Endoscopic surgery for large posterior fossa arachnoid cysts

The authors report two cases of large arachnoid cysts of the posterior fossa treated by endoscopic surgery. One patient underwent a successful endoscopic cyst fenestration by burr hole approach after several procedures of shunt revision. In another an endoscope-assisted microsurgical intervention was necessary. Lateral (cerebellar or cerebellopontine angle) cysts, as two reported cases, may be treated through a lateral retromastoid approach by fenestration into the prepontine cistern and eventually into the cisterna magna. We advise to start the operation through a burr hole and to try to realize the fenestration by endoscopy only. If this attempt fails, an endoscope-assisted microsurgical technique may be performed by enlarging the craniectomy. In this last instance the endoscope is useful particularly deeply to fenestrate the anterior cyst wall in the prepontine or ambient cisterns, where it provides more illumination and helps to identify the nervous and vascular structures.