Surgical management of quadrigeminal cistern arachnoid cysts: case series and literature review

OBJECTIVE Quadrigeminal cistern arachnoid cysts (QACs) are congenital lesions that can cause pineal region compression and obstructive hydrocephalus when sufficiently large. Management of these cysts is controversial and rates of reintervention are high. Given the limited data on the management of QACs, the authors retrospectively reviewed 20 years of cases managed at their institution and performed a literature review on this topic. METHODS The authors performed a retrospective analysis of patients treated for QAC at their institution between 2001 and 2021. They also performed a literature review of studies published between 1980 and 2021 that reported at least 5 patients treated for QACs. Patient characteristics, radiographic findings, management course, and postoperative follow-up data were collected and analyzed. RESULTS A total of 12 patients treated for a QAC at the authors’ institution met the inclusion criteria for analysis. Median age was 9 months, mean cyst size was 5.1 cm, and 83% of patients had hydrocephalus. Initial treatment was endoscopic fenestration in 92% of these patients, 27% of whom had an endoscopic third ventriculostomy (ETV) performed concurrently. Reintervention was required in 42% of patients. Cases that required reintervention had a statistically significant lower median age at the initial intervention (5 months) than the cases that did not require reintervention (24.33 months; p = 0.018). There were no major complications. At a mean follow-up of 5.42 years, 83% of patients had improvement or resolution of their symptoms. A literature review revealed 7 studies that met the inclusion criteria, totaling 108 patients with a mean age of 8.8 years. Eighty-seven percent of patients had hydrocephalus at presentation. Ninety-two percent of patients were initially treated with endoscopic fenestration, 44% of whom underwent concurrent ETV. Complications occurred in 17.6% of cases, and reintervention was required in 30.6% of cases. The most frequent reason for reintervention was untreated or unresolved hydrocephalus after the initial procedure. CONCLUSIONS Endoscopic fenestration is the most common treatment for QACs. While generally safe and effective, there is a high rate of reintervention after initial treatment of QACs, which may be associated with a younger age at the first intervention. Additionally, identifying patients who require initial treatment of hydrocephalus is critically important, as the literature suggests that untreated hydrocephalus is a common cause of reintervention.

The efficacy of cystoperitoneal shunting for the surgical management of intracranial arachnoid cysts in the elderly: A systematic review of the literature

Background: Intracranial arachnoid cysts (AC) are benign, cerebrospinal fluid filled spaces within the arachnoid layer of the meninges. Neurosurgical intervention in children and young adults has been extensively studied, but the optimal strategy in the elderly remains unclear. Therefore, we performed a single center retrospective study combined with a systematic review of the literature to compare cystoperitoneal (CP) shunting with other surgical approaches in the elderly cohort. Methods: Retrospective neurosurgical database search between January 2005 and December 2018, and systematic review of the literature using PRISMA guidelines were performed. Inclusion criteria: Age 60 years or older, radiological diagnosis of intracranial AC, neurosurgical intervention, and neuroradiological (NOG score)/clinical outcome (COG score). Data from both sources were pooled and statistically analyzed. Results: Our literature search yielded 12 studies (34 patients), which were pooled with our institutional data (13 patients). CP shunts (7 patients; 15%), cyst fenestration (28 patients; 60%) and cyst marsupialisation/resection (10 patients; 21%) were the commonest approaches. Average duration of follow-up was 23.6, 26.9, and 9.5 months for each approach, respectively. There was no statistically significant association between choice of surgical intervention and NOG score (P = 0.417), COG score (P = 0.601), or complication rate (P = 0.955). However, CP shunting had the lowest complication rate, with only one patient developing chronic subdural haematoma. Conclusion: CP shunting is a safe and effective surgical treatment strategy for ACs in the elderly. It has similar clinical and radiological outcomes but superior risk profile when compared with other approaches. We advocate CP shunting as first line neurosurgical intervention for the management of intracranial ACs in the elderly.

Intracranial arachnoid cysts: Review of natural history and proposed treatment algorithm

Background: With a prevalence of 1.4%, intracranial arachnoid cysts are a frequent incidental finding on MRI and CT. Whilst most cysts are benign in the long-term, clinical practice, and imaging frequency does not necessarily reflect this. Methods: A literature review was conducted searching the Medline database with MESH terms. This literature was condensed into an article, edited by a consultant neurosurgeon. This was further condensed, presented to the neurosurgery department at Princess Alexandra Hospital for final feedback and editing. Results: This review advises that asymptomatic patients with typical cysts have a low risk of cyst growth and development of new symptomatology, thus do not require surveillance or intervention. The minority of symptomatic patients or those with cysts in sensitive areas may require referral to a neurosurgeon for clinical follow-up or intervention. Conclusion: Greater than 94% of patients are asymptomatic, practitioners can be confident in reassuring patients of the benign nature of a potentially worrying finding. Recognizing the small number of symptomatic patients and those with cysts in areas sensitive to causing hydrocephalus is where GP decision making in conjunction with specialty input is of highest yield.

Intrasellar Arachnoid Cyst, a Rare Radiological Finding: Report of a Case.

Intrasellar arachnoid cysts are uncommon radiological findings, generally incidental and clinically silent. We present the case of 70 year-old female who was treated of meningitis due to cerebrospinal fluid nasal fistulae. She was diagnosed of intrasellar arachnoid cyst and managed conservatively because no neurologic, hormonal, symptomatic either CSF fistulae appeared during follow-up. The origin of intrasellar arachnoid cysts is unclear; although an incomplete diaphragma sellae through basal arachnoid membrane herniates may be a plausible theory. Conservative treatment is the usual option, but if hormonal, visual or intracranial hypertension symptoms appeared, surgery may be the best therapy. This entity should be in the differential diagnosis of cystic sellar lesions with other benign cysts and tumors as craniopharyngioma.

Endoscopic fenestration for treating Galassi type III middle cranial fossa arachnoid cysts: single- and multiple-stoma have the same curative effect

Background and Study Aims For endoscopic fenestration of middle cranial fossa arachnoid cysts (MCFACs), the decisions on the location and number of stomas are key issues in the operation. However, research on this particular topic has been limited. Thus, this study aimed to compare single-stoma versus multiple-stoma endoscopic fenestration for treating Galassi type III MCFACs. Patients and Methods This retrospective study included 86 patients with Galassi type III MCFACs treated with endoscopic fenestration. Single-stoma fenestration to the basal cistern was performed in 37 cases, while multiple-stoma fenestration to the basal cistern and the carotid cistern was performed in 49 cases. Clinico-radiological profiles and follow-up data were analyzed. Results The rate of symptom relief was 83.7%(72/86), and the rate of cyst shrinkage was 96.5%(83/86). Postoperative ipsilateral subdural effusion, which was significant(P=0.042), and non-infectious fever were the two most common complications in the single-stoma and multiple-stoma groups. No significant differences in intraoperative nerve injury, vascular injury, proportion of cases with cyst reduction, and symptom remission rate were observed between both groups. The rates of cyst recurrence and secondary surgery in the single-stoma group were higher than those in the multiple-stoma group, although the difference was not significant. Conclusion Endoscopic fenestration is an effective and minimally invasive approach for treating Galassi type III MCFACs. Single-stoma and multiple-stoma have the same curative effect.