====== Suprasellar arachnoid cyst treatment ======

[[Suprasellar arachnoid cyst]] treatment is required when the cyst evolves or the patient is symptomatic, but endocrine disturbances alone are not an indication for surgery. 

When hydrocephalus is present, endoscopic fenestration is the primary treatment of choice. The goal of the procedure should be to open the cyst into both the ventricles and the cisterns. 

Suprasellar arachnoid cysts can be treated with favorable clinical and radiological results with endoscopic interventions when feasible
((Pei A, Zhang YZ, Zong XY, Wang XS, Song M. [Endoscopic treatment of
suprasellar arachnoid cysts]. Zhonghua Yi Xue Za Zhi. 2007 Jan 30;87(5):311-4.
Chinese. PubMed PMID: 17456358.))
((Erşahin Y, Kesikçi H, Rüksen M, Aydin C, Mutluer S. Endoscopic treatment of
suprasellar arachnoid cysts. Childs Nerv Syst. 2008 Sep;24(9):1013-20. doi:
10.1007/s00381-008-0615-7. Epub 2008 Apr 4. PubMed PMID: 18389259.))
((Dagain A, Lepeintre JF, Scarone P, Costache C, Dupuy M, Gaillard S. Endoscopic
removal of a suprasellar arachnoid cyst: an anatomical study with special
reference to skull base. Surg Radiol Anat. 2010 Apr;32(4):389-92. doi:
10.1007/s00276-009-0579-7. Epub 2009 Oct 24. PubMed PMID: 19855917.)).

The use of an endoscope in the treatment of suprasellar arachnoid cysts provides an opening of the upper and lower cyst walls, thereby allowing the surgeon to perform a ventriculocystostomy (VC) or a [[ventriculocystocisternostomy]] (VCC). To discover which procedure is appropriate, magnetic resonance (MR)-imaged cerebrospinal fluid (CSF) flow dynamics in two patients were analyzed, one having undergone a VC and the other a VCC using a rigid endoscope. Magnetic resonance imaging studies were performed before and after treatment, with long-term follow-up periods (18 months and 2 years). The two patients were reoperated on during the follow-up period because of slight headache recurrence in one case and MR-imaged CSF flow dynamics modifications in the other. In each case surgery confirmed the CSF flow dynamics modifications appearing on MR imaging. In both cases, long-term MR imaging follow-up studies showed a secondary closing of the upper wall orifice. After VCC, however, the lower communication between the cyst and the cisterns remained functional. The secondary closure of the upper orifice may be explained as follows: when opened, the upper wall becomes unnecessary and tends to return to a normal shape, leading to a secondary closure. The patent sylvian aqueduct aids the phenomenon, as observed after ventriculostomy when the aqueduct is secondarily functional. The simplicity of the VCC performed using endoscopic control, which is the only procedure to allow the opening in the cyst's lower wall to remain patent, leads the authors to advocate this technique in the treatment of suprasellar arachnoid cysts
((Decq P, Brugieres P, Le Guerinel C, Djindjian M, Keravel Y, Nguyen JP.
Percutaneous endoscopic treatment of suprasellar arachnoid cysts:
ventriculocystostomy or ventriculocystocisternostomy? Technical note. J
Neurosurg. 1996 Apr;84(4):696-701. PubMed PMID: 8613867.
)).

Results with [[ventriculocystocisternostomy]] are believed superior to those of ventriculocystostomy
((El-Ghandour NM. Endoscopic treatment of suprasellar arachnoid cysts in
children. J Neurosurg Pediatr. 2011 Jul;8(1):6-14. doi: 10.3171/2011.4.PEDS1184. 
PubMed PMID: 21721882.
))
((Ozek MM, Urgun K. Neuroendoscopic management of suprasellar arachnoid cysts.
World Neurosurg. 2013 Feb;79(2 Suppl):S19.e13-8. doi: 10.1016/j.wneu.2012.02.011.
Epub 2012 Feb 10. Review. PubMed PMID: 22381821.
)).


Preoperative cisternography may be useful for selecting the optimal endoscopic treatment method.

If the cyst communicates with the basal cisterns, a ventriculocystostomy could be an effective, safe, and simpler treatment option
((Ogiwara H, Morota N, Joko M, Hirota K. Endoscopic fenestrations for
suprasellar arachnoid cysts. J Neurosurg Pediatr. 2011 Nov;8(5):484-8. doi:
10.3171/2011.8.PEDS11226. PubMed PMID: 22044374.
)).

Suprasellar and third ventricular size does respond to the surgical intervention at long-term follow-up
((Rizk E, Chern JJ, Tagayun C, Tubbs RS, Hankinson T, Rozzelle C, Oakes WJ,
Blount JP, Wellons JC. Institutional experience of endoscopic suprasellar
arachnoid cyst fenestration. Childs Nerv Syst. 2013 Aug;29(8):1345-7. doi:
10.1007/s00381-013-2032-9. Epub 2013 Jan 24. PubMed PMID: 23345020.
)).

The endoscopic method is used to treat suprasellar arachnoid cysts (SACs) but it is sometimes difficult to make sufficiently sized fenestrations. Creating a larger fenestration on the cyst wall is preferable to prevent closure of the stoma. 

Fuji et al. report a novel endoscopic approach for SAC treatment in which we use bilateral burr holes to achieve a more extensive cyst fenestration. A 7-year-old girl was referred to our hospital because of incidentally detected hydrocephalus by computed tomography scans. Physical examination did not show any signs of intracranial hypertension, but a digital impression of her skull on X-ray implied chronic intracranial hypertension. Magnetic resonance imaging (MRI) revealed enlargement of both lateral ventricles and a cystic mass occupying the third ventricle. They performed cyst wall fenestration using a bilateral approach in which we created two burr holes to introduce a flexible endoscope and a rigid endoscope. The cyst wall was held by forceps with the flexible endoscope, and resection of the cyst wall was achieved by using a pair of scissors with the rigid endoscope. There were no postoperative complications, and MRI performed 1 year after treatment showed disappearance of the superior part of the cyst wall
((Fujio S, Bunyamin J, Hirano H, Oyoshi T, Sadamura Y, Bohara M, Arita K. A
Novel Bilateral Approach for Suprasellar Arachnoid Cysts: A Case Report. Pediatr 
Neurosurg. 2015 Oct 29. [Epub ahead of print] PubMed PMID: 26509420.
)).
====Postoperative complications====

see [[Suprasellar arachnoid cyst postoperative complication]]