Endoscopic treatment of quadrigeminal arachnoid cysts in children

Quadrigeminal arachnoid cysts (QACs) are rare, comprising approximately 5%-10% of all intracranial arachnoid cysts. The management of these cysts is challenging, and their optimal surgical treatment is controversial. This study evaluates the role of endoscopy in the treatment of QACs in children, focusing on some factors or technical aspects that might influence the outcome.

Eighteen children with symptomatic QACs were the subject of this study. The group included 10 boys and 8 girls, with a mean age of 2.5 years. All patients had hydrocephalus. Surgical treatment included ventriculocystostomy (14 cases), endoscopic third ventriculostomy (14 cases), ventriculocystocisternostomy (2 cases), cystocisternostomy (2 cases), and removal of preexisting malfunctioning cystoperitoneal shunt (4 cases).

Significant clinical improvement occurred in 15 cases (83.3%). Postoperative MRI showed a reduction in the cyst size in 14 cases (77.8%), whereas in the remaining 4 cases (22.2%) the cyst size was unchanged. A postoperative decrease in ventricular size was encountered in 16 cases (88.9%). Minor intraoperative bleeding occurred in 1 case (5.6%), which stopped spontaneously without any postoperative sequelae. Postoperative subdural hygroma occurred in 3 cases (16.7%) and required a subduroperitoneal shunt in 2 cases. During follow-up (mean 45.8 months), a repeat endoscopic procedure was performed in 7 patients (all 4 patients with a prior shunt and 3 patients without a prior shunt), and new shunt placement was required in 5 patients (all 4 patients with a prior shunt and 1 patient without a prior shunt). Thus, none of the patients with a prior shunt was able to become shunt independent, whereas 92.9% of patients without a prior shunt were able to avoid shunt placement.

Arachnoid cysts of the quadrigeminal cistern and the associated hydrocephalus can be effectively treated by endoscopy. The procedure is simple, minimally invasive, and associated with low morbidity and mortality rates. The fact that all patients who previously received shunts required a repeat endoscopic procedure and that none of these patients was able to become shunt independent makes it clear that endoscopic treatment should be considered the first choice in the management of patients with arachnoid cysts in the quadrigeminal cistern.