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Microscope neuronavigation-guided microsurgical fenestration of quadrigeminal cistern arachnoid cysts: how I do it

  • How I Do it - Neurosurgical technique evaluation
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Abstract

Background

Management options for treatment of quadrigeminal arachnoid cysts (QAC) include microsurgical/endoscopic fenestration or shunt. There is an open debate about which method is the best. Microsurgical fenestration is well suited for treatment of QAC with predominant infratentorial component and without hydrocephalus making endoscopic procedures more challenging.

Method

We describe the microsurgical technique and related anatomy to fenestrate infratentorial QAC through supracerebellar infratentorial approach. We also discuss our experiences with this approach, some of the drawbacks and nuances.

Conclusion

Navigation-guided microsurgical fenestration of infratentorial QAC is the authors’ surgical approach of choice for treating these rare challenging lesions when not associated with hydrocephalus.

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Author information

Authors and Affiliations

  1. Neurosurgery, Department of Neuroscience, Psychology, Pharmacology and Child Health, Careggi University Hospital and University of Florence, Largo Palagi 1, 50134, Florence, Italy

    Luca Campagnaro, Camilla Bonaudo, Federico Capelli & Alessandro Della Puppa

Authors
  1. Luca Campagnaro
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  2. Camilla Bonaudo
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  3. Federico Capelli
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  4. Alessandro Della Puppa
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Corresponding author

Correspondence to Luca Campagnaro.

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Ethical approval

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Informed consent

Informed patient consent was obtained for the procedure illustrated.

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The authors declare no competing interests.

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Key points

1 Microsurgical fenestration through SCIT, with the use of real-time neuronavigation-guided microscope, is well suited for treatment of QAC without hydrocephalus as far as these conditions make the execution of endoscopic procedures challenging.

2. The success rate reported in literature was almost similar after the microsurgical fenestration and the endoscopic procedure.

3. Concorde position is the senior author’s position of choice for this surgery. This position, with operating table in a minimal anti-Trendelenburg position and effective cisternal opening, allows an adequate cerebellar relaxation and avoids venous air embolism that is the major complication of the sitting and semi-sitting positions. Therefore, concorde position is an effective and safe position to approach the pineal region.

4. The exposure of the transverse sinus is important to provide a full access to the superior cerebellar surface.

5. Large and small QACs are usually associated with different anatomical conditions. The former is associated with a large surgical corridor and a distorted anatomy of surrounding venous and neural structures of the posterior fossa. In contrast, small QACs are usually associated with a narrow surgical corridor, limited deep veins exposure, and a substantially normal anatomy of the surrounding venous and neural structures.

6. The SCIT approach implies a long working distance that requires microsurgical expertise with the use of long microinstruments.

7. Small lateral bridging veins located along the trajectory of the surgical corridor can be sacrificed if necessary, during microscope dissection. On the contrary, the sacrificing of larger veins on the midline, such as superior vermian veins and precentral cerebellar vein, must be avoided.

8. Arachnoid band dissection and a wide opening of the AMQ are necessary to identify deep veins and their branches, thus avoiding injury to them. Therefore, an extensive knowledge of the deep veins anatomy is the cornerstone to achieve a safe QAC fenestration.

9. The microsurgical approach allows the surgeon to control the bleeding from deep veins promptly and easily when compared with endoscopic approach.

10. A wide fenestration of the cyst wall is important to ensure a free CSF flow from the cisterns into the cyst and to minimise the risk of recurrence.

This article is part of the Topical Collection on Neurosurgical technique evaluation

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Campagnaro, L., Bonaudo, C., Capelli, F. et al. Microscope neuronavigation-guided microsurgical fenestration of quadrigeminal cistern arachnoid cysts: how I do it. Acta Neurochir 165, 2561–2565 (2023). https://doi.org/10.1007/s00701-023-05531-8

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