Endoscopic cystoventriculostomy for treatment of paraxial arachnoid cysts

Positive outcome after endoscopic treatment of a symptomatic convexity arachnoid cyst in an elderly

Cerebral convexity arachnoid cysts (ACs) only represent around 10-14% of the cysts. Symptomatic ACs in the elderly are rare. We present a 66-year-old woman with headache and a focal epileptic seizure. Imaging revealed a left parietal AC. Conservative management chosen but the patient's neurological condition worsened, and an endoscopic fenestration was then performed. Postoperatively, her symptoms completely resolved and MRI image showed significant shrinkage of the AC.

Purely Endoscopic Treatment for Arachnoid Cysts

Arachnoid cysts are benign, mostly congenital lesions that are asymptomatic in most patients. In some cases, due to their location or sheer size, they produce a mass effect or hydrocephalic obstruction of the cerebrospinal fluid (CSF) flow and thus might warrant surgical treatment. The goal of the surgery is usually to reduce pressure inside the cysts, to reduce the mass effect, or to restore the CSF pathway. Surgical treatment options are resection, fenestration, or shunting of the cyst. Over the past decades, treatment under sheer endoscopic control either through a tube or via craniotomy of arachnoid cysts has been studied thoroughly and replaced open microsurgical cyst surgery in the opinion of many neurosurgeons. Endoscopic treatment has proven to be a safe and feasible technique for both patients and surgeons. In the following chapter, the authors describe their indications for surgery and pre- and postoperative workup, where precautions should be taken, and discuss the different possibilities and techniques of endoscopic cyst fenestration. The aim is to give detailed instructions and present cases for ventriculocystostomy, cystocisternostomy, ventriculocystocisternostomy, and cystoventriculostomy and point out specifics deemed to be important to avoid complications and to ensure the best possible outcome for each patient.

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.

Endoscopic management of periventricular and intraventricular arachnoid cysts

Introduction

The most successful surgical management of periventricular and intraventricular cysts is still a matter of debate. Up to the early 1990s, open cyst fenestration and cystoperitoneal shunts were the only options available. Recently, different endoscopic approaches to these lesions have gained popularity.

Methods

Eighteen endoscopic procedures were performed for the treatment of arachnoid cysts in 18 patients. Sylvian fissure arachnoid cysts were excluded from this study. Ten of them were females and eight were males with their ages ranging from 6 months to 50 years with a mean of 16 years. All patients were prospectively observed.

Results

Seven of the arachnoid cysts were in the suprasellar region, 5 in the quadrigeminal region, 2 in the posterior fossa, 2 parietal, and 2 intraventricular. Seventeen cases (94%) had hydrocephalus. The main presenting manifestations were those of increased intracranial pressure. All fenestrations were done in the lateral ventricle except for the 2 cases with posterior fossa arachnoid cysts, the fenestrations were done to the fourth ventricle. Endoscopic ventriculocytostomies (VC) were performed in 14 cases without operative complications and no stents were placed. Endoscopic cystocisternostomies (C) were done in all suprasellar cases. Endoscopic cystoventriculostomies (CV) were done in 4 cases. The mean surgical time was 1 h. The mean follow-up period was 15 months. Symptoms improved in 17 cases. Seventeen cases demonstrated a significant decrease of the cysts’ size in the postoperative computed tomography (CT) and magnetic resonance imaging (MRI). A single case developed a complication in the form of subdural hygroma which required no intervention and was managed conservatively.

Conclusion

Endoscopic management of periventricular and intraventricular arachnoid cysts is a useful safe option in the management of arachnoid cysts related to the ventricular system.

Endoscopic Treatment of Intracranial Arachnoid Cysts: A Retrospective Analysis of a 25-Year Experience

BACKGROUND

Since the development of neuroendoscopy, pure endoscopic fenestration for intracranial arachnoid cysts (ACs) became more and more popular and is actually preferred by many neurosurgeons.

OBJECTIVE

To explore their techniques and experiences with endoscopic treatment of intracranial ACs over a 25-yr period.

METHODS

A total of 95 endoscopic procedures in 87 patients with 88 intracranial ACs performed at the authors’ departments between February 1993 and October 2018 were retrospectively analyzed. Particular respect was given to surgical technique, complications, patients’ outcome, and radiological benefit in relation to cyst location.

RESULTS

Patients’ ages ranged from 23 d to 81 yr (mean: 29.9 yr). Cysts were located temporobasal (n = 31; 35.2%), paraxial supratentorial (n = 14; 15.9%), suprasellar/prepontine (n = 14; 15.9%), quadrigeminal (n = 12; 13.6%), infratentorial (n = 11; 12.5%), and supratentorial intraventricular (n = 6; 6.8%). Four different endoscopic techniques were applied: cystocisternostomies (n = 48; 50.5%), ventriculocystostomies (n = 23; 24.2%), cystoventriculostomies (n = 14; 14.7%), and ventriculocystocisternostomies (n = 10; 10.5%). Pure endoscopic technique was feasible in 89 of the 95 surgeries (93.7%). Clinical improvement was documented after 82 surgeries (86.3%) and radiological benefit after 62 surgeries (65.3%). Recurrences developed in 8 cases (8.4%). Overall complication rate was 21.1% (n = 20), postoperative new shunt dependency was observed in 4.2% of the cases (n = 4).

CONCLUSION

Pure endoscopic AC fenestration is a safe, effective, and less invasive technique providing high success and low permanent complication rates. The most frequent temporobasal cysts are the most difficult to treat endoscopically. A long-term follow-up is recommended because recurrences may occur many years after first treatment.

Cerebral vasospasm after endoscopic fenestration of a temporal arachnoid cyst in a child-a case report and review of the literature

INTRODUCTION

Intracranial arachnoid cysts (ACs) represent rare extra-axial CSF-containing lesions. Surgical management mainly depends on the cyst location and its size. Nevertheless, pure endoscopic fenestration represents a relatively straightforward and safe technique, and-in most cases-the treatment of choice for symptomatic intracranial ACs. The postoperative complication rate of the procedure is low including subdural hematomas, hygromas, and intraparenchymal hemorrhages. Symptomatic cerebral vasospasm after endoscopic treatment of ACs is a very uncommon event.

CASE REPORT/RESULTS

To the authors' knowledge, this adverse event in children has not yet been reported in the literature yet. The authors present a case of a 9-year-old child developing an early symptomatic cerebral vasospasm with an insignificant secondary ischemia following endoscopic fenestration of a large temporal arachnoid cyst.

DISCUSSION

The clinical approach, possible pathogenesis, and the therapeutic strategy is discussed particularly with regard to the literature.

The view through the ventricle catheter - The new ShuntScope for the therapy of pediatric hydrocephalus

PURPOSE

Correct placement of the ventricle catheter directly influences the function of cerebral shunt systems. The incidence of proximal catheter misplacement reaches up to 45%. To avoid misplacements and revisions a new intra-catheter endoscope for precise ventricle catheter placement in children was evaluated.

METHODS

The semi-rigid ShuntScope (Karl Storz GmbH & Co.KG, Tuttlingen, Germany) with an outer diameter of 1.0 mm and an image resolution of 10,000 pixels was used in a series of 27 children and adolescents (18 males, 9 females, age range 2 months-18 years). Indications included catheter placement in aqueductal stenting (n = 4), first time shunt placement (n = 5), burr hole reservoir insertion (n = 4), catheter placement after endoscopic procedures (n = 7) and revision surgery of the ventricle catheter (n = 7).

RESULTS

ShuntScope guided precise catheter placement was achieved in 26 of 27 patients. In one case of aqueductal stenting, the procedure had to be abandoned. One single wound healing problem was noted as a complications. Intraventricular image quality was always sufficient to recognize the anatomical structures. In case of catheter removal, it was helpful to identify adherent vessels or membranes. Penetration of small adhesions or thin membranes was feasible. Postoperative imaging studies demonstrated catheter tip placements analogous to the intraoperative findings.

CONCLUSIONS

Misplacements of shunt catheters are completely avoidable with the presented intra-catheter technique including slit ventricles or even aqueductal stenting. Potential complications can be avoided during revision surgery. The implementation of the ShuntScope is recommended in pediatric neurosurgery.

Transaqueductal trans-Magendie fenestration of arachnoid cyst in the posterior fossa

BACKGROUND

Neuroendoscopy is currently recommended as the first choice to treat posterior fossa arachnoid cysts. It has proven to be effective, providing improved outcome, and safe, having a low complication rate. Compared to craniotomy and shunt placement, it has lower surgical morbidity, minimizing or avoiding risks of subdural fluid collections, shunt infection, malfunction, overdrainage, and dependence. Usually, rigid scopes maneuvered through a suboccipital approach are used. When symptomatic obstructive hydrocephalus develops, CSF diversion is the first aim of surgery.

METHODS

In these patients, a flexible scope introduced through a frontal burr hole allows not only immediate and efficient management of hydrocephalus with endoscopic third-ventriculostomy, but in selected cases also direct cyst inspection and fenestration. Navigation of an enlarged cerebral aqueduct is actually safe when performed by experienced neurosurgeons.

RESULTS

We describe the cystocisternostomy of a cisterna magna arachnoid cyst using a transaqueductal trans-Magendie approach.

CONCLUSIONS

This minimally invasive technique gives the possibility of performing both endoscopic third-ventriculostomy and cyst fenestration, which alone may not be enough to efficiently treat hydrocephalus.

The effectiveness of microsurgical fenestration for middle fossa arachnoid cysts in children

OBJECTIVE

Although middle fossa arachnoid cysts (MFACs) are common, the optimal surgical treatment for these lesions remains controversial. In this study, we present our experiences of treating MFACs by microsurgical fenestration and evaluate its effectiveness.

METHODS

We performed retrospective review of 28 patients who underwent microsurgical fenestration for MFACs between May 2003 and December 2014. We reviewed patient characteristics and treatment outcomes including age, sex, symptoms, complicating hydrocephalus, Gallasi classification, change in cyst size after surgery, complicating subdural hygroma, symptom resolution, regrowth of the cyst, and reoperation (including additional CSF diversion).

RESULTS

Twenty-eight MFACs in 28 patients were investigated. The average age at the time of surgery was 61.6 months. The average follow-up duration was 53.5 months. After surgery, 19 (90.5 %) of 21 patients with symptomatic MFACs experienced improvements. The cysts decreased in size in all cases (100 %, 28/28) and disappeared in three cases (11 %, 3/28). None of the cases experienced regrowth of the cyst. Subdural hygroma was identified in 23 cases (82.1 %) at the immediate postoperative period. Hygroma was asymptomatic in all cases but one. Hygroma disappeared in 19 cases (83 %) and decreased in size in three cases (13 %) in the long term. Only one case (4 %) required an additional subdural-peritoneal shunt. The rate of CSF diversion after the fenestration was significantly higher in patients with preoperative ventricular dilation (p = 0.0002).

CONCLUSION

Microsurgical fenestration for pediatric MFACs was considered to be safe and effective. Although subdural hygroma developed in significant number of patients at the immediate postoperative period, it was mostly asymptomatic and disappeared or decreased in size in the long term.

Comparison of Intracranial Neuroendoscopic Procedures in Children versus Adults

BACKGROUND

The emphasis regarding intracranial neuroendoscopy has been traditionally advocated and focused on the role in pediatric patients, although a significant usage has developed in adult patients. In this study, we examine and contrast the role of predominantly intracranial neuroendoscopy in both a pediatric and adult population with a minimum postprocedure follow-up of 5 years.

METHODS

A retrospective review was conducted for patients in the two hospitals that manage neurosurgical care for Southern Alberta, Canada, undergoing neuroendoscopic surgery between 1994 and 2008. The pediatric group was defined as age ≤17 years and the adult group as age ≥18 years.

RESULTS

A total of 273 patients who underwent a total of 330 procedures with a mean postprocedure follow-up of 12.9 years were identified. There were 161 adult and 112 pediatric patients, and both groups underwent surgery by the same surgeons. The most common procedure was endoscopic third ventriculostomy, accounting for 55% of procedures. One postoperative death occurred in an adult patient. Endoscopic third ventriculostomy success 1-year postprocedure was 81%, with only three late-term failures. Postoperative infection was the most common serious complication (two pediatric/four adult patients). Adult and pediatric patients had similar major complication rates (4.2% vs 5.7%, p=0.547).

CONCLUSIONS

Neuroendoscopy overall had a similar role in both pediatric and adult neurosurgical populations, with the most commonly associated complication being infection. Neuroendoscopy is an important therapeutic modality in the management of appropriate adult patients.

Minimally invasive pediatric neurosurgery

Advances in technology have facilitated the development of minimally invasive neurosurgical options for the treatment of pediatric neurological disease. This review seeks to familiarize pediatric neurologists with some of the techniques of minimally invasive pediatric neurosurgery, focusing on treatments for hydrocephalus, arachnoid cysts, intracranial mass lesions, and craniosynostosis.

Endoscopic treatment of intraparenchymal arachnoid cysts in children

OBJECT

Arachnoid cysts account for 1% of all intracranial lesions. They usually occur in the subarachnoid space of the major cerebral fissures and arachnoid cisterns. They are very rarely located within the brain parenchyma devoid of communication with the subarachnoid space. The author of this study evaluated the role of endoscopy in the treatment of intraparenchymal arachnoid cysts (IPACs), which have a paraventricular location noncontiguous with the basal cisterns.

METHODS

The records of all patients who had undergone surgery performed by one neurosurgeon between March 2004 and October 2011 were retrospectively reviewed to find cases of arachnoid cysts with a paraventricular location noncontiguous with the basal cisterns that were treated with a purely endoscopic cystoventriculostomy. Data were collected, summarized, and analyzed as regards improvement in symptomatology, decrease in cyst size, improvement in hydrocephalus, incidence of complications, surgical failure, and incidence of recurrence.

RESULTS

Twelve pediatric patients with symptomatic IPACs were included in this study. The group included 7 boys and 5 girls with a mean age of 5.2 years. All of the patients had undergone endoscopic cystoventriculostomy. In addition, endoscopic third ventriculostomy had been performed during the same operative session in 3 patients who had associated hydrocephalus. Significant clinical improvement occurred in 10 patients (83.3%). Postoperative imaging showed a reduction in the cyst size in 9 patients (75%), whereas the cyst size was unchanged in the remaining 3 patients (25%). A reduction in ventricle size occurred in 2 (66.7%) of the 3 patients who had hydrocephalus. A postoperative subdural hygroma occurred in 2 patients (16.7%) and required the insertion of a subduroperitoneal shunt in 1 patient. During the follow-up period (mean 42.5 months), 1 patient had a recurrence and required a repeat endoscopic procedure.

CONCLUSIONS

Endoscopic cystoventriculostomy is recommended in the treatment of symptomatic IPACs. It maintains the basic strategy of cyst fenestration into the lateral ventricle without either the invasiveness of open craniotomy or the implantation of shunt systems. The procedure is simple, effective, and minimally invasive. It saves operative and recovery times and is associated with low morbidity and mortality rates.

Comparison of two algorithms for the application of real-time image mosaicking in neuroendoscopy

OBJECT

Neuroendoscopy is used more and more frequently in neurosurgical procedures and has become an important tool in the neurosurgical armamentarium. However, the main restriction of neuroendoscopy is the limited field of view. A better overview of the area of interest would increase surgical safety and decrease procedure-related morbidity rates. In the present study, the authors aimed to improve this restriction by using and comparing two algorithms to create endoscopic panoramic images, which increase the field of view during neuroendoscopic procedures.

METHODS

Different endoscopic methods with or without a stand and with linear or circular endoscope movements were performed in cadaveric ventricles. Video of the endoscopy was used to create image mosaics of the lateral ventricle with the help of the Kourogi or LogSearch (LS) algorithm. In the LS algorithm, different template sizes were used. Three observers graded the quality of the image mosaic in terms of usefulness in surgery. The fastest frame rate was 3-4 frames/second.

RESULTS

The LS algorithm with a larger template size showed significantly better results for the creation of image mosaics than the Kourogi algorithm in linear endoscopic movement with or without a stand. In circular endoscopic movements, the results seemed to be better with the LS algorithm but were not significantly different from those obtained with the Kourogi algorithm. In summary, image quality in the experimental paradigms was satisfying.

CONCLUSIONS

Results in the study showed that the creation of image mosaics is possible and reliable with the featured algorithms. Image mosaicking is an applicable device for neuroendoscopy and can increase the field of view during endoscopic procedures. Its use can increase the safety and the field of application of neuroendoscopy. However, faster frame rates will be required to create a smooth image for practical use during surgery.

Pediatric intracranial arachnoid cysts: comparative effectiveness of surgical treatment options

PURPOSE

A variety of surgical approaches for the treatment of pediatric intracranial arachnoid cysts exist. In an effort to identify the optimal surgical treatment for this disorder, we developed a decision analytic model to evaluate outcomes of four surgical approaches in children. These included open craniotomy for cyst excision, open craniotomy for cyst fenestration, endoscopic cyst fenestration, and cystoperitoneal shunting.

METHODS

Pooled data were used to create evidence tables, from which we calculated incidence, relative risks, and summary outcomes in quality-adjusted life years (QALYs) for the four surgical treatments. Our study incorporated data up to 5 years postsurgery.

RESULTS

We analyzed 1,324 cases from 36 case series. There were no significant differences in outcome among the four surgical strategies. The QALYs (maximum of 5) for surgical approaches resulted in a range from 4.79 (for open craniotomy and excision) to 4.92 (for endoscopic fenestration).

CONCLUSIONS

Overall quality of life is comparable between patients undergoing open craniotomy for cyst excision or fenestration, endoscopic fenestration, and cystoperitoneal shunting up to 5 years after surgery. While each approach offers unique advantages and disadvantages, an individualized treatment strategy should be employed in the setting of surgical outcome equipoise.

Adult symptomatic and growing arachnoid cyst successfully treated by ventriculocystostomy: a new insight on adult arachnoid cyst history

BACKGROUND

Adult arachnoid cysts are known to be stable and asymptomatic but their history remains undefined.

CASE DESCRIPTION

The authors report the case of an 81-year-old woman with progressive hemiplegia and aphasia. CT scan revealed a voluminous left frontotemporal arachnoid cyst with a major mass effect on the midline and contralateral blocked hydrocephalus. Endoscopic ventriculocystostomy was performed with a spectacular neurological improvement.

DISCUSSION AND CONCLUSIONS

Symptomatic adult arachnoid cysts are extremely rare. To our knowledge, no similar clinical case of a growing arachnoid cyst in elderly patients has yet been reported in the literature. The mechanisms of cyst enlargement and decompensation still remain undefined and debated. The possibility of adult arachnoid cyst growth has to be considered in clinical practice. Endoscopic ventriculocystostomy is as effective as in paediatric cases.

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.

Fenestration methods for Sylvian arachnoid cysts--endoscopy or microsurgery

INTRODUCTION

Two different approaches to fenestration, endoscopic and microsurgical, are in use for Sylvian arachnoid cysts (SACs), the most frequent among intracranial arachnoid cysts. We presented the clinical data and compared our results, with regard to technique and clinical success, with either microsurgical or neuroendoscopic fenestration of SACs.

MATERIALS AND METHODS

Twenty-nine patients who subjected to cysto-cisternostomy by the same team, using either of the two methods, were studied retrospectively.

RESULTS

Thirteen patients underwent microsurgery, and 16 had endoscopic cysto-cisternostomy. No reoperation was needed in either of these groups, i.e., full clinical and radiological success was achieved in both. The complication rate was 23% in the microsurgery patients and 47% in the endoscopic surgery group, with no statistically significant difference.

CONCLUSIONS

No relevant differences between the two methods are seen either in the published data or in our results. Adding our results to the published data, both techniques were reviewed in a discussion of the one that allows a better controlled or safer fenestration. We conclude that endoscopic fenestration of SACs is not superior to microsurgical cyst fenestration, and the latter seems safer.

Endoscopic treatment of interhemispheric arachnoid cysts

BACKGROUND

To describe the neuroendoscopic treatment of interhemispheric arachnoid cysts.

METHODS

Five children (aged 1-9 months) harboring interhemispheric arachnoid cysts underwent the procedure. The neuroendoscopic technique included cystoventriculostomy and cystocisternostomy. Imaging exams were compared before and after surgery, and the differences in cyst diameters were calculated. Head circumference and neurological development were also evaluated.

RESULTS

The cystoventriculostomy was performed through the lateral ventricle in 4 cases and through the third ventricle in 4 cases. An added cystocisternostomy was performed in 1 case. Cyst diameters were reduced in the anterior-posterior, lateral-medial and superior-inferior planes in 22, 31 and 31% of the cases, respectively. The rate of increasing head circumference slowed; however, all the children continued to show slight macrocrania. There were complications in 2 cases: cerebrospinal fluid fistula was managed by lumbar puncture in 1 case and subdural collection was treated with a shunt in another single case.

CONCLUSION

The neuroendoscopic approach to interhemispheric arachnoid cysts was effective with few complications.

Assessment of endoscopic treatment for middle cranial fossa arachnoid cysts

BACKGROUND

Endoscopic cystocisternotomy is one of three surgical methods used to treat middle cranial fossa arachnoid cysts. There is debate about which method is the best.

OBJECTIVE

The aim of this study is to evaluate the effectiveness and safety of endoscopic cystocisternotomy for treatment of arachnoid cysts of the middle cranial fossa.

METHODS

Thirty-two patients with arachnoid cysts of the middle cranial fossa who had undergone endoscopic cystocisternal fenestration between 2004 and 2009 were studied retrospectively. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up.

RESULTS

Among the 27 patients with symptoms before surgery, 8 had disappearance of symptoms and 17 had improvement of symptoms. The cyst was reduced in size or it completely disappeared in 24 (75%) patients. The incidence rate of complications was 18.8%.

CONCLUSIONS

Endoscopic cystocisternal fenestration is an effective treatment for symptomatic arachnoid cysts of the middle cranial fossa and should be the initial surgical procedure.

Cyst-ventricle stent as primary or salvage treatment for posterior fossa arachnoid cysts

OBJECT

The optimal treatment of symptomatic posterior fossa arachnoid cysts is controversial. Current options include open or endoscopic resection, fenestration, or cyst-peritoneal shunt placement. There are potential drawbacks with all options. Previous authors have described stenting a cyst into the ventricular system for supratentorial lesions. The current authors have used a similar strategy for posterior fossa cysts.

METHODS

The authors performed a retrospective review of 79 consecutive patients (1993-2010) with surgically treated intracranial arachnoid cysts.

RESULTS

The authors identified 3 patients who underwent placement of a stent from a posterior fossa arachnoid cyst to a supratentorial ventricle. In 2 patients the stent construct consisted of a catheter placed into a posterior fossa arachnoid cyst and connecting to a lateral ventricle catheter. Both patients underwent stent placement as a salvage procedure after failure of open surgical fenestration. In the third patient a single-catheter cyst-ventricle stent was stereotactically placed. All 3 patients improved clinically. Two patients remained asymptomatic, with radiographic stability in a follow-up period of 1 and 5 years, respectively. The third patient experienced initial symptom resolution with a demonstrable reduction of intracystic pressure. However, he developed recurrent headaches after 2 years.

CONCLUSIONS

Posterior fossa cyst-ventricle stenting offers the benefits of ease of surgical technique and a low morbidity rate. It may also potentially reduce the incidence of shunt-related headaches by equalizing the pressure between the posterior fossa and the supratentorial compartments. While fenestration is considered the first-line therapy for most symptomatic arachnoid cysts, the authors consider cyst-ventricle stenting to be a valuable additional strategy in treating these rare and often difficult lesions.

Endoscopic Treatment of Arachnoid Cysts

BACKGROUND

Surgical treatment of arachnoid cysts remains under debate. Although many authors favor endoscopic techniques, others attribute a higher recurrence rate to the endoscope.

OBJECTIVE

The authors report their experience with endoscopic procedures for arachnoid cyst.

METHODS

All pure endoscopic procedures for arachnoid cysts performed by the authors were analyzed. Particular reference was given to surgical complications and patient outcome in relation to cyst location and endoscopic technique.

RESULTS

Sixty-six endoscopic procedures were performed in 61 patients (mean age, 28 years; range, 23 days to 74 years; 35 males, 26 females). The main presenting symptoms were cephalgia (61%), hemisymptoms (18%), and macrocephalus (18%). Cyst location was temporobasal (34%), suprasellar (21%), at the cisterna quadrigemina (18%), paraxial supratentorial (16%), and various (10%). Thirty cystocisternostomies, 14 ventriculocystostomies, 12 cystoventriculostomies, and 10 ventriculocystocisternostomies were performed. The overall clinical success rate was 90%. The endoscopic technique was abandoned in 4 cases (7%). Postoperative complications were found in 16%; there was only one permanent deficit (2%). Five recurrences (8%) occurred up to 7 years after the first procedure. Of the various locations, the temporobasal cysts were the most difficult to treat with lowest clinical success (81%), highest recurrence (19%), and highest complication rate (24%). Of the various endoscopic techniques, ventriculocystostomy and ventriculocystocisternostomy reached the highest success rates with 100%.

CONCLUSIONS

Endoscopic techniques provide very good results in arachnoid cyst treatment. The most frequent cyst location is the most difficult to treat. A long-term follow-up is recommended since recurrences can occur many years after the procedure.

Limits of endoscopic treatment of sylvian arachnoid cysts in children

INTRODUCTION

The optimal surgical management of sylvian arachnoid cysts is debated. We present our experience in children who were treated endoscopically, focusing on the limits and complications of this approach.

MATERIALS AND METHODS

Seventeen children with a temporo-sylvian arachnoid cyst have been treated using a purely temporal endoscopic approach.

RESULTS

In all but one case, the recognition of anatomical landmarks was obtained at the insertion of the endoscope. In one child, the orientation and opening of the basal cisterns were more difficult due to the thickness and opacity of the membranes. Nevertheless, it was possible to perform the cysto-cisternostomy endoscopically in all children with several stomies in 13. In one child, a venous bleeding occurred. There were no other intraoperative complications. There were no postoperative cerebrospinal fluid leaks. In two patients, a symptomatic subdural collection developed which required a transient subdural-peritoneal shunt. No subdural collection was noted on a delayed follow-up (mean, 23 months). Preoperative symptoms related to the mass effect exerted by the cyst resolved in all children. Two children presented a recurrence, 12 and 20 months after endoscopic surgery, respectively. At the redo-endoscopy, the stomies were found to be closed. Their reopening resulted in the disappearance of the symptoms.

CONCLUSIONS

An endoscopic approach can be used safely in the management of sylvian arachnoid cysts. An effective opening of the deep arachnoid membranes into the basal cisterns could be performed in all patients with the resolution of the preoperative symptoms. However, the long-term efficacy of the stoma needs to be assessed.

Endoscopic third ventriculostomy for obstructive hydrocephalus due to intracranial hemorrhage with intraventricular extension

Object

Endoscopic third ventriculostomy (ETV) is well accepted for obstructive hydrocephalus of various etiologies. Nevertheless, it is seldom considered in intracranial hemorrhage even in cases involving obstruction of the CSF circulation.

Methods

Between May 1993 and April 2008, 34 endoscopic procedures were performed for hemorrhage-related obstructive hydrocephalus with an intraventricular component. All patients were prospectively followed up. Special attention was paid to presurgical clinical status, type of hemorrhage, type of surgery, postsurgical clinical status, postsurgical ventricular size, and necessity of ventriculoperitoneal shunt implantation.

Results

An ETV was performed for treatment of obstructive hydrocephalus due to intracranial hemorrhage in 34 patients (15 male, 19 female; mean age 60.8 years [range 3 months–83 years]). Hydrocephalus was caused by 17 cerebellar, 6 thalamic, 5 intraventricular, 3 basal ganglia, 2 subarachnoid, and 1 pontine hemorrhage. Thirty-three patients (97.1%) presented with impaired consciousness. Intraventricular blood was present in all cases. In 16 cases (47.1%), blood clots had to be evacuated to achieve access to the third ventricle floor. The mean operation time was 58.2 minutes (range 25–120 minutes). Three complications occurred (rate of 8.8%) with 2 being asymptomatic (5.9%) and 1 being transient (2.9%). There was no procedure-related permanent morbidity, and no procedure-related mortality. After surgery, there was clinical improvement in 17 cases (50.0%) and radiological evidence of improvement in 22 cases (64.7%). Two patients required postoperative ventriculoperitoneal shunting (5.9%). Seven patients died of hemorrhage while in the hospital (20.6%), and another 4 died during follow-up (11.8%). Fifteen patients (44.1%) showed a persistent clinical improvement at the final follow-up (mean 12.2 months after surgery).

Conclusions

Endoscopic third ventriculostomy represents a safe treatment option in intraventricular hemorrhage–related obstructive hydrocephalus yielding similar results as an external drainage but with less risk of infection and a very low subsequent shunt placement rate. In cases with a predominant obstructive component, ETV should be considered in hydrocephalus due to intracerebral hemorrhage. However, performing an ETV with a blurred field of vision and distorted ventricular anatomy is a challenge for any endoscopic neurosurgeon and should be reserved for experienced neuroendoscopists.