The study included patients treated at Nanchong Central Hospital and Guangyuan Central Hospital in Sichuan, China, between July 2020 and February 2026. Eligible patients were 18 to 90 years old, had symptomatic chronic subdural haematoma of at least three weeks’ duration, and had either maximum haematoma thickness above 10 mm or midline shift above 5 mm. Of the 265 participants, 46 received middle meningeal artery embolization, 152 underwent burr hole drainage and 67 received neuroendoscopic-assisted evacuation with middle meningeal artery disconnection.

The primary outcome was radiological recurrence within six months, defined as increased haematoma thickness on follow-up CT, with or without worsening symptoms, regardless of whether further surgery was required. An independent radiologist blinded to treatment allocation re-measured haematoma thickness and midline shift. Secondary outcomes included neurological improvement, defined as a decrease of at least one point on the modified Rankin Scale; reoperation; any additional surgery; complications; operation time; hospital stay; and imaging follow-ups.

Six-month recurrence occurred in 30 of 152 patients treated with burr hole drainage, a rate of 19.74% (95% CI 13.73–26.96%). Recurrence occurred in two of 46 patients treated with embolization, a rate of 4.35% (95% CI 0.53–14.84%), and three of 67 patients treated with neuroendoscopic evacuation and artery disconnection, a rate of 4.48% (95% CI 0.93–12.53%). The overall difference among the three groups was statistically significant (p = 0.001), while the difference between embolization and neuroendoscopic evacuation was not. Recurrence odds were higher with burr hole drainage than with embolization or neuroendoscopic evacuation, and the blinded radiological measurements produced the same group estimates.

Neurological improvement was documented in 59 of 67 patients in the neuroendoscopic group, or 88.06% (95% CI 77.82–94.70%), compared with 71.71% in the burr hole drainage group and 60.87% in the embolization group; the overall difference was significant (p = 0.003). Reoperation for recurrence was required in 19.08% of the burr hole drainage group, compared with 4.35% after embolization and 4.48% after neuroendoscopic evacuation, also a significant overall difference (p = 0.002).

Embolization did not produce the lowest rate under every measure. Five patients, or 10.87% of the embolization group, underwent salvage burr hole drainage during the same hospitalization because of persistent or worsening symptoms without radiological progression. When recurrence-related reoperations and this salvage procedure were combined, any additional surgery occurred in 15.22% of the embolization group, 19.08% of the burr hole drainage group and 4.48% of the neuroendoscopic group. After Bonferroni-corrected pairwise comparisons, the neuroendoscopic group had a significantly lower rate than the burr hole drainage group, but the other pairwise differences were not significant.

The embolization procedure had the shortest median operation time, 31 minutes, compared with 45 minutes for burr hole drainage and 70 minutes for neuroendoscopic evacuation. Median hospital stay was seven days after embolization, nine days after burr hole drainage and eight days after neuroendoscopic evacuation. The embolization and neuroendoscopic groups each had a median of four imaging follow-ups, compared with six in the burr hole drainage group. Complication rates did not differ significantly: 8.70% after embolization, 9.21% after burr hole drainage and 5.97% after neuroendoscopic evacuation.

One patient in the embolization group experienced permanent blindness after inadvertent embolization through a dangerous meningo-ophthalmic anastomosis. No comparable severe event was reported in the other groups. The authors described embolization as offering rapid procedures and low recurrence, but cautioned that it does not immediately remove an established haematoma and that five patients required salvage drainage for delayed resolution of mass effect. Neuroendoscopic evacuation with artery disconnection allowed direct removal of liquid and solid haematoma, coagulation of bleeding points and disruption of fibrous septations, but required the longest operation.

The observational design limits causal interpretation. Treatment was not randomized, and selection may have reflected operator preference, patient willingness and local resources. Although measured baseline characteristics were balanced, unmeasured factors such as frailty, disease severity and operator experience could have influenced the results. The embolization and neuroendoscopic groups were small and had few recurrence events, preventing multivariable adjustment, propensity-score matching and reliable time-to-event analysis. Secondary outcomes were exploratory without correction for multiple testing, and follow-up beyond one year was not established.

Based on the findings and their clinical interpretation, the authors proposed individualized selection that accounts for haematoma characteristics, patient condition and available resources. They presented burr hole drainage as a reasonable option for first-onset, non-septated haematoma; embolization as potentially suitable for older or medically frail patients and those with coagulopathy, subject to caution because of blindness risk; and neuroendoscopic evacuation with artery disconnection as potentially appropriate for septated, organized, recurrent or markedly space-occupying haematomas. The study itself was observational, so these positions require confirmation in larger prospective comparative research.

Subject of Research: Comparative outcomes of three treatments for chronic subdural haematoma in a 265-patient retrospective cohort

Article Title: Comparative outcomes of middle meningeal artery embolization, burr hole drainage, and neuroendoscopic-assisted evacuation with MMA disconnection for chronic subdural haematoma: a multicenter retrospective cohort study

Article References: Song, X., Zhang, Y., Luo, B., & Tang, X. (2026). Comparative outcomes of middle meningeal artery embolization, burr hole drainage, and neuroendoscopic-assisted evacuation with MMA disconnection for chronic subdural haematoma: a multicenter retrospective cohort study. Frontiers in Neurology, 17, Article 1975364. https://doi.org/10.3389/fneur.2026.1975364

Image Credits: AI Generated

DOI: 10.3389/fneur.2026.1975364

Keywords: chronic subdural haematoma, middle meningeal artery embolization, burr hole drainage, middle meningeal artery disconnection, neuroendoscopy, haematoma recurrence, retrospective cohort study, neurological outcome, neurosurgery, Comparative, outcomes, middle

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