Endoscopic management of pineal cyst-associated aqueductal stenosis
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ORIGINAL ARTICLE - CSF CIRCULATION
Endoscopic management of pineal cyst-associated aqueductal stenosis Laurence Davidson 1 Received: 24 March 2020 / Accepted: 19 May 2020 # This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2020
Abstract Object The purpose of this study was to evaluate whether endoscopic third ventriculostomy (ETV) and endoscopic cyst fenestration are effective minimally invasive alternatives to a craniotomy with cyst resection for the treatment of symptomatic pineal cyst-associated aqueductal stenosis. Methods Sixteen patients with symptomatic pineal cysts were operatively managed endoscopically and these cases were retrospectively reviewed. There were 12 females and 4 males. The median age at the time of surgery was 31 years (range 3 to 62 years). Results All patients presented with symptoms and imaging consistent with elevated intracranial pressure. The median maximum cyst diameter was 15 mm (range 10 mm to 27 mm). In all cases, there was mass effect on the tectum that resulted in effacement of the cerebral aqueduct and ventriculomegaly was present in 38% of cases. ETV was performed in 15 patients. Cyst fenestration was performed in 2 patients, one of which also had an ETV. Resolution of symptoms was achieved in 81% of patients with a median follow-up of 13 months. Conclusion This study showed that ETV is effective for symptomatic pineal cyst-associated aqueductal stenosis. Patients can be symptomatic without overt ventriculomegaly and normal ventricular volume does not preclude safe endoscopic management. Endoscopic cyst fenestration is recommended if a Perinaud syndrome is present or if ETV is not feasible. Keywords Aqueductal stenosis . Endoscopic third ventriculostomy . Headache . Pineal cyst
Introduction Pineal cysts are typically found incidentally and intervention is usually not indicated. They are shown on MR imaging of the brain in 1.3–4.5% of patients and in up to 40% of pineal glands examined at autopsy [8, 9, 17, 19]. Pineal cysts appear to occur more commonly in women, especially those under 41 years old [17, 19]. Surgery is indicated for symptomatic mass effect on the tectum, which can result in obstructive hydrocephalus and Perinaud syndrome. Even without overt evidence of hydrocephalus some pineal cysts can exert enough mass effect on the rostral tectum to cause aqueductal stenosis and resultant headaches [18]. By removing the cyst This article is part of the Topical Collection on CSF Circulation * Laurence Davidson [email protected] 1
Division of Neurosurgery, Walter Reed National Military Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889, USA
the cerebral aqueduct diameter can increase, which correlates with headache resolution [18]. The purpose of this study was to evaluate whether endoscopic third ventriculostomy (ETV) and endoscopic cyst fenestration are an effective minimally invasive alternative to a craniotomy with cyst resection for the treatment of symptomatic pineal cyst-associated aque
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