Endonasal management of sellar arachnoid cysts: simple cyst obliteration technique

Technical note

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Object

Symptomatic sellar arachnoid cysts (ACs) have typically been treated via the transsphenoidal route. After sellar cyst wall fenestration, some authors have advocated cyst wall resection and increasing communication between the AC and suprasellar subarachnoid space (SAS). This study is a report of the authors' experience using a simplified approach to reinforce a defective diaphragma sellae or unseen arachnoid diverticulum by deliberately not enlarging the AC-SAS communication and obliterating the cyst cavity with adipose tissue followed by skull base reconstruction.

Methods

A retrospective analysis was conducted of patients who underwent an endonasal transsphenoidal obliteration of symptomatic ACs with a fat graft and skull base repair.

Results

Between July 1998 and September 2010, 8 patients with a sellar AC were identified (6 women and 2 men, mean age 57 years). Clinical presentation included headache, pituitary dysfunction, and visual dysfunction (4 patients each group). Maximal cyst diameter averaged 22 mm (range 15–32 mm). In all cases the sellar communication to the SAS was deliberately not enlarged. The endoscope was used for visualization in 8 of 9 procedures. Postoperatively, headache improved in all 4 patients, vision in all 4 patients, and partial resolution of endocrine dysfunction (hyperprolactinemia and/or recurrent hyponatremia) occurred in 3 (75%) of 4 patients. No new endocrinopathy, CSF leak, meningitis, or neurological deficits occurred. Two patients experienced cyst reaccumulation: 1 symptomatic recurrence was treated with reoperation at 43 months postsurgery, and 1 asymptomatic partial recurrence continued to be monitored at 29 months postsurgery.

Conclusions

Sellar ACs can be effectively treated using endonasal fenestration and obliteration with fat with resultant reversal of presenting symptoms in the majority of patients. This simplified technique of AC cavity obliteration without enlarging communication to the SAS has a low risk of CSF leakage, and in most cases appears to effectively disrupt cyst progression, although longer follow-up is required to monitor for cyst recurrence.

Abbreviations used in this paperAC = arachnoid cyst; IGF-I = insulin-like growth factor–I; SAS = subarachnoid space; UCLA = University of California, Los Angeles.

Article Information

Address correspondence to: Daniel F. Kelly, M.D., Brain Tumor Center, John Wayne Cancer Institute at Saint John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, California 90404. email: kellyd@jwci.org.

Please include this information when citing this paper: published online January 27, 2012; DOI: 10.3171/2011.12.JNS11399.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraoperative steps of the management of an intrasellar AC (Case 8). A: Exposure of the thinned-out sellar floor. B: View of the cystic intrasellar lesion through the dura using the endoscope. C and D: View of the cyst's cavity using the endoscope. E: Filling of the cavity with adipose tissue. F: Skull base reconstruction using micromesh.

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    Case 8. Preoperative MR imaging (upper row; sagittal, sagittal, coronal, and axial orientations from left to right) showing a cystic sellar lesion with suprasellar extension measuring 14 × 16 × 17 mm following CSF signal intensity on all sequences. The gland was thinned and pushed toward the right, as was the pituitary stalk. Postoperative (PO) Day 1 MR imaging (center row) showing cyst drainage and obliteration with fat, and skull base reconstruction. At 10 months after surgery (lower row), MR imaging shows continued collapse of the AC with minimal residual fat graft and thicker pituitary gland.

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    Case 4. Sagittal (upper row), coronal (center row), and axial (lower row) MR images showing rapid fat resorption. Preoperative imaging (left column) shows an intrasellar AC with suprasellar extension. Postoperative imaging at 3 (center column) and 22 months (right column) shows progressive fat tissue resorption but no recurrence of the cystic cavity.

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    Case 1. Sagittal (upper row), coronal (center row), and axial (lower row) MR images showing minimal fat resorption over time. Preoperative imaging (left column) documents an intrasellar AC with suprasellar extension. Postoperative imaging at 16 (center column) and 39 months (right column) shows minimal fat resorption and no cyst recurrence.

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