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|NI FEATURE: THE EDITORIAL DEBATE I-- PROS AND CONS
|Year : 2017 | Volume
| Issue : 3 | Page : 471-472
Endoscopic management of intracranial cysts: Need of the hour
Department of Neurosurgery, Brain-Sparsh Hospital, Bangalore, Karnataka, India
|Date of Web Publication||9-May-2017|
N K Venkataramana
Department of Neurosurgery, Brain - Sparsh Hospital, Bangalore, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Venkataramana N K. Endoscopic management of intracranial cysts: Need of the hour. Neurol India 2017;65:471-2
A variety of intracranial cystic lesions ranging from developmental, inflammatory, neoplastic, parasitic and those arising secondary to parenchymal insults, are known. Many of these cysts are asymptomatic and can remain unnoticed for life. Multiple or bilateral Sylvian cysts are rare and are known to have glutaric aciduria type 1. Detection of the intracranial cysts has increased several folds by the availability of advanced imaging. Congenital cysts arise due to an alteration in the cerebrospinal fluid (CSF) flow during the early phase of subarachnoid space formation and can be associated with other congenital anomalies like corpus callosal agenesis and cerebral venous system maldevelopment. Arachnoid cysts are the most prominent types of intracranial cysts and were first described by Bright in 1831. Arachnoid cysts could be secondary to trauma that splits the membrane with complete cisterns. Symptoms arise either by progressive or intermittent cyst enlargement, secondary to infection or minor trauma, causing raised intracranial pressure (ICP), seizures or neurological deficits. The enlargement has been postulated to be due to active CSF secretion from the membrane, establishment of an osmotic gradient by the protein content of the cyst fluid, entrapment of CSF due to a ball-valve mechanism during Valsalva maneuver, or due to rupture with either a subdural hygroma or hematoma formation associated with raised ICP.,,, Craniotomy and membrane excision, marsupialization, stereotactic fenestration, reservoir placement, cystoperitoneal shunt and endoscopic fenestration are the available surgical options.,,, Though each technique has its own merits and demerits, craniotomy and endoscopic approaches have the distinct advantages of visualization of the pathology, with an option of taking a biopsy. Both the procedures have comparable results, in which endoscopy scores over microsurgery in being a minimally invasive procedure, that is repeatable with less morbidity and hospital stay. At the same time, it allows the inspection of the cyst wall, coagulation of arachnoidal blood vessels, harvesting of biopsy from abnormal areas, resection of membranes to a certain extent and communication with the neighboring cisterns or ventricles.,, The rapidity of enlargement of the arachnoidal cyst might be responsible for hydrocephalus and an early onset of clinical symptoms. A cysto-peritoneal (CP) shunt was proposed for the hydrocephalus and early onset of clinical symptoms that could be performed either concomitantly with the primary procedure or following failure of cyst resolution after fenestration. However, it has its own share of complications with a revision rate of as high as 30%. The success rate of endoscopy, microsurgery and shunt in the cases of intracranial arachnoid cysts is 83%, 86% and 90%, respectively.,,,,
This is an interesting analyses of an institutional series of intracranial cysts. Despite the low numbers, it highlights certain differences in outcomes between an arachnoid cyst and others types of cysts responsible for hydrocephalus in children as well as adults. It is interesting to note the postoperative reduction in outcome over time. It is difficult to predict the exact dynamics of such cysts and therefore, maldevelopment of subarachnoid spaces and basal cisterns may lead to failure of surgery, often requiring a CSF diversion. This could possibly explain the poorer outcomes and a higher requirement of an additional CSF diversion procedure in children. This univariate analysis also identifies the beneficiaries and the high risk groups.
The current evidence clearly indicates the need to intervene in symptomatic intracranial cysts and an endoscopic approach should be the preferred choice. With the designing of more advanced instrumentation that also facilitates in vitro training, endoscopy is gaining popularity over the other procedures even in the case of posterior fossa cysts. Endoscopy requires a good imaging, a perfect trajectory, an accurate image guidance and advanced surgical skills. Meticulous follow up with serial imaging are essential to prognosticate and improve the overall outcome.
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