Metabolic syndrome in people with epilepsy.

BACKGROUND: Little is known about the association of metabolic syndrome (MetS) and quality of life (QoL) in people with epilepsy (PWE). We evaluate the trends of MetS in PWE across various age groups. We also evaluate the association of MetS and QoL in PWE. METHODS: Clinical and seizure data were collected in 173 people with controlled epilepsy. Physical fitness was assessed by using the six-minute walk test and one-minute step test. Self-reported SF-12 questionnaire, was used to derive physical (PCS) and mental (MCS) component scores. RESULTS: The average age of the study population was 25.85 ±â€¯9.62 years, and MetS was observed in 91 (52.6%). Obesity was seen in 153 (88.4%). Average distance walked in the six-minute walk test was 385.55 ±â€¯71.52 m. Mean PCS and MCS were 45.95 ±â€¯7.92 and 45.72 ±â€¯10.40, respectively. More number of women had MetS (47.6% vs. 62.6%; p = 0.049) and women in the study population had lower high-density lipoprotein (HDL)-C (44.34 ±â€¯11.60 vs. 38.65 ±â€¯10.13 mm Hg; p < 0.001). Except for the variables that define MetS, none of the clinical characteristics were associated with MetS. Across age groups, prevalence of MetS was consistently at 50.0% although prevalence of hypertension showed a linear increase with age. While low HDL-C was seen highest (61.5%) in ≤20 years age, impaired fasting blood sugar (FBS) was highest in PWE aged >40 years. CONCLUSION: Metabolic syndrome is seen in more than half of PWE, and this increased prevalence is not associated with the number of antiepileptic medicines. While prevalence of MetS was stable at 50.0% across all age groups, components of MetS have varying prevalence across age groups hence, suggesting their varied contribution across age groups.

Crescent durotomy for midline posterior fossa lesions.

OBJECTIVE: The conventional midline suboccipital craniectomy, the standard approach for posterior fossa lesions, involves ligation of the occipital sinus. Postoperative sequelae that could occur from ligation of the occipital sinus include hydrocephalus, cerebrospinal fluid (CSF) leak, and pseudomeningiocoele formation. The standard of practice of venous pathway preservation, as practiced elsewhere in the cranium, should also be attempted in the posterior fossa. In the current study, we compared postsurgical complications between conventional "Y" durotomy with the proposed crescent durotomy in patients with posterior fossa lesions who underwent midline suboccipital craniectomy. MATERIALS AND METHODS: The prospective data of 104 patients who underwent a midline suboccipital craniotomy for posterior fossa tumors between January 2011 and December 2015 was performed. Comparison of study variables was done between the durotomy techniques used. RESULTS: Of the 104 patients who formed the study population, 39 (37.5%) were women. While 75 patients underwent crescent durotomy, the remaining underwent the conventional "Y" durotomy. Among the postsurgical complications, there were no differences between groups in terms of their surgical site hematoma (2.7% vs 3.4%; P = 1.000) and edema (1.3% vs 0.0%; P = 1.000). The groups were also similar in terms of the incidence of postsurgical CSF leak (1.3% vs 6.9%; P = 0.187) and cranial nerve deficits (4.0% vs 6.9%; P = 0.617). However, more number of patients who underwent the "Y" durotomy had postoperative pseudomeningiocoele (2.7% vs 17.2%; P = 0.017). CONCLUSION: The "crescent" durotomy is a novel dural opening technique which attempts to preserve the normal venous flow physiology. The crescent durotomy reduces the need for a duroplasty, facilitates a comfortable primary closure, thus reducing the risk of developing a postoperative pseudomeningiocoele.

Ictal FDGPET and SPECT in hemifacial seizures due to cerebellar epilepsy-Case report.

The role of cerebellum in seizure generation is debatable. Semiology and electroencephalography (EEG) findings are non-specific and sometimes misleading, posing further difficulty in proving the epileptogenicity in pre-surgical workup. We report two cases of cerebellar lesions who presented with hemifacial seizures since the neonatal period and were refractory to antiepileptic drugs (AEDs). Both inter-ictal and ictal EEGs were non-contributory. Magnetic resonance imaging (MRI) showed a lesion in the cerebellum, in proximity to cerebellar peduncle in both the patients. (18) F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and ictal single photon emission computed tomography (SPECT) showed focal hypermetabolism and hyperperfusion respectively, corresponding to the lesion on MRI in both the cases. Intraoperative electrocorticography showed rhythmic spikes confirming the epileptogenic nature of the lesion. Both patients were operated with a favorable surgical outcome. Histopathology was suggestive of a ganglioglioma in one child and a low-grade glioma in the other. Both cases illustrate that FDG-PET and SPECT can act as surrogate markers for invasive recordings to prove the epileptogenicity of cerebellar lesions, especially in resource limited settings.

Corticosteroids in the management of lymphocytic hypophysitis: Case series.

BACKGROUND: The diagnosis of lymphocytic hypophysitis (LYH) is a clinical challenge. Medical management with steroids may result in complete resolution of the symptoms and radiological features. We report our approach to the diagnosis and treatment of LYH. MATERIALS AND METHODS: Retrospective analysis of data of nine consecutive patients of LYH from August 2013 to August 2015 was done. The average age of the study population was 38.4 ± 19.8 years, with five (55.5%) women. Presumptive diagnosis of LYH was made in six patients who were treated with steroids. Among the medical intervention group, one patient developed progressive ocular symptoms involving the third cranial nerve, which required surgical intervention. Out of the five remaining patients under medical treatment, four patients showed improvement in clinical symptoms and resolution of radiological features and one patient showed recurrence of the lesion. In the surgical group, the diagnosis was made after the histopathological confirmation. RESULTS:: In the surgical group, the diagnosis was made after the histopathological confirmation in all patients except one. All the patients in this group presented with optic nerve compression requiring surgical decompression. All the patients in this group showed symptomatic improvement postoperatively. Symptoms for deficiency of hormones required supplementation dose of steroids. CONCLUSION:: Steroids should be considered as the first line of management in LYH. Surgical resection should be considered in the presence of optic nerve and/or chiasmal compression and for lesions nonresponsive to medical management.

Epilepsy surgery in children.

Approximately 60% of all patients with epilepsy suffer from focal epilepsy syndromes. In approximately 15% of these patients, the seizures are not adequately controlled with anticonvulsive drugs, and such patients are potential candidates for surgical treatment and majority are children. Epilepsy surgery in children, who have been carefully chosen, can result in either seizure freedom or a marked (>90%) reduction in seizures in approximately two-third of children with intractable seizures. In the multimodality presurgical evaluation approach, sufficient concordance should be established among various independent investigations, thus identifying the location and extent of the epileptogenic zone with a high degree of confidence. Early surgery improves the quality of life and cognitive and developmental outcome of the child. Surgically remediable epilepsies in children should be identified early and include temporal lobe epilepsy with focal lesions, lesional extratemporal epilepsies, hemispherical epilepsies, and gelastic epilepsy with hypothalamic hamartoma, and can be treated by resective or disconnection surgery. Palliative procedures include corpus callosotomy and vagal nerve stimulation for children with diffuse and multifocal epilepsies, who are not candidates for resective surgery. Deep brain stimulation in patients with epilepsy is still under evaluation. For children with "surgically remedial epilepsy," surgery should be offered as a procedure of choice rather than as a treatment of last resort.

Far lateral approach: Is condylar resection required?

BACKGROUND: We report our experience with the far lateral approach (FLA) and its modifications in the surgical resection of tumors of craniocervical junction (CCJ). MATERIALS AND METHODOLOGY: We retrospectively reviewed data of 36 patients with CCJ lesions who underwent surgical excision. Data are presented as frequency/percentages. Tumor locations were classified by anatomical relation around the CCJ (on axial plane). For anterior and laterally placed tumors, we preferred the FLA and its modification. A postoperative complication was defined as a new neurological deficit without subsequent recovery. The perioperative mortality was defined as death within 30 days of surgery. RESULTS: The mean age of the study population was 48.8 years (5-64 years) with 15 women. Simpson's Scale Grade 2 resection was achieved in 18 out of 19 patients with meningiomas. Overall, transient complications were observed in eight patients (22%); none of the patients developed postoperative cerebrospinal fluid fistula. The permanent morbidity rate was 5.6%. One patient died on the 6th postoperative day. The mean follow-up period was 4.1 years (range, 3 months-12 years). Tumor recurrence was observed in two patients who were advised radiotherapy. Twenty patients (96%) were independent for activities of daily living. CONCLUSION: The FLA is a versatile approach and is useful for a variety of lesions located ventrolateral to the brainstem and upper cervical cord. It allows adequate exposure with minimal retraction. Most of the foramen magnum meningiomas can be excised either without or with only partial resection of the condyle. The transjugular process approach to the jugular foramen (JF) is effective for JF tumors without the necessity of facial nerve transposition.

Psychiatric disorders among 165 patients with juvenile myoclonic epilepsy in India and association with clinical and sociodemographic variables.

OBJECTIVE: The current study evaluated the association between clinical variables and psychiatric disorders (PDs) in patients with juvenile myoclonic epilepsy (JME). METHODS: Consecutive patients with JME who had at least two years of regular follow-up from May 2011 to April 2014 formed the study population. The association between clinical and sociodemographic data with psychiatric evaluation on structured clinical interview and quality of life in epilepsy - 31 (QOLIE-31) was evaluated using logistic regression analysis. RESULTS: Out of 165 patients in the current study, 77 (46.6%) patients were diagnosed with PDs; while 50 were categorized to having anxiety disorders, 27 patients had depressive disorders. The mean age of the study population was 25.35 ± 7.6 years with 37.52% women. Patients with PDs had lower overall QOLIE score (55.84 ± 13.07 vs 68.70 ± 11.23, p<0.001) and lower social function score (80.95 ± 19.22 vs 91.09 ± 14.74, p<0.001). Being married was the strongest predictor of depressive disorders (ß=8.59; 95% CI, 1.44-51.28; p=0.018); whereas, lower emotional well-being (ß=0.942; 95% CI, 0.907-0.978; p=0.002) was the only variable associated with anxiety disorders. Patients with depressive disorders had longer duration of PDs (11.85 ± 8.68 years vs 7.75 ± 6.70 years, p=0.039), and a majority of them were married (66.7% vs 26.0%, p=0.001). Patients with depressive disorders scored low on emotional well-being (50.81 ± 14.62 vs 61.02 ± 13.05, p=0.002), energy levels (52.78 ± 11.71 vs 62.80 ± 10.84, p<0.001), and social function (70.96 ± 20.69 vs 86.34 ± 16.16, p=0.001). Depressive disorders were more prevalent among married patients above 35 years of age (5.2% vs 36.8%, p=0.042). SIGNIFICANCE: Nearly half of the patients with JME had coexisting PDs. The psychological profile of anxiety disorders was different from depressive disorders in patients with JME. Depressive disorders were more prevalent among older patients with JME, and marriage was strongly associated with depressive disorders.

Novel classification for surgical approach of petroclival meningiomas: A single-surgeon experience.

BACKGROUND: Management of petroclival meningiomas (PCMs) is a surgeons' challenge. Planning the surgical approach and extent of excision play a vital role. The current study discusses a novel grading system that may help to choose the surgical approach. MATERIALS AND METHODS: We prospectively analyzed 76 patients operated after selecting the surgical approach through a novel grading system based on the extent of dural attachment of PCM in the posterior fossa. RESULTS: The mean age of the study group was 39.74 ± 13.38 years and 51% of the patients were women. Gross total resection (GTR) was achieved in 59 (77.6%) patients. Among patients who underwent subtotal resection (STR), the mean sagittal diameter of the tumor was greater than axial (4.6 ± 0.9 mm vs. 3.4 ± 1.3 mm; P = 0.01) and coronal diameters (4.6 ± 0.9 mm vs. 3.8 ± 1.4 mm; P < 0.01). The complication rate was 34.2%. The most frequent complication was cerebrospinal fluid leak in 10 (13.1%) patients. In patients where STR was done, the sagittal diameter of the tumor was higher in patients without complications (4.5 ± 0.9 mm vs. 3.9 ± 1.1 mm; P = 0.02). At 6 years follow-up, 6 patients where STR was performed, developed tumor progression. CONCLUSION: The proposed grading is helpful in achieving higher rates of GTR with minimal complications in surgical excision of PCMs. The role of sagittal diameter in planning the extent of excision needs further research.

Impact of family support on psychiatric disorders and seizure control in patients with juvenile myoclonic epilepsy.

OBJECTIVE: Psychiatric disorders (PDs) are frequently observed in patients with juvenile myoclonic epilepsy (JME). In this study, we aimed to assess factors associated with PDs in patients with JME. METHODS: Retrospective analysis of data of 90 consecutive patients with JME was performed. Assessment of DSM-IV Axis I clinical disorders was done using Structured Clinical Interview for Axis I. Diagnosis of PDs is made when the score exceeds the threshold provided by the DSM-IV. We also applied the Global Assessment of Functioning (GAF) scale which is part of the multiaxial evaluation of the DSM-IV (Axis-V). Using seizure frequency score at presentation, we classified subjects into controlled and uncontrolled groups. RESULTS: In the current cohort, 29 (32.2%) patients were diagnosed with PDs. Fewer patients with PDs had family support (48.3% vs. 83.6%; p=0.001). Lifetime prevalence of PDs was higher among patients with current PDs (96.6% vs. 18.0%; p<0.0001). Subthreshold illness was not different between the groups (17.2% vs. 27.9%; p=0.204). Mean GAF was higher in patients without PDs than in patients with PDs (89.19±6.92 vs. 64.22±9.76; p<0.0001). Patients with PDs had lower seizure control (7.8% vs. 73.1%; p<0.0001) compared with patients without PDs. Logistic regression analysis for factors associated with diagnosis of PDs revealed that none of the factors significantly affected the odds of seizure control. Patients with lack of family support had poor seizure control (0% vs. 36.9%; p<0.0001); 51.7% of patients with JME with PDs reported lack of family support. Patients with family support had lower lifetime prevalence of PDs (30.8% vs. 76.0%; p<0.0001), whereas patients with JME without family support had lower levels of education (8.0% vs. 35.4%; p=0.009). CONCLUSION: Lack of family support is associated with poor seizure control and higher incidence of PDs in patients with JME. Lack of family support increases neither the odds of PDs nor seizure control.

Socio economic factors and adherence to home based exercise in people with epilepsy.

Exercise is a well-established component in the management of chronic illness both as a primary prevention and secondary intervention. The assumption that in otherwise healthy individuals, higher socioeconomic status (SES) is positively associated with physical activity (PA) has been debated. We report the influence of SES on adherence to home-based exercise program in people with epilepsy (PWE) from a developing country. Participants' response to self-reported Social Needs Screening Tool of the American Academy of Family Physicians was collected. The current study is a secondary follow-up and post-hoc analysis of data from patients we have previous published. The average age of the study population was 26.93 ± 10.20 years with 57.8 % men. Among the 116 study participants, 31 (26.72 %) were adherent to the exercise program. Unemployment (14.1 % vs. 0.0 %; p = 0.034) was higher, fewer people had least high school education (76.6 % vs 93.5 %; p = 0.050) in PWE who did not adhere to exercise program. A significantly higher number of PWE who were not adherent to exercise reported that their family members or anyone else never physically hurt them (97.6 % vs 80.6 %; p = 0.05), never threaten (94.1 % vs 74.2 %; p = 0.007) and/or never scream at them (90.6 % vs 74.2 %; p = 0.011). In PWE education and employment are associated with adherence to home-based exercise programs. The role of family support and personal safety in adherence to exercise should be evaluated in detail.

Management of patients with Reflex Vasovagal syncope with a protocol involving a yoga maneuver Tadasana.

BACKGROUND: There is no universally followed protocol for managing Reflex Vasovagal syncope (VVS). METHODS: VVS patients were treated with a 2 step protocol. Step I - counseling, hydration, physiotherapy, and Tadasana Yoga maneuver. Patients with ≥2 VVS recurrences were given step II care - intensification of step I, elastic stockings,and pharmacotherapy. Follow-up included assessment by periodic functional status questionnaires. RESULTS: 157 patients (103 males & 54 females,mean age - 53 ± 20 years & mean LVEF - 62 ± 5%.) experienced 867 total events - 382 syncopal, and 485 near syncopal episodes over 14 ± 9 months. After step I protocol, the mean total, syncopal and near syncopal events declined from 5 ± 7 to 0.3 ± 1.2 (P < 0.0001), 3 ± 2 to 0.1 ± 0.4 (P < 0.0001) and 3 ± 6 to 0.2 ± 1.1 (P < 0.0001) respectively. Twenty (12.7%) patients had 53 event recurrences, 15- syncopal episodes in 7 and 38 near syncope events in 13. After step II, 5 patients had 14 events. At 33 ± 15 months, in 152 patients (96.8%) there were no recurrences and syncope was prevented in all (100%). The median total, syncopal and near syncopal events declined from 3 to 0,(p < 0.001) 2 to 0 (p < 0.001) and 1 to 0 (p < 0.001) respectively. There was an improvement in all the 3 quality of life parameters. CONCLUSION: We demonstrate a simple and effective protocol that can be universally adopted to prevent VVS recurrences,with improvement in quality of life.

Surgical Approach for Suprasellar Meningiomas Based on Attachment-Single-Surgeon Experience.

BACKGROUND: Suprasellar meningiomas (SMs) can originate from midline or paramedian dura. Complexity of surgery and visual outcome depend on the attachment of SM. Conventional surgery for SM was ipsilateral to the visual deficit. We report our experience of surgical management of SM after choosing a surgical approach based on the attachment of the SM. METHODS: Sixty consecutive patients who underwent surgery for SM between January 2016 and January 2022 formed the study population. In patients with SM attached to the midline, the surgical approach was ipsilateral to the side of vision loss. In contrast, in those with a paramedian attachment, the approach was contralateral. Outcome variables included extent of resection achieved, recurrence, and assessment for visual acuity and fields, done at 3 months and 6 months after surgery and every year subsequently. RESULTS: The average age of the study population was 49.99 ± 13.38 (13-74) years with 23 (38.3%) men. Surgery for SM was done via the ipsilateral approach in 18 (30.0%) and the contralateral approach in 42 (70.0%) patients. The average preoperative visual impairment scale score was 54.68 ± 37.55. Gross total resection was achieved in 58 (96.7%) patients. The average duration of follow-up was 3 years, and at latest follow-up, improvement in vision was reported in 46 (76.6%) patients. CONCLUSIONS: In patients with SM undergoing surgical resection, opting for an ipsilateral approach when the SM had a midline attachment and a contralateral approach if the SM had a paramedian attachment may ensure greater resection of the lesion and better clinical outcomes. Our findings need validation in larger, randomized studies.

Anxiety, depression, and psychosocial adjustment in people with epilepsy.

Objective: Effect of psychological disorders on social functioning in people with epilepsy (PWE) is not extensively reported. We evaluate psychosocial functioning in PWE attending an outpatient clinic and aim to understand the differences in psychosocial functioning between anxiety, depression, and coexisting anxiety and depression in PWE. Materials and Methods: A prospective evaluation of psychosocial functioning of 324 consecutive adult PWE attending outpatient epilepsy clinic was done using self-reported Washington Psychosocial Seizure Inventory. The study population was divided in four groups - without psychological disorders, anxiety, depression, and both anxiety and depression. Results: The mean age of study population was 25.90 ± 6.22 years. Anxiety was noted in 73 (22.5%), depression in 60 (18.5%), and both anxiety and depression were seen in 70 (21.6%) and the rest had normal psychosocial function. There were no significant differences across all the four sub-groups for sociodemographics. Psychosocial functioning did not differ significantly between PWE with normal psychosocial function and PWE with anxiety alone. However, psychosocial functioning scores were worse in PWE with depression and PWE with both anxiety and depression when compared to PWE with normal psychosocial function. Conclusion: In the present study of PWE attending an outpatient epilepsy clinic, one-fifth of PWE had both anxiety and depression. Psychosocial functioning in PWE with anxiety was similar to otherwise healthy/normal PWE, whereas PWE with depression showed poor psychosocial functioning. Role of psychological interventions on psychosocial aspects of epilepsy should be studied extensively in future.

Long-Term Seizure Freedom, Resolution of Epilepsy and Perceived Life Changes in Drug Resistant Temporal Lobe Epilepsy With Hippocampal Sclerosis: Comparison of Surgical Versus Medical Management.

BACKGROUND: Outcome of temporal lobe epilepsy associated with hippocampal sclerosis (TLE-HS) has rarely been evaluated exclusively. OBJECTIVE: To compare long-term seizure freedom, resolution of epilepsy, and perceived life changes in patients with drug-resistant TLE-HS who underwent surgery vs those who opted for best medical management. METHODS: In this retrospective longitudinal study, 346 patients with TLE-HS who underwent surgery were compared with 325 who received best medical management. Predictors for long-term remission, resolution of epilepsy, and seizure recurrence were analyzed. RESULTS: The duration of follow-up ranged from 3-18 (mean 12.61) years. The average age of study population was 28.54 ± 12.27 years with 321 (47.8%) women. Age at onset of epilepsy (11.84 ± 8.48 vs 16.29 ± 11.88; P ≤ .001) was lower, and duration of epilepsy (15.65 ± 9.33 vs 12.97 ± 11.44; P < .001) was higher in the surgery group. Seizure freedom at 3 (81.8 vs 19.0%; P < .001), 5 (73% vs 16.1%; P < .001), and 10 years (78.3% vs 18.5; P < .001) and resolution of epilepsy (30.5% vs 0.6%; P < .001) was higher in the surgery group. The overall perceived life changes score was higher in the surgery group (80.96 ± 25.47 vs 66.24 ± 28.13; P < .001). At long-term follow-up (≥10 years), the presence of an aura was the strongest predictor for resolution of epilepsy (ß: 2.29 [95% CI; 1.06-4.93]; P = .035), whereas acute postoperative seizures (APOS) (ß: 6.06 [95% CI 1.57-23.42]; P < .001) and an abnormal postoperative EEG (ß: 0.222 [95% CI 0.100-0.491]; P < .001) were predictors of persistent seizures. Seizure freedom both at 3 and 5 years predicted seizure freedom at 10 years. CONCLUSION: Surgery for drug-resistant TLE-HS was associated with higher rate of long-term seizure-freedom, resolution of epilepsy, and reduction of anti-seizure medications with improvement in perceived life changes compared with best medical management. The presence of an aura was predictor for resolution of epilepsy while APOS and an abnormal postoperative EEG were predictors of persistent seizures.

Predictors of surgical outcome in focal cortical dysplasia and its subtypes.

OBJECTIVE: The authors analyzed predictors of surgical outcome in patients with focal cortical dysplasia (FCD) and its ILAE (International League Against Epilepsy) subtypes after noninvasive multimodal evaluation and calculated time to first seizure. METHODS: Data of 355 patients with refractory epilepsy, confirmed FCD pathology, and 2-13 years of postsurgical follow-up were analyzed to determine the predictive roles of clinical, EEG, imaging, and surgical factors that influence seizure freedom. RESULTS: The mean ± SD age at surgery was 20.26 ± 12.18 years. In total, 142 (40.0%) patients had daily seizures and 90 (25.3%) had multiple seizure types. MRI showed clear-cut FCD in 289 (81.4%) patients. Pathology suggested type I FCD in 27.3% of patients, type II in 28.4%, and type III in 42.8% of patients. At latest follow-up, 72.1% of patients were seizure free and 11.8% were seizure free and not receiving antiepileptic drugs. Among the subtypes, 88.8% of patients with type III, 69.3% with type II, and 50.5% with type I FCD were seizure free. Multiple seizure types, acute postoperative seizures (APOS), and type I FCD were predictors of persistent seizures, whereas type III FCD was the strongest predictor of seizure freedom. Type I FCD was associated with daily seizures, frontal and multilobar distribution, subtle findings on MRI, incomplete resection, and persistent seizures. Type II and III FCD were associated with clear-cut lesion on MRI, regional interictal and ictal EEG onset pattern, focal pattern on ictal SPECT, complete resection, and seizure freedom. Type III FCD was associated with temporal location, whereas type I and II FCD were associated with extratemporal location. Nearly 80% of patients with persistent seizures, mostly those with type I FCD, had their first seizure within 6 months postsurgery. CONCLUSIONS: Long-term seizure freedom after surgery can be achieved in more than two-thirds of patients with FCD after noninvasive multimodal evaluation. Multiple seizure types, type I FCD, and APOS were predictors of persistent seizures. Seizures recurred in about 80% of patients within 6 months postsurgery.

Endoscopic Management of Lateral Ventricle Arachnoid Cysts-Case Series with Proposed Classification.

BACKGROUND: We present a case series of 7 patients with intraventricular arachnoid cysts of lateral ventricle managed with endoscopic treatment with proposed classification of the cyst based on anatomic extent. METHODS: In all patients, the lateral ventricle arachnoid cyst was primarily located in the trigone and body of the lateral ventricle. Proposed classification is based on extension of the arachnoid cyst. Type 1 is an arachnoid cyst located in the lateral ventricle only, type 2 is a lateral ventricle arachnoid cyst extending to the quadrigeminal cistern, and type 3 is the lateral ventricle arachnoid cyst extending to the velum interpositum cistern. RESULTS: Two patients were managed with multiple fenestration and septostomy, and in 1 patient where the cyst was not adherent to the ventricular wall it was excised completely. Two patients who had a lateral ventricle cyst located in the atrium but extending to quadrigeminal cyst were managed with 3 fenestrations. Two patients with a lateral ventricle arachnoid cyst located into the atrium of lateral ventricle and extending to the velum interpositum cistern through the choroid fissure were managed with 3 endoscopic fenestrations. Postoperatively, patients were followed clinically and by radiologic imaging. None of the patients reported recurrence until the latest follow-up. CONCLUSIONS: Multiple endoscopic fenestrations for lateral ventricle arachnoid cyst according to its location and anatomic extension help to reduce recurrence and good outcome. Cyst excision is recommended only when the cyst wall is easily separable from the lateral ventricle wall. Intraoperative use of thulium light amplification by stimulated emission of radiation helps in achieving early hemostasis and easy perforation of the thick cyst wall.