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KEYWORDS: Arachnoid cyst, Pediatric,
Microsurgery, Endoscopy.
CASE PRESENTATION
The 1-year old boy presented with muscular hypotension, psychomotor
retardation and strabismus (esotropia). The head circumference percentile
jumped from 50 % at 6 months postnatal to 97 % at 12 month. While lying on his
back the child was not able to turn on his belly. Sitting was not possible.
Preoperative magnetic resonance imaging (MRI) of the head displayed a
large arachnoid cyst of the posterior cranial fossa. The cyst obviously
compressed the right cerebellar hemisphere and the brainstem with shift of the
midline structures (brainstem) to the left. Due to obstruction of cerebrospinal
fluid (CSF) pathways at the level of the forth ventricle hydrocephalus was
demonstrated on the images.
The video shows microsurgical, endoscopic assisted fenestration of the
arachnoid cyst to the basal cisterns via a small right-sided retroauricular
osteoplastic craniotomy. Fenestration of the cyst was performed towards the
spinal arachnoid space through the foramen magnum, between the lower cranial
nerve (CN) group (IX, X, XI) and the VIIth and VIIIth CN and between these
latter nerves and the trigeminal nerve. Particular care was taken to preserve
the delicate vasculature of the CNs, cerebellum, and brainstem. Neuronavigation
although performed was of limited value due to gross distortion of the
structures.
The postoperative course was uncomplicated. The child made a good
neuropsychological progression postoperatively and was able to sit 6 weeks
after surgery. He was able to walk unassisted 9 months after the intervention.
Strabismus was unchanged so far. Follow-up MRI after 2.5 years demonstrated
deflation of the cyst with decompression of the brainstem and regression of
hydrocephalus.
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