Fully Endoscopic Supraorbital Resection of Congenital Middle Cranial Fossa Arachnoid Cysts: Report of 2 Cases

Abstract

Intracranial congenital arachnoid cysts are benign intra-arachnoidal fluid collections with a wall composed of arachnoid cells encompassing a cavity containing a fluid similar to cerebrospinal fluid. This cavity frequently communicates with the subarachnoid space. Arachnoid cysts are reported to account for about 1% of all intracranial space-occupying lesions. The most frequent localization of congenital intracranial arachnoid cysts is in the middle cranial fossa, constituting more than half of the cases reported in the literature. We report our use of a fully endoscopic supraorbital approach through the eyebrow for accessing and resecting congenital middle cranial fossa arachnoid cysts. The approach was performed on 2 patients, a 9-month-old infant and a 12-year-old female patient. In both cases, the cysts were resected in their entirety utilizing a 1-cm ‘keyhole’ craniotomy, without the need for a corticotomy and with virtually no brain retraction. The outcomes were favorable and both patients were discharged from hospital within 48 h of surgery. There were no perioperative complications and the cosmetic outcomes were excellent.

Operative Technique and Complication Avoidance in Supraorbital Endoscopic Keyhole Craniotomy

“…Due to its beneficial effects like, minimal brain retraction, limited surgical exposurebecause of the CSF drainage from the chiasmatic, carotid cisterns and frontal lobe relaxation with gravity related positions, the supraorbital endoscopic keyhole approach is gaining widespread acceptance in skull base surgery. 7,8,[14][15]21 Improved surgical view, shorter hospital stay, satisfactory aesthetic results,prompt recovery, less post-operative pain and economic costs are other advantages. 8,[14][15] There are loads and loads of articles in the literature on microscopic and endoscopic assisted supra orbital keyhole surgery, but very limited data regarding endoscopic supraorbital approach.…”

“…7,8,[14][15]21 Improved surgical view, shorter hospital stay, satisfactory aesthetic results,prompt recovery, less post-operative pain and economic costs are other advantages. 8,[14][15] There are loads and loads of articles in the literature on microscopic and endoscopic assisted supra orbital keyhole surgery, but very limited data regarding endoscopic supraorbital approach. 2,5,7,11,20,[22][23][24] Contemporary, with the developments in the endoscopic equipment, supraorbital endoscopic keyhole access is also in use to manage the pathologies related to anterior and some middle cranial fossae.…”

“…Furthermore, surgical microscopic anatomical details through this approach was studied well. [8][9][10][11][12][13][14][15][16] Though, there are insufficient cadaveric studies internationally and up to our knowledge, no study has been previously published in Pakistan so far, related to the endoscopic technique of this procedure. [17][18][19][20] Furthermore, the rationale of our study was to describe the endoscopic supra orbital keyhole craniotomy technique and how to avoid certain potential complications, with measuring the distances in between the targeted anatomical structures.…”

Endoscopic fenestration of middle cranial fossa arachnoid cysts: Does size matter?

“…29 In addition, Kabil and Shahinian have reported a supraorbital transfrontal approach as a potentially more direct and less injurious route to the basal cisterns. 35 Notwithstanding this, the technique of endoscopic fenestration appears to be an effective method of fenestrating arachnoid cysts. It is still a new technique and further experience will determine whether there is an optimal method of fenestrating these lesions.…”

“…Indeed, even those surgeons who perform cyst resections will undertake fenestrations into the basal cisterns due to the observation that the medial cyst wall is often thickened and adherent to vital neurovascular structures. 35 The accepted practice for fenestration is to achieve the largest cystocisternal opening as possible without undue damage to the surrounding structures. This appears to be based on assumptions regarding the potential of the cyst wall to scar over.…”