Surgical management of quadrigeminal cistern arachnoid cysts: case series and literature review

Abstract

OBJECTIVE Quadrigeminal cistern arachnoid cysts (QACs) are congenital lesions that can cause pineal region compression and obstructive hydrocephalus when sufficiently large. Management of these cysts is controversial and rates of reintervention are high. Given the limited data on the management of QACs, the authors retrospectively reviewed 20 years of cases managed at their institution and performed a literature review on this topic. METHODS The authors performed a retrospective analysis of patients treated for QAC at their institution between 2001 and 2021. They also performed a literature review of studies published between 1980 and 2021 that reported at least 5 patients treated for QACs. Patient characteristics, radiographic findings, management course, and postoperative follow-up data were collected and analyzed. RESULTS A total of 12 patients treated for a QAC at the authors’ institution met the inclusion criteria for analysis. Median age was 9 months, mean cyst size was 5.1 cm, and 83% of patients had hydrocephalus. Initial treatment was endoscopic fenestration in 92% of these patients, 27% of whom had an endoscopic third ventriculostomy (ETV) performed concurrently. Reintervention was required in 42% of patients. Cases that required reintervention had a statistically significant lower median age at the initial intervention (5 months) than the cases that did not require reintervention (24.33 months; p = 0.018). There were no major complications. At a mean follow-up of 5.42 years, 83% of patients had improvement or resolution of their symptoms. A literature review revealed 7 studies that met the inclusion criteria, totaling 108 patients with a mean age of 8.8 years. Eighty-seven percent of patients had hydrocephalus at presentation. Ninety-two percent of patients were initially treated with endoscopic fenestration, 44% of whom underwent concurrent ETV. Complications occurred in 17.6% of cases, and reintervention was required in 30.6% of cases. The most frequent reason for reintervention was untreated or unresolved hydrocephalus after the initial procedure. CONCLUSIONS Endoscopic fenestration is the most common treatment for QACs. While generally safe and effective, there is a high rate of reintervention after initial treatment of QACs, which may be associated with a younger age at the first intervention. Additionally, identifying patients who require initial treatment of hydrocephalus is critically important, as the literature suggests that untreated hydrocephalus is a common cause of reintervention.

Quadrigeminal plate arachnoid cyst presenting with eye movement related migraine: a rare case report

“…The mechanism was unclear, but we believed that removing the cyst eventually released (continued) Microsurgical fenestration and excision of the quadrigeminal cyst using the SCIT technique were preferred, considering the clear evidence of cerebellar compression, cyst size, predominant infratentorial extension, and progressive worsening of the symptoms without hydrocephalus findings. 7,10,34 Microsurgery is preferred in type II quadrigeminal cysts without hydrocephalus, as sudden cyst decompression may invoke bleeding in the surrounding fragile neurovascular structures. 6,7,34 Bleeding can be more efficiently controlled with microsurgery than an endoscopic approach.…”

Arachnoid cysts of the quadrigeminal cistern: Proposal of a therapeutic algorithm based on a systematic review of literature

“…Silva et al [1] retrospectively analyzed 12 patients, with one adult, reported an incidence of 83% of hydrocephalus, and performed the ventricular endoscopic approach using the ETV concurrently in three cases. In addition, they advocated the avoidance of shunt whenever possible and have indicated it in selected cases.…”

“…Arachnoid cysts are uncommon malformations of the subarachnoid space, in which the cerebrospinal fluid (CSF) is arrested into the splitting arachnoid membrane, forming a cyst that could become enlarged, isolated from the rest of the subarachnoid space and ventricles, and compressed the surrounding structures [1,2]. Additionally, other hypotheses have been put forward to explain its origin, such as the ectopic production of the CSF by the cyst wall, a slit-valve mechanism, and the osmotic gradient between the CSF and the cyst fluid [3].…”

Intracranial arachnoid cysts

“…However, some retrospective studies have reported that 86% of patients who refused surgical treatment despite being symptomatic might be recovered clinically without surgical intervention (39). It has been reported that endoscopic techniques such as cyst fenestration and removal via the suboccipital supracerebellar approach, lateral ventricle cystostomy, and third ventricle cystostomy should be preferred as a minimally invasive surgical treatment in the treatment of these cysts and that 78-93% of patients treated with these techniques are independent of a shunt (40,41,42).…”