Intracranial arachnoid cysts: What is the appropriate surgical technique? A retrospective comparative study with 61 pediatric patients

OBJECTIVE: Symptomatic intracranial arachnoid cysts (ACs) should be treated either through microsurgical (MS) or endoscopic surgical (ES) fenestration. Implantation of cysto-peritoneal shunt (CPS) system is another treatment option with decreasing indication. In our study, we compared the complication and revision rates between the three operative techniques in pediatric patients. METHODS: We included patients below 18 years with symptomatic intracranial ACs operated between 2004 and 2021. Initial symptoms, location, complication rate, clinical and radiological improvement, postoperative events and revision rate were compared retrospectively. RESULTS: Sixty-one patients; 33 (54.1%) MS operated (mean age 7.6 years), 18 (29.5%) ES operated (mean age 6.2 years) and 10 (16.4%) with CPS (mean age 3.0 years) were collected. The most common initial symptom was headache in 45.9%. 20 (32.8%) postoperative events were documented. The highest revision rate (60%) was seen in the CPS group compared to 33.3% in MS group and 16.7% in ES group. 31 patients harbored perisylvian ACs, 89% remained event-free after ES, 71% after MS and 20% after CPS. Clinical improvement immediately after surgery was observed in 58 patients (96.9% in MS, 88.9% in ES and 100% in CPS). A radiological volume reduction could be proven postoperative in 51 patients (78.8% MS, 88.9% ES and 90% CPS). CONCLUSION: Endoscopic fenestration of AC is a safe and efficient technique which is being widely used nowadays with the highest event free survival compared to microsurgical fenestration especially in perisylvian arachnoid cysts. CPS shows on long terms the highest revision rate but carries the least surgical risks.