Surgical Experience and Literature Review of Sellar and Suprasellar Arachnoid Cysts: Endoscopic Management and Surgical Anatomy-Based Reorganization

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BACKGROUND: The suprasellar cistern containing major neurovascular structures is accessible by various microscopic and endoscopic approaches. While literature strengthening the case for skull-base endoscopic management of neoplastic sellar-suprasellar lesions abounds, a straightforward algorithm for endoscopically managing sellar/suprasellar arachnoid cysts (SAC) has not been set forth. This is likely due to their low incidence and the wide variation in both nomenclature and surgical management described in the literature. METHODS: All (10) cases of SAC managed at our institution over the past 5 years have been analyzed and included in this retrospective study. All cases underwent endoscopic surgery as deemed appropriate by the managing teams. All studies published after 2010 describing endoscopic management of six or more SAC cases were reviewed. RESULTS: Endoscopic fenestration of the cyst with wall biopsy was done in all cases. Wide cysto-cisternostomy was done in all large suprasellar cysts. This was performed via the endonasal route in cases with a large(r) sellar + suprasellar component (anterior to the dorsum sellae) or via transventricular endoscopy in cases with a large(r) premesencephalic/prepontine (retrosellar) component. Postoperatively, all patients in our series experienced relief of symptoms with no complicating CSF leaks or evidence of recurrence at last follow-up. Literature review revealed gross inconsistencies in the nomenclature of each cyst type while largely describing successful endoscopic management. We encountered three main types of cysts and found that the most useful method of grouping SACs to aid surgical approach selection is based on their predominant cisternal location. Therefore, we suggest that they be organized into the intrasellar, sellar-suprasellar, and premesencephalic/prepontine types. CONCLUSION: Reorganizing SACs based on their anatomical extent simplifies academic communication and aids in choosing the surgical approach. In our experience treating these rare cysts, transventricular as well as transnasal endoscopic surgery has proven safe and efficient.

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