Surgical treatment of patients with midline arachnoid cysts

The effectiveness of ventriculocystocisternostomy for suprasellar arachnoid cysts

OBJECT

The aim of this study was to report the long-term outcomes of patients receiving endoscopic ventriculocystocisternostomy (VCC) for suprasellar arachnoid cysts (SACs), and to analyze all published reports on outcomes of ventriculocystostomy (VC) versus VCC to compare the effectiveness of the 2 techniques.

METHODS

Eleven consecutive patients with previously untreated SACs were surgically treated using endoscopic VCC. Another 2 patients were treated with VCC following ventriculoperitoneal shunt placement. Clinical imaging data were recorded. An analysis was performed of all published patient outcomes following endoscopic VC or VCC for an SAC.

RESULTS

Developmental delay and progressive macrocephaly were the most common preoperative symptoms. At a mean clinical follow-up interval of 63 months, 10 of 11 patients undergoing primary VCC did not require reoperation. An analysis of the literature suggests that VCC may be more effective than VC. Of the 44 reported patients that underwent VC as a first treatment, 7 (16%) required reoperation, and 7 (8%) of 86 patients who underwent VCC as a first treatment required reoperation. When VC or VCC was performed following a prior surgical procedure, 4 of 11 patients undergoing VC had a treatment failure requiring reoperation. In contrast, only 2 of the 17 reported cases of VCC following a prior procedure required further treatment. The difference in reoperation rates following either primary or secondary VC was significantly higher than following primary or secondary VCC (p = 0.04).

CONCLUSIONS

The authors conclude that VCC is an effective and durable treatment for symptomatic SACs in most cases.

Neuroendoscopic surgery of intracranial cysts in adults

OBJECTS

The purpose of this study was to describe the indications, surgical techniques and postoperative outcome of neuroendoscopic interventions in a heterogeneous group of intracranial cystic pathologies.

PATIENTS AND METHODS

Between 1992 and 2003, 127 patients with symptomatic intracranial cysts and cystic tumours underwent neuroendoscopic treatment in our department. In 22 patients indication for surgery was colloid cysts, in 9 patients pineal cysts and in 3 patients cavum vergae cysts. Twelve arachnoid cysts, 10 cystic craniopharyngiomas, 2 Rathke's cleft cysts and 69 malignant cystic tumours were operated on. The patients' mean age was 45 years and their clinical presentations varied from typical signs of increased intracranial pressure to focal neurological deficits.

RESULTS

One hundred and twenty-seven patients with intracerebral cystic space-occupying lesions were operated on using stereotactic frameless or frame-based endoscopic techniques. There was no operative mortality. The operative morbidity was 3.1% including 1 memory deficit due to fornix injury, 1 hemiparesis due to postoperative haematoma after lesion biopsy, 1 aseptic meningitis and 1 subdural fluid collection.

CONCLUSIONS

Endoscopic interventions enable neurosurgeons to manage intracranial cystic lesions. Via the same approach, the obstructed CSF pathways may be restored and consequently the increased intracranial pressure diminishes. With the aid of stereotactic guidance or a neuronavigation system, access to the lesion can be gained rapidly and with high accuracy.

Arachnoid cyst rupture with subdural hygroma: Case report and literature review

Arachnoid cyst rupture causing subdural hygroma is rare. Twenty-one cases have been previously reported in the literature. We report a case of a 9-year-old boy presenting signs and symptoms of increased intracranial pressure due to the rupture of a type III arachnoid cyst causing subdural hygroma. The clinical and radiological findings as well as the management of the patient are discussed in relation to the pertinent literature.

Subdural hygroma in association with middle fossa arachnoid cyst: acetazolamide therapy

Intracranial arachnoid cysts are cerebrospinal fluid-filled collections between arachnoid layers. While many are silent, arachnoid cysts can become symptomatic if there is sudden expansion, haemorrhage or rupture with the development of subdural hygroma or subdural hematoma. Several studies have demonstrated the association of arachnoid cysts with subdural hygroma and subdural hematoma. We describe a 9-year-old girl with a moderate-sized middle-fossa arachnoid cyst and bilateral frontal subdural hygroma presenting with raised intracranial pressure. She was treated with acetazolamide which resulted in resolution of the subdural hygroma and relief of symptomatology.

Neuroendoscopic approach to arachnoid cysts

A prospective study of seven consecutive patients with congenital arachnoid cysts treated endoscopically is reported. The ages of the patients at the time of diagnosis ranged from 6 to 47 years with three patients under 15 years. Two cysts were located in the posterior cranial fossa, four in the middle cranial fossa, and one in the suprasellar-prepontine area. The patients' symptoms included headache, seizures, vomiting, nausea, dizziness, balance problems, and precocious puberty. The authors performed cystocisternostomies and ventriculocystostomies via burr holes with the aid of a universal neuroendoscopic system. Minor bleeding was easily controlled by rinsing. In one case, the endoscopic procedure had to be abandoned because of significant bleeding, which obscured a clear operative view, and an open microsurgical cyst fenestration was performed. The follow-up review periods in this group of patients ranged from 15 to 30 months. There was no mortality or morbidity. Symptoms were relieved in five patients and improved in one. Precocious puberty in one case continued. In six cases, follow-up magnetic resonance images or computerized tomography scans revealed a decrease in the size of the cysts. Although the follow-up period is too short to make statements on long-term outcome, the authors recommend the minimally invasive endoscopic approach for treatment of arachnoid cysts as the first therapy of choice. Should the endoscopic procedure fail, established treatment options such as microsurgical fenestration or cystoperitoneal shunting can subsequently be performed without causing additional risk to the patient.

Arachnoid cysts in adults: experience with internal shunts to the subdural compartment

Twelve patients (10 males, 2 females) with symptomatic arachnoid cysts of the middle cranial fossa (9 patients) or overlying the frontal cortex (3 patients) were included. Under local anesthesia, an internal shunt was implanted from the cyst to the subdural compartment. Postoperative computed tomography scans showed volume reduction in eight patients. Permanent clinical improvement was also seen in eight patients. In the remaining four, the improvement was only temporary or partial, necessitating additional surgery in three patients. Complications (two subdural hematomas, one subdural infusion), were observed in three patients, all with large cysts. The complications were treated without sequelae. Internal shunts may be tried in adults as the first treatment for this condition.

Stereotactic management of congenital midline cysts

The treatment of congenital midline cysts remains a controversial issue. The stereotactic management of 27 patients (6 symptomatic cavum septi pellucidi/cavum Vergae, 6 suprasellar cysts, 5 intraventricular cysts, 4 parasagittal cysts, and 6 supracollicular cysts) is reviewed. In 23 patients stereotactic ventriculo-cystostomy by catheter implantation (internal drainage) led to clinical recovery or improvement accompanied by decreased cyst size. In four patients the internal drainage was not sufficient and was therefore completed as a ventriculo-atrial shunt system. Three minor complications (bleeding, aseptic meningitis, catheter infection) led to no sequelae. The results suggest that stereotactic internal drainage of these benign lesions is a safe, minimally invasive and efficient procedure.