Obliteration Operation of Cavity for Symptomatic Sellar Arachnoid Cysts via Endoscopic Endonasal Transsphenoidal Approach

Special Article – Endoscopic Surgery

Austin J Surg. 2019; 6(22): 1220.

Obliteration Operation of Cavity for Symptomatic Sellar Arachnoid Cysts via Endoscopic Endonasal Transsphenoidal Approach

Wang P, Wang JW, Zou DW and Wu N*

Department of Neurosurgery, Southwest Hospital, Army Military Medical University, China

*Corresponding author: Wu Nan, Department of Neurosurgery, Southwest Hospital, Army Military Medical University, Gaotanyan 30#, Shapingba, Chongqing, China

Received: September 05, 2019; Accepted: October 21, 2019; Published: October 28, 2019


Background: Various ways are used to treat symptomatic sellar arachnoid cysts (ACs) such as cyst aspiration and wall fenestration; however, many complications exist and it is easy to recur.

Object: This paper described a new way to alleviate symptomatic sellar arachnoid cysts.

Methods: Retrospective analysis for the patients who underwent an endonasal transsphenoidal obliteration of symptomatic sellar ACs with gelatin sponge and biological membrane.

Results: Between January 2015 and December 2018, 8 patients (3 women and 5 men, mean age 40 years) with symptomatic sellar ACs were identified. Clinical presentation included headache (5 patients), impaired vision (5 patients) and vision field defects (4 patients). During intraoperative, we repaired diaphragma sellae using biological membrane; then obliterating cyst cavity with gelatin sponge; and the last repaired sellar floor with two biological membranes. Headache, impaired vision and vision field defects all improved postoperatively. One case occurred with complication of CSF leak; but recovery after two weeks. No endocrine dysfunction, meningitis or neurological deficits occurred. The mean follow-up time were 10.5 months (from 9 to 15 months). Cyst cavity volume eliminated in two patients and other six patients experienced cyst shrinking from MR imaging.

Conclusion: Symptomatic sellar ACs can be effectively cured by cyst obliteration with gelatin sponge and repaired diaphragma sellae and sellar floor with biological membrane via endonasal transsphenoidal for patients. It is with low complications occurring and the recurrence rate is low. It is a good way to alleviate symptoms for sellar ACs.

Keywords: Endoscopic endonasal transsphenoidal approach; Symptomatic sellar arachnoid cysts; Obliteration operation with gelatin sponge; Biological membranes; low recurrence rate


ACs: Arachnoid cysts; CSF: Cerebrospinal Fluid; MR imaging: Magnetic Resonance Imaging; SAS: Subarachnoid Space


Arachnoid cysts (ACs) arises in brain and most of them are located in the middle cranial fossa with roughly 3% growing in the sellar [1-3]. Some sellar ACs are asymptomatic and does not need to be treated. However, some others present symptoms such as headache, endocrine dysfunction or diminution of vision; and the symptoms ACs should be treated [4-6]. Unfortunately, the optimal treatment of symptomatic sellar ACs is always a challenge to neurosurgeons [5,7]. According to the literatures, fenestration of the cyst’s anterior wall through transsphenoidal treatment or craniotomy and excision of the cyst’s membranes maybe a good way to alleviate symptoms [1,8-10]. However, the recurrence of ACs is so high that many neurosurgeons holds a controversial opinion on this method. Besides this idea, some authors prefer to obliteration of the cyst cavity alone and the materials used for cavity obliteration are always fat, fascia and muscles [11- 14]. Unlucky, there also exist many complications such as visual loss [14,15], CSF leak [11,13,14,16], intracranial infection [17] and the most important is that it will cause extra damage for other tissues because the fat, fascia and muscles derive from patients themselves [14]. Actually, another obvious disadvantage is the difficulty to control infection once it (intracranial or sphenoid sinus infection) occurs.

Based on the literature reviews above we described a new way to operate this surgery. In this process, we made a fenestration of the cyst’s anterior wall firstly and used biological membrane to reinforce diaphragma sellae; then obliterating the cyst cavity with gelatin sponge; nest, two biological membranes were used to repair sellar floor; one was located between subdural and gelatin sponge, the other was kept in epidural. In this study, we described 8 patients who experienced this surgery and as a result the volume of ACs got smaller for 6 patients and another two of them even vanished completely. In addition, the most significance is its recurrence is relatively low and it does not destroy CSF flow dynamics for most traditional method that always enlarge the communication between the AC and SAS.


Patient’s information

8 patients in this study were operation between January 2015 and December 2018, and the age ranged from 32 to 49 years. The symptoms included headache, endocrine dysfunction, diminution of vision or vision field defects (Tables 1 & 2). The symptoms kept the longest was 1.6 years and the least was over 1 month. In these symptoms headache and diminution of vision were the most common and vision field defects kept in the second. All of them were operated via endonasal transsphenoidal approach; repaired diaphragma sellae using biological membranes made with collagen substitute [18], obliterated cavity using gelatin sponge and repaired sellar floor with two biological membranes.

Preoperative evaluation

Firstly, pain evaluation was done by VAS score; optical examination employed uncorrected visual acuity (UCVA) and visual field was detected through 2010 Carl Zeiss Meditec. Standard hormonal assays were detected to represent endocrine function, including levels for adrenocorticotropic hormone (ACTH), cortisol (COR), thyroid-stimulating hormone (TSH) and thyroxine (T3, T4, FT3, FT4), growth hormone (GH), Insulin-like growth factor-1 (IGF-I), insulin-like growth factor binding protein-3 (IGFBP-3), luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone (T), corporin (P), estradiol (E2) and prolactin (PRL). No patients received hormone replacement therapy before surgery. Besides, diabetes insipidus defined as urine volume over 4000ml was assessed for each patient. The last we detected electrolyte (K+, Na+, Cl-) and assessed whether it was in the normal range.

Postoperative evaluation

Pain VAS score also was important and assessed after operation 7d. Then was the vision and visual field examination postoperative day 5-7. Visual function was considered improved if UCVA value increased and visual field defect decreased. Besides, standard hormonal assays including ACTH, COR, TSH, T3, T4, FT3, FT4, GH, IGF-1, IGFBP-3, LH, FSH, T, P, E2 and PRL were demonstrated after surgery 1d, 3d, 7d and 1 months for postoperative patients. Besides, diabetes insipidus was assessed through urine volume and detected every 1h and 24h. Electrolyte (K+, Na+, Cl-) was employed to detect and alleviated if it was imbalance.

MR Imaging

All patients underwent enhanced brain MR imaging (Diffuse+ FLAIR) pre- and postoperative. After surgery, MR imaging was first examined on day 1 and then subsequent detection at 3 to 6- month intervals; and then re-examination every 1 to 2- years.

Surgical techniques

Before surgery, vibrissa was cut off completely and all patients were operated through a direct endonasal trans sphenoidal approach via neuroendoscopy in the whole surgery. The whole steps were as follows; looked for sphenoidal ostium, made mucosal flap from nasal septum, opened sphenoid sinus anterior wall, abraded bone around sphenoid sinus, cut sellar floor and cyst membrane, released liquid from cyst cavity, observed diaphragma sellae, repaired diaphragm sellae, obliterated cyst cavity with gelatin sponge, repaired sellar floor using biological membrane with a location between subdural and gelatin sponge, repaired sellar floor using another biological membrane with a location at epidural, put hemostatic gauze on the second biological membrane, put mucosal flap on hemostatic gauze and the last put tela iodoformum in nose. Here we should take care was abrading sellar floor bone slightly and let sellar bone opening large enough. Dura was cut by bistoury and scissored dura via endoscopic scissor in a U-shaped fashion. The dura didn’t need to open too large but it was large enough to pass through the endoscope and we should pay attention to the opening margin couldn’t extend to lateral sellar edges so that a dural margin remained circumferentially to help to hold the biological membrane and promoted gelatin sponge obliterated cyst cavity. Then opened ACs membrane and acquired some ACs membrane to pathology. Once ACs membrane was opened, clear liquid was pouring forth and then observed vascularity in diaphragm sellae, diaphragm pulse with breath and arachnoid diverticula using the endoscope. According to the size of diaphragm sellae and then tailored biological membrane which must cover the whole diaphragm sellae. The next was obliterating cyst cavity with gelatin sponge and we must insure there was no cavity residual. However, excess gelatin sponge should be avoided because extra optic injury may be produced if there were much more gelatin sponge. Next, cut out two suitable biological membranes, both them must cover the dura opening and extended to dura opening at least 1-2mm. One biological membrane was put into subdural and another was in epidural. All the process must not damage the pituitary gland to avoid worsening pituitary dysfunction. Then covered hemostatic gauze and mucosal flap on outer biological membrane; and lastly put tela iodoformum in nose and pulled it out after surgery 3 to 7d. A brief summary of the surgical procedure described above was listed as follows (Figure 1). For the patients, not all of they did lumbar cistern drainage pre- and postoperative.