Intracranial arachnoid cysts in an infant: A technical note on the innovative use of navigation and flexible endoscopy for cyst fenestration

Abstract

Background: Intracranial arachnoid cysts (ACs) are a cerebral spinal fluid (CSF) collection within the meninges. They typically arise during embryologic development. Some are stable overtime with little consequence, but large or growing cysts may require surgical intervention. The optimal surgical technique is debated and may be more technically challenging in the infant age group. Case Description: Our unique case report details a 10-month-old (6 months corrected age) infant who presented with a drastic increase in head circumference and was found to have midline shift and three cysts – one large and two smaller ones. He was treated with an innovative surgical approach combining stereotactic introduction of a catheter to facilitate subsequent flexible endoscopy allowing three separate cysts to be treated through one small surgical incision with no complications and a stable examination on 2-year follow-up. Conclusion: Symptomatic ACs in the infant population that require treatment can be addressed with open surgery to fenestrate the cyst, endoscopic cyst fenestration, or cystoperitoneal shunting. Typically, surgeons must choose between a rigid endoscope which allows stereotactic navigation or a flexible endoscope which allows multiple trajectories but precludes navigation. Our case demonstrates that combining stereotactic ventricular placement before flexible endoscopy provides the benefit of both approaches and allows for successful endoscopic treatment in a young patient with durable results.

Evaluation of the precision of navigation-assisted endoscopy according to the navigation tool setup and the type of endoscopes

“…The upper screen shows the calibration (3), and the lower screen shows the endoscope’s view. B ) Material: [ 15 ] Box, [ 25 ] navigation view, [ 26 ] Brainlab workstation/reference array/navigation array, [ 10 ] Storz workstation …”

“…4 Angulation of the neuroendoscope according to the box. [ 15 ] Neuroendoscope, [ 25 ] box with the screws (targets), [ 26 ] angulation …”

“…The upper screen shows the calibration (3), and the lower screen shows the endoscope's view. B) Material: [15] Box, [25] navigation view, [26] Brainlab workstation/reference array/navigation array, [10] Storz workstation Fig. 3 A) Distance D: positions of the reference array [15] from the box [25] (CLOSE, MIDDLE, FAR).…”

“…4 Angulation of the neuroendoscope according to the box. [15] Neuroendoscope, [25] box with the screws (targets), [26] angulation quartile (Q1) and third quartile (Q3). A p value < 0.05 was considered significant.…”

“…Endoscopy is gaining interest in neurosurgery, not only during endonasal approaches, but also for intracranial procedures [6,10,15,23,25,26,29]. Its main advantage over open procedures resides in its minimal invasiveness with less postoperative morbidity, especially to reach deep-seated brain lesions, skull base surgery or to open basal cisterns in case of hydrocephalus [4,6,23,25].…”