[Endoscopic fenestration of median supratentorial cerebrospinal fluid cysts]

Mid-supratentorial liquor cysts are a relatively rare and generally congenital abnormality of the cerebral ventricles and subdural spaces. The data and views available in the literature on rational surgical policy is contradictory. The authors' experience in treating 16 patients was used to consider whether endoscopic techniques can be employed for invasive fenestration of the cysts. The goal of surgery was to remove the masses caused by cystic malformations and their local compression of the brain via fenestration of the walls of the cysts and via communication of their cavities with the ventricles and cisterns. There were solitary cysts in all cases (arachnoidal cysts of the interpedicular cistern and the third ventricle in 9; cysts of the ventricular septum in 4, ependicular cysts of the lateral ventricle in 2, and cysts of the celiac plexus of the third ventricle in other 2 cases, in 1 cases a liquor cyst was located in the midbrain thickness). The clinical picture was characterized by a combination of hypertensive, hydrocephalic and focal symptoms of damages to the hypothalamic and thalamic structures and the adjacent formations of the brain (pyramidal and extrapyramidal disorders, ataxia, chiasmal syndrome, metabolic and endocrine disorders, etc.). In 6 cases these symptoms were persistent despite preimplanted VP anastomosis. Rigid Storz endoscopes (Germany) with an external coat, 6 mm in diameter, and a Codman fibroendoscope (USA), 4 mm in diameter, were employed. Cystic ventriculostomy and cystic ventriculocisternostomies were made in 11 and 6 patients, respectively; one patient underwent endoscopic resection of the walls of an ependymal cyst. In one patient with signs of decreased liquor resorption, endoscopic fenestration was concurrently developed into a ventricle-peritoneal anastomosis. In other 4 anastomosis-dependent patients, the preimplanted mechanically consistent bypass system was left at its site. In 2 of these cases, cystic ventriculostomy was supplemented by ventricular septal fenestration and third-ventricular bottom perforation. Twelve patients were followed up for 6 to 36.5 months (mean 15 months). There has been no information about 6 patients since their discharge. In 12 (66.5%) surgery yielded expected results and the fenestration of cystic walls was followed by their retraction and a steady-state regression of local and/or hypertensive symptoms. In 5 (28%) patients, the complaints and clinical data remained unchanged despite although incomplete but objective cystic relaxation. This was most frequently noted in patients (n = 4) with arachnoidal cysts of the interpedicular cistern and the third ventricle who had endocrine disorders. In one case the operation was stopped due to bleeding. Totally, 5 patients were found to have complications (hemorrhage, ventriculitis). None patient died. Some aspects of indications for endoscopy and surgical techniques are considered. It is concluded that endoscopic internal bypass surgery in patients wit median cystic liquor malformations is the treatment of choice. When equipment is adjusted, fenestration of the membranous walls of these cysts by using an endoscope is reliable and safe. Such patients may be recommended endoscopic technology used as the method of choice.