Presentation of a New Imaging Classification for Giant Dermoid Cyst. Case Report And Literature Review

Presentation of a New Imaging Classification for Giant Dermoid Cyst. Case Report And Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Presentation of a New Imaging Classification for Giant Dermoid Cyst. Case Report And Literature Review Gervith Reyes Soto, Daniel Alejandro Vega Moreno, Carlos Castillo Rangel, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5685800/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction : Intracranial dermoid cysts are rare, benign tumors, making up 0.04–0.6% of brain tumors and originating from ectodermal cells, unlike more complex teratomas from pluripotent germ cells. Dermoid cysts, containing only ectodermal derivatives, differ from epidermoid cysts by lacking dermal appendages. They commonly cause symptoms like seizures and headaches, with specific types associated with their rupture or chronic presence, impacting nearby brain structures. Material and Method : Our systematic literature review and case series presentation on neurosurgical management of Giant Dermoid Cysts (GDCs) began by identifying 15 full-text articles that met all inclusion criteria were analyzed in detail along with specific cases from our clinical series. These studies and cases provided insights into diagnostic approaches, surgical techniques, and patient outcomes, emphasizing the complexities of complete resection and the use of advanced surgical technologies. Results : The clinical outcomes of two patients from our case series were also included: a 32-year-old female presented with progressive headaches and occasional dizziness, undergoing subtotal resection with two subsequent surgeries due to recurrence over a 10-year period, and a 45-year-old male experiencing dizziness and seizures, who underwent successful total resection with no recurrence after 10 years. Conclusions : This study highlights the complexities involved in managing Giant Dermoid Cysts (GDCs) neurosurgical and underscores the critical role of advanced diagnostic and surgical technologies in improving patient outcomes. Importantly, the introduction of the Reyes-Velez classification system offers a structured approach to diagnosing and managing these cysts, providing clinicians with a valuable tool to enhance surgical planning, predict potential complications, and guide therapeutic decisions. This new classification system is instrumental in advancing the standardization and effectiveness of treatment protocols for GDCs. Dermoid Cyst Pediatric neurosurgery Neuroncology neurosurgery literature review Figures Figure 1 Figure 2 Figure 3 Introduction Intracranial dermoid cysts are rare, benign entities, accounting for only 0.04–0.6% of primary brain tumors [ 1 ]. These tumors are distinct from teratomas; while both can include elements such as hair or bone, dermoid cysts specifically originate from ecto-dermal cells. In contrast, teratomas arise from pluripotent germ cells that can differentiate into various tissue types, making them more complex and generally neoplastic [ 2 – 5 ]. Unlike teratomas, which contain tissues from all three embryonic layers, dermoid cysts are limited to ectodermal derivatives [ 3 , 6 ]. Furthermore, dermoid cysts differ from epidermoid cysts, another type of congenital inclusion cyst, which are characterized by their content of keratinaceous debris and cholesterol crystals but lack dermal appendages [ 7 ]. Clinically, dermoid cysts commonly manifest with symptoms such as seizures and headaches, noted in approximately 44% and 67% of cases, respectively [ 5 , 8 ]. Seizures associated with dermoid cysts can be of two distinct types. One type includes generalized seizures that occur following the rupture of a cyst, leading to exposure to its inflammatory contents. This type of seizure, often accompanied by symptoms of aseptic meningitis, is categorized as an acute symptomatic seizure [ 7 – 9 ]. The term "acute symptomatic seizure" refers to a seizure that occurs as a direct consequence of a specific insult or injury to the brain, such as infection, trauma, or in this case, the rupture of a dermoid cyst. The "acute" designation highlights that the seizure is linked temporally to the event causing the brain disturbance (such as inflammation from cyst rupture). The term "symptomatic" refers to the fact that the seizure is a symptom of an underlying cause, in contrast to unprovoked or chronic epileptic seizures. The irritation and mass effect exerted by the dermoid cyst, along with the potential chemical effects from cyst contents (e.g., rupture or leakage), can provoke focal seizures, which might manifest with impaired awareness, especially if key cortical regions are involved [ 8 , 9 ]. Thus, while seizure semiology is often related to the location of the lesion, in this case, the pathology of the dermoid cyst itself—through irritation, pressure effects, or rupture—also contributes to this seizure pattern. Another seizure type related to dermoid cysts is characterized by impaired awareness. These seizures, which do not typically accompany symptoms of aseptic meningitis, suggest a chronic condition and are classified as epileptic seizures [ 9 , 10 ]. This distinction highlights the diverse neurological impacts of dermoid cysts, reflecting their com-plex interaction with surrounding brain structures. The average age of onset is varied, but there has been an increased incidence of suprasellar supratentorial lesions in young adults aged 20–30 years; involvement of the cavernous sinus in this pathology is rare in itself [ 11 ]. These can be classified and divided them according to their location, behavior, and relationships with adjacent structures into 3 types: a) invasive to adjacent structures, b) intradural, c) intracavernous [ 12 ]. The intradural ones are found within the originating from the lateral wall of the cavernous sinus between the outer dural layer and the inner layer. According to this classification, purely intradural dermoid cysts can therefore originate from the lateral wall of the cavernous sinus [ 13 ]. These are rare in the literature, with up to 6 cases reported. As with all intracranial lesions, the clinical presentation will depend on the structures compromised by the compression caused by the lesion; regarding clinical aspects, the spectrum is broad, and it appears more striking when cases of chemical aseptic meningitis due to spontaneous rupture of the cyst are presented [ 14 – 16 ]. Materials and Methods Case Description This is a case of a 32-year-old female patient who presented with progressive headaches and occasional dizziness of unspecified etiology. Clinical correlation and imaging studies revealed a pathology with hyperintense characteristics on T1, hypointense on T2, with poorly defined edges, no enhancement with contrast medium, diffusion restriction, and slightly hyperintense relative to the parenchyma on FLAIR imaging. The case 1 radiologically appears T1W hypo intense and T2W hyperintense. Subsequently, a surgical resection was performed, resulting in a subtotal re-section of the lesion due to its proximity to vascular and nervous structures. Two more surgical events were carried out due to recurrence over a 10-year period, after which the patient declined further surgical intervention (Figure. 1). The second case involves a 45-year-old male patient experiencing occasional dizziness and a report of a seizure of unspecified onset without loss of consciousness but with sensory-type symptoms. After clinical exclusion and in the absence of guiding clinical symptoms beyond those mentioned, imaging studies were performed. These revealed a lesion with characteristics similar to the previously described pathology, leading to surgical resection achieving total removal. However, a recurrence of the lesion was detected 10 years after treatment due to the presence of unintended movements reported by the patient in the left hand, which was fluctuating. The diagnosis was confirmed by imaging. A new resection was performed with no subsequent recurrence (Fig. 2 ). Lesion Characteristics: We will explicitly state whether the characteristics of the recurrent lesion were the same as the initial pathology or if there were notable differences that could explain the recurrence or changes in clinical presentation. Surgical Resection and Recurrence: We will detail the circumstances leading up to the recurrence 10 years after total resection. Specifically, we will include a description of any radiological findings that were monitored over the 10-year period and any prior symptoms or signs that might have indicated early recurrence. Fluctuating Movements and Clinical Correlation: The presence of unintended, fluctuating movements in the left hand, which prompted further investigation, should be discussed in relation to the location of the lesion and its potential impact on motor control. We will provide a more thorough discussion on how these movements were related to the recurrence and specify the surgical and imaging correlation. Research Objective The aim of this literature review is to comprehensively summarize and synthesize existing research on the epidemiology, diagnosis, management, and outcomes of Giant Dermoid Cysts (GDCs) in neurosurgery. This review intends to highlight the advancements in diagnostic imaging and surgical techniques, as well as to identify gaps in current knowledge and suggest directions for future research. Data Sources The primary sources of literature included peer-reviewed journal articles, clinical trial reports, and review articles. Databases searched were PubMed, Scopus and Cochrane. Additionally, references from relevant articles were manually searched to identify further studies. Search Strategy A systematic search was conducted using the following key terms and their combinations: "giant dermoid cysts", "intracranial dermoid cysts", "neurosurgical management of dermoid cysts", "imaging of dermoid cysts", "complications of dermoid cyst surgery", and "outcomes of dermoid cyst resection". The search was limited to articles published in English from January 2020 to December 2023 to focus on the most recent and relevant data. Inclusion and Exclusion Criteria Articles were included if they provided data on the epidemiology, diagnostic imaging, surgical treatment, no histopathological images were included due to the focus of our study being primarily on imaging-based classification and surgical management, or clinical outcomes of GDCs. Studies were excluded if they were not in English, focused on non-neurosurgical management, or if they dealt with dermoid cysts outside the cranial cavity without relevance to intracranial cases. Data Extraction Two reviewers independently extracted data from each article using a standardized data extraction form. Extracted information included study design, patient demographics, methods of diagnosis (including specific imaging techniques), details of surgical intervention, histopathological findings, follow-up duration, clinical outcomes, and complications. Any discrepancies between reviewers were resolved through discussion or by consulting a third reviewer. Quality Assessment The quality of the included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Collaboration’s tool for randomized controlled trials. Reviews and case reports were assessed for relevance and content depth rather than methodological quality. Data Synthesis and Analysis Due to the expected heterogeneity in study designs and outcomes, a narrative synthesis approach was used. The information was organized thematically according to the aspects of GDCs under study: epidemiology, diagnostic imaging, surgical techniques, histopathological findings, and patient outcomes. Key findings and consensus points were summarized, and discrepancies or variations in the literature were noted. Imaging Techniques Magnetic Resonance Imaging (MRI) was the primary diagnostic tool, providing details on the cyst’s location, intensity patterns on T1 and T2, Fluid-Attenuated Inversion Recovery (FLAIR) imaging features, and any signs of diffusion restriction. Computed Tomography (CT) scans were reviewed to identify calcification and other radiodense materials within the cysts. Results Our literature review began with the identification of 119 records across PubMed, Cochrane Library, and Scopus. After removing 46 duplicates, 83 records underwent a rigorous screening process. Criteria for exclusion included non-neurosurgical focus (6 articles), non-English language (7 articles), incomplete data or lack of peer review (23 articles), and studies of dermoid cysts outside the cranial cavity (28 articles). Following these exclusions, 19 articles were closely reviewed, leading to the further exclusion of 4 non-research letters or commentaries, resulting in 15 full-text articles that met all inclusion criteria for detailed analysis. These selected studies provided comprehensive insights into the diagnostic approaches, surgical techniques, and patient outcomes for GDCs, emphasizing the complexities of complete resection and the utility of advanced surgical technologies. This refined selection offers a foundational perspective on current practices and highlights potential areas for future research and improvement in clinical approaches to managing GDCs in neurosurgery (Fig. 3 ) (Table 1 ) Table 1 Comparative Analysis of Recent Studies on Giant Dermoid Cysts Study Type of study Clinical presentation Diagnostic methods Surgical techniques Complications Outcomes Ahuja et al. (2024) [ 16 ] Retrospectively Headache, vomiting, vertigo, dizziness, seizures, weakness in bilateral limbs. Radiological imaging. Craniotomy No Lesions exhibited diverse distribution, gross findings, and microscopic features. Mishra et al. (2023) [ 17 ] Case report Headache with on and off vomiting. MRI Right paramedian suboccipital craniotomy No The postoperative course was uneventful Hirayama et al. (2023) [ 18 ] Illustrative case Headache, ataxia, hearing loss, gait disturbance, dizziness, vertigo, and trigeminal neuralgia. CT AND MRI Left lateral suboccipital craniotomy. Hemifacial spasm The lesion grew so slowly that surrounding edema did not occur, despite the lesion’s large size Saifi et al. (2023) [ 19 ] Case report Headache, intense, sharp, throbbing, sporadic, burning, and shock-like pain around the eyes, lips, nose, jaw, forehead, and scalp on the left side. MRI Craniotomy None All of the symptoms disappeared with no signs of tumor recurrence. Cao et al. (2023) [ 20 ] Illustrative case Dizziness, blurring of left visual acuity, and gait unsteadiness CT Left frontotemporal craniotomy. None All of the symptoms disappeared with no signs of tumor recurrence. Yazan et al. (2023) [ 21 ] Case report Convulsions and vision impairment. CT and MRI Transcranial approach combining the use of the microscope with the endoscope. None Favorable Obled et al. (2020) [ 22 ] Case report Headache, asthenia, and a left visual field defect. MRI and CT Fronto-temporo-parietal craniotomy None Favorable Emmanuel et al. (2023) [ 23 ] Case report Episodes of abnormal tonic-clonic seizures, followed by altered sensorium, and frothing from the mouth and incontinence. CT and MRI Craniotomy without recurrence or discernible complications of the resection The patient has resumed most normal activities. Onoda et al (2023) [ 24 ] Case Report Headache CT and MRI right temporal craniotomy None All of the symptoms disappeared with no signs of tumor recurrence. Discussion The management of Giant Dermoid Cysts (GDCs) presents a significant challenge in neurosurgery due to their rare occurrence, diverse presentation, and complex inter-actions with critical brain structures. This discussion delves deeply into the various aspects of GDCs, based on findings from the literature and enhanced by the proposed new imaging classification. Epidemiological and Demographic Insights The epidemiological understanding of Giant Dermoid Cysts (GDCs) is notably limited due to their rare occurrence. Typically, these cysts are documented through individual case reports and small case series, which, while insightful, often lack the statistical power of larger epidemiological studies. This rarity means comprehensive demographic studies are sparse, leaving a gap in our comprehensive understanding of these conditions across diverse populations [ 25 , 26 ]. Historically, foundational insights into the epidemiology of GDCs have been provided by seminal works such as those by Lunardi and Missori, who explored the prevalence and characteristics of supratentorial dermoid cysts [ 1 ] Their research highlights an important age distribution, with GDCs predominantly diagnosed in younger adults, suggesting a developmental component to their etiology [ 27 ]. Additionally, these cysts show no strong preference for any specific gender or race, indicating a broad demographic impact [ 28 , 29 ]. The detailed demographic analysis reveals that these cysts can occur at any age, with cases documented from early childhood to late adulthood. This wide age range at presentation may reflect the slow-growing nature of GDCs, which can remain asymptomatic for years before detection. The sporadic nature of case reports complicates the ability to draw more definitive conclusions about age, gender, and racial pre-dispositions [ 30 ]. The acute symptomatic seizures observed in relation to dermoid cyst rupture are generally motor seizures but can occasionally manifest as sensory-motor. The inflammatory reaction triggered by the release of cyst contents, particularly when they come into contact with cortical regions, often leads to motor manifestations, such as jerking movements or focal clonic activity. However, if the cyst or its inflammatory impact extends to sensory cortex areas or pathways, sensory-motor seizures involving both sensory disturbances (such as tingling or numbness) and motor symptoms may also occur [ 31 , 32 ]. Diagnostic imaging, particularly Magnetic Resonance Imaging (MRI), is central to the effective management of Giant Dermoid Cysts (GDCs). MRI not only facilitates the initial diagnosis but also plays a critical role in the surgical planning and long-term management of these cysts, Large lesions typically refer to cysts measuring between 3–5 cm in diameter,Giant lesions usually exceed 5 cm in diameter. [ 33 , 34 ]. The high-resolution images produced by MRI provide detailed insights into the size, location, and specific characteristics of GDCs, which are essential for differentiating them from other intracranial lesions such as epidermoid cysts or tumors [ 35 ]. Hirayama et al. have provided a thorough description of GDCs as typically appearing hyperintense on T1-weighted images and hypointense on T2-weighted images [ 18 ]. This contrast is attributed to the lipid-rich content of the cysts, which differentiates them from the more fluid-filled characteristics of other cystic structures. Further, MRI can identify subtle features such as the presence of calcifications or hair follicles within the cyst, which are telltale signs of GDCs and critical for accurate diagnosis [ 35 , 36 ]. Beyond basic identification, MRI also assists in assessing the potential challenges and risks associated with surgical intervention. It provides unparalleled visualization of the cyst’s relationship with surrounding neurovascular structures, which is crucial for determining the feasibility of complete surgical resection and anticipating potential complications. [ 35 , 36 , 37 ]. Furthermore, advances in MRI technology, such as diffusion-weighted imaging (DWI) and magnetic resonance spectroscopy (MRS), offer additional layers of diagnostic information. DWI, for example, can help in distinguishing GDCs from other similar lesions by analyzing the diffusion of water molecules within the tissue, which is restricted in GDCs due to their dense content. MRS provides metabolic data, which can be used to understand the biochemical environment of the cysts, further aiding in their characterization [ 20 ]. Dermoid cysts generally contain lipid-rich contents, including sebaceous material and hair follicles, giving them a unique appearance on MRI. They are typically hyperintense on T1-weighted images due to their lipid composition but show variable intensity on T2-weighted images. Dermoid cysts rarely demonstrate restricted diffusion on DWI unless they have undergone rupture, in which case the inflammatory reaction from lipid release into the surrounding cerebrospinal fluid (CSF) may cause chemical meningitis and lead to DWI changes [ 37 , 38 ]. In contrast, epidermoid cysts consist primarily of keratin and cellular debris, lacking the lipid component of dermoid cysts. They characteristically show restricted diffusion on DWI due to the dense cellular content, which differentiates them from both dermoid and arachnoid cysts. Epidermoid cysts are usually isointense to slightly hyperintense on T1-weighted images and hyperintense on T2-weighted images, with their restricted diffusion serving as a definitive diagnostic marker [ 39 , 40 ]. Arachnoid cysts differ fundamentally in structure, containing only CSF or CSF-like fluid without solid or lipid components. As a result, they exhibit signal characteristics similar to CSF across all MRI sequences—hypointense on T1 and hyperintense on T2. Importantly, arachnoid cysts do not restrict diffusion on DWI, appearing as CSF does, which provides a clear distinction from epidermoid cysts [ 41 ]. The inclusion of DWI as a routine part of MRI for suspected GDCs or other cystic lesions supports accurate differentiation among these entities, ensuring that the clinical and surgical approach is appropriate for the specific lesion type. For instance, epidermoid cysts, due to their higher recurrence potential and tendency to infiltrate adjacent structures, might require more aggressive resection strategies, while arachnoid cysts, which generally lack an aggressive clinical course, may not require intervention unless symptomatic. Trigeminal schwannomas typically appear as solid, enhancing masses with heterogeneous signal intensity on MRI [ 43 ]. Unlike epidermoid cysts, which characteristically show restricted diffusion on DWI due to their dense cellular content, trigeminal schwannomas do not exhibit restricted diffusion. Instead, they appear isointense or slightly hypointense on DWI, similar to surrounding brain tissue [ 39 , 40 , 44 ]. This lack of restricted diffusion can help differentiate schwannomas from epidermoid cysts, which restrict diffusion due to keratinized material, and dermoid cysts if rupture is absent [ 40 ]. DWI into the imaging protocol for suspected trigeminal schwannomas aids in distinguishing them from epidermoid cysts, which may occupy similar anatomical spaces, such as the posterior fossa or Meckel's cave. The absence of restricted diffusion in schwannomas on DWI, combined with their characteristic heterogeneous post-contrast enhancement, helps confirm the diagnosis, distinguishing them from both dermoid and epidermoid cysts [ 42 , 43 , 44 ]. Inclusion of trigeminal schwannomas in the differential diagnosis list highlights the importance of considering vascularized multicompartmental lesions in the context of diagnostic imaging. Schwannomas, due to their solid nature and enhancement patterns, may require a different surgical approach compared to non-vascular cystic lesions. For example, while dermoid and epidermoid cysts can often be managed with microsurgical resection, schwannomas may necessitate a more complex resection strategy due to their vascular involvement and proximity to critical neurovascular structures. In cases of dermoid cyst rupture, recognizing the lipid content and associated inflammation is essential for anticipating complications like chemical meningitis, influencing both surgical planning and postoperative care [ 38 , 39 , 40 ]. Histological examination plays a critical role in the definitive diagnosis of Giant Dermoid Cysts (GDCs). The unique cellular composition and structural characteristics of these cysts provide essential diagnostic clues that distinguish them from other types of intracranial lesions. Dermoid cysts feature a markedly thickened capsule composed of squamous epithelium as well as dermal debris, which causes this thickening. Additionally, structures of dermal origin such as hair, hair follicles, sebaceous glands, teeth, and nails have been described. This gives them a differential diagnosis from teratomas; however, teratomas contain all three germ layers, not just the ectodermal layer. Besides the characteristics described, the content classically found is of a yellowish or brown color, a product of residual epithelial cells and glandular secretion [ 32 , 45 ]. Histological evaluation also describes concentric lamellae of cholesterol crystals. Within the mentioned capsule structure, there are less thickened areas which depend on the variety of dermal elements that compose it. In the histological findings, we find abundant keratin material and occasionally the hairs originating from the ectodermal layer, as well as numerous foreign bodies and giant cells. The main differential diagnosis is with the epidermoid cyst, which, although it shares many histological characteristics, the differences between the two are well described [ 28 , 29 ]. The surgical management of Giant Dermoid Cysts (GDCs) presents numerous challenges, especially when deciding between complete and subtotal resection due to the intricate relationship of these cysts with critical neurovascular structures. The technical complexities of surgically addressing GDCs have been thoroughly discussed by Obled et al., who elaborate on the nuanced microsurgical approaches required for these procedures [ 22 ]. These methods emphasize meticulous dissection and careful manipulation to minimize damage to surrounding tissues, which are crucial for preserving neurological function. Microsurgical techniques play an essential role in maximizing resection while protecting vital brain areas. Using microscopes, surgeons can better visualize the surgical field, leading to more precise dissection and safer removal of the cyst. However, Ahuja et al. point out that incomplete resections can lead to recurrence, making the goal of achieving a gross total resection paramount [ 16 , 46 ]. A significant innovation in the field is the adoption of the exoscope, a high-definition, 3D visualization tool that serves as an alternative to traditional operating microscopes [ 47 ]. The exoscope offers several advantages over traditional methods, including improved ergonomics for the surgical team, which may reduce fatigue during lengthy surgeries. It also provides a wider field of view and allows the visual field to be shared with the entire operating room team, enhancing the collaborative aspect of complex surgeries [ 48 ]. The decision between complete and subtotal resection is critical in managing GDCs. While complete resection is ideal to prevent recurrence, the risks of damaging vital neurovascular structures often necessitate a more conservative approach. Advanced surgical tools like the exoscope can aid this decision-making process by providing clearer views and more detailed information about the cyst’s boundaries and its relationship to critical structures [ 48 , 49 ]. As surgical technology evolves, so too does the potential for safer and more effective interventions for GDCs. The integration of tools like the microscope or exoscope into neurosurgical practice is just one example of how technological advancements are reshaping the landscape. Future developments may include augmented reality systems that can overlay imaging data directly onto the surgical field, offering real-time navigation aids that could further enhance the surgeon’s ability to perform precise and safe resections [ 50 ]. The Reyes-Encarnacion classification system for giant dermoid cysts (GDCs) aims to streamline decision-making in their complex management. This classification facilitates personalized surgical planning by categorizing cysts based on anatomical location, involvement with adjacent structures, and their specific characteristics. It provides neurosurgeons with clear guidance on the surgical approach, identifying cases where complete resection is feasible versus those that may necessitate a more conservative or staged approach to minimize risks to critical neurovascular structures. The classification system for giant dermoid cysts (GDCs) directly supports surgical utility by providing a clear framework for determining the most appropriate surgical approach, staging, and management based on the anatomical characteristics and complexity of the cyst. Here’s how the Reyes Encarnacion translates into practical surgical decision making: 1. Tailoring Surgical Approaches Based on Location and Complexity The classification divides GDCs into distinct types based on their anatomical location, relationship with critical neurovascular structures, and whether the cyst has ruptured or involved surrounding tissues. This helps the surgeon determine whether a standard microsurgical approach or a more advanced technique like endoscopy is required: • Supratentorial cysts with clear arachnoid planes (Type A): These allow for a straightforward, standard microsurgical approach, where the surgeon can anticipate complete resection with minimal risk to surrounding tissues. • Parasellar or cavernous sinus involvement (Type C): This necessitates a more advanced approach, often using endoscopic techniques or complex microsurgical dissection, given the proximity to cranial nerves and dural structures. • Infratentorial cysts (Type E): These require careful microsurgical planning, as the brainstem and associated cranial nerves are at high risk for injury. The classification alerts the surgical team to plan for a more delicate and strategic dissection. 2. Planning Staged Surgeries for Complex Cases The classification highlights situations where staged surgeries may be more appropriate, particularly for cysts that are extensive, involve multiple compartments, or are positioned in high-risk anatomical regions: • Type D (diffuse involvement, both infra- and supratentorial): These cases may require multistage surgeries to reduce risks associated with aggressive resection in a single operation. The classification helps surgeons plan for a staged approach, balancing between maximizing tumor removal and minimizing neurological damage. • Cyst rupture with chemical meningitis (Type F): The classification emphasizes the need for immediate intervention in cases of rupture, potentially with initial medical management (e.g., controlling inflammation and infection) followed by surgery to address the residual cyst[ 51,52]. 3. Predicting Surgical Risks and Intraoperative Challenges By defining the anatomical boundaries and involvement of critical structures, the classification helps predict intraoperative challenges and guide decisions about the extent of resection: • Type B cysts (supratentorial with indistinct arachnoid planes): These cysts are infiltrative, often making complete resection risky. The classification informs the surgeon that subtotal resection may be safer in these cases, reducing the risk of damaging important cortical or vascular structures. • Type C and D cysts: In these more complex cysts, the classification assists in identifying the need for microsurgical precision and enhanced visualization tools (e.g., exoscopes or intraoperative imaging) to navigate around critical neurovascular tissues [28,29]. 4. Improving Surgical Planning and Anticipation of Postoperative Outcomes The classification not only helps determine the surgical approach but also aids in anticipating postoperative complications and guiding postoperative care: • Type F (cyst rupture): For ruptured cysts, the classification highlights the risk of chemical meningitis, requiring both immediate management of inflammation and subsequent surgical resection to prevent further neurological decline[51,52]. • Anticipation of recurrence: The classification of cysts based on their involvement with surrounding tissues (e.g., Type B or C) helps predict the likelihood of residual tumor and guides decisions regarding the need for adjuvant therapies (such as radiotherapy) or close postoperative monitoring. 5. Personalized Approach to Surgical Techniques The classification allows for a personalized surgical strategy tailored to the patient’s specific cyst type and anatomy. Surgeons can use the classification to choose between: • Standard craniotomy for simpler, well-demarcated cysts. • Minimally invasive or endoscopic techniques for cysts in deeper, high-risk regions (e.g., parasellar or cavernous sinus involvement). • Combined approaches or staged resections for more extensive, complex cysts involving both supra- and infratentorial regions. Existing classifications are primarily based on the location and surgical accessibility of the cysts, rather than detailed imaging characteristics or surgical staging, which makes the proposed Reyes-Encarnacion classification a valuable contribution. Here's how classifications for these cysts compare and how multicompartmental involvement influences the selection of surgical approaches: 6. Enhancing Multidisciplinary Decision-Making The classification serves as a communication tool among the multidisciplinary team (neurosurgeons, radiologists, oncologists), enabling clearer discussions about the extent of surgery and the risks versus benefits of aggressive versus conservative surgical strategies. Existing classifications are primarily based on the location and surgical accessibility of the cysts, rather than detailed imaging characteristics or surgical staging, which makes the proposed Reyes-Encarnacion classification a valuable contribution. Here's how classifications for these cysts compare and how multicompartmental involvement influences the selection of surgical approaches: 1. Dermoid and Epidermoid Cyst Classifications: While no single, widely adopted classification system exists for dermoid and epidermoid cysts, clinicians often categorize them based on: • Location: Supratentorial, infratentorial, and spinal. • Relationship to surrounding structures: Close proximity to critical neurovascular structures or cranial nerves. • Ruptured vs. Non-ruptured: Particularly relevant for dermoid cysts, as ruptured cysts can cause chemical meningitis. For example, Supratentorial epidermoid cysts may be classified based on their origin (e.g., sylvian fissure, parasellar region) and whether they encroach on adjacent vital structures like the cranial nerves or the brainstem. Infratentorial cysts in the posterior fossa are often categorized based on their potential to affect cranial nerves or cerebellar function. The existing classification systems are typically surgical and location-based, guiding surgeons to decide whether they can approach the cyst via: • Microsurgical approaches (craniotomy). • Endoscopic methods (minimally invasive). • Combined approaches for large, multicompartmental cysts. However, these systems lack the comprehensive imaging-based detail and surgical decision-making utility of the Reyes-Velez classification proposed for GDCs, which provides more specific guidance on surgical strategies based on the cyst’s anatomical presentation and complexity. 2. Arachnoid Cyst Classifications: For arachnoid cysts, the Galassi classification is the most commonly used, especially for middle fossa arachnoid cysts. This classification divides cysts into three types: • Type I: Small, non-communicating cysts. • Type II: Cysts that may have partial communication with the subarachnoid space. • Type III: Large cysts causing mass effect, often requiring surgical intervention. Arachnoid cysts in other locations (e.g., suprasellar or posterior fossa) are typically classified based on their anatomical location and the degree of mass effect on surrounding brain structures. These classifications often influence decisions on whether endoscopic fenestration, shunting, or more aggressive microsurgical approaches are necessary [53]. 3. Surgical Approach Selection for Multicompartmental Cysts [38-43]: When dermoids, epidermoids, or arachnoid cysts extend into multiple compartments, their involvement with critical neurovascular structures and the brain's functional regions dictates the surgical approach. Here's how this differs: Dermoid/Epidermoid Cysts: Multicompartmental involvement (such as crossing supra- and infratentorial regions, or involving both hemispheres) presents unique challenges. These cysts are often located near or within critical areas like the brainstem, cranial nerves, or ventricles, necessitating a multistage surgical approach or combined microsurgical and endoscopic techniques. Endoscopic approaches are generally considered when cysts are in deep or confined spaces with narrow corridors, such as the third ventricle or pineal region. Microsurgical resection may be more appropriate for larger cysts or those with more extensive involvement, where careful dissection around critical structures is required. Arachnoid Cysts: Type III cysts with significant multicompartmental extension (e.g., from the middle fossa into the posterior fossa or across the hemispheres) may require endoscopic fenestration or shunting to relieve pressure and drain the cyst. Microsurgical approaches might be needed for more extensive cysts with significant mass effect or when cysts are located near delicate regions such as the optic chiasm or cerebellum. 4. Key Differences in Surgical Strategy for Multicompartmental Cysts: • Dermoid/Epidermoid Cysts: Given the higher risk of chemical meningitis upon rupture and the potential involvement of critical neurovascular structures, a more aggressive resection is often necessary, balancing the risk of cyst rupture with the goal of maximal safe resection. Multistage surgeries may be planned to minimize risks. • Arachnoid Cysts: These are generally less invasive, and surgical strategies like fenestration or shunting focus on relieving pressure rather than complete removal, as their contents are not as problematic (no risk of chemical meningitis). Multistage procedures are less common unless the cyst is causing significant neurological symptoms or mass effect. Table 2: Reyes-Encarnacion classification system for giant dermoid cysts Type Location Involvement with Adjacent Structures Surgical Approach Key Considerations A Supratentorial with well-defined arachnoid plane Minimal involvement with critical structures Standard microsurgical approach Low risk of complications; favorable outcome with complete resection. If ruptured, reclassified as Type AF. B Supratentorial with indistinct arachnoid plane Infiltration between sulci and fissures Microsurgical techniques Higher risk of complications; subtotal resection may be necessary. If ruptured, reclassified as Type BF. C Parasellar region or cavernous sinus involvement Compromises cranial nerves or dural structures Endoscopic or tailored approach Requires advanced techniques due to complex anatomy; higher risk of cranial nerve involvement. D Diffuse, involving both infra- and supratentorial spaces Indistinct margins with extensive involvement across compartments Staged surgeries or combined approaches High risk, potential need for multiple procedures; complex anatomical navigation required. E Infratentorial (posterior fossa) with potential for chemical meningitis Proximity to brainstem and cranial nerves Careful microsurgical dissection Significant risk of neurovascular complications; heightened management of inflammation. If ruptured, reclassified as Type EF. F Cyst rupture across any location (supratentorial, infratentorial, or other) Chemical meningitis and inflammatory response Immediate intervention to manage inflammation and seizures Rupture can occur in Types A, B, or E (reclassified as Af, Bf, Ef, etc.); involves specific management of rupture-related complications. Notes: • Type F (rupture) serves as a secondary designation for any cyst type, indicating rupture status and the associated risk of chemical meningitis. • Overlap Scenarios: Types Af, Bf, and Ef clarify cysts where rupture has occurred in respective anatomical locations, providing a layered classification system that accounts for both anatomical and pathological characteristics. Conclusions The Reyes-Encarnacion scale can be summarized as a comprehensive, anatomically-based classification system for giant dermoid cysts (GDCs) that provides clear guidance for surgical planning and risk assessment. This scale categorizes GDCs by their location, involvement with critical structures, and rupture status, thereby helping neurosurgeons anticipate intraoperative challenges, decide on the surgical approach (including the need for staged or combined procedures), and manage potential postoperative complications, such as chemical meningitis. The scale's design promotes a standardized approach to managing GDCs, facilitating tailored, patient-specific surgical strategies, and improving clinical outcomes by systematically addressing both anatomical and pathological characteristics. Can be summarized as a comprehensive, anatomically-based classification system for giant dermoid cysts (GDCs) that provides clear guidance for surgical 511 planning and risk assessment. This scale categorizes GDCs by their location, involvement with 512 critical structures, and rupture status, thereby helping neurosurgeons anticipate intraoperative 513 challenges, decide on the surgical approach (including the need for staged or combined procedures), 514 and manage potential postoperative complications, such as chemical meningitis. The scale's design 515 promotes a standardized approach to managing GDCs, facilitating tailored, patient-specific surgical 516 strategies, and improving clinical outcomes by systematically addressing both anatomical and 517 pathological characteristics 518 519. Declarations Funding : This research received no external funding. Conflicts of Interest: “The authors declare no conflicts of interest. Ethics approval : This study was approved by the National Cancer Institute, Mexico. Informed Consent Statement : This article is published with the authorization of the patient in question and their responsible family members for the purposes of medical disclosure. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Manuel De Jesús Encarnación Ramírez (M.D.J.E.R.), Carlos Castillo Rangel (C.C.R.), and Andreina Rosario Rosario (A.R.R.). The first draft of the manuscript was written by Gervith Reyes Soto (G.R.S.) and Daniel Alejandro Vega Moreno (D.A.V.M.), and all authors, including Mario Alejandro Fulcar (M.A.F.), Neysa Sabrina Vásquez Segura (N.S.V.S.), Vladmir Nikolenko (V.N.), Mario Antonio Furcal Aybar (M.A.F.A.), and Tshiunza Mpoyi Chérubin (T.M.C.), commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Lunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg. 1991, 75(2), 262-6. doi: 10.3171/jns.1991.75.2.0262 Geyik AM, Geyik S, Erkutlu I, Alptekin M, Gezgin I, Dokur M. Multicentric Dentigerous Dermoid Cyst with an Unusual Location in the Central Nervous System. Surg J (N Y). 2016, 20;2(2), e1-e4. doi: 10.1055/s-0036-1583205. Agrawal M, Uppin MS, Patibandla MR, Bhattacharjee S, Panigrahi MK, Saradhi V, Rani JY, Purohit AK, Challa S. Teratomas in central nervous system: a clinico-morphological study with review of literature. Neurol India. 2010, 58(6), 841-6. doi: 10.4103/0028-3886.73740. Schijman E, Monges J, Cragnaz R. Congenital dermal sinuses, dermoid and epidermoid cysts of the posterior fossa. Childs Nerv Syst. 1986, 2(2), 83-9. doi: 10.1007/BF00286226. Forbes K. Osborn, Salzman, Barkovich et al.: Diagnostic Imaging; Springer: Berlin/Heidelberg, Germany, 2012. Louis DN, Perry A, Wesseling P, Brat DJ, Cree IA, Figarella-Branger D, Hawkins C, Ng HK, Pfister SM, Reifenberger G, Soffietti R, von Deimling A, Ellison DW. The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro Oncol. 2021, 2;23(8), 1231-1251. doi: 10.1093/neuonc/noab106. Ray MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012, 25(1), 23-5. doi: 10.1080/08998280.2012.11928775. Shashidhar A, Sadashiva N, Prabhuraj AR, Narasingha Rao K, Tiwari S, Saini J, Shukla D, Devi BI. Ruptured intracranial dermoid cysts: A retrospective institutional review. J Clin Neurosci. 2019, 67, 172-177. doi: 10.1016/j.jocn.2019.04.025. Alam Y, Mugge LA, Purdy J, Mrak RE, Schroeder J. Long-term Seizure Disorder Caused by a Dermoid Cyst with Catastrophic Developments. Cureus. 2018, 10;10(9), e3272. doi: 10.7759/cureus.3272. Shehadi JA, Alorainy IA, Johnston KM. Temporal dermoid cyst with a partial dermal sinus tract. Can J Neurol Sci. 1999, 26(4), 321-4. doi: 10.1017/s0317167100000470. Caldarelli M, Massimi L, Kondageski C, Di Rocco C. Intracranial midline dermoid and epidermoid cysts in children. J Neurosurg. 2004 ;100(5 Suppl Pediatrics), 473-80. doi: 10.3171/ped.2004.100.5.0473. Liu JK, Gottfried ON, Salzman KL, Schmidt RH, Couldwell WT. Ruptured intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery. 2008, 62(2), 377-84; discussion 384. doi: 10.1227/01.neu.0000316004.88517.29. Skovrlj B, Mascitelli JR, Steinberger JM, Weiss N. Progressive visual loss following rupture of an intracranial dermoid cyst. J Clin Neurosci. 2014, 21(1), 159-61. doi: 10.1016/j.jocn.2013.02.005. Akhaddar A, Mandour C, Belhachmi A, Boucetta M. Chronic headache and hemiparkinsonism due to a sylvian fissure dermoid cyst. Headache. 2010, 50(3), 479-80. doi: 10.1111/j.1526-4610.2010.01617.x. Anand D, Aggarwal S, Soin D, Garg R. Sylvian Fissure Dermoid Cyst - A Rare case. J Clin Diagn Res. 2014, 8(9), RD01-2. doi: 10.7860/JCDR/2014/8917.4789. Bahakeem B, Alqahtani TF, Darwish A, Alkhotani A, Rawah E. Dermoid Cyst in the Posterior Fossa Associated With Dermal Sinus and Abscess Formation: A Case Report. Cureus. 2023, 15(4), e38032. doi: 10.7759/cureus.38032. Ahuja S, Shankar M, Mankotia DS, Shankar KB, Zaheer S. Epidermoid cyst of central nervous system: A case series and review of literature. Int J Surg Case Rep. 2024, 115, 109293. doi: 10.1016/j.ijscr.2024.109293. Mishra MK, Yadav V, Pradhan RS, Prasad RS. Intracranial Interdural and Extradural Cerebellar Convexity Dermoid Cyst: A Case Report of Rare Tumor at the Rarest Location. Asian J Neurosurg. 2023, 18(3), 631-635. doi: 10.1055/s-0043-1771325. Hirayama K, Tanei T, Kato T, Hasegawa T, Ito E, Nishimura Y, Saito R. Hemifacial spasm caused by multiple vascular at-tachments due to remote compression effects of a dermoid cyst in the cerebellar hemisphere: illustrative case. J Neurosurg Case Lessons. 2023, 6(23), CASE23592. doi: 10.3171/CASE23592. Saifi I, Kashikar SV, Dhande R, Pavanan A, Reddy SNG. Magnetic Resonance Imaging Findings in a Rare Case of a Ruptured Intracranial Dermoid Cyst. Cureus. 2023, 15(8), e43316. doi: 10.7759/cureus.43316. Cao D, Xu H, Hu J, Mo J, Yu X, Wang J, Hu H. Frontotemporal giant extradural dermoid cyst: illustrative case. J Neurosurg Case Lessons. 2023, 5(14), CASE22547. doi: 10.3171/CASE22547. Yazan AS, Omer GL, Gubari MIM, Maurizi R, Baban K, Xasraw A, Kareem RHR. Epidermoid cyst of the posterior fossa: A case report of a combined microscopic and endoscopic transcranial approach. Ann Ital Chir. 2023, 12, S2239253X23038288. Obled L, Peciu-Florianu I, Perbet R, Vannod-Michel Q, Reyns N. Rare Case of Giant Supratentorial Dermoid Cyst. World Neurosurg. 2020, 135, 72-75. doi: 10.1016/j.wneu.2019.12.007. Emmanuel S, Inban P, Akuma O, Nouman Aslam M, Talat F, Nizamani A, Chenna VSH, Romain EM, Chu Carredo CK, Khan A. An Atypical Case of Intracranial Dermoid Cyst in an Adult Female: A Case Report and Literature Review. Cureus. 2023, 15(5), e39807. doi: 10.7759/cureus.39807. Onoda K, Kawaguchi A, Takaya Y, Inoue Y, Nakazato I, Saito Y, Ishikawa H, Oyama K, Oshima Y, Saito K, Sasajima Y, Matsuno A. A Case of Dermoid Cyst Arising in the Temporal Lobe. NMC Case Rep J. 2021, 8(1), 529-534. doi: 10.2176/nmccrj.cr.2020-0293. Lakhani DA, Morris MO, Deng F. Intracranial Dermoid Cyst. Radiology. 2024, 311(1), e232952. doi: 10.1148/radiol.232952. Li G, Kim J, Garcia M, Reyes-McChesney I, Hanna A, Bhalala U. A Rare Presentation of Occipital Dermoid Cyst with Intra-cranial Extension and Secondary Infection: Case Report and Follow-Up. J Neurol Surg Rep. 2024, 85(2), e39-e42. doi: 10.1055/a-2287-2108. Abbou Z, Djennati R, Khalil Z. A rare association between a dermoid cyst and arachnoid cyst of the cerebellopontine angle: a case report. Pan Afr Med J. 2021, 40, 125. doi: 10.11604/pamj.2021.40.125.32040. Ghosn JA, Mourad C, Farhat M, Yazbeck M, Mansour J, Noun P. Intradural dermoid cyst with complete dermal sinus of the posterior fossa: Contribution of 3D imaging with histopathological correlation. Radiol Case Rep. 2022, 17(6), 2071-2077. doi: 10.1016/j.radcr.2022.03.047. Blitz SE, Bernstock JD, Dmytriw AA, Ditoro DF, Kappel AD, Gormley WB, Peruzzi P. Ruptured Suprasellar Dermoid Cyst Treated With Lumbar Drain to Prevent Postoperative Hydrocephalus: Case Report and Focused Review of Literature. Front Surg. 2021, 8, 714771. doi: 10.3389/fsurg.2021.714771. Ramdasi R, Thorve S, Karnavat C. Explosion of dermoid cyst into five intracranial spaces- a rare event. Br J Neurosurg. 2020, 34(6), 667-668. doi: 10.1080/02688697.2019.1687849. Ochoa A, Saenz A, Argañaraz R, Mantese B. Ruptured dermoid cyst in the Meckel's cave presenting with trigeminal neu-ralgia in a pediatric patient: a case report. Childs Nerv Syst. 2020, 36(12), 3141-3146. doi: 10.1007/s00381-020-04646-y. Xin WQ, Lei Y, Chen D, Chen ZJ, Yang XY, Zhang N. Patient with Epilepsy Caused by the Spontaneous Rupture of an Intracerebral Dermoid Cyst. World Neurosurg. 2020, 136, 140-145. doi: 10.1016/j.wneu.2020.01.069. Kumaran SP, Srinivasa R, Ghosal N. Unusual Radiological Presentation of Intracranial Dermoid Cyst: A Case Series. Asian J Neurosurg. 2019, 14(1), 269-271. doi: 10.4103/ajns.AJNS_304_17. Johnson DG, Stemper SJ, Withers TK. Ruptured "giant" supratentorial dermoid cyst. J Clin Neurosci. 2005 Feb;12(2):198-201. doi: 10.1016/j.jocn.2004.03.035. PMID: 15749433. Nakamura Y, Iwata S, Inoue A, Ohue S, Fukumoto S, Ichikawa H, Onoue S, Ozaki S, Kohno K. [A Case of Right Frontal Dermoid Cyst with Temporal Imaging Changes in the Desease Course]. No Shinkei Geka. 2019, 47(7), 769-776. Japanese. doi: 10.11477/mf.1436204021. Balasundaram P, Garg A, Prabhakar A, Joseph Devarajan LS, Gaikwad SB, Khanna G. Evolution of epidermoid cyst into dermoid cyst: Embryological explanation and radiological-pathological correlation. Neuroradiol J. 2019, 32(2), 92-97. doi: 10.1177/1971400918821086. Chen JC, Chen Y, Lin SM, Tseng SH. Sylvian fissure dermoid cyst with intratumoral hemorrhage: case report. Clin Neurol Neurosurg. 2005, 108(1), 63-6. doi: 10.1016/j.clineuro.2004.11.003. Oprişan, A., & Popescu, B. O. (2012). Intracranial Cysts: An Imagery Diagnostic Challenge. The Scientific World Journal, 2013(1), 172154. https://doi.org/10.1155/2013/172154. Dutt SN, Mirza S, Chavda SV, Irving RM. Radiologic differentiation of intracranial epidermoids from arachnoid cysts. Otol Neurotol. 2002 Jan;23(1):84-92. doi: 10.1097/00129492-200201000-00019. PMID: 11773853. Jamjoom, D. Z., Alamer, A., & Tampieri, D. (2022). Correlation of radiological features of white epidermoid cysts with histopathological findings. Scientific Reports, 12(1), 1-8. https://doi.org/10.1038/s41598-022-06167-x. Sood S, Gupta R. Susceptibility artifacts in ruptured intracranial dermoid cysts: a poorly understood but important phenomenon. Neuroradiol J. 2014 Dec;27(6):677-84. doi: 10.15274/NRJ-2014-10090. Epub 2014 Dec 1. PMID: 25489890; PMCID: PMC4291801. Westermaier T, Schweitzer T, Ernestus RI. Arachnoid cysts. Adv Exp Med Biol. 2012;724:37-50. doi: 10.1007/978-1-4614-0653-2_3. PMID: 22411232. Ortega-Merchan MP, Reyes F, Mejía JA, Rivera DM, Galvis JC, Marquez JC. Cystic trigeminal schwannomas. Radiol Case Rep. 2019 Oct 19;14(12):1513-1517. doi: 10.1016/j.radcr.2019.09.031. PMID: 31660099; PMCID: PMC6807068. Mak YH, Ho G. Multicompartmental cystic trigeminal schwannoma as an uncommon differential diagnosis of cerebellopontine angle tumors. Radiol Case Rep. 2024 Apr 5;19(6):2552-2557. doi: 10.1016/j.radcr.2024.03.013. PMID: 38596177; PMCID: PMC11001620. Kato N, Radke J, Vajkoczy P, Schneider UC. [Intrasylvian dermoid cysts of the pediatric patient: a case report and review]. No Shinkei Geka. 2014, 42(10), 925-9. Japanese. doi: 10.11477/mf.1436200006. Fornari M, Solero CL, Lasio G, Lodrini S, Balestrini MR, Cimino C, Visintini S, Pluchino F. Surgical treatment of intracranial dermoid and epidermoid cysts in children. Childs Nerv Syst. 1990, 6(2):66-70. doi: 10.1007/BF00307923. Encarnacion Ramirez MJ, Peralta I, Ramirez I, Dauly V, Mainer G, Nurmukhametov R, Efe IE. Development of a Novel Low-Cost Exoscope to Expand Access to Microneurosurgical Care in Low- and Middle-Income Countries. World Neurosurg. 2022, 163, 5-10. doi: 10.1016/j.wneu.2022.03.144. Encarnacion Ramirez M, Peralta Baez I, Nurmukhametov R, Goncharov E, Efe IE, Sufianov A, Ramirez Pena I. Comparative survey study of the use of a low cost exoscope vs. microscope for anterior cervical discectomy and fusion (ACDF). Front Med Technol. 2023, 4, 1055189. doi: 10.3389/fmedt.2022.1055189. Kocaeli H, Korfali E, Doğan S, Savran M. Sylvian cistern dermoid cyst presenting with dysgeusia. Acta Neurochir (Wien). 2009, 151(5), 561-3. doi: 10.1007/s00701-009-0261-1. Bergström A, Staalsø JM, Romner B, Olsen NV. Impaired endothelial function after aneurysmal subarachnoid haemorrhage correlates with arginine:asymmetric dimethylarginine ratio. Br J Anaesth. 2014, 112(2), 311-8. doi: 10.1093/bja/aet331. Bristow RG, Laperriere NJ, Tator C, Milosevic M, Wong CS. Post-operative radiotherapy for recurrent dermoid cysts of the spine: a report of 3 cases. J Neurooncol. 1997, 33(3), 251-6. doi: 10.1023/a:1005739606895. Ray MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012 Jan;25(1):23-5. doi: 10.1080/08998280.2012.11928775. PMID: 22275778; PMCID: PMC3246848. Ray MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012 Jan;25(1):23-5. doi: 10.1080/08998280.2012.11928775. PMID: 22275778; PMCID: PMC3246848. Santos A, Viegas AF, Porto LM, Gomes A, Nascimento E. Arachnoid Cyst: An Asymptomatic Exuberance. Cureus. 2022 Nov 22;14(11):e31782. doi: 10.7759/cureus.31782. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5685800","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":396850111,"identity":"141d3ce9-187a-4684-bcf7-a3907bdcb425","order_by":0,"name":"Gervith Reyes Soto","email":"","orcid":"","institution":"Instituto Nacional de Cancerología","correspondingAuthor":false,"prefix":"","firstName":"Gervith","middleName":"Reyes","lastName":"Soto","suffix":""},{"id":396850115,"identity":"18625f9a-32e3-436e-80d2-c881bcc2ec79","order_by":1,"name":"Daniel Alejandro Vega Moreno","email":"","orcid":"","institution":"Hospital Central Sur de Alta Especialidad, PEMEX, Fuentes del Pedregal","correspondingAuthor":false,"prefix":"","firstName":"Daniel","middleName":"Alejandro Vega","lastName":"Moreno","suffix":""},{"id":396850116,"identity":"fc100fd5-1250-40c8-970a-c8d758c57a64","order_by":2,"name":"Carlos Castillo Rangel","email":"","orcid":"","institution":"Neurosurgery departament, Hospital 1ero de Octubre","correspondingAuthor":false,"prefix":"","firstName":"Carlos","middleName":"Castillo","lastName":"Rangel","suffix":""},{"id":396850118,"identity":"33d7bbc0-d6f1-400d-8769-fc218b01b6e0","order_by":3,"name":"Vladmir Nikolenko","email":"","orcid":"","institution":"I.M. Sechenov First Moscow State Medical University (Sechenov University)","correspondingAuthor":false,"prefix":"","firstName":"Vladmir","middleName":"","lastName":"Nikolenko","suffix":""},{"id":396850120,"identity":"e7d41853-1fad-4eae-8124-a55b13d09251","order_by":4,"name":"Mario Alejandro Fulcar","email":"","orcid":"","institution":"Medical intern, Oncology and specialties Medical Center INTEGRAL 3","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"Alejandro","lastName":"Fulcar","suffix":""},{"id":396850121,"identity":"b457d126-2a2c-4d1c-9411-c20c07bbc40e","order_by":5,"name":"Neysa Sabrina Vasquez Segura","email":"","orcid":"","institution":"Medicine school Autonomous University of Santo Domingo (UASD)","correspondingAuthor":false,"prefix":"","firstName":"Neysa","middleName":"Sabrina Vasquez","lastName":"Segura","suffix":""},{"id":396850122,"identity":"aaffa4b5-35f3-436e-a579-c4312ba5c0c1","order_by":6,"name":"Tshiunza Mpoyi Chérubin","email":"","orcid":"","institution":"Neurosurgery Department, Clinique Ngaliema, Kinshasa","correspondingAuthor":false,"prefix":"","firstName":"Tshiunza","middleName":"Mpoyi","lastName":"Chérubin","suffix":""},{"id":396850123,"identity":"59dd213b-f353-4f24-af57-579b1f937bbd","order_by":7,"name":"Mario Antonio Furcal Aybar","email":"","orcid":"","institution":"Department of Oncological Surgery, Rosa Emilia Sánchez Pérez de Tavares National Cancer Institute (INCART)","correspondingAuthor":false,"prefix":"","firstName":"Mario","middleName":"Antonio Furcal","lastName":"Aybar","suffix":""},{"id":396850124,"identity":"0e5d9c36-fef0-456e-9a9e-08f25732d4c7","order_by":8,"name":"Andreina Rosario Rosario","email":"","orcid":"","institution":"Medicine school Autonomous University of Santo Domingo (UASD)","correspondingAuthor":false,"prefix":"","firstName":"Andreina","middleName":"Rosario","lastName":"Rosario","suffix":""},{"id":396850125,"identity":"f6941b10-febd-45a6-a80a-493b2f33ea4d","order_by":9,"name":"Manuel De Jesus Encarnacion Ramirez","email":"data:image/png;base64,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","orcid":"","institution":"Russian People's Friendship University","correspondingAuthor":true,"prefix":"","firstName":"Manuel","middleName":"De Jesus Encarnacion","lastName":"Ramirez","suffix":""}],"badges":[],"createdAt":"2024-12-20 16:53:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5685800/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5685800/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73049567,"identity":"c311f6fe-8dd7-4264-bd6d-c6b20cdf1052","added_by":"auto","created_at":"2025-01-06 09:18:37","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":228469,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative Brain magnetic resonance images: A) Axial Contrast in a section inferior to the basal ganglia. B) Diffusion in an axial section, restriction is observed. C) Coronal T2, D) Axial, infratentorial FLAIR.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-5685800/v1/256e79e1a9b6da0f442ca3e6.png"},{"id":73049563,"identity":"f64fef4f-24bb-45c7-8eda-0d18b0de25c3","added_by":"auto","created_at":"2025-01-06 09:18:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":238383,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative imagesT2. E) Infratentorial axial. F) Supratentorial coronal with right syl-vian extension. G) axial at the level of cerebral peduncles. H) Coronal infratentorial.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-5685800/v1/19ed0516bea56dca5c9db75a.png"},{"id":73049566,"identity":"6a56a31d-6d90-41e5-a331-9dccb76346db","added_by":"auto","created_at":"2025-01-06 09:18:37","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":132507,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram for the literature review detailing the database search.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-5685800/v1/722b70ab2e280b6109c9414d.png"},{"id":73118920,"identity":"3779dcea-60e9-49f1-b0cd-84cbc9d43780","added_by":"auto","created_at":"2025-01-07 02:01:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1259321,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5685800/v1/61625dae-7a0b-4c84-a8b7-b9dc56240029.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Presentation of a New Imaging Classification for Giant Dermoid Cyst. Case Report And Literature Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIntracranial dermoid cysts are rare, benign entities, accounting for only 0.04\u0026ndash;0.6% of primary brain tumors [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These tumors are distinct from teratomas; while both can include elements such as hair or bone, dermoid cysts specifically originate from ecto-dermal cells. In contrast, teratomas arise from pluripotent germ cells that can differentiate into various tissue types, making them more complex and generally neoplastic [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Unlike teratomas, which contain tissues from all three embryonic layers, dermoid cysts are limited to ectodermal derivatives [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Furthermore, dermoid cysts differ from epidermoid cysts, another type of congenital inclusion cyst, which are characterized by their content of keratinaceous debris and cholesterol crystals but lack dermal appendages [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Clinically, dermoid cysts commonly manifest with symptoms such as seizures and headaches, noted in approximately 44% and 67% of cases, respectively [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Seizures associated with dermoid cysts can be of two distinct types. One type includes generalized seizures that occur following the rupture of a cyst, leading to exposure to its inflammatory contents. This type of seizure, often accompanied by symptoms of aseptic meningitis, is categorized as an acute symptomatic seizure [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR8\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The term \"acute symptomatic seizure\" refers to a seizure that occurs as a direct consequence of a specific insult or injury to the brain, such as infection, trauma, or in this case, the rupture of a dermoid cyst. The \"acute\" designation highlights that the seizure is linked temporally to the event causing the brain disturbance (such as inflammation from cyst rupture). The term \"symptomatic\" refers to the fact that the seizure is a symptom of an underlying cause, in contrast to unprovoked or chronic epileptic seizures. The irritation and mass effect exerted by the dermoid cyst, along with the potential chemical effects from cyst contents (e.g., rupture or leakage), can provoke focal seizures, which might manifest with impaired awareness, especially if key cortical regions are involved [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThus, while seizure semiology is often related to the location of the lesion, in this case, the pathology of the dermoid cyst itself\u0026mdash;through irritation, pressure effects, or rupture\u0026mdash;also contributes to this seizure pattern.\u003c/p\u003e \u003cp\u003eAnother seizure type related to dermoid cysts is characterized by impaired awareness. These seizures, which do not typically accompany symptoms of aseptic meningitis, suggest a chronic condition and are classified as epileptic seizures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. This distinction highlights the diverse neurological impacts of dermoid cysts, reflecting their com-plex interaction with surrounding brain structures.\u003c/p\u003e \u003cp\u003eThe average age of onset is varied, but there has been an increased incidence of suprasellar supratentorial lesions in young adults aged 20\u0026ndash;30 years; involvement of the cavernous sinus in this pathology is rare in itself [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These can be classified and divided them according to their location, behavior, and relationships with adjacent structures into 3 types: a) invasive to adjacent structures, b) intradural, c) intracavernous [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The intradural ones are found within the originating from the lateral wall of the cavernous sinus between the outer dural layer and the inner layer. According to this classification, purely intradural dermoid cysts can therefore originate from the lateral wall of the cavernous sinus [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. These are rare in the literature, with up to 6 cases reported. As with all intracranial lesions, the clinical presentation will depend on the structures compromised by the compression caused by the lesion; regarding clinical aspects, the spectrum is broad, and it appears more striking when cases of chemical aseptic meningitis due to spontaneous rupture of the cyst are presented [\u003cspan additionalcitationids=\"CR15\" citationid=\"CR15\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eCase Description\u003c/p\u003e \u003cp\u003eThis is a case of a 32-year-old female patient who presented with progressive headaches and occasional dizziness of unspecified etiology. Clinical correlation and imaging studies revealed a pathology with hyperintense characteristics on T1, hypointense on T2, with poorly defined edges, no enhancement with contrast medium, diffusion restriction, and slightly hyperintense relative to the parenchyma on FLAIR imaging. The case 1 radiologically appears T1W hypo intense and T2W hyperintense. Subsequently, a surgical resection was performed, resulting in a subtotal re-section of the lesion due to its proximity to vascular and nervous structures. Two more surgical events were carried out due to recurrence over a 10-year period, after which the patient declined further surgical intervention (Figure. 1).\u003c/p\u003e \u003cp\u003eThe second case involves a 45-year-old male patient experiencing occasional dizziness and a report of a seizure of unspecified onset without loss of consciousness but with sensory-type symptoms. After clinical exclusion and in the absence of guiding clinical symptoms beyond those mentioned, imaging studies were performed. These revealed a lesion with characteristics similar to the previously described pathology, leading to surgical resection achieving total removal. However, a recurrence of the lesion was detected 10 years after treatment due to the presence of unintended movements reported by the patient in the left hand, which was fluctuating. The diagnosis was confirmed by imaging. A new resection was performed with no subsequent recurrence (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLesion Characteristics: We will explicitly state whether the characteristics of the recurrent lesion were the same as the initial pathology or if there were notable differences that could explain the recurrence or changes in clinical presentation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSurgical Resection and Recurrence: We will detail the circumstances leading up to the recurrence 10 years after total resection. Specifically, we will include a description of any radiological findings that were monitored over the 10-year period and any prior symptoms or signs that might have indicated early recurrence.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eFluctuating Movements and Clinical Correlation: The presence of unintended, fluctuating movements in the left hand, which prompted further investigation, should be discussed in relation to the location of the lesion and its potential impact on motor control. We will provide a more thorough discussion on how these movements were related to the recurrence and specify the surgical and imaging correlation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\u003cp\u003eResearch Objective\u003c/p\u003e \u003cp\u003eThe aim of this literature review is to comprehensively summarize and synthesize existing research on the epidemiology, diagnosis, management, and outcomes of Giant Dermoid Cysts (GDCs) in neurosurgery. This review intends to highlight the advancements in diagnostic imaging and surgical techniques, as well as to identify gaps in current knowledge and suggest directions for future research.\u003c/p\u003e \u003cp\u003eData Sources\u003c/p\u003e \u003cp\u003eThe primary sources of literature included peer-reviewed journal articles, clinical trial reports, and review articles. Databases searched were PubMed, Scopus and Cochrane. Additionally, references from relevant articles were manually searched to identify further studies.\u003c/p\u003e \u003cp\u003eSearch Strategy\u003c/p\u003e \u003cp\u003eA systematic search was conducted using the following key terms and their combinations: \"giant dermoid cysts\", \"intracranial dermoid cysts\", \"neurosurgical management of dermoid cysts\", \"imaging of dermoid cysts\", \"complications of dermoid cyst surgery\", and \"outcomes of dermoid cyst resection\". The search was limited to articles published in English from January 2020 to December 2023 to focus on the most recent and relevant data.\u003c/p\u003e \u003cp\u003eInclusion and Exclusion Criteria\u003c/p\u003e \u003cp\u003eArticles were included if they provided data on the epidemiology, diagnostic imaging, surgical treatment, no histopathological images were included due to the focus of our study being primarily on imaging-based classification and surgical management, or clinical outcomes of GDCs. Studies were excluded if they were not in English, focused on non-neurosurgical management, or if they dealt with dermoid cysts outside the cranial cavity without relevance to intracranial cases.\u003c/p\u003e \u003cp\u003eData Extraction\u003c/p\u003e \u003cp\u003eTwo reviewers independently extracted data from each article using a standardized data extraction form. Extracted information included study design, patient demographics, methods of diagnosis (including specific imaging techniques), details of surgical intervention, histopathological findings, follow-up duration, clinical outcomes, and complications. Any discrepancies between reviewers were resolved through discussion or by consulting a third reviewer.\u003c/p\u003e \u003cp\u003eQuality Assessment\u003c/p\u003e \u003cp\u003eThe quality of the included studies was assessed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane Collaboration\u0026rsquo;s tool for randomized controlled trials. Reviews and case reports were assessed for relevance and content depth rather than methodological quality.\u003c/p\u003e \u003cp\u003eData Synthesis and Analysis\u003c/p\u003e \u003cp\u003eDue to the expected heterogeneity in study designs and outcomes, a narrative synthesis approach was used. The information was organized thematically according to the aspects of GDCs under study: epidemiology, diagnostic imaging, surgical techniques, histopathological findings, and patient outcomes. Key findings and consensus points were summarized, and discrepancies or variations in the literature were noted.\u003c/p\u003e \u003cp\u003eImaging Techniques\u003c/p\u003e \u003cp\u003eMagnetic Resonance Imaging (MRI) was the primary diagnostic tool, providing details on the cyst\u0026rsquo;s location, intensity patterns on T1 and T2, Fluid-Attenuated Inversion Recovery (FLAIR) imaging features, and any signs of diffusion restriction. Computed Tomography (CT) scans were reviewed to identify calcification and other radiodense materials within the cysts.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur literature review began with the identification of 119 records across PubMed, Cochrane Library, and Scopus. After removing 46 duplicates, 83 records underwent a rigorous screening process. Criteria for exclusion included non-neurosurgical focus (6 articles), non-English language (7 articles), incomplete data or lack of peer review (23 articles), and studies of dermoid cysts outside the cranial cavity (28 articles). Following these exclusions, 19 articles were closely reviewed, leading to the further exclusion of 4 non-research letters or commentaries, resulting in 15 full-text articles that met all inclusion criteria for detailed analysis. These selected studies provided comprehensive insights into the diagnostic approaches, surgical techniques, and patient outcomes for GDCs, emphasizing the complexities of complete resection and the utility of advanced surgical technologies. This refined selection offers a foundational perspective on current practices and highlights potential areas for future research and improvement in clinical approaches to managing GDCs in neurosurgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparative Analysis of Recent Studies on Giant Dermoid Cysts\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eClinical presentation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDiagnostic methods\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSurgical techniques\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOutcomes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAhuja et al. (2024) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetrospectively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache, vomiting, vertigo, dizziness, seizures, weakness in bilateral limbs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRadiological imaging.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCraniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eLesions exhibited diverse distribution, gross findings, and microscopic features.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMishra et al. (2023) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache with on and off vomiting.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRight paramedian suboccipital craniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe postoperative course was uneventful\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHirayama et al. (2023) [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIllustrative case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache, ataxia, hearing loss, gait disturbance, dizziness, vertigo, and trigeminal neuralgia.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT AND MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft lateral suboccipital craniotomy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eHemifacial spasm\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe lesion grew so slowly that surrounding edema did not occur, despite the lesion\u0026rsquo;s large size\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSaifi et al. (2023) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache, intense, sharp, throbbing, sporadic, burning, and shock-like pain around the eyes, lips, nose, jaw, forehead, and scalp on the left side.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCraniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAll of the symptoms disappeared with no signs of tumor recurrence.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCao et al. (2023) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIllustrative case\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDizziness, blurring of left visual acuity, and gait unsteadiness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLeft frontotemporal craniotomy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAll of the symptoms disappeared with no signs of tumor recurrence.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYazan et al. (2023) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConvulsions and vision impairment.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT and MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTranscranial approach combining the use of the microscope with the endoscope.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFavorable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObled et al. (2020) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache, asthenia, and a left visual\u003c/p\u003e \u003cp\u003efield defect.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMRI and CT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eFronto-temporo-parietal craniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFavorable\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmmanuel et al. (2023) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEpisodes of abnormal tonic-clonic seizures, followed by altered sensorium, and frothing from the mouth and incontinence.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT and MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCraniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ewithout recurrence or discernible complications of the resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eThe patient has resumed most normal activities.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnoda et al (2023) [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase Report\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHeadache\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCT and MRI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eright temporal craniotomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAll of the symptoms disappeared with no signs of tumor recurrence.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe management of Giant Dermoid Cysts (GDCs) presents a significant challenge in neurosurgery due to their rare occurrence, diverse presentation, and complex inter-actions with critical brain structures. This discussion delves deeply into the various aspects of GDCs, based on findings from the literature and enhanced by the proposed new imaging classification.\u003c/p\u003e \u003cp\u003eEpidemiological and Demographic Insights\u003c/p\u003e \u003cp\u003eThe epidemiological understanding of Giant Dermoid Cysts (GDCs) is notably limited due to their rare occurrence. Typically, these cysts are documented through individual case reports and small case series, which, while insightful, often lack the statistical power of larger epidemiological studies. This rarity means comprehensive demographic studies are sparse, leaving a gap in our comprehensive understanding of these conditions across diverse populations [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHistorically, foundational insights into the epidemiology of GDCs have been provided by seminal works such as those by Lunardi and Missori, who explored the prevalence and characteristics of supratentorial dermoid cysts [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] Their research highlights an important age distribution, with GDCs predominantly diagnosed in younger adults, suggesting a developmental component to their etiology [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Additionally, these cysts show no strong preference for any specific gender or race, indicating a broad demographic impact [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The detailed demographic analysis reveals that these cysts can occur at any age, with cases documented from early childhood to late adulthood. This wide age range at presentation may reflect the slow-growing nature of GDCs, which can remain asymptomatic for years before detection. The sporadic nature of case reports complicates the ability to draw more definitive conclusions about age, gender, and racial pre-dispositions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe acute symptomatic seizures observed in relation to dermoid cyst rupture are generally motor seizures but can occasionally manifest as sensory-motor. The inflammatory reaction triggered by the release of cyst contents, particularly when they come into contact with cortical regions, often leads to motor manifestations, such as jerking movements or focal clonic activity. However, if the cyst or its inflammatory impact extends to sensory cortex areas or pathways, sensory-motor seizures involving both sensory disturbances (such as tingling or numbness) and motor symptoms may also occur [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDiagnostic imaging, particularly Magnetic Resonance Imaging (MRI), is central to the effective management of Giant Dermoid Cysts (GDCs). MRI not only facilitates the initial diagnosis but also plays a critical role in the surgical planning and long-term management of these cysts, Large lesions typically refer to cysts measuring between 3\u0026ndash;5 cm in diameter,Giant lesions usually exceed 5 cm in diameter. [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The high-resolution images produced by MRI provide detailed insights into the size, location, and specific characteristics of GDCs, which are essential for differentiating them from other intracranial lesions such as epidermoid cysts or tumors [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHirayama et al. have provided a thorough description of GDCs as typically appearing hyperintense on T1-weighted images and hypointense on T2-weighted images [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This contrast is attributed to the lipid-rich content of the cysts, which differentiates them from the more fluid-filled characteristics of other cystic structures. Further, MRI can identify subtle features such as the presence of calcifications or hair follicles within the cyst, which are telltale signs of GDCs and critical for accurate diagnosis [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBeyond basic identification, MRI also assists in assessing the potential challenges and risks associated with surgical intervention. It provides unparalleled visualization of the cyst\u0026rsquo;s relationship with surrounding neurovascular structures, which is crucial for determining the feasibility of complete surgical resection and anticipating potential complications. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, advances in MRI technology, such as diffusion-weighted imaging (DWI) and magnetic resonance spectroscopy (MRS), offer additional layers of diagnostic information. DWI, for example, can help in distinguishing GDCs from other similar lesions by analyzing the diffusion of water molecules within the tissue, which is restricted in GDCs due to their dense content. MRS provides metabolic data, which can be used to understand the biochemical environment of the cysts, further aiding in their characterization [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDermoid cysts generally contain lipid-rich contents, including sebaceous material and hair follicles, giving them a unique appearance on MRI. They are typically hyperintense on T1-weighted images due to their lipid composition but show variable intensity on T2-weighted images. Dermoid cysts rarely demonstrate restricted diffusion on DWI unless they have undergone rupture, in which case the inflammatory reaction from lipid release into the surrounding cerebrospinal fluid (CSF) may cause chemical meningitis and lead to DWI changes [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn contrast, epidermoid cysts consist primarily of keratin and cellular debris, lacking the lipid component of dermoid cysts. They characteristically show restricted diffusion on DWI due to the dense cellular content, which differentiates them from both dermoid and arachnoid cysts. Epidermoid cysts are usually isointense to slightly hyperintense on T1-weighted images and hyperintense on T2-weighted images, with their restricted diffusion serving as a definitive diagnostic marker [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eArachnoid cysts differ fundamentally in structure, containing only CSF or CSF-like fluid without solid or lipid components. As a result, they exhibit signal characteristics similar to CSF across all MRI sequences\u0026mdash;hypointense on T1 and hyperintense on T2. Importantly, arachnoid cysts do not restrict diffusion on DWI, appearing as CSF does, which provides a clear distinction from epidermoid cysts [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe inclusion of DWI as a routine part of MRI for suspected GDCs or other cystic lesions supports accurate differentiation among these entities, ensuring that the clinical and surgical approach is appropriate for the specific lesion type. For instance, epidermoid cysts, due to their higher recurrence potential and tendency to infiltrate adjacent structures, might require more aggressive resection strategies, while arachnoid cysts, which generally lack an aggressive clinical course, may not require intervention unless symptomatic. Trigeminal schwannomas typically appear as solid, enhancing masses with heterogeneous signal intensity on MRI [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Unlike epidermoid cysts, which characteristically show restricted diffusion on DWI due to their dense cellular content, trigeminal schwannomas do not exhibit restricted diffusion. Instead, they appear isointense or slightly hypointense on DWI, similar to surrounding brain tissue [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis lack of restricted diffusion can help differentiate schwannomas from epidermoid cysts, which restrict diffusion due to keratinized material, and dermoid cysts if rupture is absent [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDWI into the imaging protocol for suspected trigeminal schwannomas aids in distinguishing them from epidermoid cysts, which may occupy similar anatomical spaces, such as the posterior fossa or Meckel's cave. The absence of restricted diffusion in schwannomas on DWI, combined with their characteristic heterogeneous post-contrast enhancement, helps confirm the diagnosis, distinguishing them from both dermoid and epidermoid cysts [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e44\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInclusion of trigeminal schwannomas in the differential diagnosis list highlights the importance of considering vascularized multicompartmental lesions in the context of diagnostic imaging. Schwannomas, due to their solid nature and enhancement patterns, may require a different surgical approach compared to non-vascular cystic lesions. For example, while dermoid and epidermoid cysts can often be managed with microsurgical resection, schwannomas may necessitate a more complex resection strategy due to their vascular involvement and proximity to critical neurovascular structures.\u003c/p\u003e \u003cp\u003eIn cases of dermoid cyst rupture, recognizing the lipid content and associated inflammation is essential for anticipating complications like chemical meningitis, influencing both surgical planning and postoperative care [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHistological examination plays a critical role in the definitive diagnosis of Giant Dermoid Cysts (GDCs). The unique cellular composition and structural characteristics of these cysts provide essential diagnostic clues that distinguish them from other types of intracranial lesions.\u003c/p\u003e \u003cp\u003eDermoid cysts feature a markedly thickened capsule composed of squamous epithelium as well as dermal debris, which causes this thickening. Additionally, structures of dermal origin such as hair, hair follicles, sebaceous glands, teeth, and nails have been described. This gives them a differential diagnosis from teratomas; however, teratomas contain all three germ layers, not just the ectodermal layer. Besides the characteristics described, the content classically found is of a yellowish or brown color, a product of residual epithelial cells and glandular secretion [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Histological evaluation also describes concentric lamellae of cholesterol crystals. Within the mentioned capsule structure, there are less thickened areas which depend on the variety of dermal elements that compose it. In the histological findings, we find abundant keratin material and occasionally the hairs originating from the ectodermal layer, as well as numerous foreign bodies and giant cells. The main differential diagnosis is with the epidermoid cyst, which, although it shares many histological characteristics, the differences between the two are well described [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe surgical management of Giant Dermoid Cysts (GDCs) presents numerous challenges, especially when deciding between complete and subtotal resection due to the intricate relationship of these cysts with critical neurovascular structures. The technical complexities of surgically addressing GDCs have been thoroughly discussed by Obled et al., who elaborate on the nuanced microsurgical approaches required for these procedures [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. These methods emphasize meticulous dissection and careful manipulation to minimize damage to surrounding tissues, which are crucial for preserving neurological function.\u003c/p\u003e \u003cp\u003eMicrosurgical techniques play an essential role in maximizing resection while protecting vital brain areas. Using microscopes, surgeons can better visualize the surgical field, leading to more precise dissection and safer removal of the cyst. However, Ahuja et al. point out that incomplete resections can lead to recurrence, making the goal of achieving a gross total resection paramount [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA significant innovation in the field is the adoption of the exoscope, a high-definition, 3D visualization tool that serves as an alternative to traditional operating microscopes [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. The exoscope offers several advantages over traditional methods, including improved ergonomics for the surgical team, which may reduce fatigue during lengthy surgeries. It also provides a wider field of view and allows the visual field to be shared with the entire operating room team, enhancing the collaborative aspect of complex surgeries [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe decision between complete and subtotal resection is critical in managing GDCs. While complete resection is ideal to prevent recurrence, the risks of damaging vital neurovascular structures often necessitate a more conservative approach. Advanced surgical tools like the exoscope can aid this decision-making process by providing clearer views and more detailed information about the cyst\u0026rsquo;s boundaries and its relationship to critical structures [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAs surgical technology evolves, so too does the potential for safer and more effective interventions for GDCs. The integration of tools like the microscope or exoscope into neurosurgical practice is just one example of how technological advancements are reshaping the landscape. Future developments may include augmented reality systems that can overlay imaging data directly onto the surgical field, offering real-time navigation aids that could further enhance the surgeon\u0026rsquo;s ability to perform precise and safe resections [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Reyes-Encarnacion classification system for giant dermoid cysts (GDCs) aims to streamline decision-making in their complex management. This classification facilitates personalized surgical planning by categorizing cysts based on anatomical location, involvement with adjacent structures, and their specific characteristics. It provides neurosurgeons with clear guidance on the surgical approach, identifying cases where complete resection is feasible versus those that may necessitate a more conservative or staged approach to minimize risks to critical neurovascular structures.\u003c/p\u003e \u003cp\u003eThe classification system for giant dermoid cysts (GDCs) directly supports surgical utility by providing a clear framework for determining the most appropriate surgical approach, staging, and management based on the anatomical characteristics and complexity of the cyst. Here\u0026rsquo;s how the Reyes Encarnacion translates into practical surgical decision making:\u003c/p\u003e\u003cp\u003e1. Tailoring Surgical Approaches Based on Location and Complexity\u003c/p\u003e\n\u003cp\u003eThe classification divides GDCs into distinct types based on their anatomical location, relationship with critical neurovascular structures, and whether the cyst has ruptured or involved surrounding tissues. This helps the surgeon determine whether a standard microsurgical approach or a more advanced technique like endoscopy is required:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Supratentorial cysts with clear arachnoid planes (Type A): These allow for a straightforward, standard microsurgical approach, where the surgeon can anticipate complete resection with minimal risk to surrounding tissues.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Parasellar or cavernous sinus involvement (Type C): This necessitates a more advanced approach, often using endoscopic techniques or complex microsurgical dissection, given the proximity to cranial nerves and dural structures.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Infratentorial cysts (Type E): These require careful microsurgical planning, as the brainstem and associated cranial nerves are at high risk for injury. The classification alerts the surgical team to plan for a more delicate and strategic dissection.\u003c/p\u003e\n\u003cp\u003e2. Planning Staged Surgeries for Complex Cases\u003c/p\u003e\n\u003cp\u003eThe classification highlights situations where staged surgeries may be more appropriate, particularly for cysts that are extensive, involve multiple compartments, or are positioned in high-risk anatomical regions:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type D (diffuse involvement, both infra- and supratentorial): These cases may require multistage surgeries to reduce risks associated with aggressive resection in a single operation. The classification helps surgeons plan for a staged approach, balancing between maximizing tumor removal and minimizing neurological damage.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Cyst rupture with chemical meningitis (Type F): The classification emphasizes the need for immediate intervention in cases of rupture, potentially with initial medical management (e.g., controlling inflammation and infection) followed by surgery to address the residual cyst[ 51,52].\u003c/p\u003e\n\u003cp\u003e3. Predicting Surgical Risks and Intraoperative Challenges\u003c/p\u003e\n\u003cp\u003eBy defining the anatomical boundaries and involvement of critical structures, the classification helps predict intraoperative challenges and guide decisions about the extent of resection:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type B cysts (supratentorial with indistinct arachnoid planes): These cysts are infiltrative, often making complete resection risky. The classification informs the surgeon that subtotal resection may be safer in these cases, reducing the risk of damaging important cortical or vascular structures.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type C and D cysts: In these more complex cysts, the classification assists in identifying the need for microsurgical precision and enhanced visualization tools (e.g., exoscopes or intraoperative imaging) to navigate around critical neurovascular tissues [28,29].\u003c/p\u003e\n\u003cp\u003e4. Improving Surgical Planning and Anticipation of Postoperative Outcomes\u003c/p\u003e\n\u003cp\u003eThe classification not only helps determine the surgical approach but also aids in anticipating postoperative complications and guiding postoperative care:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type F (cyst rupture): For ruptured cysts, the classification highlights the risk of chemical meningitis, requiring both immediate management of inflammation and subsequent surgical resection to prevent further neurological decline[51,52].\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Anticipation of recurrence: The classification of cysts based on their involvement with surrounding tissues (e.g., Type B or C) helps predict the likelihood of residual tumor and guides decisions regarding the need for adjuvant therapies (such as radiotherapy) or close postoperative monitoring.\u003c/p\u003e\n\u003cp\u003e5. Personalized Approach to Surgical Techniques\u003c/p\u003e\n\u003cp\u003eThe classification allows for a personalized surgical strategy tailored to the patient\u0026rsquo;s specific cyst type and anatomy. Surgeons can use the classification to choose between:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Standard craniotomy for simpler, well-demarcated cysts.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Minimally invasive or endoscopic techniques for cysts in deeper, high-risk regions (e.g., parasellar or cavernous sinus involvement).\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Combined approaches or staged resections for more extensive, complex cysts involving both supra- and infratentorial regions.\u003c/p\u003e\n\u003cp\u003eExisting classifications are primarily based on the location and surgical accessibility of the cysts, rather than detailed imaging characteristics or surgical staging, which makes the proposed Reyes-Encarnacion classification a valuable contribution. Here\u0026apos;s how classifications for these cysts compare and how multicompartmental involvement influences the selection of surgical approaches:\u003c/p\u003e\n\u003cp\u003e6. Enhancing Multidisciplinary Decision-Making\u003c/p\u003e\n\u003cp\u003eThe classification serves as a communication tool among the multidisciplinary team (neurosurgeons, radiologists, oncologists), enabling clearer discussions about the extent of surgery and the risks versus benefits of aggressive versus conservative surgical strategies.\u003c/p\u003e\n\u003cp\u003eExisting classifications are primarily based on the location and surgical accessibility of the cysts, rather than detailed imaging characteristics or surgical staging, which makes the proposed Reyes-Encarnacion classification a valuable contribution. Here\u0026apos;s how classifications for these cysts compare and how multicompartmental involvement influences the selection of surgical approaches:\u003c/p\u003e\n\u003cp\u003e1. Dermoid and Epidermoid Cyst Classifications:\u003c/p\u003e\n\u003cp\u003eWhile no single, widely adopted classification system exists for dermoid and epidermoid cysts, clinicians often categorize them based on:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Location: Supratentorial, infratentorial, and spinal.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Relationship to surrounding structures: Close proximity to critical neurovascular structures or cranial nerves.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Ruptured vs. Non-ruptured: Particularly relevant for dermoid cysts, as ruptured cysts can cause chemical meningitis.\u003c/p\u003e\n\u003cp\u003eFor example, Supratentorial epidermoid cysts may be classified based on their origin (e.g., sylvian fissure, parasellar region) and whether they encroach on adjacent vital structures like the cranial nerves or the brainstem. Infratentorial cysts in the posterior fossa are often categorized based on their potential to affect cranial nerves or cerebellar function.\u003c/p\u003e\n\u003cp\u003eThe existing classification systems are typically surgical and location-based, guiding surgeons to decide whether they can approach the cyst via:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Microsurgical approaches (craniotomy).\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Endoscopic methods (minimally invasive).\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Combined approaches for large, multicompartmental cysts.\u003c/p\u003e\n\u003cp\u003eHowever, these systems lack the comprehensive imaging-based detail and surgical decision-making utility of the Reyes-Velez classification proposed for GDCs, which provides more specific guidance on surgical strategies based on the cyst\u0026rsquo;s anatomical presentation and complexity.\u003c/p\u003e\n\u003cp\u003e2. Arachnoid Cyst Classifications:\u003c/p\u003e\n\u003cp\u003eFor arachnoid cysts, the Galassi classification is the most commonly used, especially for middle fossa arachnoid cysts. This classification divides cysts into three types:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type I: Small, non-communicating cysts.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type II: Cysts that may have partial communication with the subarachnoid space.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type III: Large cysts causing mass effect, often requiring surgical intervention.\u003c/p\u003e\n\u003cp\u003eArachnoid cysts in other locations (e.g., suprasellar or posterior fossa) are typically classified based on their anatomical location and the degree of mass effect on surrounding brain structures. These classifications often influence decisions on whether endoscopic fenestration, shunting, or more aggressive microsurgical approaches are necessary [53].\u003c/p\u003e\n\u003cp\u003e3. Surgical Approach Selection for Multicompartmental Cysts [38-43]:\u003c/p\u003e\n\u003cp\u003eWhen dermoids, epidermoids, or arachnoid cysts extend into multiple compartments, their involvement with critical neurovascular structures and the brain\u0026apos;s functional regions dictates the surgical approach. Here\u0026apos;s how this differs:\u003c/p\u003e\n\u003cp\u003eDermoid/Epidermoid Cysts:\u003c/p\u003e\n\u003cp\u003eMulticompartmental involvement (such as crossing supra- and infratentorial regions, or involving both hemispheres) presents unique challenges. These cysts are often located near or within critical areas like the brainstem, cranial nerves, or ventricles, necessitating a multistage surgical approach or combined microsurgical and endoscopic techniques.\u003c/p\u003e\n\u003cp\u003eEndoscopic approaches are generally considered when cysts are in deep or confined spaces with narrow corridors, such as the third ventricle or pineal region.\u003c/p\u003e\n\u003cp\u003eMicrosurgical resection may be more appropriate for larger cysts or those with more extensive involvement, where careful dissection around critical structures is required.\u003c/p\u003e\n\u003cp\u003eArachnoid Cysts:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eType III cysts with significant multicompartmental extension (e.g., from the middle fossa into the posterior fossa or across the hemispheres) may require endoscopic fenestration or shunting to relieve pressure and drain the cyst.\u003c/li\u003e\n \u003cli\u003eMicrosurgical approaches might be needed for more extensive cysts with significant mass effect or when cysts are located near delicate regions such as the optic chiasm or cerebellum.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e4. Key Differences in Surgical Strategy for Multicompartmental Cysts:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Dermoid/Epidermoid Cysts: Given the higher risk of chemical meningitis upon rupture and the potential involvement of critical neurovascular structures, a more aggressive resection is often necessary, balancing the risk of cyst rupture with the goal of maximal safe resection. Multistage surgeries may be planned to minimize risks.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Arachnoid Cysts: These are generally less invasive, and surgical strategies like fenestration or shunting focus on relieving pressure rather than complete removal, as their contents are not as problematic (no risk of chemical meningitis). Multistage procedures are less common unless the cyst is causing significant neurological symptoms or mass effect.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Reyes-Encarnacion classification system for giant dermoid cysts\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eLocation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eInvolvement with Adjacent Structures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSurgical Approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eKey Considerations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSupratentorial with well-defined arachnoid plane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMinimal involvement with critical structures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eStandard microsurgical approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eLow risk of complications; favorable outcome with complete resection. If ruptured, reclassified as Type AF.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eB\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSupratentorial with indistinct arachnoid plane\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eInfiltration between sulci and fissures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eMicrosurgical techniques\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eHigher risk of complications; subtotal resection may be necessary. If ruptured, reclassified as Type BF.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eParasellar region or cavernous sinus involvement\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCompromises cranial nerves or dural structures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eEndoscopic or tailored approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eRequires advanced techniques due to complex anatomy; higher risk of cranial nerve involvement.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eDiffuse, involving both infra- and supratentorial spaces\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eIndistinct margins with extensive involvement across compartments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eStaged surgeries or combined approaches\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eHigh risk, potential need for multiple procedures; complex anatomical navigation required.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eInfratentorial (posterior fossa) with potential for chemical meningitis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eProximity to brainstem and cranial nerves\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCareful microsurgical dissection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eSignificant risk of neurovascular complications; heightened management of inflammation. If ruptured, reclassified as Type EF.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eCyst rupture across any location (supratentorial, infratentorial, or other)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eChemical meningitis and inflammatory response\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eImmediate intervention to manage inflammation and seizures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eRupture can occur in Types A, B, or E (reclassified as Af, Bf, Ef, etc.); involves specific management of rupture-related complications.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNotes:\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Type F (rupture) serves as a secondary designation for any cyst type, indicating rupture status and the associated risk of chemical meningitis.\u003c/p\u003e\n\u003cp\u003e\u0026bull; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Overlap Scenarios: Types Af, Bf, and Ef clarify cysts where rupture has occurred in respective anatomical locations, providing a layered classification system that accounts for both anatomical and pathological characteristics.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Reyes-Encarnacion scale can be summarized as a comprehensive, anatomically-based classification system for giant dermoid cysts (GDCs) that provides clear guidance for surgical planning and risk assessment. This scale categorizes GDCs by their location, involvement with critical structures, and rupture status, thereby helping neurosurgeons anticipate intraoperative challenges, decide on the surgical approach (including the need for staged or combined procedures), and manage potential postoperative complications, such as chemical meningitis. The scale's design promotes a standardized approach to managing GDCs, facilitating tailored, patient-specific surgical strategies, and improving clinical outcomes by systematically addressing both anatomical and pathological characteristics.\u003c/p\u003e \u003cp\u003eCan be summarized as a comprehensive, anatomically-based classification system for giant dermoid cysts (GDCs) that provides clear guidance for surgical 511 planning and risk assessment. This scale categorizes GDCs by their location, involvement with 512 critical structures, and rupture status, thereby helping neurosurgeons anticipate intraoperative 513 challenges, decide on the surgical approach (including the need for staged or combined procedures), 514 and manage potential postoperative complications, such as chemical meningitis. The scale's design 515 promotes a standardized approach to managing GDCs, facilitating tailored, patient-specific surgical 516 strategies, and improving clinical outcomes by systematically addressing both anatomical and 517 pathological characteristics 518 519.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u003c/strong\u003e \u0026ldquo;The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e: This study was approved by the National Cancer Institute, Mexico.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent Statement\u003c/strong\u003e: This article is published with the authorization of the patient in question and their responsible family members for the purposes of medical disclosure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Manuel De Jes\u0026uacute;s Encarnaci\u0026oacute;n Ram\u0026iacute;rez (M.D.J.E.R.), Carlos Castillo Rangel (C.C.R.), and Andreina Rosario Rosario (A.R.R.). The first draft of the manuscript was written by Gervith Reyes Soto (G.R.S.) and Daniel Alejandro Vega Moreno (D.A.V.M.), and all authors, including Mario Alejandro Fulcar (M.A.F.), Neysa Sabrina V\u0026aacute;squez Segura (N.S.V.S.), Vladmir Nikolenko (V.N.), Mario Antonio Furcal Aybar (M.A.F.A.), and Tshiunza Mpoyi Ch\u0026eacute;rubin (T.M.C.), commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLunardi P, Missori P. Supratentorial dermoid cysts. J Neurosurg. 1991, 75(2), 262-6. doi: 10.3171/jns.1991.75.2.0262\u003c/li\u003e\n\u003cli\u003eGeyik AM, Geyik S, Erkutlu I, Alptekin M, Gezgin I, Dokur M. Multicentric Dentigerous Dermoid Cyst with an Unusual Location in the Central Nervous System. Surg J (N Y). 2016, 20;2(2), e1-e4. doi: 10.1055/s-0036-1583205. \u003c/li\u003e\n\u003cli\u003eAgrawal M, Uppin MS, Patibandla MR, Bhattacharjee S, Panigrahi MK, Saradhi V, Rani JY, Purohit AK, Challa S. Teratomas in central nervous system: a clinico-morphological study with review of literature. Neurol India. 2010, 58(6), 841-6. doi: 10.4103/0028-3886.73740.\u003c/li\u003e\n\u003cli\u003eSchijman E, Monges J, Cragnaz R. Congenital dermal sinuses, dermoid and epidermoid cysts of the posterior fossa. Childs Nerv Syst. 1986, 2(2), 83-9. doi: 10.1007/BF00286226. \u003c/li\u003e\n\u003cli\u003eForbes K. Osborn, Salzman, Barkovich et al.: Diagnostic Imaging; Springer: Berlin/Heidelberg, Germany, 2012.\u003c/li\u003e\n\u003cli\u003eLouis DN, Perry A, Wesseling P, Brat DJ, Cree IA, Figarella-Branger D, Hawkins C, Ng HK, Pfister SM, Reifenberger G, Soffietti R, von Deimling A, Ellison DW. The 2021 WHO Classification of Tumors of the Central Nervous System: a summary. Neuro Oncol. 2021, 2;23(8), 1231-1251. doi: 10.1093/neuonc/noab106.\u003c/li\u003e\n\u003cli\u003eRay MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012, 25(1), 23-5. doi: 10.1080/08998280.2012.11928775.\u003c/li\u003e\n\u003cli\u003eShashidhar A, Sadashiva N, Prabhuraj AR, Narasingha Rao K, Tiwari S, Saini J, Shukla D, Devi BI. Ruptured intracranial dermoid cysts: A retrospective institutional review. J Clin Neurosci. 2019, 67, 172-177. doi: 10.1016/j.jocn.2019.04.025.\u003c/li\u003e\n\u003cli\u003eAlam Y, Mugge LA, Purdy J, Mrak RE, Schroeder J. Long-term Seizure Disorder Caused by a Dermoid Cyst with Catastrophic Developments. Cureus. 2018, 10;10(9), e3272. doi: 10.7759/cureus.3272.\u003c/li\u003e\n\u003cli\u003eShehadi JA, Alorainy IA, Johnston KM. Temporal dermoid cyst with a partial dermal sinus tract. Can J Neurol Sci. 1999, 26(4), 321-4. doi: 10.1017/s0317167100000470.\u003c/li\u003e\n\u003cli\u003eCaldarelli M, Massimi L, Kondageski C, Di Rocco C. Intracranial midline dermoid and epidermoid cysts in children. J Neurosurg. 2004 ;100(5 Suppl Pediatrics), 473-80. doi: 10.3171/ped.2004.100.5.0473. \u003c/li\u003e\n\u003cli\u003eLiu JK, Gottfried ON, Salzman KL, Schmidt RH, Couldwell WT. Ruptured intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery. 2008, 62(2), 377-84; discussion 384. doi: 10.1227/01.neu.0000316004.88517.29.\u003c/li\u003e\n\u003cli\u003eSkovrlj B, Mascitelli JR, Steinberger JM, Weiss N. Progressive visual loss following rupture of an intracranial dermoid cyst. J Clin Neurosci. 2014, 21(1), 159-61. doi: 10.1016/j.jocn.2013.02.005.\u003c/li\u003e\n\u003cli\u003eAkhaddar A, Mandour C, Belhachmi A, Boucetta M. Chronic headache and hemiparkinsonism due to a sylvian fissure dermoid cyst. Headache. 2010, 50(3), 479-80. doi: 10.1111/j.1526-4610.2010.01617.x. \u003c/li\u003e\n\u003cli\u003eAnand D, Aggarwal S, Soin D, Garg R. Sylvian Fissure Dermoid Cyst - A Rare case. J Clin Diagn Res. 2014, 8(9), RD01-2. doi: 10.7860/JCDR/2014/8917.4789.\u003c/li\u003e\n\u003cli\u003eBahakeem B, Alqahtani TF, Darwish A, Alkhotani A, Rawah E. Dermoid Cyst in the Posterior Fossa Associated With Dermal Sinus and Abscess Formation: A Case Report. Cureus. 2023, 15(4), e38032. doi: 10.7759/cureus.38032.\u003c/li\u003e\n\u003cli\u003eAhuja S, Shankar M, Mankotia DS, Shankar KB, Zaheer S. Epidermoid cyst of central nervous system: A case series and review of literature. Int J Surg Case Rep. 2024, 115, 109293. doi: 10.1016/j.ijscr.2024.109293.\u003c/li\u003e\n\u003cli\u003eMishra MK, Yadav V, Pradhan RS, Prasad RS. Intracranial Interdural and Extradural Cerebellar Convexity Dermoid Cyst: A Case Report of Rare Tumor at the Rarest Location. Asian J Neurosurg. 2023, 18(3), 631-635. doi: 10.1055/s-0043-1771325.\u003c/li\u003e\n\u003cli\u003eHirayama K, Tanei T, Kato T, Hasegawa T, Ito E, Nishimura Y, Saito R. Hemifacial spasm caused by multiple vascular at-tachments due to remote compression effects of a dermoid cyst in the cerebellar hemisphere: illustrative case. J Neurosurg Case Lessons. 2023, 6(23), CASE23592. doi: 10.3171/CASE23592.\u003c/li\u003e\n\u003cli\u003eSaifi I, Kashikar SV, Dhande R, Pavanan A, Reddy SNG. Magnetic Resonance Imaging Findings in a Rare Case of a Ruptured Intracranial Dermoid Cyst. Cureus. 2023, 15(8), e43316. doi: 10.7759/cureus.43316.\u003c/li\u003e\n\u003cli\u003eCao D, Xu H, Hu J, Mo J, Yu X, Wang J, Hu H. Frontotemporal giant extradural dermoid cyst: illustrative case. J Neurosurg Case Lessons. 2023, 5(14), CASE22547. doi: 10.3171/CASE22547. \u003c/li\u003e\n\u003cli\u003eYazan AS, Omer GL, Gubari MIM, Maurizi R, Baban K, Xasraw A, Kareem RHR. Epidermoid cyst of the posterior fossa: A case report of a combined microscopic and endoscopic transcranial approach. Ann Ital Chir. 2023, 12, S2239253X23038288. \u003c/li\u003e\n\u003cli\u003eObled L, Peciu-Florianu I, Perbet R, Vannod-Michel Q, Reyns N. Rare Case of Giant Supratentorial Dermoid Cyst. World Neurosurg. 2020, 135, 72-75. doi: 10.1016/j.wneu.2019.12.007. \u003c/li\u003e\n\u003cli\u003eEmmanuel S, Inban P, Akuma O, Nouman Aslam M, Talat F, Nizamani A, Chenna VSH, Romain EM, Chu Carredo CK, Khan A. An Atypical Case of Intracranial Dermoid Cyst in an Adult Female: A Case Report and Literature Review. Cureus. 2023, 15(5), e39807. doi: 10.7759/cureus.39807.\u003c/li\u003e\n\u003cli\u003eOnoda K, Kawaguchi A, Takaya Y, Inoue Y, Nakazato I, Saito Y, Ishikawa H, Oyama K, Oshima Y, Saito K, Sasajima Y, Matsuno A. A Case of Dermoid Cyst Arising in the Temporal Lobe. NMC Case Rep J. 2021, 8(1), 529-534. doi: 10.2176/nmccrj.cr.2020-0293.\u003c/li\u003e\n\u003cli\u003eLakhani DA, Morris MO, Deng F. Intracranial Dermoid Cyst. Radiology. 2024, 311(1), e232952. doi: 10.1148/radiol.232952.\u003c/li\u003e\n\u003cli\u003eLi G, Kim J, Garcia M, Reyes-McChesney I, Hanna A, Bhalala U. A Rare Presentation of Occipital Dermoid Cyst with Intra-cranial Extension and Secondary Infection: Case Report and Follow-Up. J Neurol Surg Rep. 2024, 85(2), e39-e42. doi: 10.1055/a-2287-2108.\u003c/li\u003e\n\u003cli\u003eAbbou Z, Djennati R, Khalil Z. A rare association between a dermoid cyst and arachnoid cyst of the cerebellopontine angle: a case report. Pan Afr Med J. 2021, 40, 125. doi: 10.11604/pamj.2021.40.125.32040.\u003c/li\u003e\n\u003cli\u003eGhosn JA, Mourad C, Farhat M, Yazbeck M, Mansour J, Noun P. Intradural dermoid cyst with complete dermal sinus of the posterior fossa: Contribution of 3D imaging with histopathological correlation. Radiol Case Rep. 2022, 17(6), 2071-2077. doi: 10.1016/j.radcr.2022.03.047.\u003c/li\u003e\n\u003cli\u003eBlitz SE, Bernstock JD, Dmytriw AA, Ditoro DF, Kappel AD, Gormley WB, Peruzzi P. Ruptured Suprasellar Dermoid Cyst Treated With Lumbar Drain to Prevent Postoperative Hydrocephalus: Case Report and Focused Review of Literature. Front Surg. 2021, 8, 714771. doi: 10.3389/fsurg.2021.714771.\u003c/li\u003e\n\u003cli\u003eRamdasi R, Thorve S, Karnavat C. Explosion of dermoid cyst into five intracranial spaces- a rare event. Br J Neurosurg. 2020, 34(6), 667-668. doi: 10.1080/02688697.2019.1687849. \u003c/li\u003e\n\u003cli\u003eOchoa A, Saenz A, Arga\u0026ntilde;araz R, Mantese B. Ruptured dermoid cyst in the Meckel\u0026apos;s cave presenting with trigeminal neu-ralgia in a pediatric patient: a case report. Childs Nerv Syst. 2020, 36(12), 3141-3146. doi: 10.1007/s00381-020-04646-y.\u003c/li\u003e\n\u003cli\u003eXin WQ, Lei Y, Chen D, Chen ZJ, Yang XY, Zhang N. Patient with Epilepsy Caused by the Spontaneous Rupture of an Intracerebral Dermoid Cyst. World Neurosurg. 2020, 136, 140-145. doi: 10.1016/j.wneu.2020.01.069.\u003c/li\u003e\n\u003cli\u003eKumaran SP, Srinivasa R, Ghosal N. Unusual Radiological Presentation of Intracranial Dermoid Cyst: A Case Series. Asian J Neurosurg. 2019, 14(1), 269-271. doi: 10.4103/ajns.AJNS_304_17.\u003c/li\u003e\n\u003cli\u003eJohnson DG, Stemper SJ, Withers TK. Ruptured \u0026quot;giant\u0026quot; supratentorial dermoid cyst. J Clin Neurosci. 2005 Feb;12(2):198-201. doi: 10.1016/j.jocn.2004.03.035. PMID: 15749433.\u003c/li\u003e\n\u003cli\u003eNakamura Y, Iwata S, Inoue A, Ohue S, Fukumoto S, Ichikawa H, Onoue S, Ozaki S, Kohno K. [A Case of Right Frontal Dermoid Cyst with Temporal Imaging Changes in the Desease Course]. No Shinkei Geka. 2019, 47(7), 769-776. Japanese. doi: 10.11477/mf.1436204021.\u003c/li\u003e\n\u003cli\u003eBalasundaram P, Garg A, Prabhakar A, Joseph Devarajan LS, Gaikwad SB, Khanna G. Evolution of epidermoid cyst into dermoid cyst: Embryological explanation and radiological-pathological correlation. Neuroradiol J. 2019, 32(2), 92-97. doi: 10.1177/1971400918821086. \u003c/li\u003e\n\u003cli\u003eChen JC, Chen Y, Lin SM, Tseng SH. Sylvian fissure dermoid cyst with intratumoral hemorrhage: case report. Clin Neurol Neurosurg. 2005, 108(1), 63-6. doi: 10.1016/j.clineuro.2004.11.003.\u003c/li\u003e\n\u003cli\u003eOprişan, A., \u0026amp; Popescu, B. O. (2012). Intracranial Cysts: An Imagery Diagnostic Challenge. The Scientific World Journal, 2013(1), 172154. https://doi.org/10.1155/2013/172154.\u003c/li\u003e\n\u003cli\u003eDutt SN, Mirza S, Chavda SV, Irving RM. Radiologic differentiation of intracranial epidermoids from arachnoid cysts. Otol Neurotol. 2002 Jan;23(1):84-92. doi: 10.1097/00129492-200201000-00019. PMID: 11773853.\u003c/li\u003e\n\u003cli\u003eJamjoom, D. Z., Alamer, A., \u0026amp; Tampieri, D. (2022). Correlation of radiological features of white epidermoid cysts with histopathological findings. Scientific Reports, 12(1), 1-8. https://doi.org/10.1038/s41598-022-06167-x.\u003c/li\u003e\n\u003cli\u003eSood S, Gupta R. Susceptibility artifacts in ruptured intracranial dermoid cysts: a poorly understood but important phenomenon. Neuroradiol J. 2014 Dec;27(6):677-84. doi: 10.15274/NRJ-2014-10090. Epub 2014 Dec 1. PMID: 25489890; PMCID: PMC4291801.\u003c/li\u003e\n\u003cli\u003eWestermaier T, Schweitzer T, Ernestus RI. Arachnoid cysts. Adv Exp Med Biol. 2012;724:37-50. doi: 10.1007/978-1-4614-0653-2_3. PMID: 22411232.\u003c/li\u003e\n\u003cli\u003eOrtega-Merchan MP, Reyes F, Mej\u0026iacute;a JA, Rivera DM, Galvis JC, Marquez JC. Cystic trigeminal schwannomas. Radiol Case Rep. 2019 Oct 19;14(12):1513-1517. doi: 10.1016/j.radcr.2019.09.031. PMID: 31660099; PMCID: PMC6807068.\u003c/li\u003e\n\u003cli\u003eMak YH, Ho G. Multicompartmental cystic trigeminal schwannoma as an uncommon differential diagnosis of cerebellopontine angle tumors. Radiol Case Rep. 2024 Apr 5;19(6):2552-2557. doi: 10.1016/j.radcr.2024.03.013. PMID: 38596177; PMCID: PMC11001620.\u003c/li\u003e\n\u003cli\u003eKato N, Radke J, Vajkoczy P, Schneider UC. [Intrasylvian dermoid cysts of the pediatric patient: a case report and review]. No Shinkei Geka. 2014, 42(10), 925-9. Japanese. doi: 10.11477/mf.1436200006.\u003c/li\u003e\n\u003cli\u003eFornari M, Solero CL, Lasio G, Lodrini S, Balestrini MR, Cimino C, Visintini S, Pluchino F. Surgical treatment of intracranial dermoid and epidermoid cysts in children. Childs Nerv Syst. 1990, 6(2):66-70. doi: 10.1007/BF00307923.\u003c/li\u003e\n\u003cli\u003eEncarnacion Ramirez MJ, Peralta I, Ramirez I, Dauly V, Mainer G, Nurmukhametov R, Efe IE. Development of a Novel Low-Cost Exoscope to Expand Access to Microneurosurgical Care in Low- and Middle-Income Countries. World Neurosurg. 2022, 163, 5-10. doi: 10.1016/j.wneu.2022.03.144.\u003c/li\u003e\n\u003cli\u003eEncarnacion Ramirez M, Peralta Baez I, Nurmukhametov R, Goncharov E, Efe IE, Sufianov A, Ramirez Pena I. Comparative survey study of the use of a low cost exoscope vs. microscope for anterior cervical discectomy and fusion (ACDF). Front Med Technol. 2023, 4, 1055189. doi: 10.3389/fmedt.2022.1055189. \u003c/li\u003e\n\u003cli\u003eKocaeli H, Korfali E, Doğan S, Savran M. Sylvian cistern dermoid cyst presenting with dysgeusia. Acta Neurochir (Wien). 2009, 151(5), 561-3. doi: 10.1007/s00701-009-0261-1. \u003c/li\u003e\n\u003cli\u003eBergstr\u0026ouml;m A, Staals\u0026oslash; JM, Romner B, Olsen NV. Impaired endothelial function after aneurysmal subarachnoid haemorrhage correlates with arginine:asymmetric dimethylarginine ratio. Br J Anaesth. 2014, 112(2), 311-8. doi: 10.1093/bja/aet331.\u003c/li\u003e\n\u003cli\u003eBristow RG, Laperriere NJ, Tator C, Milosevic M, Wong CS. Post-operative radiotherapy for recurrent dermoid cysts of the spine: a report of 3 cases. J Neurooncol. 1997, 33(3), 251-6. doi: 10.1023/a:1005739606895.\u003c/li\u003e\n\u003cli\u003eRay MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012 Jan;25(1):23-5. doi: 10.1080/08998280.2012.11928775. PMID: 22275778; PMCID: PMC3246848.\u003c/li\u003e\n\u003cli\u003eRay MJ, Barnett DW, Snipes GJ, Layton KF, Opatowsky MJ. Ruptured intracranial dermoid cyst. Proc (Bayl Univ Med Cent). 2012 Jan;25(1):23-5. doi: 10.1080/08998280.2012.11928775. PMID: 22275778; PMCID: PMC3246848.\u003c/li\u003e\n\u003cli\u003eSantos A, Viegas AF, Porto LM, Gomes A, Nascimento E. Arachnoid Cyst: An Asymptomatic Exuberance. Cureus. 2022 Nov 22;14(11):e31782. doi: 10.7759/cureus.31782.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dermoid Cyst, Pediatric neurosurgery, Neuroncology, neurosurgery, literature review","lastPublishedDoi":"10.21203/rs.3.rs-5685800/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5685800/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eIntroduction\u003c/em\u003e: Intracranial dermoid cysts are rare, benign tumors, making up 0.04–0.6% of brain tumors and originating from ectodermal cells, unlike more complex teratomas from pluripotent germ cells. Dermoid cysts, containing only ectodermal derivatives, differ from epidermoid cysts by lacking dermal appendages. They commonly cause symptoms like seizures and headaches, with specific types associated with their rupture or chronic presence, impacting nearby brain structures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMaterial and Method\u003c/em\u003e: Our systematic literature review and case series presentation on neurosurgical management of Giant Dermoid Cysts (GDCs) began by identifying 15 full-text articles that met all inclusion criteria were analyzed in detail along with specific cases from our clinical series. These studies and cases provided insights into diagnostic approaches, surgical techniques, and patient outcomes, emphasizing the complexities of complete resection and the use of advanced surgical technologies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResults\u003c/em\u003e: The clinical outcomes of two patients from our case series were also included: a 32-year-old female presented with progressive headaches and occasional dizziness, undergoing subtotal resection with two subsequent surgeries due to recurrence over a 10-year period, and a 45-year-old male experiencing dizziness and seizures, who underwent successful total resection with no recurrence after 10 years.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConclusions\u003c/em\u003e: This study highlights the complexities involved in managing Giant Dermoid Cysts (GDCs) neurosurgical and underscores the critical role of advanced diagnostic and surgical technologies in improving patient outcomes. Importantly, the introduction of the Reyes-Velez classification system offers a structured approach to diagnosing and managing these cysts, providing clinicians with a valuable tool to enhance surgical planning, predict potential complications, and guide therapeutic decisions. This new classification system is instrumental in advancing the standardization and effectiveness of treatment protocols for GDCs.\u003c/p\u003e","manuscriptTitle":"Presentation of a New Imaging Classification for Giant Dermoid Cyst. Case Report And Literature Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-06 09:18:32","doi":"10.21203/rs.3.rs-5685800/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2705591-08a2-4796-8925-ec5dd843bc73","owner":[],"postedDate":"January 6th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-01-07T01:53:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-06 09:18:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5685800","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5685800","identity":"rs-5685800","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}