If it can be done, it should be done,…or not?

Excerpt

In this issue, Feletti and colleagues have published an interesting case report: “Transaqueductal trans-Magendie fenestration of arachnoid cyst in the posterior fossa” [2]. The case they present is that of a 65-year-old female with a retrocerebellar (cisterna magna) arachnoid cyst, clearly growing over an 8-year period, with increasing symptoms of ataxia, asthenia and headache. The authors stated that there was an obstructive triventricular hydrocephalus. The authors describe a triventricular hydrocephalus also with an enlarged aqueduct. On their figure 1a and b, there is indeed an increase in the size of the cyst, but the aqueduct is patent and, to my understanding, not widened. Therefore, it was difficult to imagine a triventricular hydrocephalus with a patent aqueduct and normal-sized fourth ventricle caused by a retrocerebellar cyst, apparently closing of the foramen of Magendie. If this had also obstructed the foramina of Luschka, I would have expected a quadriventricular hydrocephalus, thus also involving the fourth ventricle. I wondered if the patient’s symptoms such as ataxia could also “just” have been caused by the enlarging cyst itself. The authors state that their primary aim was to perform an ETV to resolve the problem of hydrocephalus, and their secondary aim was to determine whether the cyst could be reached, but then, in the description of the surgical procedure, it was apparent that the cyst itself was their first target. At the end of the detailed description of the cyst fenestration, they write “An ETV was also performed, as initially planned”. If the ETV was their primary aim, that should have been performed as a first step. …