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A child with a benign intrinsic tectal tumor and obstructive hydrocephalus developed a huge intraventricular cystic lesion following insertion of a shunt, which was complicated by a subdural-subarachnoid bleeding. The lesion was identified to be an entrapped chiasmatic cistern, which disrupted the septum pellucidum in front of the third ventricle and filled gradually the anterior horn of the lateral ventricle. The condition was successfully treated endoscopically by fenestration of the cyst and a third ventriculostomy. Probable mechanisms of such unusual cyst formation and general management strategies in patients with obstructive hydrocephalus are discussed.

The authors present three boys--3 years old, 5.8 years old and 10.4 years old--who were diagnosed with isosexual precocious puberty (IPP) triggered by a rare developmental disorder of suprasellar arachnoid cyst (SAC) accompanied by corpus callosum and fornix dysgenesis as well as anterior commissura magna agenesis (patient 1) and empty sella (patients 2, 3). The reason for diagnostic management recommendation was a rapid progression of IPP signs over one year (patients 1, 2) or 6 months (patient 3) prior to hospitalization, these signs having been present but less intense since infancy (patient 1), 4th year of life (patient 2) and approximately 8 years of age (patient 3). Neurological signs (spastic paresis in patient 1, postural tremor in patient 2 and head bobbing and behavioral changes in patient 3), as well as slowly progressing increased head circumference were observed since neonatal period (patient 1), 1 year old (patient 2) and approximately 4 years old (patient 3). None of the patients manifested hypophyseal-hypothalamic axis dysfunction other than IPP prior to and after surgical management. Shunt implantation resulted in gradual resolution of neurological signs in all patients and in patient 3 also in partial normalization of serum testosterone levels and growth rate. Regression of IPP in patients 1 and 2 was achieved by administration of a long-acting GnRH analogue. Our observations are in accord with data reported by other investigators and confirm the often slow, insidious development of subsequent SAC signs, the type and intensity of which differ from patient to patient. We suggest that some of the neuroanatomical anomalies coexisting with SAC may have a common genesis, or they could under certain conditions be an additional trigger for IPP and possibly other hypothalamopituitary dysfunction.

MRI showed a large, well-defined non-enhancing thin-walled cyst with a T2 hypointense circumferential rim, arising above the sella turcica. Occlusion of the bilateral foramina of Monro by the thin-walled cyst resulted in severe obstructive hydrocephalus. Radiographic characteristics of the cyst content were consistent on all image sequences with cerebrospinal fluid (CSF), suggesting the diagnosis of a suprasellar arachnoid cyst (SAC). The child was taken to the operating room for cyst fenestration, restoration of CSF ventricular drainage, and relief of hydrocephalus. A right transfrontal endoscopic approach was undertaken (Fig. 1A, as viewed along the arrow trajectory seen in Fig. 2A of Images in Neuroscience: Question), confirming the presence of an occlusive cyst. Fenestration of this wall revealed the cyst interior (Fig. 1B). Chronic thinning of the third ventricle floor allowed striking visualization of the posterior circle of Willis (Fig. 1B, arrowheads), pituitary stalk and gland (black arrow), and bilateral third cranial nerves (white arrows). Arachnoid cysts are CSF-filled structures formed by arachnoid membranes, commonly found arising in the subarachnoid cisterns or major fissures of the brain. These cysts account for 1% of all intracranial space-occupying lesions, and are typically single, left-sided, and have a male to female predominance of 2:3 [1]. SAC represent only 9% of all arachnoid cysts in adults and 15% of all arachnoid cysts in the pediatric population [2]. While often an incidental finding on cranial imaging, surgical intervention can become necessary when compression of adjacent structures results in hydrocephalus, neurological symptoms, endocrine abnormalities, or developmental delay. As seen with this classic presentation of a SAC, approximately 90% of symptomatic SAC present with hydrocephalus due to obstructed third or lateral ventricular CSF outflow [3]. The exact etiology of SAC is unknown, though it may be linked with weakening of an arachnoid wall that later forms an inversion of the membrane, favoring cyst development [4]. Early identification of symptomatic SAC can facilitate prompt surgical interventions to relieve symptomatic compressions [1–3,5]. The morphology and periventricular location of SAC often permit endoscopic fenestration. These procedures are often effective, minimally disruptive to collateral structures, and associated with low morbidity and mortality rates, particularly in children [5]. Here, fenestration of the cyst floor allowed decompression into the adjacent subarachnoid cisterns. Despite initial successful cyst decompression, our patient later developed hydrocephalus requiring ventriculoperitoneal shunting with improvement in psychomotor development. SAC should be considered in patients demonstrating evidence of progressive hydrocephalus and a suprasellar lesion, as surgical intervention may dramatically improve cognitive trajectories and relieve potentially life-threatening hydrocephalus. Further elucidation of the natural history and evolution of SAC, including associated CSF hydrodynamic abnormalities, may help direct the optimum treatment strategy.

Bobble – head syndrome (BHDS) is a complex and rare syndrome with repetitive anteroposterior head movements. It is usually associated with expansile lesions in the third ventricular region. We present a 9 year old child with a giant suprasellar arachnoid cyst causing involuntary head movements.

The incidence of intracranial suprasellar arachnoid cysts is 9% of all arachnoid cysts. This case report describes a patient with a suprasellar arachnoid cyst who presented at the age of 4 with a rare bobble-head doll syndrome. Endoscopic ventriculocystostomy was performed. The literature on suprasellar arachnoid cysts is reviewed

A huge prepontine-suprasellar arachnoid cyst was identified by fetal sonography and magnetic resonance imaging. It was successfully treated with a two-stage operation using a neuroendoscope. The first operation during the neonatal period consisted of implantation of a cyst-peritoneal shunt. In the second operation, the cyst was fenestrated with the aid of a neuroendoscope. The cyst membrane was seen to cover the foramen magnum and to extend continuously to the ventral surface of the brain stem. At the foramen magnum, it was pulsating synchronously with the pulsation of the vertebral artery, which was suggestive of the mechanism of cyst growth. A ventriculo-peritoneal shunt was inserted to replace the cyst-peritoneal shunt. Endoscopic cyst fenestration is a less invasive alternative for the treatment of arachnoid cysts and can also be used for young children. In that case, however, special care should be taken to avoid complications, especially if the cyst exerts considerable pressure on the critical areas of the brain.

BACKGROUND The management of multiple symptomatic intracranial pathological processes in a single patient presents a rare and challenging problem for the neurosurgeon and the patient. Neurosurgeons must utilize a full spectrum of neurosurgical options to achieve the best patient outcome. CASE DESCRIPTION We present a unique case of a 63-year-old woman who presented with a large convexity meningioma causing headaches, an acoustic neuroma causing deafness and imbalance and a suprasellar arachnoid cyst compromising the visual fields. Therapeutic intervention was staged based on the primum non nocere concept. First, the patient underwent stereotactic intracavitary cyst irradiation using colloidal 32 P. Secondly, microsurgical resection of the convexity meningioma was performed. Finally, Gamma Knife radiosurgery of the acoustic neuroma was performed. One year after multimodality management, the patient was neurologically improved. There was no evidence of meningioma or cyst recurrence and the growth of the acoustic neuroma was arrested. CONCLUSION This case demonstrates the value of multi-modality treatment of neurosurgical pathology, utilizing minimally invasive techniques when possible.

Prepontine (or suprasellar) arachnoid cysts are uncommon in clinical practice and experience in their management may therefore be limited. Symptomatic cysts usually present with features of hydrocephalus due to obstruction of the third ventricle and aqueduct, and occlusion or partial obstruction of both foramina of Monro. Several treatment techniques have been used including stereotactic aspiration, microsurgical excision and shunting, but the best method of treatment remains unclear and the role of endoscopy is not yet established. We report our experience in a series of seven patients who had endoscopic treatment for prepontine arachnoid cysts; five were children under 15 years old who presented with delayed development and/or enlarged heads. The two adult patients, both of whom had insertion of shunts as children, presented with headache and vomiting due to shunt blockage. All patients improved following endoscopic cyst fenestration. There was no operative morbidity and there have been no relapses to date. Endoscopic fenestration of prepontine arachnoid cysts appears to be an effective method of treatment.

Objective: To evaluate the role of neuroendoscopy in the treatment of rare suprasellar and other third ventricle-related arachnoid cysts. Methods: A review of supratentorial midline arachnoid cysts treated by endoscopic fenestration. Results: Ten cases were identified. The median age of these ten patients was 7.5 years. In three a cysto- or ventriculoperitoneal shunt had previously been inserted. Six cysts were located in the suprasellar/prepontine area, one was a combined suprasellar/middle fossa cyst, and three were complex cysts arising mainly in the quadrigeminal cistern and extending into the third ventricle. Successful endoscopic fenestration to both the ventricular system and the basal cisterns ("bipolar" fenestration) was achieved in all cases. In seven cases a cystoventriculostomy and cystocisternostomy was performed, while in three a cystoventriculostomy was combined with a third ventriculostomy, achieving additional communication to the subarachnoid space. The previously inserted shunts were removed at the end of the procedure. The median follow-up period was 17 (range 1–30) months. The clinical outcome was excellent in all cases, despite only marginal reduction in the cyst size and persistence of ventriculomegaly in some cases. No further treatment to the cyst was required during the period of follow-up. Conclusion: Third ventricle-related arachnoid cysts can be satisfactorily and safely treated by endoscopy. This approach leaves the patient shunt independent.

Object. In this study the authors identify and investigate two new classifications of suprasellar arachnoid cysts.Methods. The authors used computerized tomography cisternography, magnetic resonance (MR) imaging, and neuroendoscopy to investigate nine cases of suprasellar arachnoid cysts. A communicating cyst with early filling and early clearance of a radioopaque tracer was found in seven of nine cases; a communicating cyst with delayed filling and delayed clearance of the tracer was observed in one case; and a noncommunicating cyst was observed in the other. The MR findings indicated a variation in the position of the basilar artery (BA) bifurcation in relation to the ventral surface of the midbrain. A distance existed between the BA bifurcation and the ventral surface of the midbrain in a communicating cyst with early filling, whereas the BA bifurcation was posteriorly displaced in a communicating cyst with delayed filling and also in a noncommunicating cyst, leaving little space between the bifurcation and the ventral surface of the midbrain. Endoscopic observation revealed, in the case of communicating cysts with early filling and early clearance of tracer, that the BA bifurcation is located inside the cyst with no overlying membrane, whereas in a noncommunicating cyst, the BA and its branches can be observed through the transparent membrane of the lesion.Conclusions. The authors postulate two different types of suprasellar arachnoid cysts: a noncommunicating intraarachnoid cyst of the diencephalic membrane of Liliequist and a communicating cyst that is a cystic dilation of the interpeduncular cistern.

We report on a female patient with a large suprasellar arachnoid cyst (3.5 × 2.5 cm) combined with right optic nerve hypoplasia. She developed growth hormone deficiency and hypothyroidism at the age of 8.5 years, adrenal insufficiency at the age of 11 years, diabetes insipidus and hypogonadotropic hypogonadism at the age of 15 years. When last seen at the age of 19 years she was extremely obese (+5.9 BMI SDS). The endocrine picture suggests that arachnoid cysts might be involved in far more complex hypothalamic-pituitary disturbances than previously thought.

Object. The empty sella syndrome (ESS) is well documented in adults, and although the same phenomenon of herniation of the arachnoid space into the enlarged sella turcica has been noted in children, it is not widely known that children suffer from this syndrome. Therefore, the aims of this paper are to increase neurosurgeons' awareness of the existence of this phenomenon in children and to add to the scant body of literature on the subject.Methods. The authors treated 12 children, ranging in age between 2 and 8 years, in whom neuroradiological studies demonstrated an enlarged sella turcica filled with cerebrospinal fluid and herniation of suprasellar and arachnoid spaces. The causes of ESS in these children were high intracranial pressure, neglected or improperly treated hydrocephalus, and suprasellar arachnoid cyst. Primary ESS was found as well. Most of the children presented with headache, abnormal body weight (the majority being underweight), and short stature. The results of hormone assays were normal in all children.Conclusions. If undiagnosed and untreated, ESS in children may lead to serious consequences, including impairment of pituitary and hypothalamic function and damage to the optic chiasm. It is important to raise awareness in the neurosurgical community about the existence of ESS in children so that it can be diagnosed and treated at an early stage. A classification system for the diaphragma sellae is recapitulated.

Background The first case of an intracranial arachnoid cyst was described by Bright in 1831. In 1935, Barlow published the first case of a suprasellar arachnoid cyst. Fewer than 200 cases of suprasellar-prepontine arachnoid cysts have been reported in the literature as of January 2011. Methods Between 1994 and 2010, the senior author operated on 34 cases of suprasellar-prepontine arachnoid cysts. Eighteen female and 16 male patients ranged in age from 6 days to 16 years (mean 5.2 years). Follow-up of the patients ranged from 1 year to 16 years. Results Outcome may be evaluated according to radiological and clinical follow-up data. Postoperative radiological examinations must reveal: 1) the adequacy of fenestrations and flow through fenestration sites, 2) reduction of the cyst and ventricle size, and 3) reorientation of the chiasma and mammillary bodies to an acceptable anatomical position. In our series, no mortality occurred. Postoperative complication occurred in 3 cases. Conclusions Suprasellar arachnoid cysts can be treated with favorable clinical and radiological results with endoscopic interventions when feasible. Results with ventriculocystocisternostomy are believed superior to those of ventriculocystostomy.

A 10-month-old girl presented with mental retardation and enlarged head, and a 3-year-old girl presented with epilepsy, both due to suprasellar arachnoid cysts. Magnetic resonance imaging demonstrated the suprasellar arachnoid cyst and the relationship between the cyst and surrounding structures. The 10-month-old patient with accompanying hydrocephalus was treated by fenestration of the cyst wall into the basal cistern. Postoperatively, bilateral subdural effusion appeared and subdural-peritoneal shunting was required. Thereafter, she regained the ability to walk. Two years postoperatively, the cyst reenlarged but communication between the cyst and surrounding cisterns and her development was normal, so she has been followed conservatively. The 3-year-old patient presented without hydrocephalus and was treated by cyst-peritoneal shunting using a Codman-Medos programmable valve through craniotomy. Postoperatively, the cyst was reduced and there has been no recurrence for 2 years and 5 months. We consider that cyst-peritoneal shunting is the most effective treatment for suprasellar arachnoid cyst.

Arachnoid cysts are space-occupying lesions filled with CSF-like content and surrounded by a membrane resembling arachnoid matter. They are regarded as a development abnormality of the arachnoid, originating from a splitting or duplication of this membrane. However, precise etiology and natural history remain controversial. Different hypotheses have been developed including agenesis of brain structures, arachnoiditis, active fluid secretion, and pulsatile pump. We present a review of the literature concerning these items and report one case of a suprasellar arachnoid cyst in which a slit-valve mechanism was observed by means of cine-mode MRI preoperatively and confirmed during the endoscopic intervention.

Objective : The endocrine dysfunction after the operation for suprasellar arachnoid cysts is not rare. The careful operation to prevent structures can prevent this complication, but it is not enough and effective to prevent it. Authors present technical surgical considerations to prevent this complication with a review of our suprasellar arachnoid cyst patients who had postoperative endocrine dysfunction. Methods : From January 2002 to December 2009, eight patients who had suprasellar arachnoid cysts with visual impairment underwent surgery. The mean age was 57.1 years (range, 33-77). Preoperatively, their endocrine function was clinically normal, and laboratory hormonal levels were within normal ranges. Cyst fenestration was performed by craniotomy (n=6) or by a neuro-endoscopic procedure (n=2), and, simultaneously, along with a cyst wall biopsy. Results : The surgery was uneventful in all eight patients, and there were no neurological morbidities. However, in four patients, endocrine dysfunction occurred postoperatively. We compared these four patients (group A) to the other 4 patients without endocrine dysfunction (group B) with intraoperative findings and with the histopathological findings of the cyst wall biopsy. The group A patients had more abundant vasculature on the cystic wall than the group B patients according to both the intraoperative findings and the histopathological findings. Conclusion : When performing a surgical cyst wall fenestration, surgeons should try to minimize the destruction of the cystic wall vasculature and not to make the fenestration at a site that contains many vascular striae.

Surgical options for suprasellar arachnoid cyst are cystoperitoneal shunt, craniotomy fenestration and endoscopic fenestration. Endoscopic management has been found to be safe and effective. We report our experience with endoscopic management in 12 (male five, female seven; age range 8 months to 42 years) patients with suprasellar arachnoid cyst. The endoscopic procedure included lateral ventricle puncture by precoronal burr hole and superior and inferior wall of the cyst was communicated with the lateral ventricle and the interpeduncular cistern respectively. All patients had hydrocephalus. Four pediatric patients had macrocephaly. All adult patients had visual disturbances. One adult patient presented with psychomotor disturbance along with features of raised intracranial pressure. All cases improved following endoscopic treatment. There were no complications or death. One patient required VP shunt. Postoperative MRI showed significant reduction in cyst volume in 11 patients. Follow-up ranged from 6 months to 6 and a half years. Our study suggests that endoscopic technique is a safe and effective alternative treatment for suprasellar arachnoid cyst. It prevents complications such as subdural effusion and intracranial hematoma, which are not uncommon with craniotomy fenestration.

Three children with a suprasellar arachnoid cyst and characteristic neuropathological signs are presented. Through the use of CT scanning and NMR imaging the location, volume and attenuation factors of these cysts can be documented. Stereotactically guided endoscopic exploration of the third ventricle region with visualization and manipulation of the cyst have been performed. This technique should be considered a safe and accurate alternative to craniotomy.

Four cases of large suprasellar arachnoid cysts in children are described. The authors propose a large fenestration into the lateral ventricles and into the basal cisterns as the treatment of choice. A specific multipurpose cerebral endoscope has been designed by the first author. The endoscopic technique with different instruments and with the use of a laser is illustrated. Results and complications are discussed.

The authors describe their experience with endoscopic ventriculo-cysto-cisternostomy and placement of cisterno-cysto-venticulo peritoneal shunt for suprasellar arachnoid cyst for a child with bobble head doll movements. The abnormal head movements improved and follow up imaging showed reduction in the cyst and ventricular size. The benefits of minimally invasive endoscopic ventriculocystocisternostomy with endoscopic guided placement of cisterno-cysto-ventriculo peritoneal shunt is been discussed.

A case of a 4-year-old child with bobble-head doll syndrome (BHDS) caused by a suprasellar arachnoid cyst and successfully treated by endoscopic cystovenriculostomy is reported from Medisch Centrum Haaglanden, The Hague; and Academical Hospital Nijmegen, The Netherlands.

cedures. This case illustrates the rapid development of a symptomatic suprasellar arachnoid cyst after shunt insertion to treat hydrocephalus. This healthy 4-month-old girl presented with communicating hydrocephalus (Fig. 1A). A ventriculoperitoneal (VP) shunt with a low-pressure valve was placed. The patient returned 2 months postoperatively with lateral and downward nystagmus. Repeated magnetic resonance (MR) imaging revealed a new suprasellar cyst (Fig. 1B and C) and an extraaxial hematoma. She subsequently underwent a right-sided pterional craniotomy with multiple cyst fenestrations into the basilar cisterns, resulting in prolonged resolution of the cyst (Fig. 1D). Pathological examination of the cyst wall revealed tissues consistent with fibrotic leptomeninges. No epithelial lining was identified. Arachnoid cysts probably arise by arachnoid reduplication during endomeninx development.1,3 Proposed mechanisms of cyst formation include one-way cerebrospinal fluid (CSF) flow into the diverticulum (ball-valve mechanism), slow distention by CSF pulsations, or active fluid secretion by the cyst wall.4 The appearance of an arachnoid cyst following VP shunt placement has been reported once2 and should be recognized as a potential complication of shunting procedures. Ventricular decompression may alter CSF dynamics, allowing for rapid enlargement of a preexisting arachnoid diverticulum. Overshunting may play a role, as indicated by the extraaxial hematoma. Therapy for suprasellar arachnoid cysts includes open fenestration, neuroendoscopic exploration, or shunting of the cyst fluid. Shunt revision with a higher pressure valve or an antisiphon device could be beneficial.

✓ Accidental death brought to autopsy a 19-year-old girl with an asymptomatic arachnoid cyst which had expanded from the region of the interpeduncular cistern so as to replace the third ventricle and extend into both lateral ventricles. Associated with this expansion was a significant degree of hydrocephalus, compression of the walls of the lateral ventricle, and obliteration of the normal structures of the floor of the third ventricle. The histological structure of the cyst wall and its relationship to the normal arachnoid are defined and found to consist of a reduplication of the normal arachnoid membrane resulting in a space within the arachnoid tissue. It is suspected but not proven that the cyst was congenital, resulting from an abnormality in development. Some suggestions are offered regarding the mechanism for its enlargement.

Summary. Five women presenting with amenorrhoea (three with secondary amenorrhoea and galactorrhoea, and two with primary amenorrhoea) were shown to have suprasellar abnormalities by computed tomography. Organic hypothalamic disease was confirmed at surgery (craniopharyngioma in three, intra- and suprasellar Rathke's cleft cyst in one, aqueductal stenosis and suprasellar arachnoid cyst in one). Moderate hyperprolactinaemia was present in the first four, while the last had isolated gonadotrophin deficiency of hypothalamic origin. One o f the hyperprolactinaemic women had entirely normal residual pituitary function, visual fields and tomography of the sella. Two of the patient, with secondary amenorrhoea and galactorrhoea had resumption of menses during bromocriptine therapy before operation. Spontaneous menarche and subsequent pregnancy occurred after ventriculoatrial shunt in the girl with aqueduetal stenosis. Organic hypothalamic diseases may present with amenorrhoea (sometimes as the only symptom) more commonly than previously appreciated. Computed tomography should replace conventional tomography of the sella and should be an essential part of the clinical investigation in all patients with amenorrhoea of hypothalamo-pituitary origin.

✓ Three cases of suprasellar arachnoid cysts in children are described. The importance of differentiating such a lesion from a dilated third ventricle is stressed. The value of computerized tomography with Conray ventriculography in preoperative diagnosis, symptomatology, and choice of treatment are discussed.

The typical CT appearance of intracranial arachnoid cysts may obviate additional neuroradiological procedures. Ventriculography using water-soluble contrast media may differentiate a suprasellar arachnoid cyst from a dilated third ventricle. Twelve cases are presented.

✓ Suprasellar arachnoid cysts, although rare, are now being found with increasing frequency with the help of the computerized tomography (CT) scanner. Forty-six cases have been reviewed from the literature, and the authors add eight patients seen at their institution during the past 6 years. This latter group have all been diagnosed by CT scan combined with an injection of metrizamide through an implanted diversionary cerebrospinal fluid shunt. Patients in whom the suprasellar arachnoid cyst had produced hydrocephalus were treated by communicating the cyst with the ventricular system via a transcallosal route, with very satisfactory results.

REPORT OF A CASE History and Preoperative Course.—S. H., a man aged 29, referred by Dr. Joseph Edeiken, was first seen on March 26, 1934. He complained of blurred vision and sharp retrobulbar pain which had been present for two weeks. The pain was especially marked on lateral movement of the eyes and on sneezing or coughing. The ophthalmic examination showed that the pupils were regular and equal and responded promptly to all the tests for normal reflexes. The media were clear. The optic disks were normal in color and well outlined, and the eyegrounds appeared entirely healthy. Visual acuity was 10/200 in the right and 20/40 in the left eye. There was a bitemporal hemianopic paracentral scotoma extending above and below the horizontal line with a moderate bitemporal peripheral contraction (fig. 1). A provisional diagnosis of retrobulbar neuritis probably secondary to sinusitis, or of a pituitary lesion

s The incidence of suprasellar arachnoid cysts (SSACs), although rare in children, is increasing as a result of the advent of computed tomography (CT) and magnetic resonance imaging (MRI). However, the pathogenesis of precocious true puberty in the presence of SSACs is unclear. In the present paper, we report the case of an 11-year-old boy with precocious true puberty who exhibited a classic SSAC that was identified using CT and MRI imaging. In addition, we highlight the occurrence of SSACs in association with precocious true puberty and discussing the imaging differential diagnosis and the role of imaging technique in reaching the diagnosis.

The authors report the case of a 2-year-old infant who presented with paroxysm and short changes characterized by acute drowsiness, cold sweats, ocular reversion, facial cyanosis, and bradycardia. Between these attacks, the condition was normal, suggesting diencephalic seizures. Over 2 months five fits were observed by the parents when some to-and-fro bobbing of the head onto the trunk appeared during drowsiness. One electroencephalogram was normal without a slow background or spikes discharges. As the skull radiographs showed erosion of the jugum and chronic intracranial hypertension features, a CT scan was performed and showed hydrocephalus associated with a congenital suprasellar cyst. The cyst was opened into basal cisterns with cystoperitoneal shunt. The histological examination revealed that it was an arachnoid cyst. Six months later, the infant was free of diencephalic seizures and head bobbing. Thus, we can assert that there was a direct relationship between this cyst and the diencephalic seizures. From this case, the authors make a review of the clinical features of diencephalic epilepsy, and their different causes and show that both diencephalic epilepsy and suprasellar arachnoid cysts are not common.

✓ The clinical and radiographic findings, surgical treatment, and outcome in 16 pediatric patients with intracranial arachnoid cysts are reviewed. The clinical presentation reflected the anatomical location of the lesions. Computerized tomography or magnetic resonance imaging scans were diagnostic in all cases. Of the nine cysts treated primarily or secondarily by craniotomy for fenestration and drainage into the basilar cisterns, five recurred. Cyst-peritoneal shunting led to diminished cyst size and clinical improvement in all seven cases in which it was used as the initial treatment and in all four cases in which fenestration had been unsuccessful. The results in this series show that cyst-peritoneal shunting is the treatment of choice for most intracranial arachnoid cysts in children.

The bobble-head doll syndrome is a rare movement disorder; fewer than 40 cases have been reported. It is usually associated with cystic abnormalities in the region of the anterior third ventricle. Various physiologic mechanisms have been proposed but none of them has been substantiated. We report a patient with this syndrome produced by a suprasellar arachnoid cyst. The CSF dynamics were investigated with CT cisternography. The phenomenon was apparently the result of intermittent obstruction at the foramina of Monro, a feature which has not previously been reported in this condition. The head movement served to partially relieve intraventricular obstruction, by both a posterior displacement of the cyst away from the foramina of Monro and a reduction in cyst size. This finding supports the concept that the bobble-head syndrome may be a "learned" behavior which lessens the symptomatology of hydrocephalus related to foramina of Monro obstruction.

A child with hydrocephalus treated by a valved shunt was reinvestigated after developing a shunt infection. A pouch was discovered invaginating the floor of the third ventricle and filling slowly with CSF from the region of the interpeduncular cistern. Histology and mechanisms of this pouch formation are discussed.

A case of suprasellar arachnoid cyst and hydrocephalus diagnosed by computed tomography (CT) and positive-contrast ventriculography is presented. Transfrontal exploration of the 3rd ventricle revealed findings consistent with the cyst being, in fact, a large forward and upward diverticulum of the arachnoidal membrane of Liliequist. The authors suggest that some of the other similarly located arachnoid cysts are extensions of this membrane imperforate by previous infection, hemorrhage, or maldevelopment.

The purpose of this paper is to present the clinical picture, diagnostic studies, and treatment of 5 cases of suprasellar cyst. The clinical symptoms and signs result from increased intracranial pressure without lateralizing signs (midline syndrome) and direct compression of the adjacent structures (hypothalmopituitary syndrome). The findings of computerized transmission tomography (CTT) and cerebral angiography in patients with suprasellar cyst are very similar to those of severe hydrocephalus. Cerebral angiography, however, reveals an inordinate mass effect in the parasellar area. Even though the location of the parasellar cyst is well demonstrated on postventriculoperitoneal shunt CTT scans, pneumonencephalography is necessary to confirm the diagnosis. We treated our patients with uni- or bilateral ventriculoperitoneal shunts, followed by craniotomy and cystosubarachnoid marsupialization. Cystoperitoneal shunting was performed after craniotomy in some instances, in place of it in others.

The treatment options for intracranial arachnoid cysts are either craniotomy and fenestration of the cyst into the cerebrospinal fluid spaces or shunting of the cyst contents extracranially. Fenestration may eliminate the need to shunt, but it is a major operative procedure and is not always successful. To determine which treatment provides the greatest benefit with the fewest complications, the records of 31 patients with 34 arachnoid cysts treated at the Children’s Hospital of Los Angeles between 1976 and 1986 were reviewed. The means age of the patients was 4.4 years, with a range of 0 to 15.5 years. The most common location was the middle fossa (14 cases), followed by the posterior fossa (7 cases), the suprasellar region (5 cases), and hemispheric (5 cases) and other locations (3 cases). Signs and symptoms were related to abnormally rapid head growth in infants and to increased intracranial pressure and seizures in older children. The initial treatment of 29 cysts was fenestration. Twenty-two (76%) procedures were successful, with no additional treatment needed for the cyst. The other 7 cysts required the subsequent placement of a cystoperitoneal shunt. In 5 cases, the cysts were treated initially with cystoperitoneal shunts. Of the total 12 cystoperitoneal shunts, 5 have required revisions on one or more occasions. No significant difference in morbidity was noted between the two treatment options. Because we consider shunt independence to be a major goal of therapy, we suggest that patients with arachnoid cysts be divided into two categories, those presenting with associated hydrocephalus and those without hydrocephalus. We recommend fenestration as the initial treatment in patients without hydrocephalus, as 76% of these patients are shunt-free.

✓ A woman with hydrocephalus and head bobbing presented with headaches and episodic loss of consciousness. Contrast studies revealed a cyst within the third ventricle. At craniotomy it occupied the entire third ventricle and its walls merged with the hypothalamus. This is considered to be a congenital suprasellar arachnoid cyst which expanded superiorly through the third ventricle. Similar cases are reviewed and therapy briefly discussed.

Нами описан случай хирургического лечения супраселярной арахноидальной кисты, которая блокировала ток ликвора на уровне III желудочка у ребенка 5 мес. С учетом возраста и сопутствующей соматической патологии было осуществлено кистовентрикулоперитонеостомію с применением нейросонографической навигации. Такая тактика позволила избежать осложнений, связанных с открытым оперативным вмешательством. Благодаря высокой информативности ультразвукового контроля, при пункции кисты возможные повреждения мозговых структур, находящихся поблизости были сведены к минимуму. Предложенную методику можно рекомендовать при подобных патологических состояниях у грудных детей., Нами описано випадок хірургічного лікування супраселярної арахноїдальної кісти, яка блокувала ток ліквора на рівні III шлуночка у дитини 5 міс. З урахуванням віку і супутньої соматичної патології було здійснено кістовентрикулоперитонеостомію із застосуванням нейросонографічної навігації. Така тактика дозволила уникнути ускладнень, які пов’язані з відкритим оперативним втручанням. Дякуючи високій інформативності ультразвукового контролю, під час пункції кісти можливі пошкодження мозкових структур, що знаходяться поблизу, були зведені до мінімуму. Запропоновану методику можна рекомендувати при подібних патологічних станах у грудних дітей., We present a case report of surgical treatment of supracellar arachnoid cyst which blocked CSF outflow on the level of third ventricle in 5 months newborn. Taking into account the age and accompany somatic pathology we performed cystoventriculoperitoneostomy by using of neurosonographic navigation. Choosing approach allows to avoid complications, associated with open surgery. Precision of cyst puncture was achieved with help of ultrasound intraoperative control. This surgical technique can be effectively used in newborns with similar lesions.