title: Exploring predictors of surgery and comparing operative treatment approaches for pediatric intracranial arachnoid cysts: a case series of 83 patients.
abstract: OBJECTIVE
  Although intracranial arachnoid cysts are a common incidental finding on pediatric brain imaging, only a subset of patients require surgery for them. For the minority who undergo surgery, the comparative effectiveness of various surgical approaches is debated. The authors explored predictors of surgery and compared operative techniques for pediatric patients with an intracranial arachnoid cyst seen at a tertiary care center.
  
  
  METHODS
  The authors reviewed records of pediatric patients with an intracranial arachnoid cyst. For each patient, data on baseline characteristics, the method of intervention, and surgical outcomes for the initial surgery were extracted, and cyst size at diagnosis was calculated (anteroposterior × craniocaudal × mediolateral). Baseline variables were analyzed as predictors of surgery by using logistic regression modeling, excluding patients whose surgery was not related to cyst size (i.e., those with obstructive hydrocephalus secondary to the cyst compressing a narrow CSF flow pathway or cyst rupture/hemorrhage). Data collected regarding surgical outcomes were analyzed descriptively.
  
  
  RESULTS
  Among 83 pediatric patients with an intracranial arachnoid cyst seen over a 25-year period (1989-2013), 27 (33%) underwent surgery; all had at least 1 cyst-attributed symptom/finding. In the multivariate model, age at presentation and cyst size at diagnosis were independent predictors of surgery. Cyst size had greater predictive value; specifically, the area under the curve for the receiver-operating-characteristic curve was 0.89 (95% CI 0.82-0.97), with an ideal cutoff point of ≥ 68 cm(3). This cutoff point had 100% sensitivity (95% CI 79%-100%), 75% specificity (95% CI 61%-85%), a 53% positive predictive value (95% CI 36%-70%), and a 100% negative predictive value (95% CI 91%-100%); the positive likelihood ratio was 4.0 (95% CI 2.5-6.3), and the negative likelihood ratio was 0 (95% CI 0-0.3). Although the multivariate model excluded 7 patients who underwent surgery (based on prespecified criteria), excluding these 7 cases did not change the overall findings, as shown in a sensitivity analysis that included all the cases. Descriptive results regarding surgical outcomes did not indicate any salient differences among the surgical techniques (endoscopic fenestration, cystoperitoneal shunting, or craniotomy-based procedures) in terms of symptom resolution within 6 months, need for reoperation to date, cyst-size change from before the operation, morbidity, or mortality.
  
  
  CONCLUSIONS
  The results of these exploratory analyses suggest that pediatric patients with an intracranial arachnoid cyst are more likely to undergo surgery if the cyst is large, compresses a narrow CSF flow pathway to cause hydrocephalus, or has ruptured/hemorrhaged. There were no salient differences among the 3 surgical techniques for several clinically important outcomes. A prospective multicenter study is required to enable more robust analyses, which could ultimately provide a decision-making framework for surgical indications and clarify any differences in the comparative effectiveness of surgical approaches to treating pediatric intracranial arachnoid cysts.
authors.affiliation: Icahn School of Medicine at Mount Sinai, New York, New York;
authors.forename: Mohsin
authors.initials: M
authors.lastname: Ali
authors.affiliation: Division of Neurosurgery, 
authors.forename: Michael
authors.initials: M
authors.lastname: Bennardo
authors.affiliation: Division of Neurosurgery, 
authors.forename: Saleh A
authors.initials: SA
authors.lastname: Almenawer
authors.affiliation: Division of Neurosurgery, 
authors.forename: Nirmeen
authors.initials: N
authors.lastname: Zagzoog
authors.affiliation: Departments of 3 Surgery and.
authors.forename: Alston A
authors.initials: AA
authors.lastname: Smith
authors.forename: Dyda
authors.initials: D
authors.lastname: Dao
authors.affiliation: Division of Neurosurgery, 
authors.forename: Olufemi
authors.initials: O
authors.lastname: Ajani
authors.affiliation: Departments of 3 Surgery and.|Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
authors.forename: Forough
authors.initials: F
authors.lastname: Farrokhyar
authors.affiliation: Division of Neurosurgery, 
authors.forename: Sheila K
authors.initials: SK
authors.lastname: Singh
mesh_terms: D000293:Adolescent; D016080:Arachnoid Cysts / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D019540:Area Under Curve; D002543:Cerebral Hemorrhage / Q000209:etiology*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology*; D007223:Infant; D016015:Logistic Models; D008279:Magnetic Resonance Imaging; D008297:Male; D008499:Medical Records; D019635:Neurosurgical Procedures / Q000379:methods*; D009864:Ontario; D011237:Predictive Value of Tests; D012372:ROC Curve; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D016896:Treatment Outcome
keywords: AUC = area under the curve; CP = cystoperitoneal; IQR = interquartile range; ROC = receiver operating characteristic; arachnoid cysts; congenital; craniotomy; cystoperitoneal shunt; endoscopic fenestration; predictors; surgery