Endoscopic endonasal management of sellar/suprasellar arachnoid cysts: tailored surgical strategies and systematic review

Introduction Sellar and suprasellar arachnoid cysts(SACs)are rare lesions that may cause headaches, visual impairment, and endocrine dysfunction. While endoscopic endonasal approaches(EEA)are increasingly preferred, optimal surgical strategy—simple fenestration versus wide cyst–subarachnoid space(SAS)communication—remains debated. This study reports one of the largest single-center series of SACs treated via EEA for SACs and integrates these findings with an updated systematic review of the literature. Methods A retrospective review was conducted on 6178 endoscopic endonasal surgeries performed between1997 and 2024, identifying 18 symptomatic patients with pathology-confirmed SACs and ≥ 6 months follow-up. Clinical, radiological, surgical, and endocrine parameters were analyzed. Surgical strategies were individualized according to cyst extension, pituitary gland position, and intraoperative CSF dynamics. A PRISMA-guided systematic review of PubMed, Scopus, and Web of Science databases was performed to integrate existing evidence. Results The mean patient age was42.66 ± 13.06 years(range,18–62 years), and headaches(83%), endocrine dysfunction(78%), and visual deficits(39%)were the most common symptoms. Mean maximal cyst diameter was21.16 ± 9.40 mm(range,7–46 mm), with sellar or sellar–suprasellar extension in most cases. All patients underwent EEA with cyst fenestration, decompression, and tailored skull-base reconstruction. Extended cyst–SAS fenestration was performed in 4 patients, whereas 12 underwent simple fenestration/obliteration and 2 needle-guided decompression due to anterior gland position. Headache improved in all patients, and visual function improved or stabilized in every case. Hyperprolactinemia resolved universally, while other pituitary deficits showed variable recovery. Two patients developed postoperative CSF rhinorrhea—both after extended fenestration—requiring revision. No vascular injuries or mortality occurred. One asymptomatic radiological recurrence(5.5%)was observed during median follow-up of 49 months. Conclusion The EEA provides safe and effective management of SACs with excellent symptom relief. Surgical strategy should be individualized based on anatomical configuration rather than cyst size alone. Although wide cyst–SAS fenestration enhances decompression, it may be associated with a higher likelihood of intraoperative high-flow CSF leakage; therefore, robust multilayer reconstruction is essential. Long-term surveillance remains crucial due to potential recurrence.