Quadrigeminal Cistern Research Articles

Lipoma of the Quadrigeminal Cistern as a Rare Cause of Vertigo: Case Report with Literature Review

Lipoma of the Quadrigeminal Cistern as a Rare Cause of Vertigo: Case Report with Literature Review

A VEIN OF GALEN MALFORMATION - A RARE CAUSE OF CONGESTIVE CARDIAC FAILURE IN NEONATE

Vein of Galen aneurysmal malformation (VGAM) is a rare congenital vascular malformation caused by the maldevelopment of its embryonic precursor, the median prosencephalic vein of Markowski. Vein of Galen aneurysmal malformation (VGAM) is a rare cause of congestive heart failure in the neonatal period and carries a high mortality rate. It is a difcult diagnosis because the clinical picture often presents with symptoms suggesting that the patient has a congenital cardiac malformation.1,2 Patients are subjected to high-risk procedures such as cardiac catheterization to establish a diagnosis. These investigations often have negative ndings and can delay correct diagnosis. Here we report a case of Four days old neonate with c/o Increased respiratory activity since 2 days with tachycardia, tachypnea and oliguria. Continuous murmur was noted with features suggestive of Congestive cardiac failure i.e. Tachycardia, tachypnoea, hepatomegaly. Bruit + over Anterior Fontanelle. USG skull revealed the presence of Vein of Gallen Aneurysmal Malformation. 2D ECHO was done which suggestive of Congenital Heart Disease; moderate OS ASD with left to right shunt Dilated cardiac chambers; No PAH; Normal biventricular function .CECT Brain showed the presence of Aneurysmal deep venous structure measuring 20 x 25 mm noted in the supratentorial region of posterior fossa (in quadrigeminal cistern) which drained to vein of galen (VGAM) and the vessel feeding the aneurysm was arising from basilar artery.Hence diagnosis was made.Child initially treated symptomatically for cardiac failure then Endovascular treatment i.e. embolization was performed on 30th day of life.The VGAM was partially occluded.Then symptoms got relieved after Embolization

Subarachnoid Fat Globules Following Spinal Surgery: A Case Report (P3-4.003)

<h3>Objective:</h3> To present a rare case of intracranial subarachnoid fat globules in a patient with a recent history of lumbar laminectomy. <h3>Background:</h3> Fat globules in the subarachnoid space are a rare phenomenon which has previously been described in association with the rupture of dermoid/epidermoid tumors of the central nervous system, or secondary to subarachnoid fat embolism in the setting of traumatic spinal injury. Computed tomography (CT) characteristics of the fat tissue resemble pneumocephalus with the hypodense appearance which might create a diagnostic challenge requiring magnetic resonance imaging (MRI). Here, we present a rare case of a patient with subarachnoid fat globules without any preceding intracranial/intraspinal tumor or traumatic injury of the neuroaxis. <h3>Design/Methods:</h3> Retrospective case review <h3>Results:</h3> A 65-year-old male presented with five weeks of daily, bitemporal, throbbing headache. Headaches started two weeks after a lumbar laminectomy. He reported his headaches built up gradually in the afternoon with increasing intensity throughout the day. They improved when lying down and sleeping overnight. There were no other associated complaints. The patient was evaluated for potential intracranial hypotension as the etiology of his headaches. Initially his CT brain reported potential air pockets in the suprasellar cistern region. MRI of the brain later identified these as multiple lobules of fat in the subarachnoid space in the inferior margin of the cerebellum, 4th ventricle and suprasellar and quadrigeminal cisterns. MRI of the neuroaxis was otherwise negative for fat tissue in the subarachnoid space. MRI of the lumbar spine showed localized soft tissue fluid collection. CT myelogram confirmed cerebrospinal fluid (CSF) leak at L4–5 in the vicinity of the thecal sac. <h3>Conclusions:</h3> The differential diagnosis of subarachnoid fat globules should include iatrogenic causes such as spinal surgery. <b>Disclosure:</b> Dr. Zhao has nothing to disclose. Dr. Beck has nothing to disclose. Dr. Erol has nothing to disclose. Dr. Gul has nothing to disclose. The institution of Dr. Beach has received research support from Neurona.

Management of Peri-mesencephalic Hemorrhage leading to acute hydrocephalus in an infant following Mild Trauma (P12-5.030)

<h3>Objective:</h3> To characterize etiology, risk factors, and management of peri-mesencephalic hemorrhage and severity of clinical presentation in pediatric populations <h3>Background:</h3> Peri-mesencephalic hemorrhage (PMH) is a form of mild subarachnoid hemorrhage (SAH) where the bleed is localized near the midbrain or just anterior to the pons without intraparenchymal or ventricular extension. It is typically a non-aneurysmal SAH (NASAH) with no clear source of bleeding after extensive vessel imaging including angiogram. Many hypotheses have been proposed such as spontaneous rupture of a perforating artery or an entirely venous source. Traumatic causes are rarely described. Outcomes are typically much better than aneurysmal SAH and other forms of NASAH with very low risk of rebleed, hydrocephalus, and little to no long-term neurologic deficits. <h3>Design/Methods:</h3> case study <h3>Results:</h3> An 8-month-old developmentally appropriate girl with no prior history of trauma who presented with three episodes of vomiting and lethargy 3–4 hours after a fall from standing position due to loss of balance while she was holding on to a folding chair. She fell backwards onto a tile floor and chair fell on top of her. CTH was obtained which showed prepontine and pontocerebellar hemorrhage spreading to ambient cisterns, IVH of the lateral and 3rd ventricles with acute noncommunicating hydrocephalus and no fracture. CTA with contrast and later MRI brain, MRA, and angiogram did not show any aneurysm or AVM per neurosurgery. EVD was placed with improvement in mental status. Repeat MRI brain was stable with very slight interval increase ventricle, and patient discharged home after 3rd ventriculostomy with no deficits. <h3>Conclusions:</h3> Though rare, trauma is a potential cause of PMH in pediatric populations and can present with acute hydrocephalus due to obstruction of ventricular system successfully treated with EVD placement and 3rd ventriculostomy with positive outcome. Hemorrhage may potentially be due to rupture of small perforating arteries through a sheering force. <b>Disclosure:</b> Dr. Johnson has nothing to disclose. Dr. Ming has nothing to disclose. Dr. Heshmati has nothing to disclose.

Percutaneously Placed Gasserian Neurostimulation Electrode Migration Into the Quadrigeminal Cistern: Pathophysiological Hypothesis and Report of Successful Repositioning

Percutaneously Placed Gasserian Neurostimulation Electrode Migration Into the Quadrigeminal Cistern: Pathophysiological Hypothesis and Report of Successful Repositioning

Comparison Between the Supracerebellar Infratentorial and Precuneal Interhemispheric, Transtentorial Approaches to the Cerebellomesencephalic Fissure: An Anatomoradiological Study and Illustrative Cases.

The dorsal brainstem and cerebellomesencephalic fissure are challenging surgical targets. To afford a preferentially craniocaudal trajectory to this region, the precuneal interhemispheric transtentorial approach (PCIT) has been proposed. To didactically describe and compare exposures and anatomic indications of the supracerebellar infratentorial approach (SCIT) and PCIT to the cerebellomesencephalic fissure. Nine formalin-fixed, latex-injected cadaveric head specimens were used to perform a midline SCIT and bilateral PCITs and measure the distance of each approach. Twenty-four formalin-fixed specimens were used to measure the distance from the most posterior cortical bridging vein entering the superior sagittal sinus to the calcarine sulcus and the torcula. Fifty-one magnetic resonance images were reviewed to calculate the angle of each approach. Three illustrative surgical cases were described. Mean distances from the brain or cerebellar surface to the operative target of the PCIT and SCIT were 7.1 cm (range: 5-7.7 cm) and 5.5 cm (range: 3.8-6.2 cm), respectively. The SCIT provided direct access to structures of the quadrigeminal cistern bilaterally. The PCIT provided access from the ipsilateral inferior colliculus to the ipsilateral infratrochlear zone. The PCIT's benefit was the direct access it provided to the cerebellomesencephalic fissure because of its superior to inferior trajectory. The PCIT is indicated for unilateral lesions of the cerebellomesencephalic fissure and dorsal brainstem that harbor a craniocaudal long axis and do not have a superior extension beyond the superior colliculi. The SCIT is beneficial for lesions that extend bilaterally, have an anteroposterior long axis, or involve the Galenic complex.

A Clinical Case Report About an Intracranial Lipoma

Intracranial lipoma is a uncommon congenital malformation, represent less than 0.1% of all intracranial tumors. Result from abnormal persistence and mal-differentiation of meninx primitiva, during embryogenesis. The cases in which the tumor presents an extracranial component are caused by a secondary dehiscence of the skull with evagination of a small tuft of primitive meninges. These lesions are frequently located in the inter-hemispheric fissure in the pericallosal region in 50% of cases, other locations as ambient or quadrigeminal cisterns present an incidence about 20-25%. In half of cases the patients present associate midline brain malformations of varying severity, the most frequent is the agenesia of the corpus callosus. The most accepted theory states that in embryonic phases, mesenchymal alterations at the level of the cranial sutures in the sagittal plane can cause anomalies of the SSS, sinus rectum, tentorium, and parietal bones that would explain the associated anomalies. Majority of intracranial lipomas are detected incidentally, being a third of the asymptomatic cases. As in all other pathologies certain localizations cause specific symptomatology of the involved area. The most common clinical manifestations are headache, epilepsy, mental dysfunctions and cranial nerve deficits. The clinical diagnosis is unclear and it is necessary release complementary exams in every suspected cases. Neuroimaging studies such as computed tomography (CT) or magnetic resonance imaging (MRI) make possible identify these lesions. We describe a clinical case about a 79-year-old woman with headache without any other symptoms. Was done CT and MRI that showed a inter-hemispheric lesion located in the pericallosal region, without any other abnormality associated. The development, during the last decades, of neuroimaging and histogenesis techniques increased the knowledge about this pathology and modified the management in recent times. The surgery is contraindicated in the majority of the cases, however still play a role in some cases especially in presence of hydrocephalus, uncontrollable seizures, and bony affectation with cosmetic influence. The medical control of the epilepsy is mandatory. We present a clinical case about pericallosal intracranial lipoma and review the current literature. Taking in account the clinical situation and the imaging findings, we decide for a conservative approach with clinical/neurological and radiological follow-up.

Cavernous Malformations: What They Have Taught Us.

Cavernous Malformations: What They Have Taught Us.

Microscope neuronavigation-guided microsurgical fenestration of quadrigeminal cistern arachnoid cysts: how I do it.

Management options for treatment of quadrigeminal arachnoid cysts (QAC) include microsurgical/endoscopic fenestration or shunt. There is an open debate about which method is the best. Microsurgical fenestration is well suited for treatment of QAC with predominant infratentorial component and without hydrocephalus making endoscopic procedures more challenging. We describe the microsurgical technique and related anatomy to fenestrate infratentorial QAC through supracerebellar infratentorial approach. We also discuss our experiences with this approach, some of the drawbacks and nuances. Navigation-guided microsurgical fenestration of infratentorial QAC is the authors' surgical approach of choice for treating these rare challenging lesions when not associated with hydrocephalus.

Young Female with Recurrent Spontaneous Cervical Artery Dissection

Previous neurosonological study demonstrated the value of neurosonology in daily monitoring of the cervical artery dissection. This study showed rate of recurrence of 27 % in unaffected arteries. There are two group of recurrences, early and late. Early spontaneous cervical artery dissection (sCAD) recurrences are not uncommon and usually involve arteries previously unaffected by dissection. They are oligosymptomatic (headache or neck pain) or asymptomatic and might be correlated with a transient arterial disorder. Late sCAD recurrences are rare and can occur at site of previous sCAD and might be indicative of an underlying persistent connective tissue weakness. In this case report we present a 31- year old female patient who presented to emergency room because of headache and pain in the neck which started 3 days before. Initial brain CT scan and CT-angiography were normal. Next day she became disoriented and complained of headache, vertigo, nausea. Magnetic resonance of the brain showed little hematoma in quadrigeminal cistern and left vertebral artery dissection in V2 segment. Initial neurovascular ultrasound (nUS) showed dissection in V2 segment left vertebral artery. Next nUS after five days showed new dissection in V1 and V2 segment in right vertebral artery. Following nUS showed initial regression hematoma in both vertebral arteries. To conclude, early sCAD recurrences are not uncommon and usually involve arteries previously unaffected by dissection. Because of that it is important to daily neurosonology monitoring of the dissection.

Neuroimaging Spectrum of Intracranial Lipomas.

Intracranial lipomas are rare congenital malformations at characteristic sites. Though largely asymptomatic, some cause significant morbidity. We are studying this for the local population. Objectives: The purpose of this article is to analyze the spectrum of intracranial lipomas, determine their distribution at characteristic locations, and assess their associations. Method: A retrospective study of 21 patients diagnosed with intracranial lipomas detected on CT and MRI performed between September 2017 and May 2022 at Dr. D.Y. Patil Medical College, Hospital & Research Center, Pune. Amongst the21 patients with intracranial lipomas, the most common locationwas the pericallosal region seen in 11 patients (n = 11, 52.3%), of which nine were curvilinear type (n = 9), more common than tubular nodular type (n = 2). Other locations (n = 10, 47.7%) were found to be; quadrigeminal cistern in six patients (28.5%), cranial diploic space in two patients (9.5%), one each ininterhemispheric falx (4.8%), and cribriform plate (4.8%). Associated anomalies were observed in three patients, which werefronto-ethmoidal encephalocele (n = 1), partial agenesis of the corpus callosum (n = 2), extension with a frontal subcutaneous lipoma (n = 1), and bilateral intraventricular extension (n = 1). Presenting symptoms were headache and dizziness (38.1%), seizures (19%), swelling on the forehead (9.5%), and other non-specific clinical symptoms (33.3%). Intracranial lipomas are rare congenital lesions that are usually asymptomatic and discovered incidentally. However, lipomas at interhemispheric locations can cause seizure disorders and some present with headaches and dizziness. Few have associations like communication with extracranial swellings and corpus callosum agenesis.

A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes. The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model. Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98-1.00; OR per point increase 10; 95% CI 2.18-46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92-1.00) of this model. A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.

A Case of Quadrigeminal Variant of Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage

AbstractThe incidence of perimesencephalic subarachnoid hemorrhage (PMSAH) is rare, 0.5 in 100,000 adults. It comprises 5 to 10% of all SAHs and approximately 33% of all nonaneurysmal SAH. Quadrigeminal SAH is a variant of perimesencephalic nonaneurysmal subarachnoid hemorrhage (PMNASAH) that is not well described in the literature. It may comprise up to one-fifth of PMNASAH cases and carries a similar benign prognosis. This variant of PMSAH is characterized by blood centered in the quadrigeminal cistern and limited to the superior vermian and posterior perimesencephalic cisterns. Noncontrast computed tomography of the brain is the initial investigation of choice, while four-vessel cerebral angiogram is the gold standard for the diagnosis of SAH.We report a case at our institute.

Endoscopic aqueductal membrane fenestration was effective for intractable hydrocephalus after removal of a nongerminomatous germ cell tumor exhibiting growing teratoma syndrome: a case report

BackgroundPrimary central nervous system (CNS) germ cell tumors (GCTs) are rare neoplasms predominantly observed in the pediatric and young adult populations. A mixed GCT including immature teratoma exhibiting growing teratoma syndrome is presented. The pathogenesis of growing teratoma syndrome remains unclear, and its treatment strategy has not been established. GCTs are often located within the ventricles, causing hydrocephalus, which sometimes improves after removal of the tumor due to restoration of cerebrospinal fluid (CSF) flow. On the other hand, even if the flow route of CSF from the third ventricle to arachnoid granulations on the brain surface quadrigeminal cistern is restored after removal of the tumor, hydrocephalus may not improve.Case presentationA case whose intractable hydrocephalus improved after penetrating the aqueductal membrane via endoscopy is described. An 11-year-old boy was treated for pineal intracranial growing teratoma syndrome (IGTS). The tumor grew rapidly in a short period, and hydrocephalus progressed despite endoscopic third ventriculostomy (ETV). Although the obstruction was removed by radiation, chemotherapy, and total tumor resection, the hydrocephalus did not improve. Endoscopic membrane perforation was performed because a membrane-like structure was seen at the entrance of the cerebral aqueduct on magnetic resonance imaging. The hydrocephalus improved immediately after the operation, and the patient’s consciousness disturbance also improved significantly.ConclusionThe purpose of this report is to update the current knowledge and standards of management for patients with growing teratoma syndrome, as well as to drive future translational and clinical studies by recognizing the unmet needs concerning hydrocephalus.

Neuroendoscopic Fenestration of Quadrigeminal Cistern Arachnoid Cyst Presenting with Developmental Regression

Quadrigeminal cistern arachnoid cyst is rare and not usually located in the tectal plate region. Such a cyst may extend to the surrounding area and compress adjacent structures due to cystic expansion. Arachnoid cysts occasionally are associated with hydrocephalus and produce related symptoms. In our case, a 20-month-old boy presented with developmental regression and macrocephaly. Image study of the brain demonstrated a large cyst on the superior portion of the posterior fossa with extension to the supratentorial space and a compressed cerebellum inferiorly and brain stem anteriorly. Lateral and third ventricles were enlarged severely. We performed lateral ventriculo-cystostomy by neuroendoscope via a precoronal approach. Additional third ventriculostomy was performed on the floor of the third ventricle. At 9 months after surgery, the patient showed restored development, and postoperative image showed a reduction of arachnoid cysts and lateral and third ventricles.

Risk factors for development of cerebral edema following cardiac arrest

BackgroundCerebral edema following cardiac arrest is a well-known complication of resuscitation and portends a poor outcome. We identified predictors of post-cardiac arrest cerebral edema and tested the association of cerebral edema with discharge outcome. MethodsWe performed a retrospective chart review including patients admitted at a single center between January 2015–March 2020 following resuscitation from in-hospital and out-of-hospital cardiac arrest who had head computed tomography imaging. Our primary outcome was moderate-to-severe cerebral edema, which we defined as loss of grey-white differentiation with effacement of the basal and ambient cisterns and radiographic evidence of uncal herniation. We used logistic regression to test associations of demographic information, clinical predictors and comorbidities with moderate-severe cerebral edema. ResultsWe identified 727 patients who met the inclusion criteria, of whom 102 had moderate-to-severe cerebral edema. We identified six independent predictors of moderate-to-severe cerebral edema: younger age, prolonged arrest duration, pulseless electrical activity/asystole as initial rhythm, unwitnessed cardiac arrest, hyperglycemia on admission, and lower Glasgow coma score on presentation. Of patients with moderate-to-severe cerebral edema, 2% survived to discharge, 56% had withdrawal of life-sustaining therapies and 42% progressed to death by neurological criteria. ConclusionsOur study identified several risk factors associated with the development of cerebral edema following cardiac arrest. Further studies are needed to determine the benefits of early interventions in these high-risk patients.

Second-look surgery for pineal region tumors.

Surgical resection of pineal region tumors is challenging because of close proximity to the vein of Galen draining system and the quadrigeminal plate. Surgical resection usually is performed through the narrow corridor by piecemeal resection and en bloc resection is difficult in cases of large tumors. Moreover, in cases of hypervascular tumors, surgical resection through the narrow corridor could entail massive intraoperative bleeding. The effectiveness of neoadjuvant chemotherapy and second-look surgery for pineal region tumors for maximal safe resection was evaluated. Retrospective institutional review of pediatric patients with pineal region tumors who underwent second look surgery after neoadjuvant chemotherapy was performed. Nine patients underwent surgical resection after neoadjuvant chemotherapy over the period of September 2017 to February 2022. The mean age was 7.7years (ranged from 1.4 to 15.3years). Three patients underwent partial resection via open craniotomy, and 6 underwent endoscopic biopsy as an initial surgery. The histopathological diagnoses were germ cell tumors in 5 patients (yolk sac tumors in 2, germinoma in 2, choriocarcinoma in 1), /rhabdoid tumor (AT/RT) in 2, medulloblastoma in 1, and high-grade glioneuronal tumor in 1. After several courses of chemotherapy, the second-look surgery was performed. The tumor volume was reduced in 8 patients (89%) after chemotherapy except for 1 case of growing teratoma syndrome. The tumor was extended laterally to the ambient cistern in 2 patients, and posteriorly to the tentorial surface of the cerebellum in 3 patients. The lesion was approached through occipital transtentorial approach in 8 patients and infratentorial supracerebellar approach in 1. Intraoperatively, the high vascularity of the tumor was not observed in all cases. Gross total resection (8 patients, 89%) or near total resection (1, 11%) was achieved in all cases. No complications were observed postoperatively in all cases. Eight patients subsequently underwent additional chemo-radiation therapy according to the initial diagnosis. All patients are alive with no evidence of recurrence with a mean follow-up of 33months. Neoadjuvant chemotherapy and second-look surgery for pediatric pineal region tumors was considered to be effective in reducing the tumor volume and vascularity, which facilitates the safe maximal tumor resection.

Intracranial arachnoid cysts: special issue

Intracranial arachnoid cysts (AC) are arachnoid-lined expansion of the normal subarachnoid space. They are very common and neurosurgeons, specially those taking care of the pediatric population, face this disease in their daily activities quite frequently. So, considering the importance of this topic, the editorial board of Archives of Pediatric Neurosurgery decided to dedicate the present issue to articles addressing any view of AC.&#x0D; The first article is an interesting and complete review of many aspects of AC that must be known by pediatric neurologists and neurosurgeons concerning epidemiology, pathophysiological, symptomatology, imaging and classification. It is well known that, frequently, AC are discovered incidentally on radiological exams. In other cases, it is difficult to stablish a relationship between the symptoms and the AC. Is a headache related do the cysts? Is the seizure an effect of the cyst? In spite of the doubts regarding symptoms and AC, Faraj et al describe some clinical manifestations according to AC locations. The association and risk of developing subdural hemorrhage and AC is also discussed. And finally, the authors analyze literature data regarding a frequent and practical aspect about how to council parents and patients harboring an AC in the sports practice.&#x0D; The knowledge of the natural history of a disease is the first step in the decision making of any patient. This is particularly important in pathological conditions that are discovered incidentally or in asymptomatic patients. Souza et al performed an excellent literature review on this topic that may guide us how to manage our patients. Who do we should operate? What are the cases of highest risk of cyst growing?&#x0D; Regarding treatment, the literature ranges from CSF shunts to microsurgery and neuroendoscopy. In this sense, Paiva et al discuss the role of neuroendoscopy and the possible associated complications that can be expected. Two articles address treatment of AC at the quadrigeminal cistern and posterior fossa. Furtado et al propose a therapeutic algorithm based on a literature review and Dastoli et al describe four posterior fossa AC treated by neuroendoscopic fenestration.&#x0D; In the setting of Clinical Images, a suprasellar arachnoid cyst with an unusual extension to the middle fossa is presented followed by a video showing the microsurgical surgery of a middle fossa AC.&#x0D; The great advantage in participate of Archives of Pediatric Neurosurgery is to be able to discover different clinical and surgical approaches, especially on controversial topics such as arachnoid cysts, around the different pediatric neurosurgery departments in our continental country. Thereby, Mansilla et al, with the honorable participation of a great friend of Brazilian pediatric neurosurgery, Gianpiero Tamburrini, share a survey that demonstrates which symptoms were considered related to AC, which complementary exams should be performed and the types of treatment chosen among Brazilian pediatric neurosurgeons. The APN editorial board invite its readers to discover these articles and delve further into the controversial topic of arachnoid cysts.

Arachnoid cysts of the quadrigeminal cistern: Proposal of a therapeutic algorithm based on a systematic review of literature

Introduction: Although quadrigeminal arachnoid cysts (QACs) are infrequent malformations of the arachnoid space, which affect the quadrigeminal cistern, they have important clinical consequences, such as hydrocephalus and compressive symptoms. Moreover, there is much controversy on its surgical management; thus, it is important to determine the current state of the art regarding the best treatment modality. Objective: This study aimed to examine the effectiveness of different surgical approaches and revisit the anatomy of the quadrigeminal cistern. Methods: A systematic review of the literature was conducted considering studies published in the last 20 years regarding the natural course and treatment of QACs. Only English papers were selected, and case reports were excluded from the analysis. Results: We identified 286 articles, of which nine were selected for the qualitative analysis. Clinical presentations of QACs included mental disorientation, bladder incontinence, dysphagia, quadriplegia, ataxia, and nocturnal headaches, which were dependent on the cyst size, and a spontaneous resolution was not described. A microsurgical technique via a supracerebellar infratentorial approach and fenestration to the third ventricle and ventricular endoscopic third ventriculostomy were the main techniques, which were performed depending on the anatomical features and presence of hydrocephalus. Shunt placement was associated with high rates of complications and recurrence. Conclusion: Despite the lack of solid evidence on the treatment of QACs, mainly due to their rarity, an endoscopic approach with ventricle cystostomy has been indicated as the more effective surgical technique.

Endoscopic Midline and Paramedian Supracerebellar Infratentorial Approaches to Pineal Region Tumors: A Clinical Study and Approach Comparison

This study was to analyze the advantages and disadvantages of endoscopic midline and paramedian supracerebellar infratentorial approaches (EM-SCITA and EPM-SCITA) for pineal region tumors. We retrospectively analyzed the clinical data of 58 patients who underwent EM-SCITA and EPM-SCITA for pineal region tumors. Among them, 23 patients were treated with EM-SCITA, and 35 with EPM-SCITA. The patients were followed up for 6-84months with magnetic resonance imaging and Karnofsky Performance Status scores. The average age of the patients was 37.98years, and there were 16 women (27.6%). The average maximum diameter of the tumors was 2.92cm. Gross total resection was achieved in 46 patients (79.31%). There were 45 patients (77.6%) whose Karnofsky Performance Status score was >70 at the final follow-up. There was no significant difference among the above items between EM-SCITA and EPM-SCITA. However, EM-SCITA required a longer craniotomy and closure time, with a larger bone and dural flap, with more bridging veins sacrificed. EPM-SCITA simplified the opening of the quadrigeminal cistern, and it was beneficial to expose the contralateral wall of the third ventricle. The longer and angled path limited the exposure of the anterior third ventricle and the ipsilateral wall of the third ventricle. Both approaches had remarkable clinical effects. The anatomy of EM-SCITA was easy to understand and has a larger operating space; it is suitable for neurosurgical beginners. In contrast, EPM-SCITA has limited operation space, an intricate anatomy, and is suitable for experienced operators. The occurrence of postoperative hydrocephalus should be alerted by EPM-SCITA.