• Philipp Hendrix, Sebastian Senger, Christoph J Griessenauer, Andreas Simgen, Stefan Linsler, and Joachim Oertel.
• Department of Neurosurgery, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar, Germany. Electronic address: hendrix.philipp@gmail.com.
• World Neurosurg. 2018 Jan 1; 109: 209-217.

ObjectiveTo report a technique for endoscopic cystoventriculostomy guided by preoperative navigated transcranial magnetic stimulation (nTMS) and tractography in a patient with a large speech eloquent arachnoid cyst.MethodsA 74-year old woman presented with a seizure and subsequent persistent anomic aphasia from a progressive left-sided parietal arachnoid cyst. An endoscopic cystoventriculostomy and endoscope-assisted ventricle catheter placement were performed. Surgery was guided by preoperative nTMS and tractography to avoid eloquent language, motor, and visual pathways.ResultsPreoperative nTMS motor and language mapping were used to guide tractography of motor and language white matter tracts. The ideal locations of entry point and cystoventriculostomy as well as trajectory for stent-placement were determined preoperatively with a pseudo-3-dimensional model visualizing eloquent language, motor, and visual cortical and subcortical information. The early postoperative course was uneventful. At her 3-month follow-up visit, her language impairments had completely recovered. Additionally, magnetic resonance imaging demonstrated complete collapse of the arachnoid cyst.ConclusionThe combination of nTMS and tractography supports the identification of a safe trajectory for cystoventriculostomy in eloquent arachnoid cysts.Copyright © 2017 Elsevier Inc. All rights reserved.

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