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Arthur Cukiert, Elcio Machado, Alcione Sousa, Jose A Buratini, Joaquim Vieira, Bernardo Liberman, Jaime Goldman, Maria ER Silva, Katia Nogueira, Martha Huayllas, Luis R Salgado.
Departments of Endocrinology and Neurosurgery, Hospital Brigadeiro, Sao Paulo SP, Brazil.
INTRODUCTION: Arachnoidal cysts (AC) may occur near or at the sellar region but they are only rarely hypertensive. On the other hand, some cysts localized in the opto-chiasmatic cistern may become larger and cause compression or distortion of the surrounding structures. These paper reports 3 of such patients with hypertensive arachnoidal cysts.
MATERIAL: Three patients with sellar or supra-sellar AC were studied. Two patients presented with progressive bitemporal hemianopsia due to chiasmatic compression by the cysts. The third patient had progressive hypopituitarism and diabetes insipidus. The cyst caused distortion of the optic chiasm and lateral displacement of the pituitary stalk. All 3 patients had an intra-sellar expansion of the cyst and an enlarged sella turcica. All patients were operated by the transesphenoidal route. In all, a transesphenoidal transdural subarachnoidal punction was performed before the dural opening and yielded normal CSF in all of them. After CSF removal, contrast was injected through the same needle and in all there was fluoroscopic confirmation of the communication between the intrasellar cyst and the ventricular system mainly through the lamina terminalis. In the first 2 patients, the cyst was opened with microcurettes. In the third patient only a punction was carried out. All surgical wounds were closed with surgicel, fat, muscle, fascia and glue. All patients had a lumbar drain installed for 3 days.
RESULTS: Visual improvement was noted in the 2 first patients within the first postoperative day and postoperative MR images showed the disappearance of the hypertensive cysts. The third patent showed no clinical or neuroimaging improvement after surgery.
DISCUSSION: Sellar AC may turn out to be hypertensive and their removal may lead to neurological improvement in these patients. On the other hand, in a subset of patients there is only distortion without compression of the surrounding structures and surgery is likely to be ineffective in this situation.