Comparative analysis of management techniques in the treatment of pediatric Middle fossa arachnoid cysts: A systematic review and meta-analysis.
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INTRODUCTION: No consensus stands regarding optimal treatment for pediatric middle fossa arachnoid cysts (MFACs). This study aims to compare interventions for management of pediatric MFACs. METHODS: A systematic review was conducted per PRISMA guidelines using PubMed, Google Scholar, and Web of Science electronic databases to highlight management strategies of pediatric MFACs. RESULTS: Sixty two articles (22 retrospective studies, 40 case reports/series) were included. Across the retrospectives, 87.3 % patients were treated surgically and 24.0 % conservatively. Those treated surgically most underwent microscopic and endoscopic/keyhole fenestration. Microscopic fenestration was more frequently performed in ruptured cysts or cases with subdural hygroma (30.6 %, p = 0.044) while endoscopy was preferred for unruptured cysts (p = 0.005). Neurologic improvement was significantly greater with microscopic (99 %,) compared to endoscopic fenestration (91 %) (p = 0.01). Postoperative subdural fluid collections and mortality did not differ significantly between approaches. Conservative management primarily involved observation (24.6 %) and anticonvulsants (61 %). In case reports, 123 patients underwent surgery (102 open, 17 endoscopic), while 27 were managed conservatively. Microscopic fenestration correlated with preoperative cyst growth (OR: 37.63, p = 0.0004). Surgery carried greater complication risk (OR: Inf, p = 0.0014), while conservative management conferred higher cyst regression rates (OR: 20.84, p < 0.001). Common complications included subdural fluid and hygroma. CONCLUSION: Surgery is only warranted in severely symptomatic patients. Management of symptomatic, ruptured MFACs should target controlling acute subdural hygromas or hematomas. Microscopic and endoscopic surgeries yielded similar outcomes and complications. Most importantly, given the benign natural history of MFACs after the age of 4 years, most patients often require neither surgery nor follow-up imaging.