Global trends and decision-making in the management of arachnoid cysts

Pramath Kakodkar; Malavan Ragulojan; Lamia Hayawi; Anne Tsampalieros; Sharini Sam Chee; Mia Wu; Ziyad Makoshi; Ashutosh Singhal; Paul Steinbok; Aria Fallah; Richard A Robison; Albert Tu

doi:10.1007/s00381-023-06212-8

Global trends and decision-making in the management of arachnoid cysts

Childs Nerv Syst. 2024 Mar;40(3):749-758. doi: 10.1007/s00381-023-06212-8. Epub 2023 Nov 13.

Authors

Pramath Kakodkar¹, Malavan Ragulojan², Lamia Hayawi³, Anne Tsampalieros³, Sharini Sam Chee⁴, Mia Wu⁵, Ziyad Makoshi⁶, Ashutosh Singhal⁷, Paul Steinbok⁷, Aria Fallah⁸, Richard A Robison⁹, Albert Tu^{10

11}

Affiliations

¹ Pathology and Laboratory Medicine, University of Saskatchewan, Saskatoon, SK, Canada.
² Department of Neurosurgery, University of Ottawa, Ottawa, ON, Canada. mragulojan@toh.ca.
³ Clinical Research Unit, University of Ottawa, Ottawa, ON, Canada.
⁴ Faculty of Science, Western University, London, ON, Canada.
⁵ School of Medicine, Queens University, Kingston, ON, Canada.
⁶ Department of Neurosurgery, El Paso Children's Hospital, El Paso, TX, USA.
⁷ Department of Neurosurgery, Children's Hospital of British Columbia, Vancouver, BC, Canada.
⁸ Department of Neurosurgery, University of California LA, Los Angeles, CA, USA.
⁹ Department of Neurosurgery, Loma Linda University, Loma Linda, CA, USA.
¹⁰ Department of Neurosurgery, University of Ottawa, Ottawa, ON, Canada.
¹¹ Department of Neurosurgery, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada.

PMID: 37955715
DOI: 10.1007/s00381-023-06212-8

Abstract

Objective: In pediatric patients, middle cranial fossa (MCF) arachnoid cysts are often discovered incidentally on imaging in asymptomatic patients during workup for other indications. This study aims to describe current management gestalt and threshold for surgical intervention by surveying an international cohort of neurosurgeons.

Methods: A web-based survey was circulated via email list of attendants of the 2019 Canadian Pediatric Neurosurgery Study Group (CPNSG) and International Society of Pediatric Neurosurgery (ISPN) mailing list. The survey consisted of 8 clinical scenarios involving patients with MCF arachnoid cysts. Demographic variables of respondents and their decisions regarding management for each scenario were analyzed using R computing software.

Results: A total of 107 respondents were included. Cysts in asymptomatic patients (92%), younger age at diagnosis (81%), and presence of a mild learning delay were predominantly managed non-surgically (80.7 ± 9.4%). Patients with cyst enlargement, headaches, new seizures, or hemorrhage were divided between non-surgical (55.8 ± 3.3%) and surgical (44.2 ± 2.9%) management. Patients with contralateral hemiparesis were treated predominantly surgically (67%). For both Galassi I and II, papilledema was favored as the primary indication for surgical intervention in 54% of patients. Those inclined to surgery (n = 17) were more likely to practice and train outside North America compared to those not pro-surgical (adjusted P = 0.092).

Conclusion: Incidental MCF arachnoid cysts in asymptomatic patients and younger age of diagnosis are predominantly managed non-surgically. Mild learning delay was not considered an indication to intervene. In contrast, radiological progression, hemorrhagic evolution, or non-focal neurological deficits lead to uncertainty in management, while focal neurological deficits and papilledema with MCF cysts were favored to be intervened surgically. Among the provider level factors, only location of training and practice trended towards a pro-surgery approach.

Keywords: Arachnoid cyst; Consensus opinion; Conservative; Galassi III; Management; Surgical.

MeSH terms

Arachnoid Cysts* / diagnostic imaging
Arachnoid Cysts* / surgery
Canada
Child
Craniotomy / methods
Humans
Neurosurgical Procedures / methods
Papilledema*
Retrospective Studies