Multiple saccular aneurysms of the extracranial and intracranial internal carotid artery associated with convexobasia and arachnoid cyst in a 6-year-old boy: a case report

INTRODUCTION

We report an extremely rare case of multiple saccular aneurysms of the extracranial and intracranial internal carotid artery associated with convexobasia of the left temporal region and arachnoid cyst in a 6-year-old boy.

CASE REPORT

A 6-year-old male patient was admitted to the hospital with chief complaint of ptosis and engorgement of the left eyelid for 50 days. A 4 x 10-cm bony protuberance of the left temporal region with hemangiectasia was observed to beat with pulse without vascular murmur. computed tomographic angiography (CTA) showed two saccular aneurysms of the left internal carotid artery. The first one which was about 3 cm in length and 2 cm in maximum diameter was located in the middle of the petrous portion (including parts of C2 and C3). The second one which was about the same size was located from the middle of the cavernous portion to the upper end of the left internal carotid artery. Computed tomography showed an arachnoid cyst in the left temporal region and abnormality of the left temporal bone. According to the specific circumstances of this patient, we believe that surgical treatment is rather risky and the loss might outweigh the gain. Therefore, we suggested to the parents that the child should be followed up for the coming years for monitoring and possible treatment.

DISCUSSION

Multiple saccular aneurysms of extracranial and intracranial internal carotid artery in children are extremely rare. According to this case, the child had congenital bony protuberance of the left temporal region with hemangiectasia, which made this case particularly specific. Besides all those discovered abnormalities, this child was a healthy boy. Due to the difficulty and high risk of possible surgical treatment, we suggested that no further treatment be performed at the moment and the child should be followed up for a long period of time. Worthy examinations such as CT, CTA, and MRI are recommended for reviewing the development of aneurysms and CNS of this boy. Further treatment might be performed in the future. We welcome all forms of discussion about this case and similar cases around the globe.

Frontal mucocoele communicating with an arachnoid cyst of the anterior cranial fossa

Mucocoeles usually involve the frontal sinus and can extend to the orbit or intracranially. In this case symptoms and radiological findings were typical of a left frontal mucocoele with intracranial extension. Intraoperative findings were compatible with a left frontal mucocoele communicating with an arachnoid cyst of the anterior cranial fossa.

[Life-threatening subdural haematoma in young man]

Pre-existence of an arachnoid cyst has previously been suggested to increase the risk of developing a subdural haematoma (SDH). In this case a young man was submitted acutely due to decreasing level of consciousness. Four weeks previously he had been hit by a football and suffered minor and transcient headache. Within minutes after submission, a further decrease in consciousness according to the Glasgow comascore was observed. Acute computed tomography showed SDH and an arachnoid cyst. Surgery was performed immediate and hours later he was improving.

Experience on Transfontanelle Neurosonography in Kano, Nigeria: a preliminary report

OBJECTIVE

To retrospectively audit and analyse all the Transfontanelle Neurosonographic scans performed at the Aminu Kano Teaching Hospital (AKTH), between January to September, 2004.

METHODS

Information on the gray scale appearance of the ventricles, cerebral and cerebellar parenchyma, extra axial fluid spaces, status of the sulci and gyri and the echogenic internal outline of the bony skull vault was extracted from the records of all the Transfontanelle neurosonographic scans performed at the specialist Ultrasound clinic of the AKTH, between January to September, 2004.

RESULTS

Eighteen infants were scanned, and 8 (44.4%) of them were neonates. Meningitis (9 patients) and increasing head size (7 patients) were the commonest clinical indication for referral. Communicating hydrocephalus was the only known complication seen in 4(44.4%) of the post meningitic patients. While in the increasing head size group, congenital malformations such as Aqueductal stenosis and Arachnoid cyst of the quadrigeminal cistern as well as hydrocephalus predominates (4 out of 7 patients). The last 2 patients referred on account of severe birth asphyxia and swollen occiput showed no abnormality and occipital meningocoele respectively.

CONCLUSION

This study confirms the earlier notion of the pre-eminence of infection as compared to congenital malformation as the leading cause of infant morbidity in developing nations. It also emphasises the value of Transfontanelle neurosonography as an excellent, non-invasive, inexpensive, rapid and safe imaging modality for the evaluation of the pathologic conditions of infants' brain.

Macrocephaly and bitemporal arachnoid cysts not associated with glutaric aciduria type I in a child

A 45-month-old child who had bitemporal arachnoid cysts and macrocephaly unrelated to glutaric aciduria type 1 (GA 1) was reported. The patient was admitted to the emergency unit after head trauma at 11 months of age. CT and MRI showed bitemporal arachnoid cysts (BACs). Acylcarnitine profile was normal in serum using tandem mass spectrometry. Urine and blood screening tests were within normal range for metabolic disorders. There were no unusual organic acids in urine and blood samples. No additional clinical findings of metabolic disorders such as GA 1 developed during follow-up. The majority of children affected with GA 1 have macrocephaly and BACs on CT or MRI. These signs should alert neurosurgeons to the possibility of GA 1. Neurosurgeons evaluating patients with head trauma or suspected non-accidental head injury should include GA 1 in the differential diagnosis of BACs associated with macrocephaly, and an evaluation should be performed.

Occlusive hydrocephalus caused by a fourth ventricle arachnoid cyst

The case history of a woman with occlusive hydrocephalus caused by a fourth ventricle cyst is presented. She had slowly progressive complaints and symptoms--concentration and memory disturbances, low-tempered mood, then slight dizziness, loss of appetite and progressive headache--transitorily misinterpreted for signs of depression. She had been treated by psychotherapy and antidepressants for months. Since she did not improve she was referred to a psychiatric hospital. The rapidly progressing neurological syndrome with worsening headache, gait disturbance and vomiting was finally identified and it turned out to be caused by a fourth ventricle CSF blockage of unknown aetiology. An acute neurosurgical intervention was indicated. It revealed a huge fourth ventricle cyst, undetectable on MRI, occupying the whole ventricle. The resection of its walls resulted in complete recovery. We conclude that since unspecific mental complaints and symptoms suggesting depression may be misleading, their organic origin has to be excluded.

A role for myelography in assessing paraparesis

Imaging of the spine is a fundamental part of assessment of paraparesis. Since the advent of MRI the indications for myelograms have diminished. However, a myelogram, although an invasive test, should still be considered a useful investigation for localising lesions in the spinal cord and for identifying rare causes of myelopathy. This case illustrates how a CT myelogram identified an arachnoid cyst, which is a potentially treatable cause of paraparesis.

[CT and MRI features of arachnoid cyst of the petrous apex: report of 3 cases]

PURPOSE

To describe the CT and MRI features of 3 cases of arachnoid cyst of the petrous apex.

PATIENTS AND METHODS

Three patients with isolated trigeminal neuralgia, trigeminal hypoesthesia, and sinusitis. Axial and coronal CT images were obtained. T1W, FSE T2W, FLAIR, T2*W and diffusion-weighted MR sequences were obtained.

RESULTS

In all cases, both CT and MRI showed expansile lesions eroding the petrous apex. Lesions were hypodense on CT and isointense to CSF on MRI, without contrast enhancement. In one case, the lesion was contiguous with Meckel's cave with temporal fossa and sphenoid sinus extension. CT and MR imaging features are useful to distinguish arachnoid cysts of the petrous apex from other benign lesions of the petrous apex.

CONCLUSION

CT and MRI imaging features allow diagnosis of arachnoid cyst of the petrous apex because its imaging features, especially on DWI, are different from other cystic lesions of the petrous apex, namely cholesteatoma. It should be considered in patients with trigeminal involvement, especially trigeminal neuralgia.

INTRASELLAR ARACHNOID CYSTS

OBJECTIVE

To evaluate the clinical, endocrinological, and radiological presentation of nine cases of surgically verified intrasellar arachnoid cysts and to discuss the physiopathological mechanisms of formation of these cysts.

METHODS

Among 1540 patients presenting with pituitary lesions, nine presented with an intrasellar arachnoid cyst. Their charts were retrospectively reviewed.

RESULTS

Presenting symptoms included headache (n = 2), visual symptoms (n = 3), menstrual irregularities (n = 2), rapid weight gain (n = 1), vertigo (n = 1), and/or confusion (n = 1). Two cysts were discovered incidentally. T1-weighted magnetic resonance imaging scans showed an intrasellar cystic lesion in all cases, with a huge suprasellar extension in six cases. The cyst was of the same intensity as the cerebrospinal fluid (CSF) in only two patients. A transsphenoidal approach allowed the transdural aspiration of fluid and injection of a water-soluble contrast agent under mild pressure. In three patients, the contrast infiltrated along the pituitary stalk toward the subarachnoid spaces; in the other patients, it remained in the intrasellar compartment. Cyst membranes were removed as completely as possible with fenestration toward the subarachnoid spaces in communicating cysts. In spite of tight packing of the sella and sphenoid sinus, CSF fistulae requiring reoperation developed in two patients.

CONCLUSION

The clinical picture of an intrasellar arachnoid cyst resembles that of a nonfunctional pituitary adenoma. Magnetic resonance imaging scans typically show a cystic intrasellar lesion with suprasellar extension, containing isointense or, more often, hyperintense fluid on T1-weighted sequences. In spite of the risk of CSF fistulae, the preferred surgical approach is transsphenoidal. A physiopathological mechanism is proposed according to anatomic variations of the sellar diaphragma allowing penetration of subarachnoid spaces into the sellar compartment and their enlargement by a ball-valve mechanism.

Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid

OBJECT

The authors assessed the efficacy of computed tomography (CT)-guided percutaneous injection of fibrin glue to treat meningeal cysts of the sacral spine in patients with back pain, and evaluated the necessity for cerebrospinal fluid (CSF) aspiration before glue injection.

METHODS

Of the 31 patients in this study, 15 underwent injection of fibrin glue under CT guidance after aspiration of more than 15 ml of CSF (Group A), and 16 patients were treated with the glue but without CSF aspiration (Group B). Clinical results were evaluated after an average of 23 months of follow-up, and changes on the imaging studies were also evaluated. The clinical outcome and postoperative complications were analyzed.

RESULTS

All 31 patients experienced resolution or marked improvement of symptoms for as long as 28 months after fibrin glue therapy. No patient experienced recurrence of symptoms during the follow-up interval. The postoperative pain relief was statistically significant (p < 0.001) according to evaluations in which a 100-mm visual analog pain scale was used. There were no statistical differences between the two groups (p > 0.05).

CONCLUSIONS

Percutaneous CT-guided fibrin glue therapy for sacral arachnoid cysts may be a definitive therapy. It is unnecessary to aspirate the CSF before injection of the fibrin glue.

Suprasellar arachnoid cyst: a 20- year follow-up after stereotactic internal drainage: case report and review of the literature

Approximately 9 to 15% arachnoid cysts occur in the sellar or suprasellar region. The optimal management of symptomatic suprasellar cysts continues to pose a challenge to neurosurgeons. This case report describes a patient with a suprasellar arachnoid cyst who presented at the age of 3 and was followed for 20 years after cystoventriculostomy. A girl was referred to neurosurgery department by a pediatric clinic because computed tomography demonstrated a suprasellar cystic lesion. The neurological examination and all routine blood tests including hormone profiles were normal. The physical examination was unremarkable except premature thelarche. Stereotactic ventriculocystostomy was performed using a catheter providing permanent internal drainage. Postoperative cystoventriculography showed contrast medium in both the cyst and the ventricles. Control computed tomography confirmed that the ventricular cyst catheter was within the cyst. During a follow-up of 20 years, signs of precocious puberty disappeared and the girl showed normal sexual development. Endocrine profiles and visual function remained normal. The stereotactic approach to suprasellar arachnoid cysts is a safe procedure in experienced hands.

[Non-haemorrhagic subependymal pseudocysts: ultrasonographic, histological and pathogenetic variability]

PURPOSE

Differentiation of non-haemorrhagic subependymal pseudocysts from subependymal pseudocysts after cerebral haemorrhage in the preterm infant.

MATERIALS AND METHODS

Selective ultrasonographic screening in 2200 neonates and retrospective analysis in 72 infants with subependymal pseudocysts, the full-term infants being analysed from birth, and the preterm infants after the second week of life, thus avoiding the gestational age at which cerebral haemorrhage occurs in the preterm infant.

RESULTS

Three variants of pseudocysts were identified: the caudothalamic germinolysis is a leukomalacic and pseudocystic gliosis. Pseudocysts in the anterior choroid plexus of the lateral ventricle could be distinguished from caudothalamic germinolysis by their location, form and movement. Pseudocysts lateral of the frontal horns are the result of regression of germinal matrix remains.

CONCLUSION

Differentiation of non-haemorrhagic from post-haemorrhagic germinolysis is necessary to clarify the aetiology and pathogenesis of non-haemorrhagic pseudocysts. Caudothalamic germinolysis possibly is the result of infection with stenotic intima proliferation following vasculitis. The results are thalamostriatal vasculopathy and germinal necrosis. Anterior plexus cysts might be the result of folding faults of the ependyma in the growth period of the choroid plexus. Pseudocysts lateral of the frontal horns should not be mistaken for ventricular ligaments.

Long-term follow-up of a multiloculated arachnoid cyst of the middle cranial fossa

Arachnoid cysts are benign intracranial lesions that are typically diagnosed incidentally. We describe the case of a 56-year-old man who presented with a multiloculated arachnoid cyst of the middle cranial fossa that extended into the sphenoid sinus. The lesion was identified on computed tomography of the head, which had been obtained for an unrelated investigation. However, establishing a definitive diagnosis proved to be difficult. Because the cyst had caused extensive skull base erosion, the patient was managed conservatively with close observation. We report the radiographic progression of this lesion during more than a decade of follow-up, and we review the literature pertaining to the presentation, pathophysiology, and treatment of arachnoid cysts.

Two-step surgical treatment using miniature Ommaya's reservoirs for a neonate with multiple large arachnoid cysts

METHOD

We followed a two-step surgical strategy using miniature Ommaya's reservoirs in an early neonate with multiple large arachnoid cysts.

CONCLUSION

Percutaneous fluid aspiration through the reservoirs placed during the first operation permitted the infant to develop sufficiently to withstand the second, more radical cyst wall excision.

Congenital malformations of the skull and meninges

The surgery and management of children who have congenital malformations of the skull and meninges require multidisciplinary care and long-term follow-up by multiple specialists in birth defects. The high definition of three-dimensional CT and MRI allows precise surgery planning of reconstruction and management of associated malformations. The reconstruction of meningoencephaloceles and craniosynostosis are challenging procedures that transform the child's appearance. The embryology, clinical presentation, and surgical management of these malformations are reviewed.

Birth trauma and development of growing fracture after coronal suture disruption

INTRODUCTION

A growing fracture is a rare complication of skull fractures characterized by progressive diastatic enlargement of the fracture line. Growing skull fractures related to birth trauma were only occasionally reported. As far as we know, only one previous case of a neonatal growing fracture secondary to coronal suture disruption has been reported.

CASE REPORT

We present the case of a full-term infant born after a nontraumatic, forceps-assisted spontaneous delivery, who developed an increasing cystic swelling over the left frontoparietal area that crossed over coronal and sagittal sutures. The lesion was initially misinterpreted as cephalhematoma. Clinical and radiological follow-up established the correct diagnosis of leptomeningeal cyst.

OUTCOME

The collection was initially tapped. Surgical treatment was undertaken thereafter, consisting of decompression and resection of the cyst and dural repair. Two months after follow-up, the patient remains asymptomatic and the porencephalic cavity remains isolated from the extradural space, with no evidence of new fluid collections.

Spontaneous resolution of arachnoid cysts: review and features of an unusual case

Most intra-cranial arachnoid cysts are quiescent and remain asymptomatic throughout life. Within the natural course of arachnoid cyst evolution, spontaneous resolution has been known to occur rarely, but its frequency is probably underestimated due to lack of systematic detection and long-term observation. We illustrate the spontaneous regression of arachnoid cysts with a patient which was conjointly diagnosed with an arachnoid cyst and a post-traumatic epidural haematoma. Cyst regression was observed 16 months later, upon examination following a second benign cranial trauma. Mechanisms underlying the resolution of the arachnoid cyst are discussed.

Stereotactic cyst/ventricular-peritoneal shunting for the treatment of prepontine arachnoid cyst: case report

BACKGROUND

Prepontine (suprasellar) arachnoid cysts are uncommon in clinical practice, so experiences in their management are limited and the best method of treatment for them remains unclear. Here we report our experience in using stereotactic cyst/ventricular-peritoneal shunting for the treatment of prepontine arachnoid cyst.

CASE DESCRIPTION

A 42-year-old woman with prepontine arachnoid cyst was treated with cyst/ventricular-peritoneal shunting: the ventricular catheter was precisely inserted at a point where it could drain from the cyst and the ventricle at the same time. The postoperation CT scan showed that the cyst and the enlarged ventricle shrunk markedly. During a 1-year follow-up period, she remained symptom-free and had returned to full-time work.

CONCLUSION

Stereotactic cyst/ventricular-peritoneal shunting appears to be an effective method for treating prepontine arachnoid cyst.

[Results of neuroendoscopic treatment of arachnoid cysts in adults]

BACKGROUND AND PURPOSE

Most arachnoid cysts (ACs) are asymptomatic, but some of them cause mass effect, mainly in adults. Surgery of ACs is controversial, especially regarding the choice of the best method of treatment. The authors present short- and long-term outcome of endoscopic surgery of ACs.

MATERIALS AND METHODS

There were 19 adults with symptomatic ACs treated surgically in the last 6 years. 16 cysts were located supratentorially, and 3 infratentorially. Cystocisternostomy was carried out in 7 patients, cystocisternostomy with catheter implantation was performed in 5 patients, cystoventriculostomy in 3 patients, and cystoventriculostomy with catheter implantation was carried out in 2 patients. In one case additional endoscopy combined with shunt was necessary, and in another one endoscopy converted to microsurgery. Outcome was assessed by means of neurological examination and computed tomography (CT).

RESULTS

During the short-term follow-up, 11 (57.9%) cases improved neurologically, and in 6 (33.0%) ACs were significantly smaller in CT. During the long-term follow-up, 14 (73.7%) patients improved significantly, and the size of ACs was reduced in 16 (84.2%). In two cases subdural haematoma was observed.

CONCLUSIONS

Outcome after endoscopic surgery of ACs in adults is good, and the complication rate is low. Endoscopy should be recommended as the treatment of choice in patients suffering from ACs.

Functional assessment of intracranial arachnoid cysts with TC99 m-HMPAO SPECT: a preliminary report

BACKGROUND

Many arachnoid cysts (AC) are detected incidentally in asymptomatic patients. Current neuroimaging methods provide only morphological details of the cysts, but they do not give information about cerebral function. While surgery is indicated in symptomatic patients, the management of asymptomatic individuals, who present with large cysts, is controversial.

STUDY OBJECTIVE

To ascertain the value of cerebral 99 mTc-HMPAO single photon emission computed tomography (SPECT) for detecting brain dysfunction in cases of intracranial ACs, aimed at allocating the patients for surgical or for conservative treatment.

PATIENTS AND METHODS

We studied prospectively 11 patients diagnosed with sylvian fissure ACs. The subjects underwent neurological examination, EEG, neuroimaging studies, neuropsychological testing, and cerebral perfusion studies with 99 mTc-HMPAO SPECT.

RESULTS

The patients' ages ranged from 2 to 42 years (median 16 years). The study group consisted of ten symptomatic patients with ACs and one patient with an incidental cyst. Seven patients showed diminished regional cerebral blood flow (rCBF) in their initial cerebral SPECT. Four individuals underwent surgery. Seven patients showed normalization of rCBF after surgical or conservative treatment.

CONCLUSIONS

Cerebral SPECT demonstrated impaired brain perfusion in 70% of symptomatic patients. The zone of decreased rCBF corresponded well with clinical symptoms and with neuroimaging findings. Patients exhibiting normal rCBF in SPECT studies remained or became asymptomatic during the follow-up time. Cerebral SPECT constitutes a valuable adjunct tool for correlating regional function with brain anatomy, and may be of help to allocate patients with ACs for surgical treatment or clinical observation. Further research on this field is warranted.

Arachnoid cyst mimicking normal pressure hydrocephalus. A case report and review of the literature

A case of a 61-year-old female patient who presents with the clinical triad of normal pressure hydrocephalus (NPH), abnormal gait, urinary incontinence and dementia. On CT scanning, she is found to have a large arachnoid cyst which mimicked the syndrome of NPH. This is also the 60th published case of arachnoid cyst presenting over the age of 60.

[Intrasellar arachnoid cyst. A case report and review of the literature]

Intrasellar arachnoid cyst (IAC) is a very rare pathological lesion occurring in 5 of 1000 autopsy cases, and constitutes 9% of all arachnoid cysts. As a space-occupying mass, IAC may cause headaches, visual disturbances, hypopituitarism, precocious puberty, and the "bobble-head doll" syndrome. The pathogenesis of IAC remains controversial. Magnetic resonance imaging (MRI) is the neurodiagnostic tool of choice to evaluate IAC. The authors presented a 38 year-old woman suffering from severe chronic headaches, dysmenorrhea, and visual disturbance. MRI revealed an intrasellar cystic lesion that had compressed the optic chiasma. Preoperative endocrinological assessment revealed hyperprolactinemia and hypogonadotropic hypogonadism. The patient underwent transsphenoidal surgery. The cyst membrane was opened and clear, serous fluid was evacuated. The postoperative course was complicated by CSF leakage, which was corrected by an autologous fat graft placement. Visual field defects improved immediately after surgery but a transient panhypopituitarism and diabetes insipidus occurred. Postoperative MRI revealed no recurrence of the lesion during the four-year follow-up.

A large arachnoid cyst of the lateral ventricle extending from the supracerebellar cistern--case report

BACKGROUND

The pathogenetic mechanism of intraventricular arachnoid cyst development is still controversial, but is believed to originate from the vascular mesenchyme or as an extension of the arachnoid cyst in the subarachnoid space into the ventricle through the choroidal fissure. We report a case supporting the extension hypothesis and suggest differential points between an intraventricular arachnoid cyst that extended from the supracerebellar space and a lateral ventricular diverticulum that extended into the supracerebellar cistern.

CASE DESCRIPTION

A 12-month-old girl presented with macrocephaly and developmental delay. Her magnetic resonance imaging showed an arachnoid cyst that had developed from the supracerebellar space in the posterior fossa, and which extended into the left lateral ventricle resulting in expansion of the left lateral ventricle and displacing the choroids plexus anteriorly and laterally and the midline to the right. We treated an intraventricular arachnoid cyst by endoscopic fenestration resulting in dramatic reduction of the intraventricular arachnoid cyst with large bilateral subdural fluid collection. We performed a subduroperitoneal shunt for subdural fluid collection and subsequent cystoperitoneal shunt for the remnant cyst.

CONCLUSION

We suggest that this case supports the extension hypothesis from the subarachnoid space through the choroidal fissure into the lateral ventricle. We also suggest that one of the radiological differential points between an intraventricular arachnoid cyst and a ventricular diverticulum is displacement and compression of the choroid plexus of the lateral ventricle.

Management of a suprasellar arachnoid cyst identified using prenatal sonography

We present a rare case of suprasellar arachnoid cyst discovered incidentally on routine fetal sonographic examination. Serial sonographic and MRI scanning led to a prenatal diagnosis and appropriate endoscopic treatment at 5 months of age. The patient is currently developing normally at 3 years of age. Careful screening of fetal intracranial abnormalities is important in routine prenatal sonographic examination for early intervention, which will prevent irreversible complications such as endocrine disorders and visual impairment.

Helmetlike skull deformity with a large arachnoid cyst

BACKGROUND

It is not difficult to find localized skull ballooning or macrocrania in patients with intracranial arachnoid cysts. However, there have been no previous reports regarding large localized skull protuberant deformities resembling a war helmet. The authors report with a review of literature a case of an adult with helmetlike skull deformity resulting from a large supratentorial arachnoid cyst.

CASE DESCRIPTION

A 35-year-old man presented with a large head deformity since his early childhood that had been the result of gradual progression from infantile macrocrania. He also had mental retardation, sixth cranial nerve palsy with recent aggravation of headache, reduced activity, poor voiding control, and walking disturbance. Magnetic resonance imaging of the head showed hydrocephalus with a large supratentorial arachnoid cyst located in the bilateral parietooccipital area compressing the hemisphere anteriorly, and the tentorium and cerebellum inferiorly. Magnetic resonance venogram demonstrated low-lying short transverse and lateral sinuses, and the superior sagittal sinus and falx were displaced to the right side. Radioisotopic cisternogram showed nonfilling of the isotope in the bilateral parietooccipital area. Cerebrospinal fluid pressure measured by lumbar puncture was 17 cm H(2)O. We tentatively diagnosed the condition as normopressure hydrocephalus with a large supratentorial arachnoid cyst. His headache, reduced activity, poor voiding control, and walking disturbance improved after a cystoperitoneal shunt.

CONCLUSIONS

This might suggest that large arachnoid cysts found in childhood should be treated for prevention of skull deformity and late aggravation of increased intracranial pressure.

Fetal arachnoid cyst of the quadrigeminal cistern in MRI and ultrasound

CASE

The authors report a fetus with an arachnoid cyst of the quadrigeminal cistern without hydrocephalus at 30 gestational weeks.

DISCUSSION AND CONCLUSION

We reviewed the literature and could find only 62 reported cases of arachnoid cyst of the quadrigeminal cistern. We present a case without hydrocephalus diagnosed by combining ultrasound (US) and magnetic resonance imaging (MRI). The fetus, born by normal delivery, was followed up and did not show hydrocephalus for 1 year. This combined prenatal study, which uses US and MRI, helps in dispensing proper counseling to parents and assists the gynecologist and the neurosurgeon in the pre- and postnatal management of this condition.

Arachnoid cyst resulting in tonsillar herniation and syringomyelia in a patient with achondroplasia

Achondroplasia has been associated with varying degrees of cervicomedullary and spinal compression, although usually in the pediatric population. Large arachnoid cysts have also been found to result in tonsillar herniation and syringomyelia. The authors present the case of a patient with achondroplasia who presented with symptoms of foramen magnum compression and syringomyelia, and who was subsequently found to have a large posterior fossa arachnoid cyst.

This 38-year-old woman with achondroplasia presented with an 8-month history of headache and numbness of the hands and fingers. Admission magnetic resonance (MR) imaging of the head and spine revealed a large arachnoid cyst in the posterior cranial fossa, a 6-mm tonsillar herniation consistent with an acquired Chiari malformation, and a large cervicothoracic syrinx. The patient was treated using suboccipital craniectomy, C-1 laminectomy, fenestration of the arachnoid cyst, and decompression of the acquired Chiari malformation with duraplasty.

Surgical decompression resulted in improvement of the presenting symptoms, adequate decompression of crowding at the foramen magnum, and resolution of the syrinx. Although there was only partial reduction in the retrocerebellar cisternal space on follow-up MR imaging, no residual symptoms were related to this.

The use of an adjustable valve to treat over-drainage of a cyst-peritoneal shunt in a child with a large sylvian fissure arachnoid cyst

INTRODUCTION

The cyst-peritoneal shunt is a recognised surgical alternative in the management of sylvian fissure arachnoid cysts. Shunt overdrainage is well described in literature on ventriculo-peritoneal shunts, but not often appreciated as a complication of cysto-peritoneal shunts.

CASE REPORT

A 5-year-old boy presented with a symptomatic left sylvian fissure arachnoid cyst. This was initially treated by craniotomy and membrane fenestration in the carotid cistern. Recurrence led to insertion of a valveless cyst-peritoneal shunt 5 months later. Initial progress was followed by persistent headaches 18 months after shunt insertion. CT scan revealed a significant reduction in the cyst size, enlargement of the ipsilateral lateral ventricle, collapse of the contra-lateral ventricle and midline shift towards the side of the shunt. These findings were interpreted as over-drainage of the cyst-peritoneal shunt.

RESULT

A Codman Medos adjustable valve was inserted, with the intention of gradually increasing the pressure until the midline shift was restored and the contra-lateral ventricle was reconstituted. This was achieved with the valve set at 90 mm H(2)O, verified by CT scan. Radiological improvement was associated with dramatic symptomatic improvement.

CONCLUSION

Over-drainage of cyst-peritoneal shunts is often not appreciated, especially when the main manifestation is headaches. As it is difficult to predict the required valve pressure setting, it may be advisable to consider the use of an adjustable valve.

Petrous apex arachnoid cyst: a case report and review of the literature

Cholesterol granuloma and cholesteatoma are the two most common destructive lesions of the petrous apex. Arachnoid cyst is much less common. These three expansile lesions are often indistinguishable on clinical grounds. Accurate pre-operative radiological diagnosis on computed tomography scan and magnetic resonance imaging is important in order to plan the appropriate treatment. Pre-operative radiological differential diagnosis between primary cholesteatoma of petrous apex and a intrapetrous arachnoid cyst remains a significant problem. The following aspects need evaluation for recognition of intrapetrous arachnoid cysts: 1) an awareness of their existence, 2) homogeneous signal on T1 and T2 weighted images, closely resembling cerebro-spinal fluid signal, 3) special heavily weighted T2 images on magnetic resonance imaging: fluid-attenuated inversion recovery imaging, 4) careful correlation of clinical-radiological data. Symptomatic arachnoid cysts are best treated with conservative drainage surgery through middle cranial fossa. A case of a petrous apex arachnoid cyst is reported which has been radiologically mistaken for a primary cholesteatoma and operated through an infratemporal fossa approach type B. The patient (40-year-old female) came to our attention with right trigeminal pain which had been present for one year and dizziness. Neurotologist and skull-base surgeons should include arachnoid cyst as a rare possibility in the evaluation and treatment of petrous apex cystic lesions.

Incidental findings in brain computed tomography scans of 3000 head trauma patients

BACKGROUND

Limited reports exist about intracranial incidental findings on computed tomography (CT) imaging. We studied the frequency of incidental findings on 3000 brain CT scans of trauma patients.

METHODS

Three thousands standard brain CT scans of trauma patients were evaluated for some incidental findings. Cisterna magna was evaluated in 1500 CT scans.

RESULTS

In this study we found 30 incidental abnormalities that include 8 cases of tumor: 3 meningioma, 2 craniopharyngioma, 1 oligodendroglioma, 1 low-grade astrocytoma, and 1 medulloblastoma. Suspect osteoma was found in 3 cases. In 3 cases, abnormal calcification was found in pineal region, basal ganglia, and temporal horn area. Three suspect lipomas were found in midline and near midline of the brain. Arachnoid cyst was found in 7 cases and hydrocephaly in 3 cases. Large cisterna magna (>10 cm(3)) was found in 11 cases.

CONCLUSION

Cisterna magna enlargement was the most common incidental finding and brain tumor and arachnoid cyst were next in frequency.

Multiple extradural arachnoid cysts at the spinal cord and cauda equina levels in the young

STUDY DESIGN

A case report of multiple extradural arachnoid cysts at the spinal cord and cauda equina levels in the young.

OBJECTIVE

To report an exceedingly rare case of multiple extradural arachnoid cysts at the spinal cord and cauda equina levels in the young.

SETTING

Department of Orthopaedic Surgery, Tokai, Japan.

CASE REPORT

An 11-year-old boy was diagnosed with multiple extradural arachnoid cysts at the spinal cord and cauda equina levels extending from the T5 to L5 vertebrae and surgery was performed. At 2 years after surgery, no recurrence was observed and muscle weakness of the lower extremities and sensory disturbance improved.

CONCLUSION

Excision of only the arachnoid cysts at the spinal cord level led to a favorable outcome.

Rapid expansion of a ventral arachnoid cyst after syringo-subarachnoid shunting in the thoracic spinal cord: case report

BACKGROUND

Intradural spinal arachnoid cysts have rarely been reported in association with intramedullary cysts. These associated lesions most commonly occur in the thoracic spine.

CASE DESCRIPTION

We reported an unusual balance of cerebrospinal fluid dynamics between an initially occult arachnoid cyst and syringomyelia. The arachnoid cyst was not allowed to express itself until the syrinx was decompressed with a syringo-subarachnoid shunt.

CONCLUSION

Only one other report in the literature described a similar case; however, our case is the first to be confirmed by intraoperative ultrasound.

[Arachnoid cysts of the middle cranial fossa presented as subdural hematomas]

The aim of the study was to present the authors' own experience and discuss the treatment method of arachnoid cysts of the middle cranial fossa disclosed as subdural hematoma. Three cases of male patients operated on because of chronic subdural hematoma are presented. Control CT studies after evacuation of hematomas revealed arachnoid cysts of the middle cranial fossa and all patients were qualified for delayed cystocisternostomy by open craniotomy. Indirect signs of presence of arachnoid cysts in the form of bony abnormalities and expanded the middle cranial fossa in the first CT were seen in all patients. Cysts were asymptomatic until the injury in all cases. The volumes of cysts in MRI scans were: 17.8 ml, 52.9 ml and 92.4 ml, respectively. All cysts were type II according to Galassi classification. After control MRI described above made to evaluate cyst appearance, delayed cystocisternostomy to basal cisterns was undertaken in two cases with full success. No complications were observed. The third patient refused surgery. During surgery the thick and non-transparent medial cyst wall and arachnoidea of tentorial notch cisterns were observed impeding the exact identification of neurovascular structures. In our opinion arachnoid cysts of the middle cranial fossa revealed as subdural hematoma should be operated on in two stages: in the first step subdural hematoma should be evacuated and in the second step cystocisternostomy should be performed. With regard to observed morphological changes of arachnoidea and cyst walls we think that open cystocisternostomy is treatment of choice in these cases.

Spinal intradural juxtamedullary cysts in the adult: surgical management and outcome

OBJECTIVE

Intradural nonneoplastic cysts compressing the spinal cord are rare lesions. We retrospectively analyzed a series of patients harboring this entity with regard to clinical and radiological features, surgical management, and follow-up results.

METHODS

In a retrospective study, we reviewed the medical charts, radiological investigations, and follow-up data of 11 women and 10 men (mean age, 43.6 yr) with intradural juxtamedullary spinal cysts, which were consecutively treated microsurgically at our institutions between January 1995 and January 2003. All lesions were approached via a laminectomy, hemilaminectomy, or laminoplasty at the corresponding vertebral levels and histopathologically verified. The patients were routinely scheduled for clinical follow-up 2 and 6 months after surgery. Baseline postoperative magnetic resonance imaging (MRI) was ordered 6 months after surgery. Thereafter, follow-up was performed at 1-year intervals, with neurological examination and MRI.

RESULTS

According to presenting symptomatology, two main patient groups could be differentiated: one group with a myelopathic syndrome (10 patients) and another group with a predominant radicular pain syndrome (8 patients). Histopathological examination revealed 16 arachnoid cysts, 4 neuroepithelial cysts, and 1 cervical nerve root cyst. Most arachnoid cysts (12 cases) were located on the dorsal aspect of the thoracic spinal cord. The mean craniocaudal extension of these cysts was 3.7 vertebral levels, and complete resection was performed. In four patients, the arachnoid cyst was situated ventral to the spinal cord and involved up to 17 vertebral levels. These patients had a history of major spinal trauma, and the cyst was generously fenestrated at its greatest circumference as depicted on preoperative MRI scans. The four neuroepithelial cysts and the cervical nerve root cyst were located on the ventral or ventrolateral aspect of the spinal cord, and their maximum sagittal extension was two spinal vertebral levels. Symptoms in all but two patients demonstrated major improvement; in particular, radiating pain disappeared immediately after surgery. There was no cyst recurrence on MRI after a mean follow-up period of 3.2 years.

CONCLUSION

Intradural cysts should be considered in the differential diagnosis of lesions causing myelopathy and/or a radicular pain syndrome. Microsurgical resection or generous fenestration in cysts with large craniocaudal extensions effectively ameliorated patients' symptomatology. A description of the first documented case of a surgically treated intradural cervical nerve root cyst is provided.

Tuberculous radiculomyelitis (arachnoiditis) associated with tuberculous meningitis

Abstract. A 17-year-old man who presented with progressive quadriparesis is reported. About 8 months prior to admission, he had miliary tuberculosis, and that improved with anti-tuberculous therapy. He had also developed tuberculous meningitis and tuberculous myelitis, respectively. He regularly took anti-tuberculous drugs until this illness. Neurological findings were compatible with cervical cord lesion. CSF analysis indicated a predominate lymphocytic pleocytosis with a high protein level and low sugar profile. MRI findings revealed a multi-loculated arachnoid cyst at C1-C3 level with pressure affecting the adjacent spinal cord and evidence of myelitis at C3-T1 level. Hemi-larminectomy and removal of the arachnoid cyst were performed, but without improvement. A CSF culture yielded M. tuberculosis, that was susceptible to anti-tuberculous drugs.

Arachnoid cysts cause cognitive deficits that improve after surgery

The authors investigated cognition in patients with arachnoid cysts by assessing 55 patients and 32 control subjects on four different cognitive tests preoperatively and 3 months postoperatively. The patients improved their performance from preoperative to postoperative testing, whereas the control subjects did not show a similar improvement.

Congenital cervical teratoma, associated with agenesis ofcorpus callosum and a subarachnoid cyst

Cervical teratoma is a neoplasm composed of embryonic tissues with representation of all three germ layers. We report an extremely rare case of fetal cervical teratoma presenting at 24 weeks of gestation. A submaxillary mass and agenesis of corpus callosum were identified on ultrasonography, associated with agenesis of corpus callosum and a subarachnoid cyst.

Arachnoid cyst presenting as subdural hygroma

Arachnoid cysts are developmental lesions which are usually asymptomatic or may present with a variety of clinical features. Subdural hygroma is an extremely unusual complication associated with arachnoid cysts. A case of subdural hygroma that developed after the rupture of an asymptomatic middle cranial fossa cyst, following minor head injury is reported.

[Pneumosinus dilatans]

Pneumosinus dilatans is a localized abnormal dilatation of paranasal sinuses which contains only air and is covered with normal epithelium. We presented the X-ray, CT and MRI findings of three cases with pneumosinus dilatans secondary to arachnoid cyst and meningioma. When evaluating the patients with long-lasting symptoms, pneumosinus dilatans should be considered.

Magnetic resonance imaging and proton magnetic resonance spectroscopy of intracranial epidermoid tumors

Intracranial epidermoid tumors or cysts are considered benign lesions. Differentiation of epidermoid tumors from arachnoid cysts is important for appropriate patient care because the treatment is different for each lesion. Arachnoid cysts can appear very similar to epidermoid tumors on computed tomography (CT). Epidermoid tumors can grow in the cerebellopontine angle (CPA) cistern, the most common location of these lesions, resulting in trigeminal neuralgia and facial paralysis. Treatment for epidermoid tumors is exclusively surgery. Arachnoid cyst, on the other hand, is a benign condition that rarely produces symptoms. Recent advances in magnetic resonance imaging (MRI) have allowed more accurate imaging diagnosis of epidermoid tumors. This article reviews the recent advances in MRI using conventional T1W, post-contrast T1W, T2W, steady-state free precession imaging, fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and proton magnetic resonance spectroscopy (MRS) in the imaging diagnosis of epidermoid tumors.