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
Report
Shingo Fujio a Jacob Bunyamin b Hirofumi Hirano a Tatsuki Oyoshi a
       

Yuko Sadamura a Manoj Bohara a Kazunori Arita a 

     

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 ·
Fenestration · Endocrine function
Abstract
The endoscopic method is used to treat suprasellar arach-
noid cysts (SACs) but it is sometimes difficult to make suffi-
ciently sized fenestrations. Creating a larger fenestration on
the cyst wall is preferable to prevent closure of the stoma. In
this paper, we report a novel endoscopic approach for SAC
treatment in which we use bilateral burr holes to achieve a
more extensive cyst fenestration. A 7-year-old girl was re-
ferred to our hospital because of incidentally detected hy-
drocephalus by computed tomography scans. Physical ex-
amination did not show any signs of intracranial hyperten-
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
and a cystic mass occupying the third ventricle. We per-
formed cyst wall fenestration using a bilateral approach in
which we created two burr holes to introduce a flexible en-
doscope and a rigid endoscope. The cyst wall was held by
forceps with the flexible endoscope, and resection of the
cyst wall was achieved by using a pair of scissors with the
rigid endoscope. There were no postoperative complica-
tions, and MRI performed 1 year after treatment showed dis-
appearance of the superior part of the cyst wall.
© 2015 S. Karger AG, Basel
198.143.44.34 - 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
Downloaded by:

E-Mail karger@karger.com
8-35-1 Sakuragaoka, Kagoshima 890-8520 (Japan)
www.karger.com/pne
E-Mail ofuji @ m2.kufm.kagoshima-u.ac.jp
 Introduction
Arachnoid cysts account for at least 1% of all intracra-
nial space-occupying lesions [1, 2] and are frequently
found in children. Al-Holou et al. [3] reported a 2.6%
prevalence rate of arachnoid cysts in 11,738 patients, aged
18 years or younger, who had undergone brain magnetic
resonance imaging (MRI). Suprasellar arachnoid cysts
(SACs) comprise 2–16% of all intracranial arachnoid
cysts in the pediatric age group [1, 3, 4]. These cysts may
cause obstructive hydrocephalus, macrocrania, visual
disturbance or endocrine dysfunction [5–8]. Several sur-
gical techniques have been developed for SAC treatment,
including microsurgical fenestration, cyst-peritoneal
shunt, ventriculoperitoneal shunt and endoscopic fenes-
tration by rigid endoscope or flexible endoscope [5–10].
The recent trend for SAC treatment is via the endoscopic
method, either by ventriculocystostomy (VC) or ventric-
ulocystocisternostomy (VCC), performed through a sin-
gle burr hole [7, 9, 11–14]. Unfortunately, some surgeons
have reported difficulties during fenestration of the cyst
wall [6, 13]. Further, some cases failed to maintain fenes-
tration and required repeated procedures [5, 11]. It ap-
pears that making a large hole in the cyst is necessary to
prevent fenestration closure [12]; however, it is difficult
to achieve a sufficient fenestration size via an endoscopic
approach. In this paper, we report a SAC case treated with
a novel bilateral endoscopic approach.
Fig. 1. Pre- and postoperative constructive
interference in steady-state MR images of a b
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
2 Pediatr Neurosurg
DOI: 10.1159/000440811
Case Report
A 7-year-old girl whose hydrocephalus was incidentally detect-
ed by a computed tomography scan was referred to our hospital.
The girl had undergone imaging due to prior suppurative parotitis.
Physical examination did not show any signs of intracranial hyper-
tension, such as headache, vomiting or papilledema. A confronta-
tion test showed no visual defects. The patient had good records in
school and did not show any developmental delay. No signs of
precocious puberty were noted.
An X-ray of the patient’s skull showed digital impression,
which implied chronic intracranial hypertension. Subsequent MRI
revealed enlargement of both lateral ventricles, and the third ven-
tricle was occupied by a cystic mass. Marked dilatation of the lat-
eral and third ventricles showed a typical ‘Mickey Mouse’ appear-
ance on an axial image (fig.1a). The cyst expanded from the pre-
pontine space, pushing the floor of the third ventricle upward, and
occluded the foramen of Monro (fig. 1b, c).
A hormone-loading test using thyrotropin-releasing hor-
mone, luteinizing hormone-releasing hormone, corticotropin-re-
leasing hormone and growth-hormone-releasing factor revealed
normal hormone responses, with the exception of slightly lower
levels of insulin-like growth factor 1 (92 ng/ml indicating a –1.9
standard deviation with regard to the average for the patient’s sex
and age).
Under the diagnosis of a SAC, cyst wall fenestration was per-
formed via a bilateral approach. The two bilateral burr holes were
1 cm anterior to the coronal suture and 3 cm lateral from the mid-
line. The dome of the arachnoid cyst was identified through the left
foramen of Monro by a flexible endoscope (Videoscope®, Olym-
pus, Tokyo, Japan; fig. 2a). The cyst comprised a dense and boun-
cy texture, which made it difficult to rip using the tip of the forceps
on the flexible endoscope. Therefore, we employed an altered,
sharp edge of scissors through a rigid endoscope (OI HandyPro®,
c
f
198.143.44.34 - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu
Fujio/Bunyamin/Hirano/Oyoshi/
Sadamura/Bohara/Arita
Downloaded by:
Karl Storz, Tutlingen, Germany) to create an opening (fig. 2b). Us-
ing only one instrument, it was difficult to enlarge the stoma; thus,
the cyst was held by forceps through the flexible endoscope (fig. 2c),
and the cyst membrane was cut off using the scissors that had been
inserted through the rigid endoscope from the opposite side
(fig. 2d). A wide fenestration was then made to prevent future clos-
ing (fig.  2e). After fenestration, the flexible endoscope was ad-
vanced to the cyst floor. Anatomical landmarks such as the abdu-
cens nerve, basilar artery, pituitary gland and stretched infundibu-
lar stalk were clearly visualized (fig.  2f, g). At the end of the
procedure, the capsule of the cyst was observed to reduce in size,
and the aqueduct was clearly visible (fig. 2h). The removed cyst
wall, which was 3 cm in diameter (fig. 2i), demonstrated a suffi-
ciently sized fenestration.
Histopathological examination of the cyst wall revealed a bi-
layer construction; the bottom of the third ventricle layer consist-
ed of ependymal cells and glial tissue, and the secondary layer was
comprised of an arachnoid membrane (fig. 3).
The postoperative course was uneventful, and an MRI obtained
1 year after the surgery showed loss of the cyst roof (fig.  1d–f).
While the size of the ventricle was still enlarged, the patient dem-
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
198.143.44.34 - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu

Bilateral Approach for Suprasellar Pediatr Neurosurg 3

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

References 1 Oberbauer RW, Haase J, Pucher R: Arachnoid
cysts in children: a European co-operative
study. Childs Nerv Syst 1992;8:281–286.
2 Nakamura Y, Mizukawa K, Yamamoto K, Na-
gashima T: Endoscopic treatment for a huge
neonatal prepontine-suprasellar arachnoid
cyst: a case report. Pediatr Neurosurg 2001;
35:220–224.
3 Al-Holou WN, Yew AY, Boomsaad ZE, Gar-
ton HJ, Muraszko KM, Maher CO: Prevalence
and natural history of arachnoid cysts in chil-
dren. J Neurosurg Pediatr 2010;5:578–585.
4 Gangemi M, Colella G, Magro F, Maiuri F:
Suprasellar arachnoid cysts: endoscopy ver-
sus microsurgical cyst excision and shunting.
Br J Neurosurg 2007;21:276–280.
5 Crimmins DW, Pierre-Kahn A, Sainte-Rose
C, Zerah M: Treatment of suprasellar cysts
and patient outcome. J Neurosurg Pediatr
2006;105:107–114.
6 El-Ghandour NM: Endoscopic treatment of
suprasellar arachnoid cysts in children. J Neu-
rosurg Pediatr 2011;8:6–14.
198.143.44.34 - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu

4 Pediatr Neurosurg Fujio/Bunyamin/Hirano/Oyoshi/

DOI: 10.1159/000440811 Sadamura/Bohara/Arita
Downloaded by:
 7 Gui SB, Wang XS, Zong XY, Zhang YZ, Li CZ:
Suprasellar cysts: clinical presentation, surgi-
cal indications, and optimal surgical treat-
ment. BMC Neurol 2011;11:52.
8 Ozek MM, Urgun K: Neuroendoscopic man-
agement of suprasellar arachnoid cysts.
World Neurosurg 2013;79:S19.e13–e18.
9 Wang JC, Heier L, Souweidane MM: Advanc-
es in the endoscopic management of suprasel-
lar arachnoid cysts in children. J Neurosurg
Pediatr 2004;100:418–426.
10 Sood S, Schuhmann MU, Cakan N, Ham SD:
Endoscopic fenestration and coagulation
shrinkage of suprasellar arachnoid cysts.
Technical note. J Neurosurg 2005; 102: 127–
133.
Bilateral Approach for Suprasellar
Arachnoid Cysts
11 Decq P, Brugieres P, Le Guerinel C, Djindjian
M, Keravel Y, Nguyen JP: Percutaneous endo-
scopic treatment of suprasellar arachnoid
cysts: ventriculocystostomy or ventriculocys-
tocisternostomy? Technical note. J Neuro-
surg 1996;84:696–701.
12 Fitzpatrick MO, Barlow P: Endoscopic treat-
ment of prepontine arachnoid cysts. Br J Neu-
rosurg 2001;15:234–238.
13 Karabatsou K, Hayhurst C, Buxton N, O’Brien
DF, Mallucci CL: Endoscopic management of
arachnoid cysts: an advancing technique. J
Neurosurg 2007;106:455–462.
Pediatr Neurosurg
DOI: 10.1159/000440811
14 Ogiwara H, Nobuhito M, Joko M, Hirota K:
Endosopic fenestrations for suprasellar
arachnoid cysts. J Neurosurg Pediatr 2011; 8:
484–488.
15 Maher CO, Goumnerova L: The effectiveness
of ventriculocysternotomy for suprasellar
arachnoid cyst. J Neurosurg Pediatr 2011; 7:
64–72.
16 Buxton N, Vloeberghs M, Punt J: Flexible
neuroendoscopic treatment of suprasellar
arachnoid cysts. Br J Neurosurg 1999;13:316–
318.
17 Caemaert J, Abdullah J, Calliauw L, Carton D,
Dhooge C, van Coster R: Endoscopic treat-
ment of suprasellar arachnoid cysts. Acta
Neurochir 1992;119:68–73.
198.143.44.34 - 10/29/2015 11:42:35 PM
Kagoshima Daigaku Igakubu
5
Downloaded by: