Middle fossa arachnoid cyst (MFAC) is the most common kind of arachnoid cyst. The objective of this study was to assess the efficacy of endoscopic fenestration for MFACs. The authors report 26 patients of MFAC with variety symptoms such as macrocrania, epilepsy, headache, and development delay. The authors performed surgery with a neuroendoscope to drain and fenestrate the cyst to obtain nearby cystocisternal communications under general anesthesia. All of the 26 patients had a successful fenestration, most of them had an improvement of at least 1 of their pretreatment symptoms with the substantial reduction of the cyst postoperatively. The authors conclude that endoscopic fenestration may be an acceptable and minimally invasive option for the management of symptomatic MFACs.