Childs Nerv Syst (2015) 31:87–93
DOI 10.1007/s00381-014-2530-4
ORIGINAL PAPER
Microsurgical fenestration and cystoperitoneal
shunt through preauricular subtemporal keyhole
craniotomy for the treatment of symptomatic middle
fossa arachnoid cysts in children
Gökalp Silav & Ramazan Sarı & Fatih Han Bölükbaşı &
Murat Altaş & Nejat Işık & İlhan Elmacı
Received: 23 July 2014 / Accepted: 10 August 2014 / Published online: 21 August 2014
# Springer-Verlag Berlin Heidelberg 2014
Abstract
Introduction The optimal surgical treatment for symptomatic
middle fossa arachnoid cyst is still controversial. The most
leading therapeutic options include cyst shunting and fenes-
tration (endoscopic, microsurgical). We present our experi-
ence on surgical treatments of arachnoid cysts.
Patients and methods A retrospective data review of 16 chil-
dren who underwent keyhole craniotomy for microsurgical
fenestration and shunting of middle fossa arachnoid cysts
between 1999 and 2012 was performed after institutional
review board approval. The average patient age was 6.1 years.
The average follow-up period was 36.5 months. There were
ten male and six female patients in the series. Indications for
surgery included intractable headaches (50 %), increasing in
cyst size (18.75 %), and seizures (31.25 %). All patient
records were reviewed for their clinical presentation, classifi-
cation, cyst resolution, symptom resolution, and cyst out-
comes. After surgery, all patients underwent assessments of
clinical and radiological improvement.
Results Postoperative complications were observed in two
cases: progressively resolving monoparesia in one case and
resolving epileptic seizure with monotherapy in the other. All
patients had a satisfactory clinical outcome, and in 87.5 %,
G. Silav (*) : R. Sarı : F. H. Bölükbaşı : İ. Elmacı
Faculty of Medicine Department of Neurosurgery,
Medipol University, İstanbul, Turkey
e-mail: gsilav@yahoo.com
M. Altaş
Faculty of Medicine, Department of Neurosurgery,
Akdeniz University, Antalya, Turkey
N. Işık
Faculty of Medicine, Department of Neurosurgery,
Medeniyet University, İstanbul, Turkey
there was either a decrease in the size or a complete disap-
pearance of the MFAC. Nevertheless, three (18.75 %) of all
patients needed shunt revision because of shunt dysfunction.
Complication related to surgical technique was cerebrospinal
fluid leak which spontaneously resolved in one patient.
Conclusion Microsurgical fenestration with keyhole craniot-
omy to provide passage between cysts to basal cisterns to-
gether with cystoperitoneal shunting during the same opera-
tion is still an effective and safe method in cases with symp-
tomatic middle fossa arachnoid cysts in children.
Keywords Arachnoid cyst . Shunting . Microsurgical
fenestration . Keyhole approach
Introduction
Arachnoid cysts are extra-parenchymal, intra-arachnoidal col-
lections of fluid with a composition close to that of the
cerebrospinal fluid. Cysts develop within the arachnoid mem-
brane because of splitting or duplication of this membrane [8].
Arachnoid cysts account for up to 1 % of non-traumatic
intracranial mass lesions as reported in autopsy and neurora-
diological studies [1, 28]. The middle fossa is the most com-
mon location for arachnoid cysts. In larger series, it was
reported that the middle fossa arachnoid cysts (MFAC) ac-
count for 34 to 50 % of all arachnoid cysts [16, 17].
Although some may consider it a benign pathology, pa-
tients with MFAC may develop a range of signs or symptoms
which include headache, seizure, temporal bulging, focal neu-
rologic deficit, macrocrania, and hydrocephalus (Table 1) [14,
19, 21, 24]. MFAC may also cause increased intracranial
pressure, cognitive decline, and endocrine dysfunction [26].
The surgical treatment of symptomatic intracranial arachnoid
88 Childs Nerv Syst (2015) 31:87–93

Table 1 Clinical signs and

symptoms No. Age Side Symptoms Galassi type Complications Radiological Clinical
and signs outcome outcome

1 7m L Seizure 2 Cyst reduced Seizure free

2 9m L Seizure 2 Cyst reduced Seizure free
3 11 m R Seizure 3 Cyst reduced Seizure free
4 1.5 y R ICS 3 Cyst reduced SD
5 4y L Headaches 3 Cyst reduced Improved
6 2y R ICS 3 Cyst reduced SD
7 2.5 y R ICS 2 Hemiparesis Cyst reduced Recovered
8 6y R Seizure 2 Cyst reduced Improved
9 5y L Seizure 3 Seizure Unchanged Improved
10 11 y L Headaches 2 Cyst reduced SD
11 14 y R Headaches 3 Cyst reduced SD
12 7y L Headaches 2 Cyst reduced SD
13 9y R Headaches 3 Cyst reduced SD
14 8y R Headaches 3 Cyst reduced SD
m month, L left, R right, y year, 15 10 y L Headaches 2 Cyst reduced SD
SD symptoms disappeared, ICS 16 17 y R Headaches 3 Unchanged SD
increasing in cyst size

cysts with mass effect remains controversial. Patients with
asymptomatic or incidental cyst should be monitored clinical-
ly and radiologically. Surgical management should be consid-
ered only for enlarging cysts causing neural compression,
hydrocephalus, or refractory symptoms attributable to mass
effect [26]. Treatment options include cyst shunting, craniot-
omy for fenestration [13, 20, 24], deviation of cyst fluid to
another intracranial space, and endoscopic fenestration [5,
17]. Each of these techniques has its own advantages and
disadvantages; but none is superior to the others, and debate
continues regarding which surgical treatment is most
effective.
Patients and methods
A retrospective review data of 16 children who underwent
keyhole craniotomy for microsurgical fenestration and
shunting of middle fossa arachnoid cysts between 1999 and
2012 was performed after institutional review board approval.
During the study period, we treated 16 cases of pediatric
arachnoid cyst. During that period, the first-line treatment
for all symptomatic MFAC was preauricular subtemporal
keyhole craniotomy, microsurgical basal cisternal fenestra-
tion, and cystoperitoneal shunt placement. All patient records
were reviewed and categorized for their age, clinical presen-
tation, Galassi classification, cyst resolution, and symptom
resolution. After surgery, all patients underwent assessments
of clinical improvement and reductions in cyst size in serial
imaging studies. Routine follow-up scans were obtained
postoperatively.
Surgical technique
Our surgical technique consists of a combination of fenestra-
tion and shunting. For microsurgical fenestration through
preauricular subtemporal keyhole craniotomy, previously de-
scribed technique by Levy et al. [23] has been used with the
following modifications. Briefly, under general anesthesia,
patient is positioned supine with a shoulder roll support. The
head is rotated 90° away from the side of the lesion. The head
is positioned on a headrest, and small area of the hair above
the zygoma is shaved. Proper medications and prophylactic
antibiotics are administered preoperatively.
A 2-cm-long linear incision is then made behind the hair-
line from the root of the zygoma. Muscle fiber separating
dissection through the temporalis muscle is then performed
that allows placement of a small self-retaining retractor. A
small hole is made with a high-speed drill, and a 1.5×2 cm
cranial flap is removed. At this stage, the operating micro-
scope is brought into the surgical field and the dura mater is
opened via a small “u”-shaped incision.
Microscissors are used to incise the outer arachnoid mem-
branes to liberate the cyst fluid. The deeply situated neural and
vascular structures are identified and sharply freed of arach-
noid membrane. The dissection then continued to the deeper
membranes. The membrane of Liliequist is fenestrated, in
order to aid in the communication of the deep basal cisterns.
Throughout the procedure, sharp surgical dissection is pre-
ferred to protect the deep neural and vascular structures. At the
end of the fenestration stage of the surgical procedure, oper-
ating microscope is removed from the surgical field. At the
shunting stage of the surgery, proximal part of a catheter used
Childs Nerv Syst (2015) 31:87–93
for standard ventriculoperitoneal shunting procedure is placed
into the cyst cavity. This catheter is then attached to a valve
and the valve is connected to the distal catheter. Subsequently,
a small incision is made on the lower abdomen followed by
opening a tunnel under the skin from the abdominal cavity to
the scalp, in order to aid in the placement of the tip of the distal
catheter inside of the peritoneal cavity (Fig. 1).
The arachnoid cyst cavity is then filled with saline solution,
and the dura is closed with 4–0 monofilament sutures. The
bone flap is fastened in place with non-absorbable sutures.
The temporalis and abdominal muscles are then
reapproximated with 3–0 Vicryl, scalp and abdominal inci-
sions are reapproximated with 4–0 Vicryl. After the
extubation process, the patient is transported to the recovery
room and then hospitalized for 72 h. Communications be-
tween the cyst and basal cisterns allow free circulation of cyst
fluid. In this keyhole approach, the operation directly involves
the cisterns surrounding the internal carotid artery and its
branches [23].
Result
The average patient age at the time of surgery was 6.1 years
(range, 7–14 years). The average follow-up period was
36.5 months (range, 12 months–5 years). There were ten male
and six female patients in the series. Seven cysts were on the
left while nine cysts were on the right hemisphere. Indications
Fig. 1 The place and route of
keyhole surgical procedure
89
for surgery included intractable headaches (50 %), increasing
in cyst size (18.75 %), and seizures (31.25 %). The patients
were hospitalized in a regular ward for 2 to 6 days. The mean
surgical time was 140 min, while the total surgical time ranges
from 120 to 160 min. Postoperative complications were ob-
served in two cases: progressively resolving monoparesia in
one case and resolving epileptic seizure with monotheraphy in
the other. All patients had a satisfactory clinical outcome, and
in 87.5 %, there was either a decrease in the size or a complete
disappearance of the MFAC (Figs. 2 and 3). Nevertheless,
three (18.75 %) of all patients needed shunt revision because
of shunt dysfunction. Radiological finding of these patients
indicated postoperative cyst reaccumulation. Complication
related to surgical technique was cerebrospinal fluid leak
which spontaneously resolved in one patient.
Discussion
Intracranial arachnoid cysts have been observed in an increas-
ing frequency in children with the routine use of CT and MRI.
Although most arachnoid cysts remain static fluid-filled com-
partments throughout life, some become enlarged and cause a
mass effect on adjacent neural structures. The enlargement of
the cyst seems to be the result of cerebrospinal fluid infiltration
across osmotic gradient and unidirectional flow through a ball-
valve mechanism [12, 34]. Controversy still exists about the
best treatment modality for intracranial arachnoid cysts.
90
Fig. 2 Preoperative cranial CT images are showing bilateral middle fossa
arachnoid cysts with the same density as CSF
Conventional options include as follows: (a) craniotomy with
resection of the cyst walls and marsupialization into the sub-
arachnoid space, basal cisterns, or ventricles [11, 37]; (b)
shunting procedures that include either cystoperitoneal [27,
37] and ventriculoperitoneal shunt when hydrocephalus is pres-
ent or internal shunt to the subdural compartment [6, 25, 39];
Fig. 3 Two years after surgery, follow-up cranial CT images are showing
complete shrinkage of cyst. The intracystic part of the shunt is visible
nearby temporal pole
Childs Nerv Syst (2015) 31:87–93
(c) stereotactic aspiration or fenestration of the cyst cavity; and
(d) neuroendoscopic fenestration [9].
Direct surgical excision or the opening of the cyst linings
once a Sylvian fissure cyst is recognized is still the favorite
approach in a significantly high percentage of neurocenters
[38]. Nevertheless, endoscopic fenestration is progressively
taking place within the different methods. The specific ap-
proach should be based on the individual characteristics of
each cyst and the surgeon’s experience [4]. Actually, the
surgical decision seems still to depend on the surgeon’s atti-
tude more then on a rational base [38].
We preferred a combined approach and performed a
preauricular subtemporal keyhole craniotomy with microsur-
gical fenestration and cystoperitoneal shunt during the same
operation. We observed the advantages of this method in
terms of radiologic and clinical improvements of our patients.
Temporal craniotomies and subtemporal approaches to
trigeminal ganglion have been described as early as 1911 by
Fedor Crause, modern anterior subtemporal approaches in the
microsurgical treatment has been demonstrated by Taniguchi
and Perneczky [30].
In this technique, the keyhole is as small as the
craniectomies required for endoscope placement. Open surgi-
cal procedures permit bimanual manipulation and the use of
regulated suction to manipulate arachnoid membranes.
Bleeding can be more easily controlled with traditional
methods such as bipolar cautery and topical application of
hemostatic agents. Stereoscopic observation through the mi-
croscope gives the surgeon superior depth perception, partic-
ularly during deep dissection. All of these factors improve the
safety of sharp arachnoid membrane dissection. The familiar-
ity of traditional microsurgical techniques makes open proce-
dures more accessible to most surgeons, avoiding a potentially
hazardous learning curve [23].
Levy et al. [23] recorded an improvement or a complete
recovery in 95 % of patients in a series of 50 patients who
underwent craniotomy and microsurgical fenestration. Two
patients in their series required a cystoperitoneal shunt, and
16 experienced a complication: pseudomeningocele in five
(with one patient requiring further surgery), CSF leak in three,
transient third cranial nerve palsy in three, postoperative sei-
zure in one, CSF infection in two, and subdural hygroma in
two patients. In our series, there was only one complication
related to surgical technique, being a spontaneously resolving
cerebrospinal fluid leak in one patient.
Hopf and Perneczky [17] reported that 60 % of patients
showed clinical improvement and 40 % exhibited radiological
improvement in a review of ten cases of endoscopically treat-
ed Sylvian fissure cysts.
Spacca et al. [35] obtained a good clinical outcome with
complete recovery or significant improvement with endoscop-
ic fenestration in 40 (92.5 %) patients. Headache was the most
likely symptom to improve, with a complete recovery or
Childs Nerv Syst (2015) 31:87–93
significant improvement in 14 (93.3 %) patients. On the other
hand, abnormalities on neurological examination and the other
non-functional signs and/or symptoms were resolved or im-
proved in 11 (78.4 %). In our series, all patients had a satisfac-
tory clinical outcome, and in 87.5 %, there was a decrease in the
size or complete disappearance (in two patients) of the MFAC.
Ciricillo et al. [7] treated 15 children by fenestration and
reported 67 % showed no clinical or radiological improve-
ment and required shunt placement. In the same study, 20
patients were treated by shunt and there was improvement in
all patients postoperatively. Shunt revision was necessary in
six (30 %) patients [7, 33].
Raffel et al. [31] reported a series of 34 arachnoid cysts
treated by fenestration and 7 (24 %) of those required a
subsequent shunt placement, 41.7 % of these were revised
for shunt dysfunction. Patients with hydrocephalus or
macrocephaly are likely to require VP shunt placement in
addition to cyst fenestration. Children with non-specific
macrocephaly may harbor a latent derangement of CSF circu-
lation [22].
Helland [16] reported a significant association between
volume reduction greater than 50 % and clinical improvement.
Kaldenwein [18] reported that shunting procedures resulted in
74 % of the cyst reduction compared with 58 % after fenes-
tration. In our series, we observed reduction of the cyst size in
87.5 % of the patients.
Cystoperitoneal shunt placement is an appealing option
given the simplicity of the surgical technique involved and
the availability of intraoperative guidance via ultrasonography
or neuronavigation [29]. MFAC can be managed with a safe
method in which a cystoperitoneal shunt is placed alone. But
this method unfortunately brings the disadvantages of a well-
known shunt dysfunction and higher incidence of additional
surgical procedures with its own complication risk [27, 37].
The development of slit-cyst syndrome is also possible fol-
lowing cystoperitoneal shunt placement.
Raffel et al. [31] reported a series of 34 arachnoid cysts.
Twenty nine cysts were treated by fenestration, and 7 (24 %)
required a subsequent shunt placement. Postoperative cyst
reaccumulation has been reported to occur in approximately
25 % of patients [31, 36]. Reported rates of shunt revision in
arachnoid cysts are approximately 30 % [15, 36]. In our series,
there are three (18.75 %) shunt revisions because of postop-
erative cyst reaccumulation.
Arai et al. [2] performed cystoperitoneal shunting in 77
patients with MFAC and reported that complete resolution
occurred in all cases of headache, hemiparesis, chocked disc,
diplopia, and macrocrania (35 patients). Eight patients in their
series required further surgical treatment for shunt malfunc-
tion with a total of 12 operative procedures with one shunt
infection, one transient oculomotor palsy, and one extra-dural
hematoma. Similar results were obtained by smaller studies
treated with craniotomy or shunt CSF diversion [16, 17].
91
Many authors report that both procedures, fenestration and
shunting, are equally effective for the treatment of the intracra-
nial arachnoid cysts, adding that factors that actually influence
outcome are the rate of volume reduction and the cyst location
more than the therapeutic modality. Decision-making for sur-
gical intervention in symptomatic arachnoid cysts should con-
sider these findings and should aim at an optimal volume
reduction to achieve the best possible results [18]. Treatment
decisions should also take into account complication rates.
Increasing attention paid toward surgical approaches such as
the endoscopic treatment, which are believed to carry a minor
surgical risk, is not surprising. Unfortunately, the clinical evidence
to demonstrate that endoscopy does bear a significantly minor risk
for surgical complications than microsurgery is still lacking [38].
While fenestration of the cysts, either open or endoscopically,
has the advantage of leaving the patient shunt independent, there
have been reports of considerable recurrences [7, 10, 27, 31, 32].
Shunt placement has been proved to effectively control cyst
volumes and related clinical symptoms. It is, however, accom-
panied by the possibility of shunt failure or infection [27, 31].
Berry et al. [3] reported a retrospective, longitudinal cohort
of 1,307 children ages 0 to 18 years undergoing initial ventric-
ular shunt placement for hydrocephalus. This study indicated
that the hospital volume of initial shunt placement was associ-
ated with lower revision rates. Hospitals where 1 to 20 initial
shunt placements per year experienced the highest initial shunt
revision rate (42 %). Hospitals performing over 83 initial shunt
placements per year experienced the lowest revision rate
(22 %). In our MFAC series, the revision rate was 18.75 %.
This lower ratio conflicting with the literature may be attributed
to the better presurgical condition of MFAC patients in terms of
prematurity and immunity in comparison with ventricular shunt
patients. Besides, malpositioning of the shunt is not an expected
situation in keyhole craniotomy technique, which may contrib-
ute for an explanation why the revision rates remain lower than
available literature. Review of the current literature does not
provide any data showing superiority of microsurgery, endo-
scopic fenestration, or cystoperitoneal shunt alone to each other
for MFAC. Cystoperitoneal shunting is usually recommended
when fenestration procedure remains insufficient. Shunt revi-
sion is also required when shunt dysfunction is present. Shunt
procedures do not seem as the prominent choice of treatment if
only the complication rates are taken into account. On the other
hand, shunting procedures surpass over fenestration while the
risk of recurrence is considered. Formerly, we did not prefer
fenestration alone in our clinic owing to the possible
reaccumulation risk and insufficient shrinkage of cyst volume.
The only method we performed for MFAC until 1999 was
cystoperitoneal shunting. We then had tendency to microsurgi-
cal fenestration in parallel with popularized fenestration tech-
niques. Even though complete avoidance of complications is
not a case for both techniques, the combined approach should
be considered as a valuable additional treatment choice when
92
treatment responses are accounted in terms of providing satis-
factory shrinkage which is the key for concomitant clinical
improvement and decreasing recurrence rate.
Cystoperitoneal shunting has been a widely accepted meth-
od for the treatment of MFACs. We prefer shunting for its
advantage of more effective reduction on cyst size and better
clinical outcome. With our technique, only minicraniotomy is
added instead of a single hole used for shunting to take the
advantage of fenestration at the same time. The technique that
we applied offers easy and safe access to MFACs. The specific
localization of MFACs offer an easy approach to basal cisterns
by forming a corridor without any necessity for brain tissue
retraction. Above-mentioned advantages of both fenes-
tration and shunting techniques led us to perform a
combined approach to benefit both aspects of each
surgical techniques. However, we combine fenestration
with shunting, we do not prefer fenestration alone be-
cause the high risk of reaccumulation. We also believe
that the combination of both techniques increase overall suc-
cess of treatment.
Our combined approach of microsurgical fenestration via
preauricular subtemporal keyhole craniotomy and
cystoperitoneal shunting have been found to be satisfactory
for both clinical and radiological improvement with 18.75 %
shunt dysfunction rate slightly lower than that documented in
literature.
According to these results, we suggest that cystoperitoneal
shunting should be performed in addition to fenestration to
avoid early reaccumulation; therefore, the need for additional
surgical procedures will be minimized.
Conclusion
Management of MFACs remains controversial. Microsurgical
subdural and basal cisternal fenestration with keyhole crani-
otomy to provide passage between cysts and basal cisterns
together with cystoperitoneal shunting during the same oper-
ation is still an effective and safe surgical method in cases with
symptomatic MFACs in children.
Acknowledgements None
Conflict of interest None (I certify that there is no actual or potential
conflict of interest in relation to this article).
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