Endonasal Management of Sellar Arachnoid Cysts: Simple Cyst Obliteration Technique

Introduction: Symptomatic sellar arachnoid cysts (SAC) have typically been treated via the transsphenoidal route. After cyst fenestration, cyst wall resection and increasing communication between the SAC and suprasellar subarachnoid space (SAS) have been performed. We describe a simplified approach to reinforce a defective diaphragma sella or unseen arachnoid diverticulum by deliberately not enlarging the SAC-SAS communication and obliterating the cyst with adipose tissue.

Methods: A retrospective analysis was conducted of patients who underwent an endonasal transsphenoidal obliteration of symptomatic SAC with a fat graft and skull base repair.

Results: Between January 2001 and September 2010, eight patients with a SAC were identified (mean age, 57 years). Clinical presentation included headache (n = 4), endocrine dysfunction (n = 4), and visual dysfunction (n = 4). Maximal cyst diameter averaged 22 mm (range, 15–32 mm). In all cases, the SAC-SAS communication was deliberately not enlarged. The endoscope was used for visualization in 8/9 procedures. Postoperatively, headache improved in 100%, vision in 100%, and partial resolution of endocrine dysfunction (hyperprolactinemia and/or recurrent hyponatremia) occurred in 75% of patients. No new endocrinopathy, CSF leak, meningitis or neurological deficits occurred. Two patients had cyst reaccumulation; one with a symptomatic recurrence required reoperation 43 months after her initial procedure.

Conclusion: SAC can be effectively treated by endonasal fenestration and obliteration with fat with resultant reversal of presenting symptoms in most patients. This simplified technique of SAC cavity obliteration without enlarging communication to the SAS has a low risk of CSF leakage and, in most cases, appears to effectively disrupt cyst progression. Longer follow-up is required to monitor for cyst recurrence.