Neurology India, Vol. 58, No. 2, March-April, 2010, pp. 280-283
Endoscopic treatment of the suprasellar arachnoid cyst
YR Yadav1, Vijay Parihar1, Mallika Sinha1, Nishin Jain2
1 Neurosurgery Unit, NSCB Medical College, Jabalpur, MP, India
Correspondence Address: Y R Yadav, 105 Nehru Nagar, Opposite Medical College, Jabalpur, MP, India, firstname.lastname@example.org
Date of Acceptance: 02-Oct-2009
Code Number: ni10070
AbstractSurgical 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
Suprasellar arachnoid cyst can be managed by shunt,  craniotomy with fenestration , and endoscopic treatment.  Shunting procedures  and craniotomy with fenestration  have their limitations. Suprasellar arachnoid cyst can present as Bobble-head doll syndrome, , hydrocephalus,  psychiatric disturbance,  macrocephaly,  endocrinological disturbances,  visual problems  and precocious puberty. 
Endoscopic fenestration has been found to be safe and effective. ,,, We report our experience of 12 patients with suprasellar arachnoid cyst.
Materials and Methods
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.
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.
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.
Transventricular approach to suprasellar arachnoid cyst has been found to be safe and effective. ,,,, It also prevents chances of subdural collection.  Dual fenestration (ventriculocystocisternostomy) in the cyst wall can be safely performed, which is more effective than single fenestration.  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.  Expanded endoscopic endonasal approach has been found to be an effective alternative method for suprasellar arachnoid cyst.  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.  Teflon sponge shunt has been found to be effective in recurrent arachnoid cyst. 
Craniotomy microscopic fenestration is one of the methods of treatment for this condition.  Craniotomy fenestration is a more-invasive technique. Sudden decompression can give rise to subdural hematoma and other intraparenchymal hematoma.  Pierangeli et al,  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. 
Stent placement under stereotactic-guided endoscopic surgery was also found to be effective.  Foreign body implanted in this method can get infected and blocked. Subfrontal endoscopic-assisted surgery has been used successfully to treat suprasellar arachnoid cyst.  Direct fenestration of superficial cyst like suprasellar arachnoid cyst can give rise to subdural effusion,  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.
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