A Seven-Year Walk Toward Diagnosis: Endoscopic Surgery Rescues Boy From Giant Brain Cyst

An eleven-year-old boy from Syria spent seven years slowly losing his ability to walk steadily, and no one could tell him why. He never had a headache, never seized, never complained about his vision, and never showed the hormonal telltale signs that so often accompany tumors at the base of the brain. Yet with each passing month his gait grew broader and more unsteady, the quiet signature of fluid building up inside his skull with nowhere to go. When he finally reached a neurosurgical team, magnetic resonance imaging revealed the astonishing cause: a giant suprasellar arachnoid cyst, a benign, cerebrospinal fluid–filled sac measuring 4.5 by 4.5 by 6.7 centimeters, wedged inside the third ventricle of his brain and pressing downward toward the brainstem. The case, published in Clinical Case Reports, is a striking illustration of how long a treatable brain lesion can hide in plain sight when access to advanced imaging is scarce.

Suprasellar arachnoid cysts are uncommon collections of cerebrospinal fluid that arise from developmental splitting or duplication of arachnoid membranes, the delicate cobweb-like layers that envelop the brain. They cluster in the suprasellar region, the crowded crossroads at the base of the brain where the optic nerves cross, the hypothalamus and pituitary gland regulate hormones, and the fluid pathways of the third ventricle drain. Although arachnoid cysts as a group are rare, the suprasellar variety makes up a disproportionately large share of them in children, accounting for up to 21 percent of pediatric arachnoid cysts in reported series compared with roughly 9 percent in adults. Their location explains their danger: even a slowly growing, non-cancerous cyst can obstruct the foramina of Monro, the narrow channels through which fluid exits the lateral ventricles, triggering obstructive hydrocephalus, compress the optic apparatus, and distort the hypothalamic–pituitary axis.

What makes this boy’s story medically remarkable is the dissociation between what his body showed and what his brain was enduring. When clinicians examined him, his visual acuity was a perfect 10/10 in both eyes, his pupils reacted normally, and his eye movements were full. Yet fundoscopic examination, the simple act of looking into the back of the eye, revealed bilateral optic disc pallor, a whitening of the optic nerve head that signals chronic injury. The MRI added more evidence of long-standing trouble: dilated optic nerve sheaths consistent with raised intracranial pressure, massively enlarged lateral ventricles, and displacement of the circle of Willis arteries and the floor of the third ventricle. In other words, the boy’s visual system had been silently damaged for years even as his central vision held on, a phenomenon the authors attribute to partial optic atrophy with relative sparing of the papillomacular fibers that carry sharp central vision.

This clinical–radiological mismatch carries a sobering lesson for pediatricians and ophthalmologists everywhere. Preserved visual acuity, the authors argue, should never be used as the sole measure of optic nerve health in patients with signs of chronic intracranial hypertension. Formal automated perimetry, which maps the full visual field, and optical coherence tomography, which measures the thickness of the nerve fiber layer, can reveal functional and structural damage long before a patient notices anything wrong. In this case, neither tool was available in the child’s resource-limited local setting, and bedside confrontation testing of visual fields showed no gross deficit. Earlier access to magnetic resonance imaging could potentially have identified the obstructive hydrocephalus before optic disc pallor ever developed, and the authors suggest that the insidious nature of gait imbalance, combined with the absence of headache, seizures, visual complaints, or endocrine symptoms, allowed the diagnosis to slip further away with each passing year.

The surgical answer to this problem was as elegant as the anatomy was daunting. Rather than opening the skull or implanting a permanent shunt, the team performed a neuroendoscopic ventriculocystocisternostomy, a minimally invasive procedure in which a rigid endoscope is threaded through a small burr hole at Kocher’s point near the top of the skull. Navigating by familiar landmarks, the choroid plexus, the septal structures, and the foramen of Monro, the surgeon reached the dome of the cyst and widely fenestrated its apical membrane, opening a communication between the lateral ventricle and the cyst cavity. The endoscope was then advanced into the cyst itself, and a second, basal fenestration was cut toward the prepontine cistern, carefully avoiding the hypothalamus, the perforating arteries, and the basilar artery complex. The result was a wide, permanent three-way channel linking ventricle, cyst, and basal cisterns, allowing trapped cerebrospinal fluid to circulate naturally once again.

The choice of a dual fenestration over simpler alternatives was deliberate and grounded in both anatomy and circumstance. Ventriculocystostomy alone, which opens only the upper membrane, is technically simpler and can suffice for smaller cysts, but in large cysts extending inferiorly toward the prepontine cistern it may fail to restore communication with the basal fluid spaces, leaving the cyst isolated or allowing the stoma to reclose. Endoscopic third ventriculostomy, which bypasses obstruction by creating a hole in the ventricular floor, addresses hydrocephalus but not the cyst’s mass effect. Pediatric series comparing the two techniques have suggested lower recurrence and reoperation rates for the dual approach in appropriately selected patients, echoing early endoscopic principles that favored fenestration into both the ventricle and the basal cisterns. In this boy, whose MRI showed a combined ventricle–cyst–cistern problem rather than isolated aqueductal obstruction, the dual strategy was the anatomically rational one.

There was also a pragmatic dimension to avoiding a shunt. Shunt-based cerebrospinal fluid diversion, the historical mainstay for cyst-related hydrocephalus, imposes lifelong device dependence, and shunts carry clinically meaningful risks of infection and mechanical malfunction that frequently demand revision surgery and ongoing surveillance. In a conflict-affected, resource-limited environment where reliable follow-up, urgent revision capacity, and sterile resources cannot be assumed, those risks are amplified. A definitive, shunt-sparing endoscopic solution that restores natural fluid pathways is therefore not merely a technical preference but a strategy for reducing downstream morbidity where continuity of care is uncertain. Reports from such settings remain relatively scarce, which gives this case particular practical relevance for neurosurgeons working where healthcare infrastructure is fragile.

The outcome, at least in the short term, was encouraging. The child spent twenty-four hours in the neurosurgical intensive care unit, remained fully alert with no new neurological deficits, and early postoperative CT confirmed the fenestration trajectory without hemorrhage or ischemia. A temporary external ventricular drain, placed to manage pressure while the fluid pathways adapted, was removed without incident. A transient dip in adrenal function was detected biochemically and treated with hydrocortisone, normalizing on follow-up testing. He was discharged on the fourth postoperative day with a normal neurological examination and, remarkably, a marked subjective improvement in balance. At three months, MRI showed a reduced cyst size and an improved ventricular configuration, and his balance continued to improve.

Yet the authors are careful to temper optimism with caution. Three months is a short interval for a pediatric suprasellar arachnoid cyst treated endoscopically, and long-term follow-up series show that endocrine abnormalities can evolve over years even when initial testing is normal. The team has arranged structured surveillance across neurosurgery, ophthalmology, and endocrinology, with interval imaging planned at approximately twelve months, to confirm durable decompression and watch for delayed visual, hormonal, or radiological recurrence. They also emphasize that their strategy should not be generalized indiscriminately: surgical decisions must be individualized according to patient age, ventricular size, cyst morphology, membrane configuration, the mechanism of hydrocephalus, and the available equipment and endoscopic expertise. In other anatomical or clinical settings, single fenestration, third ventriculostomy, combined procedures, or shunts may remain the right choice.

The broader lessons of this case reach far beyond one operating room. Children with progressive gait disturbance or subtle signs of raised intracranial pressure warrant timely MRI review for treatable obstructive lesions, because the differential diagnosis includes lesions that a timely operation can cure. Optic disc pallor, even when visual acuity is perfect, should trigger expedited treatment and structured neuro-ophthalmic surveillance, since acuity alone can mask irreversible optic nerve injury. And where shunt maintenance and follow-up reliability are limited, anatomy-based endoscopic fenestration offers a rational path to restoring cerebrospinal fluid dynamics without implanting hardware that a fragile health system may struggle to maintain. A seven-year diagnostic delay nearly cost this boy his sight and his mobility; a single endoscopic procedure, guided by careful anatomy and pragmatic judgment, gave him both back.

Subject of Research: Endoscopic ventriculocystocisternostomy for a giant suprasellar arachnoid cyst with delayed diagnosis and obstructive hydrocephalus in a child

Article Title: Seven‐Year Delayed Diagnosis of a Giant Suprasellar Arachnoid Cyst Presenting With Progressive Gait Disturbance: Successful Endoscopic Ventriculocystocisternostomy—A Case Report

Article References: Ibrahem, Z., Almjersah, A., Mouselli, A., Saleh, I. I., & Alromhain, B. (2026). Seven‐Year Delayed Diagnosis of a Giant Suprasellar Arachnoid Cyst Presenting With Progressive Gait Disturbance: Successful Endoscopic Ventriculocystocisternostomy—A Case Report. Clinical Case Reports, 14(10), Article e73681. https://doi.org/10.1002/ccr3.73681

Image Credits: AI Generated

DOI: 10.1002/ccr3.73681

Keywords: suprasellar arachnoid cyst, obstructive hydrocephalus, neuroendoscopy, ventriculocystocisternostomy, optic disc pallor, gait disturbance, cerebrospinal fluid, pediatric neurosurgery, third ventricle, shunt-sparing surgery, delayed diagnosis, conflict-affected healthcare