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Papers of the Week

2022 Mar 03

World Neurosurg

Endoscopic Management Of Quadrigeminal Arachnoid Cyst With Neuro-navigation Guidance.


Quadrigeminal cistern arachnoid cysts (QCAC) are usually asymptomatic and may be accidental findings during radiological evaluation. They are rare, comprising 5-10% of all intracranial arachnoid cysts. We report a case of Type I QCAC managed via navigation-guided cysto-ventriculostomy followed by an endoscopic third ventriculostomy. A zero-degree rod-lens type of endoscope was used for this procedure. Different types of cysts may need different endoscopic approaches and out procedure was facilitated by the presence of significant ventriculomegaly [1]. The endoscopic procedure was completed uneventfully with navigation being used to limit ventricular exploration and find the thinnest point for cysto-ventriculostomy. A bipolar without the need of cautery may be used for fenestration in both cyst and floor of third ventricle which is ultimately expanded with a fogarty balloon. This increases the eventual size of the cysto-ventriculostomy and hence the long-term patency rate [2,3]. Another marker of the success of the same is the presence of a CSF flow void in the post-operative MRI [3], both of which have been demonstrated in our video. The cyst collapsed following the endoscopic procedure during follow-up with a reduction in hydrocephalus and opening up of the aqueduct. The headache disappeared with visual complaints showing remarkable improvement. QCAC is one kind of pineal region ACs and it is advisable to plan the operative approach before the endoscopic procedure according to the different types of pineal region ACs. Pineal region ACs and the associated hydrocephalus can be successfully treated with simple, minimally invasive endoscopic procedures. Navigation assistance may not be absolutely necessary in all cases but allows for a safer and rapid location of the fenestration site. Minimally invasive route and attention to smaller nuances of anatomy are the key to the safe management of these benign conditions.