Endoscopic endonasal and transcranial approaches to sellar/suprasellar arachnoid cysts: indications and outcomes.

Abstract

Distinguishing between sellar/suprasellar arachnoid cysts (ACs) and Rathke cleft cysts (RCCs) can be challenging due to their similar clinical presentations and imaging characteristics. Endoscopic endonasal approaches (EEAs) are typically used to marsupialize RCCs, while ACs require fenestration to the suprasellar cisterns, often via a transcranial approach (TCA). This study aimed to identify indications and outcomes of EEA versus TCA for sellar/suprasellar AC management. The authors performed a retrospective analysis focusing on patients with sellar/suprasellar ACs who underwent surgical intervention, focusing on indications, clinical outcomes, and complications. A total of 17 patients with a median age of 58 years underwent surgical treatment of sellar (n = 6) or sellar with suprasellar extension (n = 11) ACs. Most patients presented with visual deficits (88%) and headaches (65%). EEA was performed in 11 cases, while TCA was used in 6 cases. The most common indications for EEA were an initial impression of RCC (n = 9), or cystic pituitary adenoma (n = 2), as well as a primarily sellar location/perceived narrow transcranial window (n = 6). During a median follow-up of 39 months, vision improved or remained stable in all patients who underwent either TCA or EEA. Complications in the EEA group included CSF leakage in 6 patients (with sellar-type AC) and transient diabetes insipidus in 1 patient. The TCA group reported no postoperative complications, but did have 1 recurrence, which was managed by an EEA. Both EEA and TCA provide long-term control and favorable clinical and visual outcomes in the management of sellar/suprasellar ACs. TCA remains the primary strategy for ACs with suprasellar extension, when feasible, due to the high CSF leak rates associated with EEA. EEA was able to successfully manage both purely sellar cases and those with suprasellar extension, while TCA cases all had suprasellar extension. All CSF leaks in this series occurred in purely intrasellar AC cases. EEA offers a viable option, particularly for purely sellar cases, unclear diagnosis, narrow transcranial window for safe fenestration, or in recurrent lesions following TCA.