Arachnoid cyst in the middle fossa can cause many symptoms include headache and seizure. When drugs therapy can not relieve or control the symptoms, it is necessary to determine whether the surgical procedure can improve patient’s outcome.
First case, 28 years old female suffered from severe headache and sometimes unconsciousness for a few minutes. Magnetic resonance images showed the lesion hypo-intense on T1-weight and hyper-intense on T2-weight images. Left M1 middle cerebral artery lay down inside the cyst. The second case, a man 18 years old had seizures every three months. He took phenytoin 600 mg a day but in the last one month seizures repeated up to five times. The brain MRI results showed a hypointense lesion of T1-weight and hyperintense at T2-weight in the right temporal region measuring approximately 5 × 4 cm and compressing the temporal bone to form a convex shape. The third case, a man 23 years old had complaints of seizures since 6 months. The patient received the drug phenytoin 3x200mg and valproic acid 1 g daily but the seizures still exist. The brain MRI showed hyperintense lesion in the right temporal region. Microscopic fenestration craniotomy was performed in all cases and at one year of follow-up the headache disappeared. Seizure attacks have never occurred again with only low doses of phenytoin.
The result of microscopic fenestration craniotomy in patients with headaches and seizures due to middle fossa arachnoid cysts is good and can be considered for controlling seizures in selected cases.

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