In recent decades, the management of middle fossa arachnoid cysts in pediatric patients has evolved significantly through the integration of novel techniques, such as the utilization of endoscopy systems1 and implementation of minimally invasive approaches like keyhole craniotomy.2,3 These cystic formations, occurring within the arachnoid membrane, may lead to neurologic impairments and raised intracranial pressure if left untreated.4 The utilization of endoscopy to aid microsurgical techniques or as a complement to them provides a level of visualization and manipulation of the cyst walls that is significantly more precise than the isolated use of a microscope.1 The keyhole craniotomy allows for reduced surgical trauma, smaller incisions, and quicker recovery times.5 In Video 1, we present the case of a 2-year-old patient with bilateral middle fossa arachnoid cysts exerting mass effect on the adjacent parenchyma. The patient was referred to our institution due to developmental delay and cognitive issues related to language and social interactions. On the basis of imaging findings and clinical correlation, we opted for a microsurgical fenestration with endoscopic inspection using a keyhole craniotomy to minimize complications and enhance the benefits of both techniques. Throughout the surgical video, tricks and considerations that contribute to the combined procedure's efficiency and ease of execution are highlighted and discussed. Postoperative images showed no complications, and the patient was discharged 3 days after surgery.
Keywords: Arachnoid cyst; Endoscopic fenestration; Keyhole; Microneurosurgery.
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