with unknown ideal management. They have been previously managed with techniques including open craniotomy with microsurgical fenestration, cystoperitoneal shunting, endoscopic ventriculocystostomy, and endoscopic ventriculocystocisternostomy (VCC), without a consistent consensus on the best surgical approach. We present an overview of the literature on surgical management of suprasellar arachnoid cysts.

METHODS

A literature search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted for all articles evaluating treatment modalities for suprasellar arachnoid cysts, using PubMed, OVID, and Web of Science.

RESULTS

Twenty-five articles on management of suprasellar arachnoid cysts in children were identified. Few published studies exist that examine different types of surgical management across a single institution. The majority of studies reported best clinical outcomes in patients treated with endoscopic approaches when compared with microsurgical fenestration or cystoperitoneal shunting, reporting lower rates of infection, shunt dependence, and need for revision in addition to better resolution of clinical symptoms. Furthermore, most studies argue that VCC is superior to ventriculocystostomy, offering better long-term improvement of clinical symptoms and lower rates of failure.

CONCLUSIONS

This study examines the current literature on suprasellar arachnoid cyst surgical management to conclude that an endoscopic approach in comparison with other approaches has the best outcomes. Of the endoscopic options available, VCC provides patients with the best long-term resolution of symptoms and the lowest need for revision. These findings should be further investigated with larger multicenter studies to further compare different surgical techniques and outcomes.

Endoscopic third ventriculostomy in children with third ventricular pressure gradient and open ventricular outlets on MRI

OBJECTIVE

Patients with non-communicating hydrocephalus due to aqueductal stenosis are often successfully treated with endoscopic third ventriculocisternostomy (ETV). In hydrocephalus, due to other locations of obstruction of the major CSF pathways, endoscopic treatment may also be a good option. We investigated our cohort of patients treated by ETV with patent ventricular outflow but pressure gradient signs at the third ventricle in a single-center retrospective study.

METHODS

We retrospectively reviewed records and imaging studies of 137 patients who underwent an ETV in our department in the time period of June 2010 to March 2018. We included patients who showed the following findings in MRI: 1st: open Sylvian aqueduct, 2nd: open outlets of the 4th ventricle, 3rd: open spinal canal, 4th: intra-/extraventricular pressure gradient seen at the 3rd ventricle and excluded patients with history of CSF infection or hemorrhage. Perioperative clinical state and possible complications or reoperations were recorded. Shunt dependency and changes in ventricular dilatation were measured as frontal and occipital horn ratio (FOHR) before surgery and during follow-up.

RESULTS

A total of 21 patients met the defined criteria. During the mean follow-up time of 40.7 ± 30 months (range; 5-102 months), two children had to undergo a re-ETV, and six children (all < 1 year of age) received a VP shunt. ETV shunt-free survival was 100% for children > 1 year of age. The ventricular width measured as FOHR was significantly reduced after ETV 0.5 ± 0.08 (range 0.42-0.69; p < 0.05). FOHR was significantly reduced at last follow-up shunt independent patients (0.47 ± 0.05; range 0.41-0.55; p < 0.001) CONCLUSION: We conclude that ETV seems to be a successful treatment option for patients with MRI signs of intra-/extraventricular pressure gradient at the 3rd ventricle and patent aqueduct and fourth ventricular outlets in children older than 1 year of age. This condition is observed only rarely and warrants further research on a multicenter basis in order to get more solid data of its pathophysiology.

A good choice for the patients with prior failed ventriculoperitoneal shunt treatment of suprasellar arachnoid cysts: endoscopic fenestration

To investigate the effectiveness of endoscopic fenestration in the patients with prior failed ventriculoperitoneal (VP) shunt treatment of suprasellar arachnoid cysts (SACs). Between 2012 and 2018, four pediatric patients of SACs with previous failed VP shunt treatment were surgically treated using endoscopic ventriculocystocisternostomy (VCC) in our hospital. The clinical symptoms, imaging data, and surgical outcomes were collected and analyzed retrospectively. A literature review is provided with regard to the reasons of shunt failure and surgical outcome of further endoscopic fenestration in the previously reported patients of SACs with prior failed VP shunt. For the 4 cases, the initial clinical symptoms relieved or even disappeared after shunt placement, but, respectively, recurred 2, 6, 11, and 6 months later. MR scans were conducted when the clinical symptoms reappeared and showed a cyst had greatly enlarged after shunt placement. Furthermore, VP shunt-related slit ventricle was also demonstrated in 3 cases. Clinical improvement and cysts shrinkage occurred in all 4 patients after VCC. Slit ventricle and hydrocephalus were also resolved. Three patients had their shunt apparatus removed after VCC, and another patient's guardian refused to remove the shunt apparatus. Subdural hematoma occurred in one case after shunt apparatus removal. Four patients have been stable during follow-up period (mean follow-up 26.5 months). All the three patients whose VP shunt were removed were shunt independence. There were 24 patients who underwent endoscopic fenestration as an alternative to the failed VP shunt treatment in the published reports. Added our 4 patients to the published group, the effective rate of endoscopic fenestration for SACs following previous failed VP shunt treatment was approximately 93% (26/28). Of the 24 patients, the shunt apparatuses were in situ or reimplantation in 9 patients due to shunt dependence. The correction to recognize the SAC is the first condition to select the optimal management philosophy. The analysis of the series suggests endoscopic operation is still an effective and safe option in the SAC patients with previous failed VP shunt, and the shunt apparatus can be removed for some patients. The short interval time between shunt operation and endoscopic fenestration is conductive to return patients to the shunt-free state.

Management of Arachnoid Cysts: A Comprehensive Review

Arachnoid cysts are non-neoplastic, intracranial cerebrospinal fluid (CSF)-filled spaces lined with arachnoid membranes. Large arachnoid cysts are often symptomatic because they compress surrounding structures; therefore, they must be treated surgically. As several surgical management options exist, we explore the best approach according to each major type of arachnoid cyst: middle cranial fossa cyst, suprasellar cyst, intrahemispheric cyst, and quadrigeminal cyst.

History, Current Situation, and Future Development of Endoscopic Neurosurgery in China

OBJECTIVE

During the past few decades, Chinese endoscopic neurosurgery has rapidly developed in synchrony with the rest of the world. The aim of this article is to review the development of Chinese endoscopic neurosurgery, including its birth, growth, current situation, and prospects.

METHODS

The history of Chinese endoscopic neurosurgery development can be divided into 3 stages: cognition and initial stage (1964-1995), exploration and maturity stage (1995-2006), and rapid development and promotion stage (2006-present).

RESULTS

In the first stage, we mainly began to become aware of endoscopic neurosurgery from the translation and review of literature. In the mid to late 1990s, Chinese neurosurgery pioneers began using neuroendoscopic techniques. In the following decade, many leading neurosurgeons made persistent efforts to push the development of Chinese endoscopic neurosurgery forward, focusing on advocating for and promoting and popularizing neuroendoscopic technology. In the rapid development and promotion stage, many representative national and regional neurosurgical centers became skilled and efficient in the application of neuroendoscopic technology and became new advocates of the technology. The number of cases, level of technology, and treatment effectiveness are gradually nearing international standards. However, future development requires promotion of balanced development to decrease regional disparities, further strengthen international exchanges, follow the latest developments, and constantly innovate for continuous improvement.

CONCLUSIONS

Following the dramatic efforts of several pioneers, development of Chinese endoscopic neurosurgery has been considerable, and it has become an important component of neurosurgery worldwide.

Bobble-head doll syndrome in an 80-year-old man, associated with a giant arachnoid cyst of the lamina quadrigemina, treated with endoscopic ventriculocystocisternotomy and cystoperitoneal shunt

Bobble-head doll syndrome (BHDS) is a rare entity, characterized by antero-posterior head bobbing, which is of the type "yes-yes." Less frequently, having a head movement of the type "no-no" is described. We report an unusual case of an 80-year-old man with a cystic mass of the lamina quadrigemina, extending to the posterior fossa. We conclude that ventriculocystocisternotomy associated with a cystoperitoneal shunt is an effective treatment for a symptomatic giant arachnoid cyst in the lamina quadrigemina.

Endoscopic treatment of suprasellar cysts without hydrocephalus

OBJECTIVE At present, endoscopic treatment is advised as the first procedure in cases of suprasellar arachnoid cysts (SSCs) with hydrocephalus. However, the appropriate therapy for SSCs without hydrocephalus has not been fully determined yet because such cases are very rare and because it is usually difficult to perform the neuroendoscopic procedure in patients without ventriculomegaly given difficulties with ventricular cannulation and the narrow foramen of Monro. The purpose of this study was to find out the value of navigation-guided neuroendoscopic ventriculocystocisternostomy (VCC) for SSCs without lateral ventriculomegaly. METHODS Five consecutive patients with SSC without hydrocephalus were surgically treated using endoscopic fenestration (VCC) guided by navigation between March 2014 and November 2015. The surgical technique, success rate, and patient outcomes were assessed and compared with those from hydrocephalic patients managed in a similar fashion. RESULTS The small ventricles were successfully cannulated using navigational tracking, and the VCC was accomplished in all patients. There were no operative complications related to the endoscopic procedure. In all patients the SSC decreased in size and symptoms improved postoperatively (mean follow-up 10.4 months). CONCLUSIONS Endoscopic VCC can be performed as an effective, safe, and simple treatment option by using intraoperative image-based neuronavigation in SSC patients without hydrocephalus. The image-guided neuroendoscopic procedure improved the accuracy of the endoscopic approach and minimized brain trauma. The absence of hydrocephalus in patients with SSC may not be a contraindication to endoscopic treatment.

Assessment of endoscopic treatment for quadrigeminal cistern arachnoid cysts: A 7-year experience with 28 cases

BACKGROUND

Quadrigeminal cistern arachnoid cysts (QACs) are difficult to treat because of their deep location and the presence of nervous and vascular structures of the pineal-quadrigeminal region. There are several surgical procedures available for QACs, including craniotomy and cyst excision or fenestration, ventriculoperitoneal or cystoperitoneal shunting, and endoscopic fenestration. There is a debate about which method is the best.

OBJECTIVE

The aim of this study is to evaluate the effectiveness and safety of endoscopic ventriculocystostomy (VC) and third ventriculostomy (ETV) for treatment of arachnoid cysts of the quadrigeminal cistern.

METHODS

Twenty-eight patients with QACs who had undergone endoscopic treatment in our department between August 2007 and June 2014 were studied retrospectively. Patient age at the time of endoscopic treatment ranged from 5 months to 42 years, including 25 children (14 males and 11 females) and 3 adults (one male and two females). All patients presented with hydrocephalus and did not undergo shunting prior to neuroendoscopic surgery. The first endoscopic procedures included lateral ventricle cystostomy (LVC) together with ETV in 18 cases, third ventricle cystostomy (3rd VC) together with ETV in 3 cases, and double VC (3rd VC and LVC) together with ETV in 7 cases. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up.

RESULTS

Complete success was achieved in 25 (89.3 %) of 28 cases. During the follow-up period, one case underwent endoscopic reoperation with success. Shunts were implanted in 2 patients due to progression of symptoms and increase in hydrocephalus after the first endoscopic operation. Shunt independency was achieved in 26 (92.9 %) of 28 cases. The cyst was reduced in size in 22 cases (78.6 %). Postoperative images showed a reduction in the size of the ventricles in 23 cases (82.1 %). There was no surgical mortality. Subdural collection developed in 4 cases (14.3 %) and required a transient subduroperitoneal shunt in 2 cases, whereas the other 2 patients were asymptomatic and did not require any surgical treatment.

CONCLUSIONS

VC together with ETV through precoronal approach is an effective treatment for symptomatic QACs and should be the initial surgical procedure. The surgical indications should include signs of elevated ICP (including increased head circumference), Parinaud syndrome, gait ataxia, and nystagmus. Also, surgery is indicated by progressive enlargement of the cyst and young children with large cysts even if the patients are asymptomatic. Contraindications to surgery include the absence of symptoms (older children and adult) and isolated developmental delay. The main criterion for successful surgery should be improvement of clinical symptoms instead of reduced cyst volume and/or ventricular size. Repeated endoscopic procedures may be considered only for the patients whose symptoms improved after first endoscopic operation.

A Novel Bilateral Approach for Suprasellar Arachnoid Cysts: A Case Report

The endoscopic method is used to treat suprasellar arachnoid cysts (SACs) but it is sometimes difficult to make sufficiently sized fenestrations. Creating a larger fenestration on the cyst wall is preferable to prevent closure of the stoma. In this paper, we report a novel endoscopic approach for SAC treatment in which we use bilateral burr holes to achieve a more extensive cyst fenestration. A 7-year-old girl was referred to our hospital because of incidentally detected hydrocephalus by computed tomography scans. Physical examination did not show any signs of intracranial hypertension, but a digital impression of her skull on X-ray implied chronic intracranial hypertension. Magnetic resonance imaging (MRI) revealed enlargement of both lateral ventricles and a cystic mass occupying the third ventricle. We performed cyst wall fenestration using a bilateral approach in which we created two burr holes to introduce a flexible endoscope and a rigid endoscope. The cyst wall was held by forceps with the flexible endoscope, and resection of the cyst wall was achieved by using a pair of scissors with the rigid endoscope. There were no postoperative complications, and MRI performed 1 year after treatment showed disappearance of the superior part of the cyst wall.

Low-Cost Interactive Image-Based Virtual Endoscopy for the Diagnosis and Surgical Planning of Suprasellar Arachnoid Cysts

OBJECTIVE

To investigate the feasibility and reliability of virtual endoscopy (VE) as a rapid, low-cost, and interactive tool for the diagnosis and surgical planning of suprasellar arachnoid cysts (SACs).

METHODS

Eighteen patients with SACs treated with endoscopic ventriculocystostomy were recruited, and 18 endoscopic patients treated with third ventriculostomy were randomly selected as a VE reconstruction control group. After loading their DICOM data into free 3D Slicer software, VE reconstruction was independently performed by 3 blinded clinicians and the time required for each reconstruction was recorded. Another 3 blinded senior neurosurgeons interactively graded the visibility of VE by watching video recordings of the endoscopic procedures. Based on the visibility scores, receiver operating characteristic curve analysis was used to investigate the reliability of VE to diagnose SACs, and Bland-Altman plots were used to assess the reliability of VE for surgical planning. In addition, the intraclass correlation coefficient was calculated to estimate the consistency among the results of 3 reconstruction performers.

RESULTS

All 3 independent reconstructing performers successfully completed VE simulation for all cases, and the average reconstruction time was 10.2 ± 9.7 minutes. The area under the receiver operating characteristic curve of the cyst visibility score was 0.96, implying its diagnostic value for SACs. The Bland-Altman plot indicated good agreement between VE and intraoperative viewings, suggesting the anatomic accuracy of the VE for surgical planning. In addition, the intraclass correlation coefficient was 0.81, which revealed excellent interperformer consistency of our simulation method.

CONCLUSIONS

This study substantiated the feasibility and reliability of VE as a rapid, low-cost, and interactive modality for diagnosis and surgical planning of SACs.

Suprasellar Arachnoid Cysts: Toward a New Simple Classification Based on Prognosis and Treatment Modality

BACKGROUND:

Suprasellar arachnoid cysts (SAC) represent between 9% and 21% of pediatric arachnoid cysts. Recent improvements in magnetic resonance imaging, as well as increasing prenatal diagnosis, have allowed more precise knowledge and follow-up.

OBJECTIVE:

To describe a novel classification of SAC.

METHODS:

We present 35 cases of SAC treated between 1996 and 2014. Patient records and imaging studies were reviewed retrospectively to assess symptomatology, radiological findings, treatment, and long-term follow-up.

RESULTS:

Fourteen SAC were diagnosed prenatally (39%). We observed 15 (43%) cases presenting hydrocephalus (SAC-1) removing Liliequist membrane downward. Lower forms (SAC-2) with free third ventricle were observed in 11 (31%) cases. Asymmetrical forms (SAC-3) with Sylvian or temporal extension were seen in the 9 (26%) remaining patients. Twenty-three (66%) patients were treated by ventriculocisternostomy, 3 (8.5%) by shunt surgery, and 3 (8.5%) by craniotomy. Six (17%) patients had no surgery, including 5 cases (14%) that had prenatal diagnosis. Outcomes were initially favorable in 26 cases (87%). Eight (22%) patients had endocrine abnormalities at the end of the follow-up, 3 (8.5%) had developmental delay, and 6 (17%) had minor neuropsychological disturbances.

CONCLUSION:

SAC are heterogeneous entities. SAC-1 may come from an expansion of the diencephalic leaf of the Liliequist membrane. SAC-2 show a dilatation of the interpeduncular cistern and correspond to a defect of the mesencephalic leaf of the Liliequist membrane. SAC-3 correspond to the asymmetrical forms expanding to other subarachnoid spaces. Surgical treatment is not always necessary. The recognition of the different subtypes will allow choosing the best treatment option.

A suprasellar arachnoid cyst resulting from an intraventricular haemorrhage and showing complete resolution following endoscopic fenestration

We present the case of a premature neonate who developed a large, acquired arachnoid cyst as a consequence of intraventricular haemorrhage. The child was managed with endoscopic fenestration and made an excellent recovery.

Anatomical variations and neurosurgical significance of Liliequist's membrane

INTRODUCTION

Liliequist's membrane is an arachnoid membrane that forms a barrier within the basilar cisternal complex. This structure is an important landmark in approaches to the sellar and parasellar regions. The importance of this membrane was largely recognized after the advance of neuroendoscopic techniques. Many studies were, thereafter, published reporting different anatomic findings.

METHOD

A detailed search for studies reporting anatomic and surgical findings of Liliequist's membrane was performed using "PubMed," and included all the available literature. Manual search for manuscripts was also conducted on references of papers reporting reviews.

RESULTS

Liliequist's membrane has received more attention recently. The studies have reported widely variable results, which were systematically organized in this paper to address the controversy.

CONCLUSION

Regardless of its clinical and surgical significance, the anatomy of Liliequist's membrane is still a matter of debate.

Endoscopic treatment of convexity arachnoid cysts

OBJECTIVE

The aim of this study was to investigate the endoscopic treatment of cerebral hemisphere convexity arachnoid cyst.

METHODS

Eight cases of hemisphere convexity arachnoid cyst treated with cyst-ventricular or cisternal endoscopic approach in September 2007 to March 2011 were retrospectively recruited. The clinical symptoms, radiological findings, surgical indications, surgical approach, complications, and follow-up studies were analyzed.

RESULTS

All patients showed convexity arachnoid cysts adjacent to the ventricles or cisternal. After treatment, all patients showed decrease in size of the cysts (100 %), with preoperative symptoms disappeared in six patients and improved in two cases. In one case, postoperative subdural effusion was found without symptoms reported.

CONCLUSION

Endoscopic surgery is ideal for treatment of arachnoid cysts adjacent to the ventricles or cisternal.