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BRIEF REPORT
Year : 2010  |  Volume : 58  |  Issue : 2  |  Page : 280-283

Endoscopic treatment of the suprasellar arachnoid cyst


1 Neurosurgery Unit, NSCB Medical College, Jabalpur, MP, India
2 Radio Diagnosis MP, MRI Centre, Jabalpur, MP, India

Date of Acceptance02-Oct-2009
Date of Web Publication26-May-2010

Correspondence Address:
Y R Yadav
105 Nehru Nagar, Opposite Medical College, Jabalpur, MP
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.63772

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 » Abstract 

Surgical options for suprasellar arachnoid cyst are cystoperitoneal shunt, craniotomy fenestration and endoscopic fenestration. Endoscopic management has been found to be safe and effective. We report our experience with endoscopic management in 12 (male five, female seven; age range 8 months to 42 years) patients with suprasellar arachnoid cyst. The endoscopic procedure included lateral ventricle puncture by precoronal burr hole and superior and inferior wall of the cyst was communicated with the lateral ventricle and the interpeduncular cistern respectively. All patients had hydrocephalus. Four pediatric patients had macrocephaly. All adult patients had visual disturbances. One adult patient presented with psychomotor disturbance along with features of raised intracranial pressure. All cases improved following endoscopic treatment. There were no complications or death. One patient required VP shunt. Postoperative MRI showed significant reduction in cyst volume in 11 patients. Follow-up ranged from 6 months to 6 and a half years. Our study suggests that endoscopic technique is a safe and effective alternative treatment for suprasellar arachnoid cyst. It prevents complications such as subdural effusion and intracranial hematoma, which are not uncommon with craniotomy fenestration.


Keywords: Endoscopic treatment, intracranial cyst, minimally invasive technique, suprasellar arachnoid cyst


How to cite this article:
Yadav Y R, Parihar V, Sinha M, Jain N. Endoscopic treatment of the suprasellar arachnoid cyst. Neurol India 2010;58:280-3

How to cite this URL:
Yadav Y R, Parihar V, Sinha M, Jain N. Endoscopic treatment of the suprasellar arachnoid cyst. Neurol India [serial online] 2010 [cited 2019 Apr 18];58:280-3. Available from: http://www.neurologyindia.com/text.asp?2010/58/2/280/63772



 » Introduction Top


Suprasellar arachnoid cyst can be managed by shunt, [1] craniotomy with fenestration [1],[2] and endoscopic treatment. [3] Shunting procedures [4] and craniotomy with fenestration [5] have their limitations. Suprasellar arachnoid cyst can present as Bobble-head doll syndrome, [6],[7] hydrocephalus, [3] psychiatric disturbance, [8] macrocephaly, [8] endocrinological disturbances, [9] visual problems [10] and precocious puberty. [11]

Endoscopic fenestration has been found to be safe and effective. [2],[7],[12],[13] We report our experience of 12 patients with suprasellar arachnoid cyst.


 » Materials and Methods Top


Prospective study was carried out from January 2003 to December 2008 in a tertiary care hospital. Detailed history and a thorough physical examination were performed with special emphasis on endocrinological and ophthalmologic check-up. Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) scans were performed in all the patients [[Figure 1]a-c]. Dual endoscopic fenestration was performed. Postoperative status was recorded. Postoperative MRI was performed in all the patients [[Figure 2]a-c]. Follow-up period ranged from 6 months to 6 and a half years.

Procedure

The right lateral ventricle was punctured by a precoronal burr hole. Cysts were partially occluding the right foramen of Monro in three patients. There was no asymmetrical enlargement of the lateral ventricle in any of the patients. In three patients, the foramen of Monro was partially obscured by the splayed out choroids pleuxes. Vessels in the wall of the cyst were coagulated. Dual endoscopic fenestration (ventriculocystocisternostomy) was performed in all the patients. Superior and inferior wall of the cyst was communicated with the lateral ventricle and the interpeduncular cistern respectively. An at least 1 cm opening was created in both the cyst walls (superior and inferior). A Gaab 6 degree endoscope was used. Storz 30 degree scope was used to inspect the ventricle and the cyst after the fenestration. Optic chiasm was displaced superiorly and anteriorly in all cases. There was upward and posterior deflection of the rostral mesencephalon and mammillary bodies. Caudal mesencephalon was posteriorly displayed. No associated abnormal intraventricular anomaly was observed in any patient. Coagulation shrinkage of the posterior cyst wall was performed in all the patients to visualize the posterior third ventricle and the aqueduct, which was patent in all the patients.


 » Results Top


Age of the patients ranged from 8 months to 42 years. There were five male patients. Symptoms ranged from 6 months to 2 years. No patient had any abnormal head movements or endocrine dysfunction. Four pediatric patients had macrocephaly. All the seven adult patients had visual disturbances. One adult presented with psychomotor disturbance along with features of raised intracranial pressure [Table 1]. MRI scans revealed hydrocephalus in all the patients. The optic chiasm was displaced superiorly and anteriorly in all the patients. There was upward and posterior deflection of the rostral mesencephalon and mammillary bodies. The caudal mesencephalon and pons were posteriorly displayed. Cysts were suprasellar and extending into the third ventricle in 10 patients while in two patients there was additional parasellar and paraventricular extension. All the patients improved after surgery. There were no complications or any death. Only one patient required VP shunt due to persistently raised intracranial pressure feature after surgery. Postoperative MRI showed significant cyst volume reduction in all the patients. Regression of cyst size occurred very slowly. Significant regression of size occurred in 3-6 months time in all our patients.


 » Discussion Top


Transventricular approach to suprasellar arachnoid cyst has been found to be safe and effective. [2],[7],[8],[12],[13] It also prevents chances of subdural collection. [14] Dual fenestration (ventriculocystocisternostomy) in the cyst wall can be safely performed, which is more effective than single fenestration. [13] We also performed transventricular dual cyst wall fenestration in all our patients. We did not come across any complications like subdural effusion, subdural hematoma or intraparenchymal hematoma, which are not uncommon with craniotomy fenestration. It has an additional advantage of identification and treatment of ventricular abnormality, such as foramen of Monro stenosis and cerebral aqueduct occlusion. [15] Expanded endoscopic endonasal approach has been found to be an effective alternative method for suprasellar arachnoid cyst. [10] We all know its limitation, such as dural closure difficulties, the risk of infection and cerebrospinal fluid leaks, especially in intradural surgeries.

Cystoperitoneal shunt is an effective alternative, but there are complications like shunt dependency, shunt block and shunt infection, etc. [4] Teflon sponge shunt has been found to be effective in recurrent arachnoid cyst. [16]

Craniotomy microscopic fenestration is one of the methods of treatment for this condition. [2] Craniotomy fenestration is a more-invasive technique. Sudden decompression can give rise to subdural hematoma and other intraparenchymal hematoma. [5] Pierangeli et al, [17] reported that a simple tapping of the cyst resulted in complete recovery of the patient. This can avoid intracranial hematoma as a result of sudden decompression. Formation of subdural effusion in superficial-located cyst-like suprasellar arachnoid cyst is another disadvantage of craniotomy fenestration, which can be avoided by transcortical endoscopic technique performed in our cases. [14]

Stent placement under stereotactic-guided endoscopic surgery was also found to be effective. [18] Foreign body implanted in this method can get infected and blocked. Subfrontal endoscopic-assisted surgery has been used successfully to treat suprasellar arachnoid cyst. [19] Direct fenestration of superficial cyst like suprasellar arachnoid cyst can give rise to subdural effusion, [14] which can be avoided by transcortical approach performed by us and also by other authors.

Considering various disadvantages associated with various treatment procedures, endoscopic fenestration is a minimally invasive technique, which is a safe and effective alternative treatment for suprasellar arachnoid cyst.

 
 » References Top

1.Shim KW, Lee YH, Park EK, Park YS, Choi JU, Kim DS. Treatment options for arachnoid cysts. Childs Nerv Syst 2009 in press.  Back to cited text no. 1      
2.Gangemi M, Colella G, Magro F, Maiuri F. Suprasellar arachnoid cysts: Endoscopy versus microsurgical cyst excision and shunting. Br J Neurosurg 2007;21:276-80.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Ersahin Y, Kesikci H, Ruksen M, Aydin C, Mutluer S. Endoscopic treatment of suprasellar arachnoid cysts. Childs Nerv Syst 2008;24:1013-20.   Back to cited text no. 3      
4.Martinez-Lage JF, Ruiz-Espejo AM, Almagro MJ, Alfaro R, Felipe-Murcia M, Lopez-Guerrero AL. CSF over drainage in shunted intracranial arachnoid cysts: A series and review. Childs Nerv Syst 2009;25:1061-9.  Back to cited text no. 4      
5.Esmaeeli B, Eftekhar B. Intraparenchymal hemorrhage after surgical decompression of a Sylvian fissure arachnoid cyst. Neurol India 2006;54:320-1.  Back to cited text no. 5  [PUBMED]  Medknow Journal  
6.Desai KI, Nadkarni TD, Muzumdar D, Goel A. Suprasellar arachnoid cyst presenting with bobble-head doll movements: A report of 3 cases. Neurol India 2003;51:407-9.  Back to cited text no. 6  [PUBMED]  Medknow Journal  
7.Van Beijnum J, Hanlo PW, Han KS, Ludo Van der Pol W, Verdaasdonk RM, Van Nieuwenhuizen O. Navigated laser-assisted endoscopic fenestration of a suprasellar arachnoid cyst in a 2-year-old child with bobble-head doll syndrome: Case report. J Neurosurg 2006;104:348-51.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]  
8.Hagebeuk EE, Kloet A, Grotenhuis JA, Peeters EA. Bobble-head doll syndrome successfully treated with an endoscopic ventriculocystocisternostomy: Case report and review of the literature. J Neurosurg 2005;103:253-9.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Nakahara Y, Koga H, Maeda K, Takagi M, Tabuchi K. Neuroendoscopic transventricular surgery for suprasellar cystic mass lesions such as cystic craniopharyngioma and Rathke cleft cyst. Neurol Med Chir (Tokyo) 2004;44:408-13;discussion 414-5.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]  
10.Dehdashti AR, Ganna A, Witterick I, Gentili F. Expanded endoscopic endonasal approach for anterior cranial base and suprasellar lesions: Indications and limitations. Neurosurgery 2009;64:677-87;discussion 687-9   Back to cited text no. 10      
11.Gupta SK, Gupta VK, Khosla VK, Dash RJ, Bhansali A, Kak VK, et al. Suprasellar arachnoid cyst presenting with precocious puberty: Report of two cases. Neurol India 1999;47:148-51.  Back to cited text no. 11  [PUBMED]  Medknow Journal  
12.Sood S, Schuhmann MU, Cakan N, Ham SD. Endoscopic fenestration and coagulation shrinkage of suprasellar arachnoid cysts: Technical note. J Neurosurg 2005;102:127-33.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]  
13.Wang JC, Heier L, Souweidane MM. Advances in the endoscopic management of suprasellar arachnoid cysts in children. J Neurosurg 2004;100:418-26.  Back to cited text no. 13  [PUBMED]  [FULLTEXT]  
14.Elhammady MS, Bhatia S, Ragheb J. Endoscopic fenestration of middle fossa arachnoid cysts: A technical description and case series. Pediatr Neurosurg 2007;43:209-15.  Back to cited text no. 14  [PUBMED]  [FULLTEXT]  
15.Rangel-Castilla L, Torres-Corzo J, Vecchia RR, Mohanty A, Nauta HJ. Coexistent intraventricular abnormalities in periventricular giant arachnoid cysts. J Neurosurg Pediatr 2009;3:225-31.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]  
16.Goel A, Shah AH, Pareikh S. Teflon sponge shunt for recurrent arachnoid cyst. Neurol India 2007;55:388-9.  Back to cited text no. 16  [PUBMED]  Medknow Journal  
17.Pierangeli E, Gigante N, Pizzoni C. Tapping of a type II sylvian fissure arachnoid cyst: Technical note. Neurol India 2003;51:553-4.  Back to cited text no. 17    Medknow Journal  
18.Berlis A, Vesper J, Ostertag C. Stent placement for intracranial cysts by combined stereotactic / endoscopic surgery. Neurosurgery 2006;59:ONS474-9;discussion ONS 479-80.   Back to cited text no. 18  [PUBMED]  [FULLTEXT]  
19.Kabil MS, Shahinian HK. Application of the supraorbital endoscopic approach to tumors of the anterior cranial base. J Craniofac Surg 2005;16:1070-4;discussion 1075.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1]

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