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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
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Kagoshima Daigaku Igakubu
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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®,
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