Surgical Decompression of Supratentorial Arachnoid Cysts in Pediatric Patients Younger than One Year

Abstract

Background: There has been much debate about the optimal surgical management of arachnoid cysts in infants younger than 1 year of age. The authors present the clinical and neuroimaging findings in pediatric patients with supratentorial arachnoid cysts treated by surgical decompression. Methods: A retrospective chart review was conducted to identify all pediatric patients who had been diagnosed with arachnoid cysts since 2003. Five infants with symptomatic supratentorial arachnoid cysts underwent surgery at Kangnam St. Mary’s Hospital. Results: The initial surgery in 4 patients involved a craniotomy with the excision of the cyst wall and fenestration into the basal cisterns. Three of the four patients needed additional procedures, such as cyst-peritoneal or subdural-peritoneal shunting due to failure of cyst resolution. A shunting procedure was performed as initial therapy in 1 patient who presented with increased intracranial pressure. Conclusion: Our strategy for approaching arachnoid cysts in pediatric patients has been to diagnose and treat the cysts as early as possible and to avoid the complications of shunts whenever possible. However, open craniotomy with excision and fenestration of the cyst is associated with a relatively high failure rate in pediatric patients younger than 1 year of age with supratentorial arachnoid cysts.

Prevalence and natural history of arachnoid cysts in adults

“…28,29,31,37,45,48,55,58,68,69,72,79,80,84,105 Shunt placement carries the additional risk of shunt dependency and overdrainage. 51,62,79 In a recent review of published cases of endoscopic treatment of middle cranial fossa arachnoid cysts, Johnson et al 43 found that this treatment resulted in subdural hygromas and subdural hematomas in 9% and 5% of cases, respectively.…”

“…Surgical treatment of posterior fossa cysts may occasionally result in iatrogenic hindbrain herniation. 22,51,62 Although any surgical technique to address an arachnoid cyst may result in complication, the preference for any given surgical technique over another has been debated 15,31,45,55,73,79,105 and is beyond the scope of this article.…”

“…12,54,74,76,78,88,94 However, there are no studies evaluating a large series of adults with untreated arachnoid cysts who have undergone clinical and imaging followup. Although arachnoid cysts may be treated surgically by endoscopic fenestration, 24,31,48,67,79,91,105 craniotomy for fenestration, 15,31,55,79 or shunt placement, 15,34,67,73,79 these operations are associated with potential morbidity. 24,39,48,55,57,58,79,80,85,105 A better understanding of the prevalence and natural history of these cysts in adults may lead to better definition of surgical indications for adult patients with arachnoid cysts discovered on imaging.…”

Long-term endocrine outcome of suprasellar arachnoid cysts

“…However, recent reports have questioned the benefits of surgical interventions for asymptomatically enlarged arachnoid cysts and stated that such enlargements almost always stop spontaneously, and the children are neurologically normal. 4,12,20 It is our cur- rent policy not to operate on patients with asymptomatic enlargement of a suprasellar arachnoid cyst. Suprasellar arachnoid cysts are a well-known cause of hypothalamic-pituitary dysfunction.…”

The Acetazolamide Challenge: A Tool for Surgical Decision Making and Predicting Surgical Outcome in Patients with Arachnoid Cysts

“…4,[11][12][13][14][15] In patients with asymptomatic ACs, conservative management with or without serial neuroimaging and neuropsychological follow-up has been advocated, even for those in whom neuroimaging suggests raised intracranial pressure (ICP) 1,2,7,8,10,12,[16][17][18][19][20] from mass effect with compression, shifting, or effacement of cerebral structures. For those with moderate and unspecific symptoms, surgical treatment for ACs is a controversial issue, with many authors expressing reluctance to operate on patients unless the symptoms were dramatic [21][22][23][24][25][26][27][28][29][30][31] while others have been more liberal and suggested that surgical cyst decompression improved 86% of patients with complication rates of 17%. 23 Criteria referring to indications for surgery were individualized per surgeon's judgment, which was very heterogeneous.…”