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Volume 1, Issue 2, Pages 21-25 (June 2014) Technical note: Endoscopic resection of a dermoid cyst anchored to the anterior optic chiasm Yuichiro Yoneoka, MD, PhD, Naoto Watanabe, MD, PhD, Mitsuo Kohno, MD, PhD, Daisuke Satoh, MD, Hitoshi Takahashi, MD, PhD, Yukihiko Fujii, MD, PhD Interdisciplinary Neurosurgery: Advanced Techniques and Case Management Volume 1, Issue 2, Pages 21-25 (June 2014) DOI: 10.1016/j.inat.2014.03.001 Copyright © 2014 The Authors Terms and Conditions

Fig. 1 Goldmann perimeter (GP) reveals bitemporal hemianopsia (upper), which is aggravated transiently after the resection of the cyst (middle). The bitemporal hemianopsia has disappeared, which is confirmed with GP (lower), four months after surgery. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions

Fig. 2 Computed tomography shows a suprasellar lesion containing a very low-density component and a relatively low-density component (A, D). A fluid level exists between them in this cystic lesion (D). T1-weighted image shows a high-signal intensity component in the cyst corresponding to internal fat content. This cystic lesion is not enhanced after the administration of gadolinium contrast. T2-weighted images show the displaced optic chiasm by the cystic lesion. The pituitary grand is observed independently from the cyst. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions

Fig. 3 The dura (arrow head) under the tuberculum sellae is opened and the cyst can be seen through the dural opening. The cyst is the same in color as the optic nerve/chiasm (A). The cyst contents obtained by needle puncture are creamy white emulsive fluids (B). Aspiration of the cyst contents enables observation of the attachment site of the cystic lesion on the anterior optic chiasm (C). The cyst wall is well-demarcated from the surrounding structures, such as the pituitary, the anterior cerebral arteries, or the basal frontal lobes, except for the anterior optic pathway (D, E). The anterior aspect of the optic chiasm can be seen through the cyst wall (C, D). The cyst wall seamlessly continued to the optic chiasm and the optic nerves bilaterally, which was visually confirmed under high-definition endoscopic vision (E). The pituitary stalk was intact and not affected by the lesion (F), which was confirmed after resection of the cyst wall. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions

Fig. 4 The cyst wall was resected along the optic chiasm (A, broken arrow). The part of the cyst wall on the optic chiasm was left (B). Arrow heads show the edge of the resected cyst wall (B). Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions

Fig. 5 Microscopic specimen of the cyst is compatible with dermoid cyst that is lined by squamous epithelium and endowed with skin appendages, including pilosebaceous units; marked lymphocytic (T-cell-dominant) infiltration is evident. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions

Fig. 6 Follow-up MR imaging shows no residual lesion or no recurrence six months after surgery. The pituitary stalk has returned to the normal position. Note the enhanced region and the less-enhanced region in the pituitary stalk, which are compatible with the intraoperative findings. Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 2014 1, 21-25DOI: (10.1016/j.inat.2014.03.001) Copyright © 2014 The Authors Terms and Conditions