Long-term outcome of large sylvian arachnoid cysts: the role of surgery has been exaggerated

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>The surgical indications for some arachnoid cysts (ACs) are controversial. While surgical procedures can be effective when an AC is a definite cause of hydrocephalus or papilledema, most ACs do not cause any symptoms or signs. Some surgeons perform several procedures to treat ACs because of their large size. The purpose of this study was to compare the long-term outcomes of Galassi type III ACs between surgery and nonsurgery groups.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>The medical records of 60 patients diagnosed with sylvian ACs (Galassi type III) who visited Seoul National University Children’s Hospital from July 1990 to March 2018 were analyzed. The authors compared the outcomes between those treated with surgery and those not treated with surgery.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Of the 60 patients, 27 patients had no symptoms, 19 patients had vague symptoms and signs associated with ACs, and the remaining 14 patients had definite AC-related symptoms and signs. Thirty-eight patients underwent surgery, and 22 patients underwent observation. Some operations were accompanied by complications. Among the 33 patients in the surgery group, excluding 5 with hydrocephalus or papilledema, 8 patients needed 18 additional operations. However, there were no patients in the nonsurgery group who needed surgical intervention during the follow-up period (mean 67.5 months), although the size of the AC increased in 2 patients. Changes in AC size were not correlated with symptom relief.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>When patients with hydrocephalus or papilledema were excluded, there was no difference in the outcomes between the surgery and nonsurgery groups regardless of the size of the sylvian AC. Surgeons should be cautious when deciding whether to operate.</jats:p></jats:sec>

Postoperative Complications of Microscopic Fenestration for Middle Fossa Arachnoid Cysts: A Retrospective Study of 38 Cases and Literature Review

“…It has been shown that AC >5 cm is associated with cyst rupture or hemorrhage [30]. For these MFACs, some researchers believe that they should be operated on for their mass effect [29], while others argue that surgery may hurt rather than help the cognitive function of asymptomatic patients, especially young children [6]. Recently, more evidence has shown that MFACs have a negative effect on general cognitive ability and that this impairment can be improved by surgery [31][32][33].…”

“…Eighteen studies were included in the analysis [6,10,11,[14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. The sample size ranged from 20 to 103 and comprised 649 cases of MFACs that were treated by microscopic or endoscopic fenestration.…”

“…There is no definite surgical indication for MFAC. Many surgeons believe that cysts causing clinical symptoms and signs or compressing brain/bone tissues are operable [5, 6]. The surgical options for such cysts include cyst fenestration, cyst-peritoneal shunting, and cyst marsupialization.…”

“…It has been accepted that fenestration is currently the best surgical approach for MFAC extending to the carotid or basal cistern [9, 10]. However, postoperative complications, such as SH, postoperative hemorrhage, and cranial nerve palsy, still represent major concerns [6]. Here, we retrospectively reviewed 38 patients with MFACs who received microscopic fenestration in our department.…”

Different Surgical Options for the Management of Intracranial Arachnoid Cysts

“…In addition, it carries many risks such as obstruction, infection and overdrainage. Cyst fenestration using either microsurgical or endoscopic technique decreases CSF pressure within the cyst and allows brain expansion especially in young children [12][13][14][15]. Microsurgical technique may also help larger cyst wall removal in association with fenestration [16].…”