PMC10159303_01
Preoperative pituitary magnetic resonance imaging showing an intrasuprasellar Arachnoid cyst. (a-c) Sagittal and coronal views reveal a large hyperintense and well-delineated sellar lesion (asterisk) with significant suprasellar extension. (d) Axial view. *This lesion occupies the whole sella turcica.
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F1
The optic chiasm (OCh) was compressed [Figure 1].
Sellar stage. (a and b) Opening of the sellar floor, tuberculum sella, and planum sphenoidale were removed. (c) After opening the sellar floor, the dura mater was exposed. (d and e) Vertical incision of the dura mater using a surgical knife. Dural leaves were lateralised to the sides using two Prolene 6.0 sutures, and an Arachnoid cyst was confirmed. OP: Optic prominence, OCR: Optocarotid recess, SF: Sellar floor, PS: Planum sphenoidale, C: Clivus, dm: Dura mater.
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After a wide sphenoidotomy and sellar bone opening, a vertical dural incision was made, dural leaves lateralized to the sides using two Prolene 6.0 sutures, and then the AC was confirmed [Figures 2a-e] A clear, nonmucinous fluid similar in color to CSF was drained out at the moment of the incision, using suction and irrigation.
Intraoperative images.(a) Excision of the left anterior part of the cyst wall. (b) Tissue collection. The pituitary stalk, optic chiasm, and right anterior cerebral artery (A1) were identified. (c) The anterior cyst wall was gradually dissected and removed from the right A1. (d) The lamina terminalis was coagulated by bipolar and fenestrated using cautery and scissors. (e) Foramen of Monroe (Wet field). Ch: Optic chiasm, Ps: Pituitary stalk, ON: Optic nerve. 1: Massa intermedia, 2: Lamina terminalis, *Thalamic veins, **Choroid plexus.
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The anterior communicating artery (Acom), right anterior cerebral artery (A1), and OCh were also clearly observed [Figures 3a and b]. The arachnoid membrane in front of the right A1 was also opened [Figure 3c]. Then, the cavity of the third ventricle was inspected, and the massa intermedia, foramen of Monro, and choroid plexus, as well as thalamic veins, were visualized [Figures 3d and e].
Reconstruction technique. Multilayer technique. Intraoperative views. (a) The view during the dural suturing. Continuous dural suture with abdominal fat, (b) The view after dural suturing, (c) Onlay fat. The dural opening is completely covered using fat, (d) Bone fragments are applied to the fat tissue, (e) The mucous membrane of the sphenoid sinus and right septum is used for the reconstruction of the sellae, (f) Synthetic dural sealant. *Bony septum fragments, **Abdominal fat,
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Then, the bony septum was divided into three pieces and laid on the fat graft and the sphenoid sinus mucosa and the upper right septal mucosa were overlaid to reconstruct the bony defect finally fixed with a dural sealant [Figures 4a-f].
Postoperative magnetic resonance imaging shows that the sellar arachnoid cyst has markedly decreased in size. The intrasellar part of the cyst covered by normal pituitary tissue is evident, and chiasma is not compressed. Fat graft is visualized as hyperintensity on T1 sagittal and coronal images.
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Follow-up (FU) MRI revealed a reduced size of the mass [Figure 5].