Evaluation of surgical treatment strategies and outcome for cerebral arachnoid cysts in children and adults

Abstract

Objective: The best treatment strategies for cerebral arachnoid cysts (CAC) are still up for debate. In this study, we present CAC management, outcome data, and risk factors for recurrence after surgical treatment, focusing on microscopic/endoscopic approaches as compared to minimally invasive stereotactic procedures in children and adults.

Methods: In our single-institution retrospective database, we identified all patients treated surgically for newly diagnosed CAC between 2000 and 2022. Microscopic/endoscopic surgery (ME) aimed for safe cyst wall fenestration. Stereotactic implantation of an internal shunt catheter (STX) to drain CAC into the ventricles and/or cisterns was used as an alternative procedure in patients aged ≥ 3 years. Treatment decisions in favor of ME vs. STX were made by interdisciplinary consensus. The primary study endpoint was time to CAC recurrence (TTR). Secondary endpoints were outcome metrics including clinical symptoms and MR-morphological analyses. Data analysis included subdivision of the total cohort into three distinct age groups (AG1, < 6 years; AG2, 6-18 years; AG3, ≥ 18 years).

Results: Sixty-two patients (median age 26.5 years, range 0-82 years) were analyzed. AG1 included 15, AG2 10, and AG3 37 patients, respectively. The main presenting symptoms were headache and vertigo. In AG1 hygromas, an increase in head circumference and thinning of cranial calvaria were most frequent. Thirty-five patients underwent ME and 27 STX, respectively; frequency did not differ between AGs. There were two (22.2%) periprocedural venous complications in infants (4- and 10-month-old) during an attempt at prepontine fenestration of a complex CAC, one with fatal outcome in a 10-month-old boy. Other complications included postoperative bleeding (2, 22.2%), CSF leaks (4, 44.4%), and meningitis (1, 11.1%). Overall, clinical improvement and significant volume reduction (p = 0.008) were seen in all other patients; this did not differ between AGs. Median follow-up for all patients was 25.4 months (range, 3.1-87.1 months). Recurrent cysts were seen in 16.1%, independent of surgical procedure used (p = 0.7). In cases of recurrence, TTR was 7.9 ± 12.7 months. Preoperative ventricular expansion (p = 0.03), paresis (p = 0.008), and age under 6 years (p = 0.03) were significant risk factors for CAC recurrence in multivariate analysis.

Conclusions: In patients suffering from CAC, both ME and STX can improve clinical symptoms at low procedural risk, with equal extent of CAC volume reduction. However, in infants and young children, CAC are more often associated with severe clinical symptoms, stereotactic procedures have limited use, and microsurgery in the posterior fossa may bear the risk of severe venous bleeding.

Keywords: Arachnoid cysts; Hydrocephalus; Microsurgery; Stereotaxy.

Fig. 1

Schematic illustration of a stereotactically placed internal shunt catheter to achieve a permanent drainage of a large frontotemporal cerebral arachnoid cyst into both the ventricles and the basal cisterns

Fig. 2

Consort diagram showing patient selection according to age groups 1–3 and treatment modality

Fig. 3

Pre- and postoperative cyst volume in the overall patient cohort (**p = 0.008, a) and absolute (p = 0.5, b) and relative (p = 0.9, c) volume reduction depending on surgical treatments microscopic/endoscopic CAC wall fenestration (ME) and stereotactic implantation of an internal shunt catheter (STX)

Fig. 4

MR imaging of patients with cerebral arachnoid cysts (*) before (left) and after (right) microsurgical/endoscopic cyst wall fenestration (images a + b and c + d) and catheter implantation (images e + f) (red arrow). Volume reduction was achieved with all surgical approaches

Fig. 5

Time to second surgery for recurrent cerebral arachnoid cysts after microsurgical/endoscopical cyst wall fenestration (ME) and stereotactic implantation of an internal shunt catheter (STX) (a) and for the three age groups (b)