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Novel Insights from Clinical Practice

Pediatr Neurosurg Received: July 6, 2015

Accepted after revision: August 31, 2015
DOI: 10.1159/000440811
Published online: October 29, 2015

A Novel Bilateral Approach for

Suprasellar Arachnoid Cysts: A Case
Shingo Fujio a Jacob Bunyamin b Hirofumi Hirano a Tatsuki Oyoshi a

Yuko Sadamura a Manoj Bohara a Kazunori Arita a 


Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University,

Kagoshima, Japan; b Department of Neurosurgery, Medical Faculty of Diponegoro University, Semarang, Indonesia

Established Facts
• The endoscopic method is used for the treatment of suprasellar arachnoid cysts.
• It is difficult to achieve sufficiently sized fenestrations in some cases of suprasellar arachnoid cysts.

Novel Insights
• This is the first report describing a bilateral approach for suprasellar arachnoid cysts.
• Extensive cyst fenestration was achieved using this method.

Key Words
Suprasellar arachnoid cysts · Endoscope · Bilateral approach · amination did not show any signs of intracranial hyperten-
Fenestration · Endocrine function sion, but a digital impression of her skull on X-ray implied
chronic intracranial hypertension. Magnetic resonance im-
aging (MRI) revealed enlargement of both lateral ventricles
Abstract and a cystic mass occupying the third ventricle. We per-
The endoscopic method is used to treat suprasellar arach- formed cyst wall fenestration using a bilateral approach in
noid cysts (SACs) but it is sometimes difficult to make suffi- which we created two burr holes to introduce a flexible en-
ciently sized fenestrations. Creating a larger fenestration on doscope and a rigid endoscope. The cyst wall was held by
the cyst wall is preferable to prevent closure of the stoma. In forceps with the flexible endoscope, and resection of the
this paper, we report a novel endoscopic approach for SAC cyst wall was achieved by using a pair of scissors with the
treatment in which we use bilateral burr holes to achieve a rigid endoscope. There were no postoperative complica-
more extensive cyst fenestration. A 7-year-old girl was re- tions, and MRI performed 1 year after treatment showed dis-
ferred to our hospital because of incidentally detected hy- appearance of the superior part of the cyst wall.
drocephalus by computed tomography scans. Physical ex- © 2015 S. Karger AG, Basel - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu

© 2015 S. Karger AG, Basel Shingo Fujio

1016–2291/15/0000–0000$39.50/0 Department of Neurosurgery
Graduate School of Medical and Dental Sciences, Kagoshima University
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8-35-1 Sakuragaoka, Kagoshima 890-8520 (Japan)
E-Mail ofuji @
Introduction Case Report
A 7-year-old girl whose hydrocephalus was incidentally detect-
Arachnoid cysts account for at least 1% of all intracra- ed by a computed tomography scan was referred to our hospital.
nial space-occupying lesions [1, 2] and are frequently The girl had undergone imaging due to prior suppurative parotitis.
found in children. Al-Holou et al. [3] reported a 2.6% Physical examination did not show any signs of intracranial hyper-
tension, such as headache, vomiting or papilledema. A confronta-
prevalence rate of arachnoid cysts in 11,738 patients, aged tion test showed no visual defects. The patient had good records in
18 years or younger, who had undergone brain magnetic school and did not show any developmental delay. No signs of
resonance imaging (MRI). Suprasellar arachnoid cysts precocious puberty were noted.
(SACs) comprise 2–16% of all intracranial arachnoid An X-ray of the patient’s skull showed digital impression,
cysts in the pediatric age group [1, 3, 4]. These cysts may which implied chronic intracranial hypertension. Subsequent MRI
revealed enlargement of both lateral ventricles, and the third ven-
cause obstructive hydrocephalus, macrocrania, visual tricle was occupied by a cystic mass. Marked dilatation of the lat-
disturbance or endocrine dysfunction [5–8]. Several sur- eral and third ventricles showed a typical ‘Mickey Mouse’ appear-
gical techniques have been developed for SAC treatment, ance on an axial image (fig.1a). The cyst expanded from the pre-
including microsurgical fenestration, cyst-peritoneal pontine space, pushing the floor of the third ventricle upward, and
shunt, ventriculoperitoneal shunt and endoscopic fenes- occluded the foramen of Monro (fig. 1b, c).
A hormone-loading test using thyrotropin-releasing hor-
tration by rigid endoscope or flexible endoscope [5–10]. mone, luteinizing hormone-releasing hormone, corticotropin-re-
The recent trend for SAC treatment is via the endoscopic leasing hormone and growth-hormone-releasing factor revealed
method, either by ventriculocystostomy (VC) or ventric- normal hormone responses, with the exception of slightly lower
ulocystocisternostomy (VCC), performed through a sin- levels of insulin-like growth factor 1 (92 ng/ml indicating a –1.9
gle burr hole [7, 9, 11–14]. Unfortunately, some surgeons standard deviation with regard to the average for the patient’s sex
and age).
have reported difficulties during fenestration of the cyst Under the diagnosis of a SAC, cyst wall fenestration was per-
wall [6, 13]. Further, some cases failed to maintain fenes- formed via a bilateral approach. The two bilateral burr holes were
tration and required repeated procedures [5, 11]. It ap- 1 cm anterior to the coronal suture and 3 cm lateral from the mid-
pears that making a large hole in the cyst is necessary to line. The dome of the arachnoid cyst was identified through the left
prevent fenestration closure [12]; however, it is difficult foramen of Monro by a flexible endoscope (Videoscope®, Olym-
pus, Tokyo, Japan; fig. 2a). The cyst comprised a dense and boun-
to achieve a sufficient fenestration size via an endoscopic cy texture, which made it difficult to rip using the tip of the forceps
approach. In this paper, we report a SAC case treated with on the flexible endoscope. Therefore, we employed an altered,
a novel bilateral endoscopic approach. sharp edge of scissors through a rigid endoscope (OI HandyPro®,

Fig. 1. Pre- and postoperative constructive

interference in steady-state MR images of a b c
the patient. a Preoperative axial image
showing a typical Mickey Mouse appear-
ance caused by marked dilatation of the
lateral and third ventricles. b, c Preopera-
tive sagittal and coronal images showing
that the upper wall of the cyst had become
convex toward the top and that it occlud-
ed the foramen of Monro. The arrow in b
indicates a susceptibility artifact of MRI.
d–f Postoperative MR images after 1 year
demonstrating a decrease in cyst size and
an undetectable upper cyst wall. d e f - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu

2 Pediatr Neurosurg Fujio/Bunyamin/Hirano/Oyoshi/

DOI: 10.1159/000440811 Sadamura/Bohara/Arita
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Karl Storz, Tutlingen, Germany) to create an opening (fig. 2b). Us- and the aqueduct was clearly visible (fig. 2h). The removed cyst
ing only one instrument, it was difficult to enlarge the stoma; thus, wall, which was 3 cm in diameter (fig. 2i), demonstrated a suffi-
the cyst was held by forceps through the flexible endoscope (fig. 2c), ciently sized fenestration.
and the cyst membrane was cut off using the scissors that had been Histopathological examination of the cyst wall revealed a bi-
inserted through the rigid endoscope from the opposite side layer construction; the bottom of the third ventricle layer consist-
(fig. 2d). A wide fenestration was then made to prevent future clos- ed of ependymal cells and glial tissue, and the secondary layer was
ing (fig.  2e). After fenestration, the flexible endoscope was ad- comprised of an arachnoid membrane (fig. 3).
vanced to the cyst floor. Anatomical landmarks such as the abdu- The postoperative course was uneventful, and an MRI obtained
cens nerve, basilar artery, pituitary gland and stretched infundibu- 1 year after the surgery showed loss of the cyst roof (fig.  1d–f).
lar stalk were clearly visualized (fig.  2f, g). At the end of the While the size of the ventricle was still enlarged, the patient dem-
procedure, the capsule of the cyst was observed to reduce in size, onstrated good scholastic performance.

Color version available online

a b c

Fig. 2. Intraoperative photographs of the

SAC. a Bluish-colored apical dome of the
suprasellar cyst bulging through and ob-
structing the foramen of Monro. b Opening
of the upper cyst wall using scissors. c The
cyst being held by forceps through a flexible
endoscope. d The cyst being held by forceps
and opened by scissors. The arrowhead in- d e f
dicates the forceps and the arrow the scis-
sors. e Image showing the achievement of a
wide VC. f, g Clear visualization of anatom-
ical landmarks such as the abducens nerve
(AN), basilar artery (BA), pituitary gland
(PG) and infundibular stalk (IS). h Clear
visibility of the aqueduct of Sylvius (indi-
cated by the arrow) and posterior commis-
sure (PC) at the end of the procedure. i The
removed upper cystic wall, measuring more
than 3 cm in diameter. g h i

Color version available online

Fig. 3. Pathological findings of the roof of

the cyst. It was revealed that the cyst com-
prised a bilayer wall consisting of ependy-
mal cells (A), compressed glial tissue (B) in
the upper level and an arachnoid mem-
brane (C) in the lower level. a Hematoxy-
lin-eosin. b Glial fibrillary acidic protein. a b - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu

Bilateral Approach for Suprasellar Pediatr Neurosurg 3

Arachnoid Cysts DOI: 10.1159/000440811
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Five months after the surgery, hormone-loading tests using ing during cystocisternostomy [6]. Thus, VC is a simple
thyrotropin-releasing hormone, luteinizing hormone-releasing procedure, and its safety may be superior to that of VCC.
hormone, corticotropin-releasing hormone and growth-hor-
mone-releasing factor were normal, and the insulin-like growth Some studies on VC have also demonstrated excellent
factor 1 level gradually improved to 204 ng/ml (–0.8 standard de- outcomes, with success rates ranging from 81.8 to 100% [4,
viation) 1 year after surgery. 6, 7, 12]. As previously mentioned, superior fenestrations
tend to close because stretching of the third ventricle cre-
ates excess tissue that can postoperatively overlap to seal
Discussion the fenestration [11, 17]. To overcome this issue, larger
fenestrations in the upper wall of the cyst have been sug-
Increased intracranial pressure due to obstruction of gested [12]. However, entering the cyst to make a fenestra-
cerebrospinal fluid, increased head circumference, visual tion that is sufficient in size can prove difficult because of
impairment and progressive cyst enlargement are the ma- the tough apical membrane [6, 12, 13]. In addition, the api-
jor indications for surgery in patients with SAC. Recently, cal membrane may bounce away when an attempt to incise
the feasibility and effectiveness of endoscopic fenestra- is made. Thus, we formulated a bilateral approach using a
tion for SACs with hydrocephalus have been demonstrat- rigid endoscope so that we could insert scissors for the fen-
ed, and it is currently the procedure of choice for such estration and a flexible endoscope to hold the cyst dome.
cases [5, 7, 9, 15]. VC and VCC are the main alternative Using this technique, an extensive surgical field allowed us
treatments of SACs with hydrocephalus. VC is an ap- to achieve a larger fenestration of the cyst wall. A follow-up
proach that is used to fenestrate the apical membrane of examination 1 year after treatment revealed successful de-
the cyst, while VCC is used to fenestrate both the apical compression of the cyst. Thus, we think that VCC is not
and basal membranes. A number of studies on VCC have always needed when a sufficiently wide fenestration can be
demonstrated excellent outcomes with success rates rang- made at the apical membrane of a cyst.
ing from 84.6 to 100% [4–9]. For example, Decq et al. [11] It should be noted that although our patient had a nor-
performed a long-term study on cerebrospinal fluid dy- mal endocrine function and growth, endocrine dysfunc-
namics following VCC and showed that there was a sec- tions are encountered in 26–38% of patients with SAC [5,
ondary closure of the upper opening in the cyst, but that 8]. This is because deflection of the stalk and protrusion
the perforation of the cyst’s lower part remained func- of the cystic wall into the third ventricle may affect endo-
tional. They postulated that, while the superior fenestra- crine function. Precocious puberty has been reported in
tion tends to close, the persistence of the basal opening young patients with SAC, not only in the preoperative
may allow for a decrease in the risk of recurrence. Indeed, stage, but also as a newly developed complication during
some reports have shown that the efficacy of VCC is bet- the postoperative follow-up [5, 7, 8]. Therefore, a long-
ter than that of VC [5–7]. However, fenestration of the term endocrinological follow-up is needed for young pa-
lower part of the cyst is a potentially risky procedure as tients with SAC.
the cyst floor often adheres to the basilar artery complex In the currently reported case, we safely conducted ex-
[12, 16]. For example, Gui et al. [7] reported that 4 of 51 tensive cyst wall fenestration using a bilateral approach
patients had transient episodes of sixth nerve palsy after with a flexible and a rigid endoscope through each burr
VCC, but that there was no cranial nerve palsy after VC. hole. However, future study is needed to prove that this
Another report mentioned intraoperative arterial bleed- technique is superior to existing techniques.

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Bilateral Approach for Suprasellar Pediatr Neurosurg 5

Arachnoid Cysts DOI: 10.1159/000440811
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