Preparation for Surgery for Arachnoid Cysts of the Head and Spine in Children

Indications for Surgery

• Symptomatic cysts: Large cysts with signs of elevated ICP (papilledema, focal neurological deficits, macrocephaly in infants, etc.) should be addressed surgically.
• Symptomatic enlarging cysts: It is rare for cysts to enlarge in children older than 4 years of age. However, if they do, and if the enlargement is accompanied by neurological symptoms, removal is indicated.
• Macrocephaly in an infant: Macrocephaly in an infant with an arachnoid cyst may be an indication for surgery, particularly if it is worsening over time. However, in these cases, the cyst may be a forme fruste of hydrocephalus, and fenestration alone without shunting may have a low chance of success.
• Ruptured arachnoid cysts: Cysts that have ruptured, causing acute subdural hematomas and/or elevated ICP, are typically addressed surgically.
• Seizures: Seizures are commonly in children with arachnoid cysts. However, seizures should be recognized as a manifestation of an underlying problem in brain development and are not an indication for cyst surgery.
• Sports clearance: There is no evidence that surgical address of asymptomatic arachnoid cysts lessens the chance of traumatic rupture from sports. Thus, prophylactic surgery should not be considered for sports clearance.
• Persistent headaches: Approximately 10% of children with arachnoid cysts may have chronic headaches. Given the prevalence of cysts in the population, care should be exercised before operating on nonenlarging cysts in a child for the sole indication of headaches.
• Polyradiculitis/myelopathy: Spinal cysts causing symptomatic spinal cord/nerve root compression should be addressed surgically. 

Anesthetic Considerations

• Standard: Standard anesthesia procedures for both intracranial and spinal surgeries should be followed.

Ancillary/Specialized Equipment

• Microscope: When an open fenestration is performed, a “keyhole” incision is typically used. Microscopic visualization is used to minimize cerebral retraction and ensure the fenestration is completed into the basilar cisterns.
• Endoscope in some cases: Endoscopic fenestration can be an accepted alternative to open fenestration if large enough fenestrations can be performed. Rigid scopes are more commonly used due to their ability to create larger fenestrations.
• Neuronavigation: Neuronavigation may be indicated to localize deep-seated cysts that do not come to the cerebral surface and to find the cisterns in cases of thick-walled membranes.
• Operative ultrasound: Intraoperative ultrasonography may be indicated for deep-seated cysts.
• Intraoperative physiological monitoring: Intraoperative monitoring may be used for spinal cyst resection to minimize the risk of spinal cord damage.