Neuroendoscopic treatment of arachnoid cysts of the quadrigeminal cistern: a series of 14 cases

Clinical article

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Object

In this paper, the authors' goal was to evaluate the role of neuroendoscopy in the treatment of arachnoid cysts of the quadrigeminal cistern.

Methods

Between March 1995 and February 2008, 14 patients affected by arachnoid cysts of the quadrigeminal cistern were treated endoscopically. The cysts were classified according to their anatomical and radiological appearance. The most frequent form (Type I) extended infratentorially and supratentorially with a dumbbell shape. Type II cysts were confined to the infratentorial space and were associated with the most severe and acute form of hydrocephalus. Type III cysts presented a significant asymmetric expansion toward the temporal fossa. Ten patients underwent an endoscopic procedure as primary treatment and 4 as an alternative to shunt revision. In 6 cases, the first endoscopic procedure was ventriculocystostomy (VC) together with endoscopic third ventriculostomy (ETV). In the other 8 cases, the first endoscopic procedure was VC alone.

Results

In the 6 cases in which VC was performed with an ETV, the procedure was successful, and the patients did not require further surgery. Of the 8 cases in which the first endoscopic procedure performed was VC without ETV, 7 underwent reoperation. Four of these patients underwent endoscopic procedures (by reopening the obstructed VC and performing ETV or cystocisternostomy) 2, 4, 4, and 5 months later with final success in all cases. Three patients (all of whom were previously treated using ventriculo- or cystoperitoneal shunts) required shunt reimplantation (complete failure). Subdural collection developed in 1 case, which was managed by transient insertion of a subduroperitoneal shunt. Neurological and developmental outcomes were good except for 1 patient who did not show improvement in preoperative developmental delay. No transient or permanent morbidity or mortality was observed.

Conclusions

The analysis of this series suggests that arachnoid cysts of the quadrigeminal cistern and the associated hydrocephalus can be effectively treated by endoscopy; this approach allows the patient to be shunt independent in more than 78% of the cases. If endoscopy is used as first option, the success rate of endoscopic procedures observed in this series was 90%. Endoscopic third ventriculostomy should be associated with a VC to offer the highest success rate with a single procedure.

Abbreviations used in this paper: DRIVE = Driven Equilibrium mode; ETV = endoscopic third ventriculostomy; VC = ventriculo-cystostomy.

Article Information

Address correspondence to: Giuseppe Cinalli, M.D., Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Via Mario Fiore n.6, 80129 Naples, Italy. email: giuseppe.cinalli@fastwebnet.it.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    A: Case 11. Type I quadrigeminal cyst. The MR image was obtained at the age of 15 months for progressive macrocrania and delayed developmental milestones. The cyst is developed half above and half below the tentorial hiatus, assuming a dumbbell shape. B: Case 7. Type II quadrigeminal cyst. The MR image was obtained at the age of 1 week following a prenatal diagnosis. The child presented with a tense fontanel and sunset gaze. The cyst is almost completely contained in the infratentorial space probably because of severe, acute supratentorial hydrocephalus. C and D: Case 13. Type III quadrigeminal cyst. Note the significant lateral extension of the cyst.

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    Case 2. Both internal cerebral veins are displaced on the right side and are well visible on axial T1-weighted (A) and T2-weighted (B) MR imaging sequences and on coronal T1-weighted sequences without (C) and with (D) contrast. The arrows indicate the veins.

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    Case 9. A VP shunt was implanted in this patient at another institution at the age of 3 weeks for progressive macrocrania. This patient underwent 2 shunt revisions at the age of 5 years. An ETV and VC are planned at the age of 6 years due to progressive ataxia and persisting upward gaze palsy. A and B: Excellent visualization of the floor of the third ventricle (A) was obtained through a single coronal bur hole placed 1.5 cm anteriorly to the coronal suture (arrowhead) with a 30° rod lens endoscope. Rotation of the endoscope of 180° around its axis allows visualization of the upper pole of the cyst (B). C and D: Postoperative MR image showing the flow artifacts of the VC (C, arrow) and of the ETV (D, arrow). Note the persistent aqueductal stenosis due to the long-standing compression from the cyst (arrowheads). Rapid resolution of ataxia and slower resolution of upward gaze palsy was observed at follow-up visits. Five years after surgery, the neurological examination is normal and the patient exhibits normal psychomotor development and is at the normal school level.

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    Case 12. A parietooccipital entry was preferred in this case because of the significant lateral expansion (Type III cyst) with significant bulging of the cyst into the lateral ventricle and lack of significant ventricular dilation.

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    Case 13. Four months after the first fenestration of the cyst through the third ventricle, the child is readmitted for macrocrania. Magnetic resonance imaging shows regrowth of the cyst with hydrocephalus. In this Type III quadrigeminal cyst, a transforaminal approach (A) was preferred due to the lack of supratentorial bulging of the upper pole of the cyst. The posterior orientation of the steerable fiberscope allowed perforation of the anterior pole of the cyst into the third ventricle. Anterior orientation of the fiberscope (dotted line) allowed visualization of the floor of the third ventricle. The procedure was therefore completed by performing an ETV. Postoperative sagittal (B) and coronal (C) T2-weighted MR images obtained 8 months after the second procedure, showing the flow artifacts through the VC (large arrows) and patency of the sylvian aqueduct (small arrows).

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    Case 12. A: Preoperative MR image. B: Postoperative CT scan, showing decreased cyst volume. C: Magnetic resonance imaging performed 2 months after the image in B was obtained, showing regrowth of the cyst and hydrocephalus. D: Magnetic resonance imaging performed 7 months after the second endoscopic treatment, showing complete resolution of the cyst.

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