2025 Proffered Presentations
S099: ENDOSCOPIC ENDONASAL AND TRANSCRANIAL APPROACHES TO SELLAR/SUPRASELLAR ARCHNOID CYSTS: INDICATIONS AND OUTCOMES
Hussam Abou-Al-Shaar, MD; Ibrahem Albalkhi; Joseph Garcia, MD; Ivo Peto, MD; Garret W Choby, MD; Eric W Wang, MD; Carl H Snyderman, MD; Paul A Gardner, MD; Georgios A Zenonos, MD; University of Pittsburgh Medical Center
Objectives: Distinguishing between sellar/suprasellar arachnoid cysts and Rathke's cleft cysts can be challenging due to their similar clinical presentations and imaging characteristics. Endoscopic endonasal approaches (EEA), are typically used to drain Rathke's cleft cysts, while arachnoid cysts generally require transcranial (TCA) fenestration to the suprasellar cisterns. This study aims to identify indications and outcomes of EEA vs TCA for sellar/supraseellar arachnoid cyst management.
Methods: The authors performed a retrospective analysis of records from the University of Pittsburgh Medical Center (UPMC), focusing on patients with sellar/suprasellar arachnoid cysts who underwent surgical intervention. The primary outcomes evaluated included indications, clinical outcomes, and complications.
Results: A total of 22 patients (15 EEA and 7 TCA) with a median age of 58.7 years (IQR 36.4-68.4 years) underwent surgical resection of sellar (n=6) or sellar with suprasellar extension (n=16) arachnoid cysts. Out of the 22 patients 54.5% were male. Most patients presented with visual deficits (72.7%) and headaches (36.3%). A total of 25 operations were performed, with one patient experiencing a single recurrence and another having two recurrences. EEA was utilized in 18 operations, while TCA, mainly supraorbital (eyebrow) craniotomy, was used in 7 operations. The most common indications for EEA were an initial impression of Rathke's cleft cyst (n=10), pituitary adenoma (n=1), or enlarging pituitary cyst (n=4). In 14 of the 15 patients who underwent EEA operations, a vascularized nasoseptal flap was used for reconstruction. Visual improvement occurred in 71.4% of patients who underwent TCA, with only one patient experiencing vision deterioration. Meanwhile, 75.5% of patients who underwent EEA experienced visual improvement, with one patient experiencing worsening. Complications in the EEA group included cerebrospinal fluid leakage (33%) and transient diabetes insipidus (22.2%). All cerebrospinal fluid leaks were managed using a lumbar drain (n=4), endoscopic endonasal repair with abdominal fat graft (n=3), or repositioning of the nasoseptal flap (n=1). The TCA group reported no postoperative complications. Recurrence occurred in one patient in both the TCA and EEA groups, with both recurrences managed by EEA. The patients had a median follow-up of 29.4 months (IQR 9.3-74.6 months).
Conclusion: Both EEA and TCA provide favorable visual outcomes in the management of sellar/suprasellar arachnoid cysts. While TCA remain the primary strategy for these lesions, EEA offers a viable option, particularly for cases initially labeled as Rathke's cleft cysts or pituitary adenomas, given its minimally invasive nature, safety, and efficacy. Nasoseptal flap remains vital in skull base reconstruction in these cases.