Transsphenoidal cyst cisternostomy with a keyhole dural opening for sellar arachnoid cysts: technical note

Abstract

A less invasive transsphenoidal approach with a keyhole dural opening for intrasellar arachnoid cysts is described. This approach was used to address seven sellar cystic lesions with suprasellar extension; they were six intrasellar arachnoid cysts (IACs) and one Rathke's cleft cyst (RCC). In all cases, preoperative MRI revealed cerebrospinal fluid (CSF) intensity on both T1- and T2-weighted images. On preoperative contrast-enhanced MRI, five of the six IACs manifested posterior displacement of the flattened pituitary gland toward the dorsum sellae; one of the six IACs and the RCC exhibited a flattened pituitary gland on the anterior surface of the cyst. Wide cyst cisternostomy through a keyhole dural opening was carried out safely using a microscope with the support of a thin angled endoscope (30° and/or 70°, diameter 2.7 mm). As we aimed to avoid iatrogenic injury of the pituitary function, we found it difficult to obtain a sufficiently wide and precise opening of the cyst wall when the pituitary gland was located on the anterior surface of the cyst wall. Our approach facilitates safe cyst cisternostomy as wide as that obtainable by transcranial manipulation. In addition, CSF leakage is prevented by dural plasty using the fascia lata and stitching with 6-0 monofilament sutures. This technique can be adapted to address various sellar cystic lesions. However, as the posterior or anterior displacement of the normal pituitary gland in the presence of IACs or RCCs, respectively, affects the width of the cyst opening, our technique is more suitable for IACs than RCCs.

Intrasellar arachnoid cyst: A case report and review of the literature

“…As described by Elliot et al suprasellar ACs are characterized by a pure cystic lesion with no contrast enhancement and calcification with a typical CSF-like signal behavior, that is a hypointense T1-weighted signal and a hyperintense T2-weighted signal on the MRI images [18] . Complementary to this, MRI findings showing a cystic intrasellar lesion with suprasellar extension, a balloon-shape, regular, isoor slightly hyper-intense to CSF, molding but no invasion to cavernous sinus may suggest a diagnosis of IAC [8] , [11] . MRI findings were consistent with these features except the rim like contrast enhancement in our patient.…”

“…Intracranial arachnoid cysts (AC) are benign lesions of the arachnoid, forming nearly 1% of all intracranial space-occupying lesions [1] . Compared to other cystic lesions of the sellar region namely the cystic adenomas, craniopharyngiomas and Rathke's cleft cysts, they are rarely seen in this localization with few reports available in the English literature [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] . ACs are most commonly found in the Sylvian fissure followed by the cerebellopontine angle, the supracollicular area and the vermian area.…”

Endoscopic Transsphenoidal Cisternostomy for Nonneoplastic Sellar Cysts

“…None of studies in the literature reported the occurrence of postoperative chemical meningitis after craniotomy of Rathke's cleft cysts, even in suprasellar Rathke's cases involving partial cyst wall removal [ 17 , 18 ]. Oyama et al published the method of transsphenoidal cyst cisternostomy with a keyhole dural opening [ 12 ]. The microscopical approach and the extended transsphenoidal approach were used.…”

Social alienation caused by precocious puberty and hypothalamic obesity in patients with suprasellar arachnoid cysts - Case studies and literature review of a rare but significant disorder

“…Nevertheless, most authors claim that currently the best method of proceeding is the use of endoscopic techniques. These techniques combine the high effectiveness, attributed to microsurgical procedures, with low invasiveness, specific for the implantation of valvular systems [33]. Approaches for accessing the suprasellar region in endoscopic techniques are: transfrontal/transcallosal and endonasal/ transsphenoidal.…”