Endoscopic management of intra and paraventricular CSF cysts

Outcome of Initial 3 Years of Cranial Endoscopy at DG Khan Medical College and Teaching Hospital, Dera Ghazi Khan

OBJECTIVE

With the evolution of surgical approaches, endoscopic skull base surgery has emerged as a suitable alternative to many other invasive methods. The aim of this study was to investigate the efficacy and outcome of cranial endoscopy in treating various neurosurgical intracranial pathologies in terms of procedural success and complications.

METHODS

This observational, prospective case series was conducted at the Department of Neurosurgery of DG Khan Medical College from November 2017 to October 2020. The study enrolled 74 patients with indications for cranial neuroendoscopy. Clinical examination was performed, and a detailed history of the disease was obtained. Follow-up was conducted in the outpatient department. The collected data were analyzed using statistical analysis software.

RESULTS

Of 77 procedures performed, endoscopic third ventriculostomy, arachnoid cyst fenestration, septostomy, colloid cyst excision, endoscopic assisted ventricular catheter placement, and intraventricular tumor biopsy were performed in 53.3%, 18.2%, 10.4%, 7.8%, 6.5%, and 3.9% of patients. Aqueductal stenosis was identified as the most common cause of obstructive hydrocephalus. Seizures and cerebrospinal fluid leaks were the most commonly reported complications (12% and 8.1%, respectively). The observed mortality rate was 2.7%.

CONCLUSIONS

Neuroendoscopic surgery has become safe and effective, as surgeon experience and learning have lowered the risk of complications, and offers a low-cost alternative intervention.

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.

Surgical management of intracranial arachnoid cysts in pediatric patients: radiological and clinical outcome

OBJECTIVE

Congenital intracranial cysts account for a significant portion of intracranial lesions in the pediatric population. The efficiency of surgical treatment in a pediatric cohort with intracranial arachnoid cysts (ACs) at different locations regarding clinical symptoms and mass effect was evaluated.

METHODS

A retrospective study of all children who underwent surgical treatment of an intracranial AC during an 11-year period (2007-2018) was performed. Demographics, clinical symptoms, and radiological cyst size pre- and postoperatively, as well as the reoperation rate and possible treatment complications, were analyzed.

RESULTS

A total of 116 intracranial cysts at 8 different anatomical locations were surgically treated in 113 children (median age 5 years and 10 months) predominantly by endoscopic technique (84%). The complication rate was 3%, and the reoperation rate was 16%. Preoperative cyst enlargement was significantly more common in infants (p < 0.0001), as was the need for reoperation (p = 0.023). After a median radiological follow-up of 26 months, > 50% reduction of cyst volume was seen in 53 cysts (46%), and 47 cysts (40%) showed a 10%-50% reduction. Acute clinical symptoms improved: nausea and vomiting, accelerated head growth, and headaches improved at 100%, 92% and 89%, respectively. However, chronic symptoms responded less favorably after a median clinical follow-up of 26 months.

CONCLUSIONS

The strategy of predominantly endoscopic treatment with navigation planning is efficient to alleviate clinical symptoms and to significantly reduce the mass effect of pediatric intracranial cysts at different anatomical locations. The subgroup of infants requires close pre- and postoperative monitoring.

Endoscopic Third Ventriculostomy for Obstructive Hydrocephalus and Ventriculocystostomy for Intraventricular Arachnoid Cysts

OBJECTIVE

To evaluate and discuss the outcomes of a combination of ventriculocystostomy (VC) and endoscopic third ventriculostomy (ETV) for obstructive hydrocephalus (HCP) due to ventricular/cisternal arachnoid cysts, and only ETV for obstructive HCP due to different etiologies.

METHODS

We retrospectively reviewed all 40 symptomatic patients (aged 4 months - 61 years) of obstructive HCP treated by ETV or VC+ETV during October 2014 - April 2019. VC+ETV was performed in 7 patients with intraventricular/cisternal arachnoid cyst and obstructive HCP. Only ETV was performed in 33 patients with obstructive HCP due to other etiologies.

RESULTS

Successful ETV or VC+ETV surgery was performed in 35 patients. The procedure failed in 5 patients aged 90 percentile at the time of surgery. Another 5 patients aged 90 percentile).

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.

Giant Arachnoid Cyst Associated with an Orbital Meningocele: A Case Report and Cystoperitoneal Shunt Management

INTRODUCTION

Intracranial arachnoid cysts (ACs) are space-occupying lesions that typically remain stable in size and clinically silent over time.

CASE REPORT

We describe an unusual pediatric case of enlarged AC impressive by its compressive phenomena. An 11-month-old girl presented with remarkable macrocephaly associated with a cystic orbital tumor. CT scan and MRI studies revealed a large intracranial ACs extending in the orbit with an orbital meningocele (OM). The intracranial cyst did communicate with the orbital one into a bony defect in the right inner region of the orbital roof and represses the globe outward. A cystoperitoneal shunting procedure was performed to remove the mass effect as soon as possible and facilitate normal development.

DISCUSSION/CONCLUSION

Cysts in infants younger than 1 year of age are remarkably different from those in older children and adults in terms of cyst localization and enlargement. Classically described complications result from compression of adjacent structures and include focal neurologic involvement, headaches and seizures and developmental deficits, or macrocephaly in younger children. There are few cases of ACs with ophthalmic manifestations reported in the literature. The paucity of literature prompted us to analyze the case. To the best of our knowledge, an AC accompanying OM has not been reported. The pathogenesis and management of the case will be discussed.

Endoscopic Transcortical Transventricular Management of Cystic Craniopharyngioma: Outcome Analysis of 32 Cases at a Tertiary Care Center

Background

Microsurgical resection has been considered the gold standard treatment of craniopharyngioma, but lately, it has found less favor due to its morbidity and is being replaced by minimally invasive cyst drainage procedures. We present our experience of transventricular endoscopy and cyst drainage along with its technique and have analyzed its results.

Materials and Methods

Clinical and radiological data of all cystic craniopharyngioma patients treated by transventricular endoscopic cyst drainage and Ommaya placement were retrieved and analyzed.

Results

Thirty-two patients underwent endoscopic cyst drainage during the study period. All patients had immediate clinical and radiological improvement. No significant complications were seen. All patients underwent adjuvant radiotherapy and six patients (18.7%) showed recurrence. Three patients died in the follow-up period.

Conclusions

Endoscopic transcortical transventricular cyst drainage with Ommaya reservoir along with adjuvant radiotherapy is a simple, safe, and effective treatment modality.

[Update on intrasellar arachnoid cyst: a case study]

Les kystes arachnoïdiens intrasellaires sont des malformations bénignes. La localisation intrasellaire est extrêmement rare de l’ordre de 3%. Leur physiopathologie est encore mal élucidée. Nous rapportons un cas de kyste arachnoïdien intrasellaire à expansion suprasellaire dont la prise en charge avait consisté en une fenestration endoscopique par voie transsphénoïdale. Les aspects épidémiologiques, cliniques, physiopathologiques, radiologiques, thérapeutiques et évolutifs ont été analysés. Les procédures neuroendoscopiques sont de plus en plus utilisées pour la prise en charge chirurgicale. Leur pronostic est bon, et la récidive fréquente même après plusieurs années d’évolution.

Treatment of multi-loculated hydrocephalus using endoscopic cyst fenestration and endoscopic guided VP shunt insertion

OBJECTIVE

To evaluate the role of endoscopic cyst fenestration and endoscopic guided VP shunt insertion in multi-loculated hydrocephalus in children.

METHOD

A retrospective analysis was performed on 20 patients with multi-loculated hydrocephalus who underwent endoscopic cyst fenestration (ECF) alone or in combination with VP shunt revision or insertion between August 2014 and December 2016 with the extended follow-up period to December 2017.

RESULTS

Thirty-one ECFs were performed: ECF alone, 10 operations in 8 cases, and 21 ECFs with shunt insertion in 12 cases. Eighteen of 20 patients required a VP shunt, 7 cases required multiple shunts. All patients with a previous shunt remained shunt dependent; and 6 cases with no prior shunt underwent endoscopic guided ventricular catheter insertion after ECF; only 2 cases did not require a shunt after ECF. The rate of repeated ECFs was 0.25 operations/year and the shunt revision rate was 0.11 operations/year. VP shunt or cystoperitoneal shunt without repeat ECF was used in 7 cases (35%). Mean duration between operations was 71 days in repeated ECF and 16 days in added-on shunt. The most common cause of re-operations was new formation of intraventricular fibrosis or compartmentalization causing ventricular catheter blockage.

CONCLUSION

Endoscopic cyst fenestration and endoscopic assisted VP shunt insertion minimize shunt complications in multi-loculated hydrocephalus. Shunt independence is unusual.

Evaluation of the Communication Between Arachnoid Cysts and Neighboring Cerebrospinal Fluid Spaces by T2W 3D-SPACE With Variant Flip-Angle Technique at 3 T

PURPOSE

Phase-contrast cine magnetic resonance imaging (PC-MRI) is a widely used technique for determination of possible communication of arachnoid cysts (ACs). Three-dimensional (3D) sampling perfection with application-optimized contrasts using different flip-angle evolutions (3D-SPACE) technique is a relatively new method for 3D isotropic scanning of the entire cranium within a short time. In this research, the usage of the 3D-SPACE technique in differentiation of communicating or noncommunicating type ACs was evaluated.

MATERIALS AND METHODS

Thirty-five ACs in 34 patients were retrospectively examined. The 3D-SPACE, PC-MRI, and contrast material-enhanced cisternography (if present) images of the patients were analyzed. Each cyst was described according to cyst size/location, third ventricle diameter, Evans index, and presence of hydrocephalus. Communication was defined as absent (score 0), suspected (score 1), or present (score 2) on each sequence. Results of PC-MRI or cisternography (if available) examinations were used as criterion standard techniques to categorize all cysts as communicating or noncommunicating type. The results of 3D-SPACE were compared with criterion standard techniques. The comparisons between groups were performed using Mann-Whitney and Fisher exact tests.

RESULTS

For demonstration of communication status of the cysts, criterion standard test results and 3D-SPACE findings were almost in perfect harmony (κ[95% confidence interval: 0.94]; P < 0.001). When evaluating the communicative properties, 3D-SPACE findings correlated with other final results at a rate of 97%. There is a positive correlation with third ventricular diameters and Evans index for all patients (r = 0.77, P < 0.001). For other analyzed variables, there is no significant difference or correlation between the groups.

CONCLUSIONS

The 3D-SPACE technique is an easy, useful, and noninvasive alternative for the evaluation of morphology, topographical relationships, and communication status of ACs.

Endoscopic surgery for intraventricular arachnoid cysts in children: clinical presentation, radiological features, management, and outcomes over a 12-year period

PURPOSE

Less than 0.5% of arachnoid cysts are intraventricular in origin. We review our experience with endoscopic surgery for intraventricular arachnoid cysts in children.

METHODS

This is a retrospective review of children with intraventricular arachnoid cysts who underwent surgery between 2005 and 2016. Clinical notes and imaging were reviewed.

RESULTS

Twenty-nine patients with endoscopically treated intraventricular arachnoid cysts were identified (M/F = 17:12; median age = 1.47 years, range = 7 days-13 years). All had hydrocephalus at presentation, many had symptoms/signs of raised intracranial pressure, and five (17%) were asymptomatic. Cysts were treated with fenestration into the ventricle alone (ventriculocystostomy [VC], n = 14), fenestration into the ventricle and cisternostomy (ventriculocystostomy plus cisternostomy [VC + C], n = 14), or endoscopic third ventriculostomy alone (n = 1). Six (21%) patients experienced transient and/or conservatively managed complications. Further surgery was required in 12 (41%). Revision-free survival was significantly shorter with VC compared to VC + C (log rank p = 0.049), and the majority of VC/VC + C revisions (n = 8 of 11, 73%) were required within 6 months of initial endoscopic surgery. One (3%) patient died during follow-up, from unrelated pathology. After a median follow-up of 67.5 months in survivors (range = 5.5-133.5 months), 24 (83%) cases were clinically and radiologically stable without a shunt in situ.

CONCLUSIONS

Endoscopic fenestration is safe and effective in most intraventricular arachnoid cysts. Additional cisternostomy at the time of cyst fenestration into the ventricle significantly improved revision-free survival in our cohort. Endoscopic surgery should be the first-line therapy when considering intervention for symptomatic intraventricular arachnoid cysts and for asymptomatic cysts increasing in size on serial imaging.

Endoscopic Management of a Fourth Ventricular Cyst

We report a case of a 12-year-old boy with previously shunted congenital hydrocephalus, presenting with a progressive headache, nausea, vomiting, and lethargy. In the brain magnetic resonance imaging, a large cyst was seen in the superior recess of the fourth ventricle extending through the cerebral aqueduct toward the third ventricle. Endoscopic dual fenestration of the cyst was performed successfully using the posterior suboccipital approach through the foramen of Magendie, which resulted in the relief of symptoms without any complications, and the patient was symptom-free in the subsequent follow-up visits for 4 years.

Intracranial extradural arachnoid cyst in a child

INTRODUCTION

Arachnoid cysts are benign developmental anomalies of arachnoid membrane origin that can occur anywhere along the neuro-axis. They are believed to develop from the splitting or duplication of the arachnoid membrane by CSF that is trapped by a ball-valve mechanism. Intracranial arachnoid cysts have only been described as intradural lesions while spinal arachnoid cysts can be both intradural or extradural.

CASE REPORT

After an extensive literature review, we report the first case of an intracranial, extradural arachnoid cyst in a 5-yearold girl. The child presented with a 2-week history of suspected seizure-like activity and imaging revealed a large midline extradural CSF-containing arachnoid cyst causing severe compression of the superior sagittal sinus and underlying brain. Venous flow through the sagittal sinus was nearly obliterated. Osseous changes and bone growth adjacent to the cyst was also noted on imaging and intraoperatively. She underwent a bifrontal craniotomy and cyst excision with decompression of underlying brain and reestablishment of venous flow through the sagittal sinus.

Pediatric intraventricular arachnoid cysts in the body of lateral ventricle: surgical outcome and its embryologic background

PURPOSE

The aim of this study is for the surgical treatment and outcome of the endoscopic fenestration of the arachnoid cyst located in the ventricular body to trigone in the pediatric population. Special concern was paid for the developmental origin of the intraventricular cysts estimated from the postoperative follow-up neuroimagings.

PATIENTS AND METHODS

Between July 2002 and June 2015, we performed endoscopic and partly CT/MRI navigated fenestrations of intraventricular arachnoid cysts located at the body to trigone of the lateral ventricle in ten pediatric patients aged 2 months to 5 years. Based on the long axis of the cyst, we have opted for two surgical approaches: anterior approach via burr hole at Kocher's point and posterior approach via burr hole at the posterior occipital region. Fenestration was performed based on the intraoperative findings, either ventriculocystostomy, ventriculocystoventriculostomy, or ventriculocystocisternostomy.

RESULTS

Intraventricular arachnoid cysts located in the body-trigone region showed a favorable outcome after endoscopic fenestration. All of the cysts shrank postoperatively. Follow-up neuroimagings taken between 6 and 126 months after surgery strongly suggested its relationship with the midline cisterns. Of our ten cases, eight were suggestive for originating from the velum interpositum cistern while two seemed to root from the quadrigeminal cistern.

CONCLUSION

In the present study, we found that endoscopic fenestration of intraventricular arachnoid cysts in the body to trigone is a safe procedure with a satisfactory outcome. In our limited experience, there are two anatomic backgrounds; velum interpositum cistern and quadrigeminal cistern. Differentiation can be possible by neuroimagings, especially those obtained after surgery.

Acute triventricular hydrocephalus caused by choroid plexus cysts: a diagnostic and neurosurgical challenge

OBJECTIVE

Intraventricular choroid plexus cysts are unusual causes of acute hydrocephalus in children. Radiological diagnosis of intraventricular choroid plexus cysts is difficult because they have very thin walls and fluid contents similar to CSF and can go undetected on routine CT studies.

METHODS

This study reports the authors' experience with 5 patients affected by intraventricular cysts originating from the choroid plexus. All patients experienced acute presentation with rapid neurological deterioration, sometimes associated with hypothalamic dysfunction, and required urgent surgery. In 2 cases the symptoms were intermittent, with spontaneous remission and sudden clinical deteriorations, reflecting an intermittent obstruction of the CSF pathway.

RESULTS

Radiological diagnosis was difficult in these cases because a nonenhanced CT scan revealed only triventricular hydrocephalus, with slight lateral ventricle asymmetry in all cases. MRI with driven-equilibrium sequences and CT ventriculography (in 1 case) allowed the authors to accurately diagnose the intraventricular cysts that typically occupied the posterior part of the third ventricle, occluding the aqueduct and at least 1 foramen of Monro. The patients were managed by urgent implantation of an external ventricular drain in 1 case (followed by endoscopic surgery, after completing a diagnostic workup) and by urgent endoscopic surgery in 4 cases. Endoscopic surgery allowed the shrinkage and near-complete removal of the cysts in all cases. Use of neuronavigation and a laser were indispensable. All procedures were uneventful, resulting in restoration of normal neurological conditions. Long-term follow-up (> 2 years) was available for 2 patients, and no complications or recurrences occurred.

CONCLUSIONS

This case series emphasizes the necessity of an accurate and precise identification of the possible causes of triventricular hydrocephalus. Endoscopic surgery can be considered the ideal treatment of choroid plexus cysts in children.

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.

Endoscope-Assisted Microsurgical Removal of an Intraventricular Ependymal Cyst That Manifested with Tremor

BACKGROUND

Intraventricular ependymal cysts (ECs) are rare, histologically benign neuroepithelial cysts. Most of these cysts are clinically silent and discovered incidentally. Rarely, they become symptomatic, leading to obstruction of the cerebrospinal fluid circulation. ECs located inside the ventricles may manifest with signs of increased intracranial pressure.

CASE DESCRIPTION

A 32-year-old woman presented with a 6-year history of tremor affecting her left hand. In the last month, she had been experiencing headache as well, and the tremor of the left hand was affecting her quality of life. The patient demonstrated a fine resting and intention tremor of the left hand and a voice tremor. Magnetic resonance imaging revealed a large cystic, nonenhancing lesion within the right lateral ventricle. The fluid within the cyst was isointense to cerebrospinal fluid on all sequences. Because of the rapid progression of her symptoms and no response to medication, surgical decompression of the cyst was considered. The cyst was removed by an endoscope-assisted microsurgical technique. Her postoperative course was uneventful. A marked reduction in her tremor was noted in the immediate postoperative period. Histopathologic diagnosis was of an EC. During the follow-up period, the patient's tremor, although still present, had improved dramatically. At 6 months postoperatively, she could hold a drinking glass without spilling.

CONCLUSIONS

This is a unique case of an intraventricular EC that manifested with tremor, which improved by endoscope-assisted microsurgical removal of the cyst. This case also supports the important role of endoscopic surgery in the treatment of intraventricular cystic lesions.

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.

Conservative treatment of cysts of the cavum septum pellucidum presenting in childhood: report of 3 cases

Cavum septum pellucidum (CSP) cysts are relatively rare. The most common presenting symptom is headache, which is thought to be secondary to elevated intracranial pressure. Many CSP cysts are treated surgically; conservative treatment is seldom recommended. The authors describe 3 cases of pediatric CSP cysts that were managed without surgery. The patients ranged in age from 5 months to 8 years old. Two presented with headaches, which were associated with mild ventricular enlargement in 1 case. Over the course of 5-15 months, 2 cysts became markedly reduced in size, and in one of these 2 cases a substantial reduction in ventricle size was also observed. At last follow-up, all 3 children were asymptomatic. The authors note that CSP cysts are often associated with headaches. In the absence of hydrocephalus, they recommend conservative management with clinical and radiological follow-up.

Transoccipital endoscopic fenestration of atrial cysts causing ventricular entrapment

OBJECT Cystic lesions in the atrium (trigone) of the lateral ventricle may become symptomatic due to obstruction of physiological CSF circulation and/or from mass effect on adjacent structures. A minimally invasive approach that not only allows for straightforward access to multiple regions of the atrial cyst wall, but also enables direct inspection of the entire lateral ventricular system, has not been elaborated. In this paper the authors describe their experience with the endoscopic transoccipital horn approach for treating cystic lesions in the atrium of the lateral ventricle. METHODS A retrospective review was performed of all patients who underwent endoscopic surgical treatment for cysts in the atrium of the lateral ventricle between 1999 and 2014. RESULTS The cohort consisted of 13 consecutive patients who presented with symptomatic lateral ventricular entrapment due to the presence of an atrial cyst. There were 9 male and 4 female patients, with a median age of 5 years. Headache was the most common complaint at presentation. The transoccipital horn approach facilitated successful cyst reduction and fenestration in all cases. Temporal and occipital horn entrapment was reversed in all cases, with reestablishment of a physiological CSF flow pattern throughout the ventricles. Hydrocephalus was also reversed in all patients presenting with this neuroimaging finding at presentation. No cyst or ventricular entrapment was noted to recur during a mean follow-up period of 36 months. No patient in the study cohort required repeat surgery or permanent CSF diversion postoperatively. CONCLUSIONS The endoscopic transoccipital horn approach represents a safe and effective treatment strategy for patients with symptomatic atrial cysts of the lateral ventricle. Using this minimally invasive technique, all poles of the lateral ventricular system can be visualized and the unobstructed flow of CSF can be confirmed after cyst resection obviating the need for additional diversion.

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.

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.

Arachnoid cyst of the velum interpositum originating from tela choroidea

BACKGROUND

Arachnoid cysts originating from the velum interpositum are very rare, and their existence as a clinicopathologic entity remains controversial. We report a case of a patient with an arachnoid cyst of the velum interpositum presenting with memory disturbance, focusing on the anatomical origin of the lesion and the physiological mechanisms causing memory disturbance.

CASE DESCRIPTION

A 65-year-old man with a large cystic lesion in the velum interpositum experienced progressive memory disturbance and enlargement of the lesion 6 months before referral to our institution. Neuropsychological evaluation on admission demonstrated severe memory disturbance. Radiological examination did not reveal hydrocephalus, but the bilateral fornices and thalami were compressed by the cyst. The patient underwent endoscopic cystoventriculostomy via the frontal horn of the right lateral ventricle through a frontal burr hole. Histopathology of the sample was consistent with that of an arachnoid cyst, and the endoscopic findings suggested that the cyst originated from the tela choroidea, which covers the velum interpositum. The symptoms resolved after surgery with significant improvement in neuropsychological test scores.

CONCLUSION

Arachnoid cysts of the velum interpositum are rare but distinct clinicopathologic entities that originate from the tela choroidea. The lesions can cause memory disturbance without hydrocephalus due to compression of the fornices and thalami, but this can be reversed by surgery.

Clinical and neuroimaging outcomes of surgically treated intracranial cysts in 110 children

Objective

The indications and optimal surgical treatments for intracranial cysts are controversial. In the present study, we describe long-term clinical and neuroimaging results of surgically treated intracranial cysts in children. The goal of this study is to contribute to the discussion of the debate.

Methods

This study included 110 pediatric patients that underwent surgeries to treat intracranial cysts. Endoscopic cyst fenestrations were performed in 71 cases, while craniotomies and cyst excisions (with or without fenestrations) were performed in 30 patients. Cystoperitoneal shunts were necessary for nine patients. Long-term results were retrospectively assessed with medical and neuroimaging records.

Results

Clinical and radiological improvement was reported in 87.3% and 92.8% of cases, respectively, after endoscopic neurosurgery, and in 93.3% and 100% using open microsurgery whereas 88.9% and 85.7% after shunt operation. There were no statistical differences in clinical outcomes (p=0.710) or volume reductions (p=0.177) among the different surgeries. There were no mortalities or permanent morbidities, but complications such as shunt malfunctions, infections, and subdural hematomas were observed in 56% of the patients that had shunt operations. A total of 13 patients (11.8%) underwent additional surgeries due to recurrences or treatment failures. The type of surgery performed did not influence the recurrence rate (p=0.662) or the failure rate (p=0.247).

Conclusion

Endoscopic neurosurgeries are less invasive than microsurgeries and are at least as effective as open surgeries. Thus, given the advantages and complications of these surgical techniques, we suggest that endoscopic fenestration should be the first treatment attempted in children with intracranial cysts.

Endoscopic septostomy through a standard precoronal ventricular access: feasibility and effectiveness

BACKGROUND

Although endoscopic septostomy is widely adopted in the treatment of unilateral or specific types of hydrocephalus, there is no consensus on surgical indications, technical aspects and postoperative outcome. In particular, the choice of the ventricular access has been recently debated. We investigated the results of endoscopic septostomy performed through a standard precoronal ventricular access using a rigid endoscope.

METHODS

Patients who underwent an endoscopic septostomy at our Institution from March 2001 to March 2011 were retrospectively identified. Clinico-radiological data and video recordings of the endoscopic procedures were reviewed.

RESULTS

Sixty-three patients (50 children and 13 adults) were collected. In adults, the obstruction of the cerebrospinal fluid (CSF) pathway was exclusively secondary to a tumor (neoplastic or pseudoneoplastic lesion). In the pediatric group hydrocephalus was most commonly due to a neoplasm (33 out of 50 patients), post-hemorrhagic and/or post-infectious hydrocephalus affecting 11 children and malformative hydrocephalus the remaining six children. We were able to perform the septostomy in all but two patients, presenting with a scarred multilayered septum secondary to post-hemorrhagic hydrocephalus. In 37 cases, one or more other endoscopic procedures were performed contemporarily. The mean follow-up was 24 months (min-max: 5-96 months). Overall, all but one patient benefited clinically and radiologically from the endoscopic septostomy. Two patients harboring a pineal/mesencephalic tumor experienced a late obstruction of the stoma secondary to neoplastic infiltration of the septum.

CONCLUSIONS

Endoscopic septostomy can be safely performed through a standard burr-hole. The effectiveness of this approach is testified by an early success rate of more than 95% and a long term success rate of 92%.

Cavum septum pellucidum cyst in children: a case-based update

BACKGROUND

Cavum septum pellucidum (CSP) cysts are rare lesions which are frequently asymptomatic. Some clinical findings may be associated with CSP cysts, such as headache and other symptoms of increased intracranial pressure, neurological deficit, and mental status changes. There is still controversy in the management of symptomatic cases, especially in children. The main difficulty is to establish a correlation between symptoms and the cyst. When indicated, the treatment is essentially surgical, and the ideal operative technique is also a matter of debate.

CASE REPORT

We present a case of a 14-year-old boy with a symptomatic CSP cyst who was successfully treated by neuronavigation-assisted neuroendoscopy with a bilateral fenestration. A literature review is provided with regard to clinical presentation, treatment, and outcome in children.

CONCLUSION

The treatment is considered whenever there is an association of a CSP cyst on imaging studies and symptoms attributable to the obstruction of the cerebrospinal fluid flow or direct compression of surrounding structures by the cyst. Endoscopic fenestration is a less invasive and highly effective technique, and is currently the treatment of choice for such lesions in children.

Neuroendoscopic approach to quadrigeminal cistern arachnoid cysts

OBJECTIVE

The introduction of neuroendoscopy has provided a minimally invasive modality for the surgical treatment of quadrigeminal arachnoid cysts. Three pediatric patients with arachnoid cyst of the quadrigeminal cistern treated by endoscopic fenestration are reported.

MATERIALS AND METHODS

The hospital records of patients were retrospectively rewieved. All patients had hydrocephalus. A lateral ventricle-cystostomy and endoscopic third ventriculostomy were performed by using rigid neuroendoscopes.

RESULTS

There were one boy and two girls with ages 7 months, 9 months and 14 years, respectively. One patient had undergone shunting prior to neuroendoscopic surgery. The postoperative course was uneventful in all cases, with no complications. They showed disappearance of intracranial hypertension symptoms and significant reduction of the cyst size.

CONCLUSION

Neuroendoscopic technique is an effective and suitable method for the treatment of quadrigeminal cistern arachnoid cysts and accompanying hydrocephalus.

Indication for endoscopic third ventriculostomy

BACKGROUND

Endoscopic third ventriculostomy (ETV) is increasingly prevalent among pediatric neurosurgeons as the initial treatment for hydrocephalus. The combination of ETV and choroid plexus cauterization (ETV/CPC) has improved the success rate among infants with hydrocephalus for whom ETV alone is much less successful. In parts of the developing world where there are economic and human resource constraints, this mode of treatment may be more appropriate than the routine use of shunts, which are prone to failures that require urgent surgical treatment. Here we review indications for the use of ETV or ETV/CPC as the primary treatment for hydrocephalus.

CONCLUSION

Primary treatment of hydrocephalus by ETV can avoid shunt-dependence and its complications for many patients. Optimal results depend upon proper patient selection and the use of combined ETV/CPC when treating infants.

Hydrocephalus and arachnoid cysts

AIM

The management of arachnoid cysts (AC) remains controversial. An additional problem derives from the management of hydrocephalus associated with an AC. In this work, we discuss existing procedures proposed in the current literature for their treatment.

METHODS

We reviewed selected reports on intracranial ACs placing special interest in those about the association of hydrocephalus and ACs. We also briefly surveyed data of our patients with this association.

RESULTS AND DISCUSSION

Hydrocephalus is often found in midline and posterior fossa ACs. Interhemispheric lesions may also evolve with ventriculomegaly, while middle fossa lesions rarely produce hydrocephalus. Patients' age, cyst location and size, and macrocephaly have all been related to the development of hydrocephalus. Some authors remark on the role played by hydrocephalus and hypothesize that some ACs would result from disturbed cerebrospinal fluid (CSF) dynamics. They also propose that ACs might represent a localized form of hydrocephalus. We also comment on hydrocephalus in relation to the diverse locations of ACs. Neuroendoscopic techniques have transformed previous ways of management as cystoperitoneal shunting and open fenestration.

CONCLUSIONS

ACs may be pathogenetically related with hydrocephalus, and conversely, ACs may cause hydrocephalus. In some patients, aberrant CSF dynamics seems to play a major role in the development of both cyst and hydrocephalus. Hydrocephalus and ACs may be treated exclusively with neuroendoscopic procedures, although some patients will still require CSF shunting. The ideal option seems to consist of choosing the method that offers the highest success with a single procedure for treating the hydrocephalus and the AC simultaneously.

Endoscopy versus microsurgical cyst excision and shunting for treating intracranial arachnoid cysts

OBJECT

Endoscopic surgery is routinely used to treat intracranial arachnoid cysts. However, the indications and results with respect to the different cyst locations, compared with those of microsurgical fenestration and cyst shunting, deserve to be discussed.

METHODS

The authors review 18 patients with intracranial arachnoid cysts treated by pure endoscopic technique in their neurosurgical department. There were 10 male and 8 female patients ranging in age from 2 months to 48 years (median age 19.4 years). The cyst location was suprasellar in 5 cases, quadrigeminal in 5, cortical hemispheric in 2, sylvian region in 3, and posterior fossa in 3. The authors also reviewed the literature, comprising 61 reports for an overall number of 645 patients with intracranial arachnoid cysts treated by different surgical techniques. These techniques included microsurgical excision or fenestration by craniotomy, cyst shunting, and endoscopic fenestration. The surgical results of the different techniques according to the different cyst locations underwent statistical analysis.

RESULTS

The overall success rate (complete or partial clinical remission) in the authors' endoscopic series was 83.3% (15 of 18 cases), which is rather similar to that of 222 patients treated endoscopically and reported on in the literature (84.2%). In the overall endoscopic group, a higher success rate was found for cysts in the suprasellar (89.7%), quadrigeminal (88.5%), and posterior cranial fossa (83.3%) regions compared with sylvian (70%) and cortical and interhemispheric (75%) regions. The statistical comparison of the results of the endoscopic series with those of craniotomy and shunting revealed no significant differences for suprasellar, quadrigeminal, or posterior cranial fossa cysts, whereas the success rate of endoscopy is lower than that of other techniques for sylvian and cortical cysts.

CONCLUSIONS

Endoscopy is a safe and effective therapeutic modality for patients with intracranial arachnoid cysts. Cysts of the suprasellar and quadrigeminal regions and posterior fossa are the best indications for neuroendoscopy; on the other hand, cortical cysts are best treated by microsurgical fenestration or shunting. For sylvian cysts, the endoscopic procedure may be advocated in most cases.

Single burr hole endoscopic biopsy with third ventriculostomy-measurements and computer-assisted planning

OBJECTIVE

In cases of non-communicating hydrocephalus, a combined endoscopic third ventriculostomy (ETV) and tumor biopsy might be necessary. We suggest a computer-assisted planning procedure to perform ETV and biopsy via a single burr hole.

METHODS

In 15 patients with non-communicating hydrocephalus with a mass obstructing the Sylvian aqueduct, an ETV in parallel to targeting the lesion was planned to be performed via a single burr hole. Prior to surgery, a 3D MRI data set was planned to be acquired for computer-assisted planning. The lesion target points were located in the third ventricle or in the lateral ventricle. By defining the optimal entry point as single burr hole, the trajectory was calculated to cause the least amount of tissue shift at the foramen of Monro (FM) or within the hemispheric tissue. The burr hole localization was measured relative to nasion and to midline. The diagnostic yield and the success rate of ETV were evaluated.

RESULTS

The optimal entry point for third ventricular lesions was 111 ± 17 mm to the nasion and 16 ± 11 mm to the midline. Tissue shift at the level of FM was 2.4 ± 4 mm. For targeting the floor of the third ventricle in parallel to lesions of the lateral ventricle, the entry point was at 122 ± 11 mm to the nasion and 17 ± 9 mm to the midline. Rate of diagnostic yield was 86.7%. Success rate of ETV at follow-up of 34 ± 19 months was 86.7%.

CONCLUSIONS

Performing ETV in parallel to target paraventricular lesions causing a hydrocephalus is feasible via a single burr hole by using computer-assisted planning and performing a navigated endoscopic procedure.

Intracranial Cysts Containing Cerebrospinal Fluid-Like Fluid: Results of Endoscopic Neurosurgery in a Series of 64 Consecutive Cases

BACKGROUND:

Intracranial cysts containing cerebrospinal fluid (CSF) may be developmental or acquired.

OBJECTIVE:

To analyze the results of endoscopic neurosurgery in the management of intracranial CSF cysts.

METHODS:

In a 7-year period, 64 consecutive patients underwent endoscopic neurosurgery for CSF cysts. Group 1 consisted of 13 patients with acquired cysts; group 2 included 51 patients with developmental cysts. In all cases, the cyst walls were fenestrated through small burr holes with frameless guided operative endoscopes. Follow-up ranged from 1 to 6 years (mean, 3.4 years).

RESULTS:

There were no mortality and no permanent morbidity, apart from a patient (1.6%) who remained neurologically intact but required ventriculoperitoneal shunting because of intraoperative hemorrhage. The planned fenestrations could be performed in all patients except 2, owing to thick, opaque cyst walls. In group 1, 6 patients fully recovered and remained intact throughout the follow-up, whereas 7 improved but had various degrees of neurological disabilities that were related to their initial diseases. Radiological results were excellent in all cases. In group 2, there were 7 asymptomatic patients who remained unchanged and 44 “symptomatic” patients: 40 (91%) clinically improved, 4 (9%) remained unchanged, and none worsened. Cyst size decreased in 37 patients (74%) and remained unchanged in 13 (26%).

CONCLUSION:

In this series, patients of different ages, harboring cysts of various sizes and locations, could be satisfactorily treated with endoscopic neurosurgery.

Intracranial migration of bone dust after intraventricular neuroendoscopy complicating acute hydrocephalus and removal of bone dust: case report

OBJECTIVE

To present the first case of neuroendoscopic removal of migrated intraventricular bone dust and gel foam after intraventricular endoscopic surgery.

CLINICAL PRESENTATION

A 37-year-old man was admitted with a 2-year history of headache. Brain computed tomography (CT) scan and magnetic resonance imaging revealed a cavum vergae cyst. The patient was operated on by stereotactically guided endoscopic cyst fenestration with no intraoperative complications. Postoperative CT scan demonstrated regression of the cyst with no other pathological findings. Because of a postoperative fever, a lumbar puncture was performed after the brain CT scan to eliminate meningitis as a differential diagnosis. After the lumbar puncture, the patient complained of severe headache and vomiting followed by depression of consciousness. The follow-up CT scan showed the migration of bone dust from the burr hole site to the ventricular system and acute hydrocephalus. It is thought that the negative pressure gradient generated after the lumbar puncture might have been transmitted through the cerebrospinal fluid pathway, resulting in a suction effect and migration of the bone dust from the burr hole to the ventricle.

INTERVENTION

An urgent reexplorative endoscopic procedure was performed, and most of the bone dust and gel foam were removed. The patient recovered with complete resolution of the previous symptoms.

CONCLUSION

We propose not using autologous bone dust for closure of the burr holes after endoscopic intraventricular procedures; instead, alloplastic materials designed especially for burr hole closure may be used. However, our main recommendation is to use an external ventricular drainage, which is maintained closed but can be opened if necessary. In addition, lumbar puncture should be avoided in cases in which bone dust is used for the burr hole reconstruction without dural closure.

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.

Improvement of obstructive sleep apneas caused by hydrocephalus associated with Chiari malformation Type II following surgery

Chiari malformation (CM) is the downward herniation of the caudal part of the cerebellum and/or medulla oblongata into the spinal canal. It can alter several neurological functions, including respiratory control and upper airway motility, and can be the cause of sleep-disordered breathing (SDB). The authors describe a 6-year-old boy affected by CM Type II associated with myelomeningocele who showed symptoms indicative of severe airway obstruction during sleep. Polysomnography revealed severe obstructive sleep apnea syndrome (OSAS). Magnetic resonance imaging demonstrated herniation of the cerebellar tonsils and diffuse ventricular dilation with a large pseudocystic formation in the third ventricle. Surgical marsupialization of the cystic wall was performed, associated with ventriculocystostomy and endoscopic replacement of the ventricular catheter. Polysomnography repeated 2 months after surgery revealed a striking improvement in the sleep-related respiratory pattern. The pathogenesis of OSAS was probably referable to a combination of CM and elevated intracranial pressure. However, the striking improvement of symptoms after ventriculoatrial shunt placement suggested that hydrocephalus plays a major role in this condition. Assessment and effective treatment of SDB is crucial in the care of patients with CM.

Guidelines for the Management of Obstructive Hydrocephalus From Suprasellar-Prepontine Arachnoid Cysts Using Endoscopic Third Ventriculocystocisternostomy

Intracranial endoscopy has emerged as an innovative surgical tool for various intracranial procedures, but its use remains limited to neurosurgeons trained in this minimally invasive technique. Complex, skull base arachnoid cysts represent one entity that is challenging to treat because of adjacent critical neurovascular structures; however, the advent of intracranial endoscopic techniques has revolutionized treatment. Arachnoid cysts located in the suprasellar-prepontine skull base region can cause obstructive hydrocephalus or symptomatic mass effect and require urgent decompression. These patients may present with nonfocal symptoms that can quickly lead to a life-threatening condition if not accurately diagnosed and treated. The authors present a summary of the world literature of suprasellar-prepontine arachnoid cysts (SPACs) to ascertain clinical presentations and provide class III evidentiary treatment guidelines for this uniquely challenging type of arachnoid cyst. Urgent endoscopic third ventriculostomy results in normalization of intracranial pressure, return of normal CSF flow, and relief of symptoms.

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.

Is all "communicating" hydrocephalus really communicating? Prospective study on the value of 3D-constructive interference in steady state sequence at 3T

BACKGROUND AND PURPOSE

3D-constructive interference in steady state (3D-CISS) sequence has been used to assess the CSF pathways. The aim of this study was to investigate the additive value of 3D-CISS compared with conventional sequences in the diagnosis of obstructive membranes in hydrocephalus.

MATERIALS AND METHODS

A total of 134 patients with hydrocephalus underwent MR imaging examination with a 3T unit consisting of turbo spin-echo, 3D-CISS, and cine phase-contrast (cine PC) sequences. 3D-CISS was used to assess obstructive membranes in CSF pathways compared with other sequences. Cine PC, follow-up imaging, and surgical findings were used to confirm obstructive membranes.

RESULTS

Comparing the number of noncommunicating cases by using the conventional and 3D-CISS images, we found 26 new cases (19.4%) of 134 cases that were previously misdiagnosed as communicating hydrocephalus by conventional images. 3D-CISS sequence identified obstructive membranes invisible in other sequences, which facilitated selection of neuroendoscopy in the treatment of 31 patients (23.1%) in total who would have been otherwise treated with shunt insertion. These patients included 26 newly diagnosed noncommunicating cases after demonstration of intraventricular and/or fourth ventricular outlet membranes and 5 cases of communicating hydrocephalus with obstructing cisternal membranes. There were obstructions of the foramina of Luschka in 22 of 26 newly found noncommunicating cases.

CONCLUSIONS

Conventional sequences are insensitive to obstructive membranes in CSF pathways, especially in the fourth ventricular exit foramina and the basal cisterns. 3D-CISS sequence, revealing these obstructive membranes, can alter patient treatment and prognosis.

Endoscopic transventricular positioning of intracystic catheter for treatment of craniopharyngioma. Technical note

The intracystic injection of chemo- and radiotherapeutic agents was introduced for the treatment of craniopharyngioma to control tumor growth and to delay the potentially harmful effects of surgery or radiation therapy. The positioning of cyst catheters has been performed by means of direct vision, stereotactically guided insertion, and ultrasonographic and ventriculoscopic guidance. The insertion of a catheter into the cyst is not devoid of complications, with an incidence ranging up to 16%, independent of the surgical technique used. Eight patients (mean age 25.8 years) with symptomatic cystic craniopharyngioma were treated by means of an endoscopic transventricular approach for the insertion of an intracystic catheter for intratumoral therapy with interferon-alpha. A single right precoronal bur hole is made, and the frontal horn of the lateral ventricle is accessed under neuronavigation guidance. A ventricular catheter with an inserted stylet was advanced anterior to the endoscope sheath through the same cortical access as the endoscope and was guided under endoscopic view down to the cyst dome wall. The coagulated surface of the craniopharyngioma cyst was punctured and the tip of the ventricular catheter was advanced; the depth was established preoperatively on MR scans and confirmed by neuronavigation guidance. The proximal end of the cystic catheter was connected to an access chamber to be left in the subcutaneous space, and the endoscope was slowly retracted. The authors' experience favors the use of neuroendoscopic positioning of intracystic catheters as safer than open and stereotactic approaches.

Endoscopic management of quadrigeminal arachnoid cysts

OBJECTIVE

Quadrigeminal cistern arachnoid cysts are rare lesions, accounting for 5% to 10% of all intracranial arachnoid cysts and 9% of all supratentorial localizations. We reviewed the patients with quadrigeminal arachnoid cyst (QAC) who were treated with neuroendoscopic intervention.

MATERIALS AND METHODS

Seventeen patients with QAC had been operated on between 2000 and 2007 in our institution. Four patients had undergone shunting prior to neuroendoscopic surgery. There were nine girls and seven boys with age ranging from 7 days to 17 years (mean, 40 months). All patients had hydrocephalus. A wide ventriculocystostomy (VC) and endoscopic third ventriculostomy were performed by using rigid neuroendoscopes. An aqueductal stent was also placed in two of the patients. Psychometric evaluation was administered postoperatively when possible. Follow-up of the patients ranged from 6 to 96 months (mean, 51.8 months).

RESULTS

Of the 17 patients, 12 underwent endoscopic procedure as the primary surgery. Five patients had been previously shunted. Macrocrania and psychomotor retardation were the main symptom and sign in all infants with QAC. Older children presented with the symptoms and signs of intracranial hypertension. Of the eight patients who were 6 months old or younger, only one did not need a ventriculo-peritoneal (VP) shunt. Endoscopic procedures were successful in all patients older than 6 months of age (P=0.005).

CONCLUSION

The patients presenting in their infancy had a psychomotor retardation, and all patients except for one, younger than 6 months of age, needed a VP shunt. Neuroendoscopic procedure is effective particularly in the patients with QAC older than 6 months of age.

ENDOSCOPIC STOMY OF THE SEPTUM PELLUCIDUM

OBJECTIVE

Although endoscopic perforation of the septum pellucidum in obstruction of the foramen of Monro is well known, detailed reports on endoscopic septostomy, including surgical technique and results are lacking in the literature.

METHODS

All intracranial endoscopic procedures performed between February 1993 and March 2008 were evaluated. All patients with blockage of the foramen of Monro that was treated with endoscopic septostomy were analyzed and prospectively followed. Particular attention was given to indications, approach, surgical technique, complications, and results.

RESULTS

Thirty-two endoscopic septostomies were performed in 30 patients (17 male patients, 13 female patients; mean age, 31 years; age range, 4 months–68 years). Cerebrospinal fluid circulation was obstructed by tumor (16 cases), multiloculated cystic hydrocephalus (8 cases, including 2 revisions), septum pellucidum cysts (3 cases), membranous or inflammatory isolated lateral ventricles (3 cases), and giant aneurysms (2 cases). Simultaneously with septostomy, 13 endoscopic tumor procedures, 9 endoscopic third ventriculostomies, and 9 other endoscopic procedures were performed. The mean surgical time was 80 minutes (range, 45–135 minutes). There were 4 asymptomatic complications (13%), 5 transient complications (16%), and no permanent complications. Postoperatively, 26 patients (87%) improved. Two revisions had to be performed. The mean follow-up period was 16 months (range, 1–93 months).

CONCLUSION

On the basis of the results, long-standing cerebrospinal fluid circulation restoration can be achieved with endoscopic septostomy. Endoscopic septostomy is a safe and reliable endoscopic technique that should be considered more frequently for the restoration of cerebrospinal fluid circulation in the treatment of blockage of the foramen of Monro.

Endoscopic management of hydrocephalus in pediatric patients: a review of indications, techniques, and outcomes

Although ventriculoperitoneal shunting remains the treatment of choice for many children with hydrocephalus, advances in endoscopic technology have greatly expanded the treatment options for these patients. For selected patients with obstructive hydrocephalus, endoscopic third ventriculostomy and other endoscopic techniques offer substantial advantages over shunting. As with any surgical procedure, appropriate patient selection is critical to successful outcomes. This article reviews modern endoscopic techniques available to treat hydrocephalus, with a focus on selection criteria and outcomes.