Arachnoid cysts of the left temporal fossa: impaired preoperative cognition and postoperative improvement

Cognition in children with arachnoid cysts - A five-year follow-up after microneurosurgical fenestration

BACKGROUND AND PURPOSE

In recent years there has been a re-evaluation regarding the clinical implications of temporal lobe arachnoid cysts (temporal arachnoid cysts) in children. These cysts have often been considered asymptomatic, or if symptomatic, only causing focal neurological symptoms or signs of increased intracranial pressure. However, several studies have more recently reported on cognitive symptoms improving after surgery. This study aimed to evaluate if reported cognitive improvement after surgery of temporal arachnoid cysts were stable after five years.

METHOD

Ten consecutive children (m = 14.65; range 12.1-19.415 were assessed cognitively five years after micro-neurosurgical fenestration of a temporal arachnoid cyst. Results were compared to results from their pre- and post-surgical evaluations. Evaluations included the Wechsler-scales, Boston Naming Test (BNT), Rey Auditory Verbal Learning Test (RAVLT), verbal fluency test (FAS) and Rey Complex Figure Test (RCFT).

RESULTS

The analysis revealed significant postsurgical improvement compared to baseline on the Wechsler-scales measures of general intelligence (FSIQ), verbal abilities (VCI) and processing speed (PSI). Mean differences after surgery were 8.3 for FSIQ, (p = 0.026), 8.5 for VI (p =  < .01) and 9.9 for PSI (p = 0.03). There were no significant differences in mean test results when comparing postsurgical scores with scores five years after surgery, indicating long-term stability of improvements.

CONCLUSION

The results indicate that affected cognitive functions in children with temporal arachnoid cysts improve after surgery and that the improvements remain stable five years later. The improvements and long term stability were also consistent with the experience of both parents and children. The findings provide a strong argument for neurosurgical fenestration of temporal arachnoid cysts in children.

Co-morbid psychiatric disorders in children with arachnoid cyst

Arachnoid Cysts (AC) are benign lesions containing cerebrospinal fluid, and although most of them are asymptomatic, they can cause neurological symptoms like headaches, seizures, and neuropsychiatric problems. The aim of this study was to asses and document co-morbid psychiatric disorders in children with AC aged between 6 and 17. Wechsler Abbreviated Scale of Intelligence-Second Edition (WASI-II), a clinical measure used to assess the intelligence quotient (IQ) scores of the patients, Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL; semi-structured interview) was used to assess psychiatric disorders among the patients. A total of 12 patients with AC was evaluated with an even distribution of males and females. Half of the patients had a normal IQ score with a mean IQ score of 104.5. Among patients with normal IQ scores, one patient had epilepsy and attention deficit hyperactivity disorder and two patients had epilepsy without any psychiatric disorder. The remaining six patients had moderate intellectual disability with a mean IQ of 48.2. Among them, three out of six had epilepsy and four had accompanying psychiatric disorders. It is therefore apparent that patients with AC have a high rate of co-morbid psychiatric disorders. Our study demonstrates that intellectual disability and psychiatric disorders should be evaluated in children with AC in the clinical settings.

Intracranial arachnoid cysts: What is the appropriate surgical technique? A retrospective comparative study with 61 pediatric patients

Objective

Symptomatic intracranial arachnoid cysts (ACs) should be treated either through microsurgical (MS) or endoscopic surgical (ES) fenestration. Implantation of cysto-peritoneal shunt (CPS) system is another treatment option with decreasing indication. In our study, we compared the complication and revision rates between the three operative techniques in pediatric patients.

Methods

We included patients below 18 years with symptomatic intracranial ACs operated between 2004 and 2021. Initial symptoms, location, complication rate, clinical and radiological improvement, postoperative events and revision rate were compared retrospectively.

Results

Sixty-one patients; 33 (54.1%) MS operated (mean age 7.6 years), 18 (29.5%) ES operated (mean age 6.2 years) and 10 (16.4%) with CPS (mean age 3.0 years) were collected. The most common initial symptom was headache in 45.9%. 20 (32.8%) postoperative events were documented. The highest revision rate (60%) was seen in the CPS group compared to 33.3% in MS group and 16.7% in ES group. 31 patients harbored perisylvian ACs, 89% remained event-free after ES, 71% after MS and 20% after CPS. Clinical improvement immediately after surgery was observed in 58 patients (96.9% in MS, 88.9% in ES and 100% in CPS). A radiological volume reduction could be proven postoperative in 51 patients (78.8% MS, 88.9% ES and 90% CPS).

Conclusion

Endoscopic fenestration of AC is a safe and efficient technique which is being widely used nowadays with the highest event free survival compared to microsurgical fenestration especially in perisylvian arachnoid cysts. CPS shows on long terms the highest revision rate but carries the least surgical risks.

Understanding intracranial arachnoid cysts: a review of etiology, pathogenesis, and epidemiology

Arachnoid cysts (AC) are one of the common pathologies encountered in pediatric neurosurgical settings. It comes to clinical attention more often incidentally but also more often than previously due to the wide availability of diagnostic imaging. However, the accurate incidence and prevalence remain unknown. There is an ongoing debate on symptomatology, indications of treatment, and best treatment modalities. In this review, we aimed to discuss the current general knowledge about the arachnoid cyst, focusing on the etiology, pathogenesis, and epidemiology. Specific findings related to locations, such as the Sylvian fissure, are also emphasized.

Temporosylvian arachnoid cysts in children. Part 2: Postoperative neuropsychological and clinical improvement

OBJECTIVE

The authors' objective was to study clinical, imaging, and neuropsychological changes in children who underwent surgery for a temporal arachnoid cyst (TAC).

METHODS

Thirty-four children were prospectively assessed similarly at diagnosis and postoperatively (mean 14 months) with clinic visits, images, cognitive tests, and parental questionnaires on mood/behavior and executive functions. The scores were compared pre- and postoperatively for the entire cohort and individually. The scores of 25 children were also compared with a control group of 23 healthy age-matched children. Parents were administered an outcome questionnaire on average 4 years postoperatively.

RESULTS

The 34 children selected for surgery had signs of raised intracranial pressure (74%) and/or selective neuropsychological disorders presumably linked to cyst location (learning difficulties in 65%, cognitive difficulties in 56%, and mood/behavior difficulties in 47%). The majority of patients had a convex cyst (85%) and underwent microsurgical fenestration (85%). The TAC volume decreased ≥ 50% for 59% of children. On the Wechsler Intelligence Scale, the entire cohort significantly improved on Full Scale IQ and verbal and perceptual nonverbal indexes. Individually, nearly half of the children (47%) highly increased their scores (≥ 15 points) on at least one IQ index and 26% on at least two indexes. Language, working memory, episodic memory, and executive functions were also significantly improved. Improvements were more pronounced in patients with a preoperative heterogeneous profile with isolated lower scores and a left-sided cyst. Parental questionnaires showed reduction in anxiety, aggressiveness, social problems, and daily life executive disorders. Preschool-aged children improved significantly in language and verbal IQ, as did middle/high school-aged children in many domains. Individual analyses revealed improvement in 76% of cases. Cognitive scores were lower for patients preoperatively than for controls and were no longer significantly different postoperatively in verbal fluency, visual memory, and working memory. Four years later, 97% of parents described an improvement in their child, correlated with cognitive improvements.

CONCLUSIONS

Among children with a TAC, some have no clinical signs or neuropsychological difficulties, and others may show signs of raised intracranial pressure and/or specific neuropsychological disorders that impact daily life and require significant and long-lasting rehabilitation. In these cases, consideration may be given to surgical decompression. It is interesting to note that 76% of this surgically treated cohort improved regardless of the child's age, particularly in patients with selective disorders and an impact on daily life. However, a larger number of children will need to be investigated before the true benefit of such treatment can be known.

Temporosylvian arachnoid cysts in children. Part 1: Cognitive profile of children with a temporal cyst and impact of the cyst in daily life. A prospective study in 100 consecutive children

OBJECTIVE

The aim of this study was to determine the cognitive profile of children with a temporal arachnoid cyst (TAC) and its impact on daily life.

METHODS

The authors prospectively analyzed the cognitive and psychological profiles of 100 consecutive children relative to age and cyst characteristics (side, cyst size, and cyst shape: convex or nonconvex) and their outcome 4 years later.

RESULTS

Mean IQs were normal but with high heterogeneity on Full Scale IQ (FSIQ; range 59-150); 29% of children had at least one Wechsler index below the norm, in particular, Processing Speed and Working Memory Indexes. Impairments were observed in language for 31% of children, as well as in verbal memory (28%), visual memory (23%), executive function (21%), and visual attention (24%). Half of the children (50%) needed rehabilitation for learning difficulties, and 26% had academic difficulties. The parental questionnaire BRIEF (Behavior Rating Inventory of Executive Function) revealed significant executive dysfunctions in daily life for 22% of the children. One-third of the patients (34%) required psychotherapy for anxiety or social disorders, with higher rates in patients with a right-sided cyst and older children. Cyst size had very little neuropsychological impact. Convex cysts were significantly associated with worse performance than nonconvex cysts on all Wechsler indexes and FSIQ, and in language, verbal memory, attention, and visuospatial skills. Children with a convex cyst had significantly more executive and behavior difficulties in daily life and more psychotherapy than other children. The effect of cyst shape was independent of Galassi type and cyst side. Children with a ruptured cyst or an incidentally discovered cyst usually had a good cognitive level. Four years later, children without initial disorders remained stable, whereas those with difficulties who did not undergo surgery needed more rehabilitation and school adaptations.

CONCLUSIONS

This large cohort study revealed a varied profile of children with a TAC: at initial assessment, 50% had neuropsychological difficulties and needed rehabilitation and/or psychotherapy for learning or behavior difficulties, and 50% had no difficulties, which may explain the debate about this pathology. Patients with neuropsychological difficulties had a heterogeneous profile with normal intelligence but selective cognitive and/or behavior disorders that may have a long-term impact on their quality of life, particularly those with a right-sided cyst. A neuropsychological evaluation is not always necessary for a cyst discovered incidentally, but early evaluation is essential in patients with academic, learning, or psychological disorders. When assessment shows selective disorders presumably linked to cyst location, surgery may be considered, particularly for convex cysts, as this study revealed more effects in association with cyst shape than with cyst size and significantly poorer performance with a convex cyst.

Reversal of cognitive, behavioral, and language impairments after the left frontal arachnoid cyst fenestration in a pediatric patient

Background:

Arachnoid cysts (ACs) are cerebrospinal fluid-containing cysts located between the surface of the brain or spinal cord and arachnoid layer of the leptomeninges. ACs have been known to cause cognitive, language, and behavioral deficits and currently there is no standard treatment paradigm. Surgical indications include papilledema, increasing growth with mass effect causing neurological deficit, or rapid head growth, however, cognitive symptoms related to mass effect may not always be considered.

Case Description:

We present a 3-year-old male with an AC of the left anterior fossa causing frontal lobe compression with resultant behavioral, language, and cognitive deficits.

Conclusion:

Surgical intervention for AC decompression may be indicated when there are cognitive, behavioral, or language delays related to the mass effect and location of the AC. Neuropsychiatric testing or more advanced imaging studies may further support surgical treatment. After craniotomy for fenestration of the left frontal AC, there was drastic improvement in cognitive, language, and behavioral symptoms in our pediatric patient.

COGNITIVE AND PSYCHOTIC SYMPTOMS IN A PATIENT WITH INFRATENTORIAL ARACHNOID CYST: CASE REPORT

We present a case of a patient with treatment resistant hallucinatory experiences with incidental finding of an arachnoid cyst localized in the posterior infratentorial cranial fossa dorsally to the cerebellum. Psychological testing revealed significant deficit of cognitive functions to the level of mild intellectual disability in a person that had previously finished high school with good grades. A combination of clozapine and lamotrigine led to significant improvement in mood and reduction of hallucinations, but without improvement in cognitive functions. We also performed a literature review of previously published case reports or case series of co-occurring posterior fossa arachnoid cyst and schizophrenia or psychosis or psychiatric symptoms using PubMed search and discuss some controversies considering their treatment outcome.

Epilepsy and cognitive deterioration as postoperative complications of the arachnoid cyst fenestration. Case report

OBJECTIVE

With the aim of contributing to the discussion on treatment of patients with arachnoid cysts (AC) and their neuropsychological functioning, we present the case of a patient who has undergone surgery of AC located in the left Sylvian fissure. Case description: The patient had no cognitive deficits and no seizures before the cyst's fenestration. After the procedure, however, occurrences of seizures have been observed. Along with the concomitant epileptic seizures, aphasia and serious memory problems also developed. The initial pharmacological treatment of the seizures brought about unsatisfactory results. The treatment was therefore modified a number of times and ultimately, seizures were brought under control to some extent. Despite the varied efforts at neuropsychological rehabilitation, cognitive impairment was still persistent up to a year after the surgery. Conclusions: 1) While referring patients with AC for surgery, one should always consider both the positive outcomes and the unintended and deleterious consequences. A cyst fenestration could in some cases lead to epilepsy and cause neuropsychological symptoms such as anomic aphasia and cognitive deterioration with memory function impairment. 2) Neurological patients, especially the ones qualified for surgery, should always undergo neuropsychological examination. The lack of data from presurgical neuropsychological examination may impact further treatment of neurosurgical patients.

Neurodevelopmental and Psychiatric Symptoms in Patients with a Cyst Compressing the Cerebellum: an Ongoing Enigma

A patient diagnosed with developmental delay, intellectual disability, and autistic and obsessive-compulsive symptoms was found to have a posterior fossa arachnoid cyst (PFAC) compressing the cerebellum. The patient was referred to our Ataxia Unit for consideration of surgical drainage of the cyst to improve his clinical constellation. This scenario led to an in-depth analysis including a literature review, functional resting-state MRI analysis of our patient compared to a group of controls, and genetic testing. While it is reasonable to consider that there may be a causal relationship between PFAC and neurodevelopmental or psychiatric symptoms in some patients, there is also a nontrivial prevalence of PFAC in the asymptomatic population and a significant possibility that many PFAC are incidental findings in the context of primary cognitive or psychiatric symptoms. Our functional MRI analysis is the first to examine brain function, and to report cerebellar dysfunction, in a patient presenting with cognitive/psychiatric symptoms found to have a structural abnormality compressing the cerebellum. These neuroimaging findings are inherently limited due to their correlational nature but provide unprecedented evidence suggesting that cerebellar compression may be associated with cerebellar dysfunction. Exome gene sequencing revealed additional etiological possibilities, highlighting the complexity of this field of cerebellar clinical and scientific practice. Our findings and discussion may guide future investigations addressing an important knowledge gap-namely, is there a link between cerebellar compression (including arachnoid cysts and possibly other forms of cerebellar compression such as Chiari malformation), cerebellar dysfunction (including fMRI abnormalities reported here), and neuropsychiatric symptoms?

Cognitive dysfunction and subjective symptoms in patients with arachnoid cyst before and after surgery

INTRODUCTION

Arachnoid cysts are congenital, benign lesions in the brain and are often incidental radiological findings. Frequently, the arachnoid cysts are left untreated; however, recent studies have shown that arachnoid cysts can cause cognitive dysfunction that affect quality of life. Moreover, the function can improve after surgical decompression. Hence, there is controversy regarding symptomatology and treatment effects of arachnoid cysts. The aim of the study was to analyse if arachnoid cysts can cause cognitive impairment and subjective symptoms and if these impairments are reversible after surgical treatment.

MATERIAL AND METHODS

Twenty-one consecutive patients with radiologically confirmed supratentorial arachnoid cysts were cognitively evaluated using a battery of seven neuropsychological tests. Twelve of these patients underwent surgery and were evaluated before and after surgery. The patients were also evaluated with neuropsychological testing after surgery. Further information was extracted from the medical records. The cognitive test results were compared to standard population values using z-test, and the test results from the surgically treated patients were compared before and after surgery using paired t-test.

RESULTS

The surgically treated patients had a statistically significant improvement of neurocognitive test results after surgery in six out of the seven tests (p < 0.05). The total patient group showed lower mean values in all tests when compared to standard population. Statistical significance was, however, only detected in two of the seven tests. All surgically treated patients reported diminished symptoms after surgery.

CONCLUSIONS

The patients with arachnoid cysts presented with cognitive dysfunction compared to the normal population which improved after surgical decompression. Arachnoid cysts should not be considered asymptomatic unless thoroughly evaluated with clinical and neuropsychological work-up.

Surgical decompression of arachnoid cysts leads to improved quality of life: a prospective study-long-term follow-up

BACKGROUND

In a previous study, we reported a short-term (6 months) postoperative improvement of health-related quality of life (Qol) in patients operated for an arachnoid cyst (AC). The aim was to investigate whether this initial improvement was permanent.

METHODS

A long-term (5 ± 2 years) prospective study comparing Qol and complaints before and 5 ± 2 years after surgical fenestration for AC in 76 adult patients, using the Short Form 36 (SF-36) scores, Glasgow Benefit Inventory (GBI) questionnaires, and Visual Analogue Scales (VAS) for headache and dizziness, similarly to what they did at short-term follow-up.

RESULTS

At short-term and long-term follow-ups, 73.4% and 82%, respectively, of the patients were better from their headache compared with preoperative scores. The corresponding improvement rates for dizziness were 61.7% (short-term) and 67.9 (long-term). Preoperatively, the mean headache VAS score was 45.6; at short-term follow-up, this was reduced to 25.7, and at long-term follow-up, this further reduced to 24.8. The preoperative mean VAS score for dizziness (35.2) was reduced to 12.2 (short-term) and 13.9 (long-term). The significant postoperative improvement of patient-reported Qol at short-term follow-up remained at long-term follow-up across seven out of eight SF-36 dimensions and three out of four GBI subscale scores. Similar to at short-term follow-up, the Qol improvement is correlated to improvement in headache and/or dizziness.

CONCLUSIONS

The previously reported postoperative, short-term improvement in Qol and complaints appears stable, as the improvement remains at long-term follow-up. This suggests that the beneficial effects of surgical treatment are long-lasting.

Case report: a giant arachnoid cyst masking Alzheimer's disease

BACKGROUND

Intracranial arachnoid cysts are usually benign congenital findings of neuroimaging modalities, sometimes however, leading to focal neurological and psychiatric comorbidities. Whether primarily clinically silent cysts may become causally involved in cognitive decline in old age is neither well examined nor understood.

CASE PRESENTATION

A 66-year old caucasian man presenting with a giant left-hemispheric frontotemporal cyst without progression of size, presented with slowly progressive cognitive decline. Neuropsychological assessment revealed an amnestic mild cognitive impairment (MCI) without further neurological or psychiatric symptoms. The patient showed mild medio-temporal lobe atrophy on structural MRI. Diffusion tensor and functional magnetic resonance imaging depicted a rather sustained function of the strongly suppressed left hemisphere. Amyloid-PET imaging was positive for increased amyloid burden and he was homozygous for the APOEε3-gene. A diagnosis of MCI due to Alzheimer's disease was given and a co-morbidity with a silent arachnoid cyst was assumed. To investigate, if a potentially reduced CSF flow due to the giant arachnoid cyst contributed to the early manifestation of AD, we reviewed 15 case series of subjects with frontotemporal arachnoid cysts and cognitive decline. However, no increased manifestation of neurodegenerative disorders was reported.

CONCLUSIONS

With this case report, we illustrate the necessity of a systematic work-up for neurodegenerative disorders in patients with arachnoid cysts and emerging cognitive decline. We finally propose a modus operandi for the stratification and management of patients with arachnoid cysts potentially susceptive for cognitive dysfunction.

Anxiety and Depression in Patients with Intracranial Arachnoid Cysts-A Prospective Study

BACKGROUND

Arachnoid cysts yield cognitive deficits that are normalized after surgical cyst decompression.

OBJECTIVE

The present study aimed to investigate whether arachnoid cysts also affect symptoms of anxiety and depression, and if surgical cyst decompression leads to reduction of these symptoms.

METHODS

Twenty-two adult patients (13 men and 9 women) with symptomatic temporal or frontal cysts were included in this questionnaire (Hospital Anxiety and Depression Scale [HADS])-based prospective study. The mean time between answering the preoperative questionnaire and surgery was 37 days. The patients answered the same HADS questionnaire 3-6 months postoperatively.

RESULTS

Preoperatively, both patients with frontal (N = 4) and patients with temporal (N = 18) cyst had higher mean HADS anxiety scores than those found in the general population. For patients with temporal cyst, there was a significant or near-significant difference in anxiety and depression scores and the combined scores between those with right-sided cysts and those with left-sided cysts. Postoperatively, the HADS scores normalized and were no longer different from those of the general population. The difference in scores between patients with right and left temporal cyst also disappeared.

CONCLUSIONS

Patients with arachnoid cyst have higher levels of anxiety and depression than do the general population and these scores were normalized after decompressive cyst surgery. We further found a hemispheric asymmetry: patients with a right temporal cyst showed higher anxiety, depression, and combined scores than did patients with a left temporal cyst. Also, this disparity normalized after cyst decompression. Thus, arachnoid cysts seem to affect not only cognition but also the level of affective symptoms.

When the brain looks imperfect: An example of neuroplasticity as seen in a patient with arachnoid cysts - a case study

Objective: This study presents a case of a teenager (J.J.) prenatally diagnosed with large arachnoid cysts which did not allow parts of his brain to develop correctly. It aims to establish whether the congenital malformation affected the boy's cognitive development.Method: In order to assess his cognitive development, the authors analyzed J.J.'s medical history, interviewed him and his parents and conducted neuropsychological examination.Results: Despite major parts of his brain undeveloped, the boy achieved average to outstanding scores in all tests.Conclusions: The scores achieved by J.J. suggest that normal development of cognitive abilities is possible even for a person whose central nervous system differs structurally from what is expected in a healthy subject.

Psychopathological Influence of Middle Fossa Arachnoid Cysts in Young Men: Analysis of Korean Conscription Data

BACKGROUND

A few reported studies have documented psychotic syndromes secondary to a middle fossa arachnoid cyst (AC). However, the association between middle fossa ACs and psychopathological symptoms remains to be determined. The present study investigated the psychopathological effects of middle fossa ACs in young men.

METHODS

We reviewed military personal inventory test profiles and baseline demographic data of 19-year-old conscription examinees from February 2013 to December 2016. In total, 132 examinees with middle fossa ACs and 350 examinees with normal findings were enrolled in the present study. Two separate comparisons were performed. First, we compared the middle fossa AC group with the control group. Second, the middle fossa AC group was divided into 2 groups according to cyst size and compared with the control group.

RESULTS

Faking bad response behavior, infrequency, inconsistency, depression, schizophrenia, paranoia, and personality disorder cluster A scales were significantly associated with the presence of a middle fossa AC. Abnormal responses to the military personal inventory were significantly and positively correlated with cyst size. The prediction rate to show abnormal psychological results with the presence of an AC was estimated to be 60.7%-68.8%.

CONCLUSIONS

The presence of ACs and cyst size were associated with psychopathology in this select group of young men. The size-dependent psychopathological effects of ACs appear to result from a local mass effect on the brain.

Neurocognitive profile in children with arachnoid cysts before and after surgical intervention

OBJECTIVES

Treatment indications for arachnoid cysts are not clear. Some surgeons take improvement in neurocognitive function into account as a surgical indication for arachnoid cysts. However, only a few studies have evaluated the relationship between arachnoid cysts and neurocognitive function. Furthermore, studies that analyze neurocognitive function as an effect of arachnoid cyst surgery are even rarer. The purpose of this study was to analyze the neurocognitive function scores of children with arachnoid cysts before and after surgery and to examine whether surgical treatment led to improved neurocognitive function.

METHODS

From June 2009 to August 2012, data for 24 children diagnosed with arachnoid cysts who underwent surgery at Seoul National University Children's Hospital were analyzed. Pre-operative and post-operative cyst volume was assessed and neurocognitive function was tested using the Korean version of the Wechsler Intelligence Scale for Children-Revised (WISC-R) and the Bender-Gestalt Test (BGT). Comparison of pre- and post-operative profiles by laterality of the arachnoid cyst was performed.

RESULTS

Patients had age-appropriate full-scale intelligent quotients (FSIQ), verbal IQ (VIQ), and performance IQ (PIQ) pre-operatively, which were maintained after surgery. Of the subtests, Block Design showed significant improvement post-operatively (p = 0.021). This means that visuo-spatial integration and mental construction abilities were improved after surgery. Patients with left or right arachnoid cysts did not show statistically significant changes in FSIQ, VIQ, or PIQ after surgery (110.21 versus 113.95, p = 0.307; 108.92 versus 111.54, p = 0.368; 107.88 versus 111.04, p = 0.152, respectively). Subanalysis showed that the pre- and post-operation VIQ mean scores of the patients with right arachnoid cysts were significantly higher (p < 0.054) than those of the patients with left arachnoid cysts, and there was no significant change after the surgery.

INTERPRETATION

There was no significant association among cyst volume reduction, laterality, and clinical neurocognitive function improvement. The present findings indicate a limited role for surgical intervention in improving the intellectual abilities of children with arachnoid cysts.

Nerve-Sheath-Risen Neuroglial Cyst: A Case Report and Review of the Literature

BACKGROUND

Neuroglial cysts are rare intracranial lesions that are believed to originate from the sequestration of neural tube lining during embryogenesis. They can present anywhere within the neuraxis; however, their most common location is the frontal lobe. Cerebellopontine angle (CPA) neuroglial cysts are extremely rare and to the best of authors' knowledge, there are no previous reports of a neuroglial cyst arising from cranial nerves.

CASE DESCRIPTION

The current study presented a male adolescent with the reoccurrence of an intracranial cyst with symptoms of diplopia and facial numbness primarily treated as CPA arachnoid cyst with fenestration of the cyst 12 months prior to admission to our center. Different magnetic resonance imaging (MRI) sequences showed a thin-walled extra-axial cyst at the right CPA without gadolinium (Gd)-enhancement. Direct visualization of the lesion revealed a cyst arising from the 5th cranial nerve sheath compressing the surrounding structures. The cyst was fenestrated and a biopsy was taken from the cyst wall. The pathological analysis along with specified histological markers indicated the neuroglial nature of the cyst.

CONCLUSION

The rising of a neuroglial cyst from the nerve sheath is a finding that brings other possible origins of neuroglial cysts into consideration.

Neurodevelopmental outcomes in children with large temporal arachnoid cysts

OBJECTIVE Management of children with large temporal arachnoid cysts (TACs) remains controversial, with limited data available on their neurodevelopmental outcome. The aim of this study was to examine neurodevelopmental outcomes in children with large TACs. METHODS In this medical center-based cohort study, 25 patients (19 males) who were diagnosed in childhood with large TACs (9 patients [36%] with a Galassi type II and 16 patients [64%] with a Galassi type III TAC) were examined. The mean ± SD age at assessment was 11.1 ± 5.6 years (range 2.7-22 years). Twelve patients (48%) had right-sided, 12 (48%) had left-sided, and 1 (4%) had bilateral cysts. Nine patients (36%) underwent surgery for the cyst. The siblings of 21 patients (84%) served as control participants. Neurodevelopmental function was assessed using the Adaptive Behavior Assessment System (ABAS), Vanderbilt Behavioral Rating Scale (VBRS), and Developmental Coordination Disorder Questionnaire (DCDQ), and quality of life was measured using the treatment-oriented screening questionnaire (TOSQ). The results of all instruments except for TOSQ were compared with those of the sibling control participants. RESULTS The mean ± SD ABAS score of the patients was 93.3 ± 20.09 compared with 98.3 ± 18.04 of the sibling control participants (p = 0.251). Regarding the incidence of poor outcome (ABAS score < 80), there was a trend for more patients with TAC to have poor outcome than the sibling controls (p = 0.058). Patients who underwent surgery scored significantly worse with regard to the VBRS total score compared with those who did not (p = 0.020), but not on ABAS, DCD, or TOSQ. The mean score of the cognitive and psychological items on TOSQ was lower than that for the physical items (p < 0.001). CONCLUSIONS Children with a large TAC performed similarly to their sibling control participants in neurodevelopmental function. However, a subgroup of those with cysts did have an increased risk for poor outcomes in general function. Neurodevelopmental assessment should be part of the management of all patients with TAC.

Improvement in cognitive function after surgery for low-grade glioma

OBJECTIVE

Cognition is a key component in health-related quality of life (HRQoL) and is currently incorporated as a major parameter of outcome assessment in patients treated for brain tumors. The effect of surgery on cognition and HRQoL remains debatable. The authors investigated the impact of resection of low-grade gliomas (LGGs) on cognition and the correlation with various histopathological markers.

METHODS

A retrospective analysis of patients with LGG who underwent craniotomy for tumor resection at a single institution between 2010 and 2014 was conducted. Of 192 who underwent resective surgery for LGG during this period, 49 had complete pre- and postoperative neurocognitive evaluations and were included in the analysis. These patients completed a full battery of neurocognitive tests (memory, language, attention and working memory, visuomotor organization, and executive functions) pre- and postoperatively. Tumor and surgical characteristics were analyzed, including volumetric measurements and histopathological markers (IDH, p53, GFAP).

RESULTS

Postoperatively, significant improvement was found in memory and executive functions. A subgroup analysis of patients with dominant-side tumors, most of whom underwent intraoperative awake mapping, revealed significant improvement in the same domains. Patients whose tumors were on the nondominant side displayed significant improvement only in memory functions. Positive staining for p53 testing was associated with improved language function and greater extent of resection in dominant-side tumors. GFAP positivity was associated with improved memory in patients whose tumors were on the nondominant side. No correlation was found between cognitive outcome and preoperative tumor volume, residual volume, extent of resection, or IDH1 status.

CONCLUSIONS

Resection of LGG significantly improves memory and executive function and thus is likely to improve functional outcome in addition to providing oncological benefit. GFAP and pP53 positivity could possibly be associated with improved cognitive outcome. These data support early, aggressive, surgical treatment of LGG.

A life in academia: My career in brief

In this article I have summarized some of the main trends and topics of my research career, spanning a time period of 50 years, from its start as a master student at the Department of Psychology, University of Uppsala, Sweden to seeing the end of a long career, now at the University of Bergen, Norway. This journey has, apart from having been a journey across various disciplines and topics in experimental psychology, psychophysiology and neuropsychology, functional neuroimaging and cognitive neuroscience, also been a social class journey for me personally. I describe my academic career from my arrival as a young student at the University of Uppsala, Sweden in the late 1960s to my graduation as PhD in 1977 at the age of 29 years, brief postdoc period at the University of Pennsylvania, USA, and finally professor at the University of Bergen, Norway. The article focuses on my view of the research and research findings during these years, including studies of hemispheric asymmetry, dyslexia and language, dichotic listening, fMRI, and during the last years, studies of auditory hallucinations in schizophrenia. I have collaborated with numerous people, both nationally and internationally over the years, far too many to mention in a space-limited overview article. I apologize for this, and wish that I had time and space to mention all the fantastic colleagues and friends that I have met during my career. This article is what I recall of dates, places, encounters, etc., and any errors and misunderstandings are entirely due to my far from perfect memory, for which I also apologize.

Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant

INTRODUCTION

Arachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.

CASE REPORT

We report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

Neuropsychological improvement after posterior fossa arachnoid cyst drainage

PURPOSE

Posterior fossa arachnoid cysts (PFAC) are mostly considered as benign lesions of the cerebellum. Although many studies have shown the major role of the cerebellum in modulating movement, language, cognition, and social interaction, there are few studies on the cognitive impact and surgical decompression of PFAC.

METHODS

We present the cases of two brothers successively diagnosed with PFAC and neuropsychological delay. After multidisciplinary discussion with the boys' parents, it was decided to drain these lesions. Clinical signs, cerebral images, and neuropsychological status were assessed on admission and then 1 and 3 years after surgery.

RESULTS

At presentation, both children had mild cerebellar signs, associated with cognitive and visual-motor impairments and academic regression. CT scans revealed retrovermian cysts, which were shunted. Post-operatively, both brothers demonstrated improved visual-motor skills and behavior. At follow-up, we observed disappearance of dysarthria and academic delay and significant improvement in cognition especially at the intelligence scale and in language. Fine motor skills had improved but remained slower than the average and writing skills appeared limited.

CONCLUSION

Except for PFAC which impair cerebrospinal fluid circulation or which are responsible for a significant mass effect, most PFAC are usually considered as "asymptomatic" and do not require surgical treatment. The two cases reported herein suggest that these lesions might be responsible for some associated but potentially reversible neuropsychological impairment. In the future, clinical assessment should include neuropsychological evaluation to help inform decision for surgical decompression in these children with PFAC.

Neurological Fallacies Leading to Malpractice: A Case Studies Approach

A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.

Neuropsychological assessment of a veteran with a large arachnoid cyst

Arachnoid cysts are benign, congenital masses that are believed to form when the arachnoid membrane splits or is duplicated and the resulting space fills with fluid. Despite their potentially alarming appearance on brain imaging, congenital cysts discovered in adulthood are usually silent and do not result in functional impairment. A left-handed male veteran with mild memory complaints was discovered to have a large (16.4 cm × 7.7 cm), left-sided arachnoid cyst. Magnetic resonance imaging (MRI) revealed significant displacement of brain structures including the hippocampus, Sylvan fissure, and splenium. Viewing brain MRI images in only 1 plane was misleading and could have erroneously resulted in assuming some structures were absent. Viewing multiple planes of section revealed significant structural displacement and provided a better 3-dimensional conceptualization of an abnormal brain. A clinical interview indicated excellent premorbid functioning, and neuropsychological test results were within the normal range with the exception of mildly impaired scores on tests reliant on processing speed and lower-than-expected visual memory scores. Results were consistent with previous research noting retained verbal abilities and low-average visual skills. Low-average and mildly impaired scores were potentially secondary to microvascular changes, slowed visual scanning, psychiatric conditions, and testing base rates.

Surgical Decompression of Arachnoid Cysts Leads to Improved Quality of Life: A Prospective Study

BACKGROUND

There is no previous prospective study on the outcome of surgical decompression of intracranial arachnoid cysts (AC).

OBJECTIVE

To investigate if surgical fenestration for AC leads to change in patients' health-related quality of life.

METHODS

Prospective study including 76 adult patients operated for AC. Patients responded to Short Form-36 and Glasgow Benefit Inventory quality of life questionnaires, and to visual analogue scales, assessing headache and dizziness pre- and postoperatively. Patient scores were compared with those of a large sample of healthy individuals.

RESULTS

Preoperatively, 84.2% of the patients experienced headache and 70.1% dizziness. Mean pre- versus postoperative Visual Analogue Scale scores for headache and dizziness dropped from 45.6 to 25.7 and from 35.2 to 12.2, respectively. Preoperative Short Form-36 scores were significantly below age norms in all subscales, but improved after surgery into normal range in 7 out of 8 subscales for middle-aged and older patients. Younger patients' scores remained lower than age norm in 6 out of 8 subscales. A significant postoperative improvement was seen in 3 out of 4 Glasgow Benefit Inventory subscales. Improvement in headache and/or dizziness, but not preoperative cyst size or reduction in cyst volume, correlated with improvement in 6 out of 8 Short Form-36 subscales and 3 out of 4 Glasgow Benefit Inventory subscales. Only 1 patient experienced a severe complication causing permanent invalidity.

CONCLUSION

Surgery for AC can be performed with a fairly low risk of complications and yields significant improvement in quality of life correlated to postoperative improvement in headache and dizziness. These findings may justify a more liberal approach to surgical treatment for AC.

Shunt placement after cyst fenestration for middle cranial fossa arachnoid cysts in children

OBJECT Some pediatric patients with middle cranial fossa arachnoid cysts present with symptoms of increased intracranial pressure (ICP) and require shunt placement after a cyst fenestration. However, factors concerning increased ICP after fenestration followed by shunt placement have not been elucidated. This study evaluated factors that are associated with shunt placement following cyst fenestration in pediatric patients with middle cranial fossa arachnoid cysts. METHODS Twenty-six pediatric patients with middle cranial fossa arachnoid cysts who were surgically treated at a single institution between 2004 and 2013 were retrospectively identified. The surgical indications for middle cranial fossa arachnoid cysts were as follows: 1) arachnoid cysts associated with symptoms such as headache and abnormally enlarging head circumference; 2) progressively expanding arachnoid cysts; and 3) large arachnoid cysts such as Galassi Type III. A cyst fenestration was performed as a first-line treatment, and shunt placement was required if symptoms associated with increased ICP were found following fenestration. The risk factors evaluated included age, sex, presenting symptoms, the presence of head enlargement, progressive cyst expansion, and subdural hematoma/hygroma. RESULTS Four patients (15.4%) required shunt placement after cyst fenestration. Younger age, abnormal head enlargement, and progressive cyst expansion before fenestration were significantly associated with the need for shunt placement following fenestration. Arachnoid cysts decreased in size in 22 patients (84.6%) after fenestration and/or shunt placement. The presence of symptoms was not associated with postoperative cyst size in this study. CONCLUSIONS In this study, younger age, abnormal head enlargement, and progressive cyst expansion were risk factors for shunt placement after cyst fenestration in pediatric patients with middle cranial fossa arachnoid cysts. It is important to consider that cyst fenestration may not be effective because of a latent derangement of CSF circulation in patients with these risk factors.

Arachnoid cysts with subdural hematoma or intracystic hemorrhage in children

Arachnoid cyst (AC) is a common congenital intracranial lesion in children. It may be complicated by subdural hematoma (SDH) and intracystic hemorrhage (ICH) to cause intracranial hypertension after minor head injury or spontaneously. However, because most bleeding after trauma is delayed, it is often overlooked. At the same time, it remains controversial for treatment of ACs complicated with SDH and ICH. So far, it lacks review, especially for pediatric patients who have ACs with SDH or ICH. Here, we report 3 pediatric cases in our department from 2010 to 2011. At the same time, we review 41 pediatric patients reported in the last 20 years. We conclude that a child with AC should be regularly followed up after minor head injury, and that therapy for children with complicated ACs should be more aggressive than for adults. The cyst wall should be resected, and communication between cyst and cerebral cistern should be established.

Intracranial arachnoid cysts: impairment of higher cognitive functions and postoperative improvement

Background

Intracranial arachnoid cysts have been shown to yield cognitive impairment over a range of basic mental functions, and these functions normalize after surgical cyst decompression. We wanted to investigate whether such cysts may also impair executive cognitive functions, and whether surgical cyst decompression leads to an improvement.

Methods

This study included 22 patients with arachnoid cysts and 13 control patients scheduled for low back surgery. All subjects were tested with Delis-Kaplan Executive Function System (D-KEFS) tests, assessing executive function 1 day before surgery and a minimum of 3 months after surgery. The data were analyzed according to scaled score computations based on raw scores provided by D-KEFS, adjusted for age, gender, and educational norms.

Results

Preoperatively, the patients with cysts group performed worse than the control group in verbal knowledge, mental flexibility, inhibitory capacity, problem solving, and planning skills. Postoperatively, the patients with cysts group significantly improved performance and were no longer different from the control group in the following subtests: inhibition, inhibition/switching, letter fluency, category switching, and total switching accuracy. The patients with cysts group also significantly improved performance in color naming, category fluency, and in the Tower test, but nevertheless remained impaired at follow-up compared with the control group. The control group did not show a similar improvement, except for the Tower test. Cyst size or postoperative volume reduction did not correlate with cognitive performance or postoperative improvement. Patients with left-sided temporal cysts performed poorer than patients with right-sided cysts on a complex verbal task demanding mental flexibility.

Conclusions

Arachnoid cysts seem to impair not only basic cognition, but also executive functions. Most of this impairment appears to be reversible after surgical cyst decompression. These results may have implications for future preoperative considerations for patients with intracranial arachnoid cysts.

Maze learning in patients with intracranial arachnoid cysts

BACKGROUND

The temporal lobe is of importance for visuospatial orientation. Intracranial arachnoid cysts have a predilection for the temporal fossa, and might therefore affect visuospatial orientation. The aim was to find out whether temporal cysts affect maze learning and if surgical cyst decompression improves maze performance.

METHODS

Forty-five patients with a temporal arachnoid cyst and 17 control patients with cervical disc disease were tested in a labyrinth route in the hospital corridors the day before surgery and at least 3 months postoperatively.

RESULTS

Thirty-five cyst patients (78 %) experienced postoperative improvement of their preoperative complaints. The cyst patients spent significantly longer time than the controls navigating through the maze in the preoperative test, 161 s and 127 s, respectively, but there was no difference in number of errors between the two groups. However, the cyst patients improved significantly in the postoperative test, both with regards to number of errors they made and time spent, contrary to the control patients, whose postoperative performance equalled that of the preoperative test. For the cyst patients, postoperative improvement in the labyrinth test correlated with the clinical outcome-but not the neuroradiological outcome-after the operation.

CONCLUSIONS

Thus, temporal arachnoid cysts may affect visuospatial orientation and learning in a reversible manner.

Prevalence and natural history of arachnoid cysts in adults

Object

Arachnoid cysts are a frequent finding on intracranial imaging. The prevalence and natural history of these cysts in adults are not well defined.

Methods

We retrospectively reviewed the electronic medical records of a consecutive series of adults who underwent brain MRI over a 12-year interval to identify those with arachnoid cysts. The MRI studies were reviewed to confirm the diagnosis. For those patients with arachnoid cysts, we evaluated presenting symptoms, cyst size, and cyst location. Patients with more than 6 months' clinical and imaging follow-up were included in a natural history analysis.

Results

A total of 48,417 patients underwent brain MRI over the study period. Arachnoid cysts were identified in 661 patients (1.4%). Men had a higher prevalence than women (p < 0.0001). Multiple arachnoid cysts occurred in 30 patients. The most common locations were middle fossa (34%), retrocerebellar (33%), and convexity (14%). Middle fossa cysts were predominantly left-sided (70%, p < 0.001). Thirty-five patients were considered symptomatic and 24 underwent surgical treatment. Sellar and suprasellar cysts were more likely to be considered symptomatic (p < 0.0001). Middle fossa cysts were less likely to be considered symptomatic (p = 0.01. The criteria for natural history analysis were met in 203 patients with a total of 213 cysts. After a mean follow-up of 3.8 ± 2.8 years (for this subgroup), 5 cysts (2.3%) increased in size and 2 cysts decreased in size (0.9%). Only 2 patients developed new or worsening symptoms over the follow-up period.

Conclusions

Arachnoid cysts are a common incidental finding on intracranial imaging in all age groups. Although arachnoid cysts are symptomatic in a small number of patients, they are associated with a benign natural history for those presenting without symptoms.

Clinical and neuroimaging outcomes of surgically treated intracranial cysts in 110 children

Objective

The indications and optimal surgical treatments for intracranial cysts are controversial. In the present study, we describe long-term clinical and neuroimaging results of surgically treated intracranial cysts in children. The goal of this study is to contribute to the discussion of the debate.

Methods

This study included 110 pediatric patients that underwent surgeries to treat intracranial cysts. Endoscopic cyst fenestrations were performed in 71 cases, while craniotomies and cyst excisions (with or without fenestrations) were performed in 30 patients. Cystoperitoneal shunts were necessary for nine patients. Long-term results were retrospectively assessed with medical and neuroimaging records.

Results

Clinical and radiological improvement was reported in 87.3% and 92.8% of cases, respectively, after endoscopic neurosurgery, and in 93.3% and 100% using open microsurgery whereas 88.9% and 85.7% after shunt operation. There were no statistical differences in clinical outcomes (p=0.710) or volume reductions (p=0.177) among the different surgeries. There were no mortalities or permanent morbidities, but complications such as shunt malfunctions, infections, and subdural hematomas were observed in 56% of the patients that had shunt operations. A total of 13 patients (11.8%) underwent additional surgeries due to recurrences or treatment failures. The type of surgery performed did not influence the recurrence rate (p=0.662) or the failure rate (p=0.247).

Conclusion

Endoscopic neurosurgeries are less invasive than microsurgeries and are at least as effective as open surgeries. Thus, given the advantages and complications of these surgical techniques, we suggest that endoscopic fenestration should be the first treatment attempted in children with intracranial cysts.

Success of pure neuroendoscopic technique in the treatment of Sylvian arachnoid cysts in children

INTRODUCTION

Neuroendoscopic approaches to Sylvian arachnoid cysts (SACs) constitute an alternative treatment option to craniotomy for fenestration and shunting procedures. In this study, the authors discuss their experience on pure neuroendoscopic technique in the treatment of SACs in children.

RESULTS

The results of treatment of 20 children (range of age, between 7 months and 17 years) with Galassi type II (n, 5) or III (n, 15) SACs who were subjected to pure neuroendoscopic fenestration procedure were presented. It was possible to perform the cystocisternostomy endoscopically in all children with several stomies. The site of the opening was between the optic nerve and the carotid artery in 19, between the carotid artery and the oculomotor nerve in 17, and below the oculomotor nerve in 7. The stomies were enlarged in all cases using the double balloon. Three of the cases required repetition of the operation and two cases required "cystoperitoneal shunt" implantation. There was one minor complication in a patient who had an asymptomatic postoperative subdural effusion, which resolved spontaneously. Of the 18 cases, in which the neuroendoscopic procedures succeeded, 10 showed a reduction in cyst size. The mean follow-up period was 53 months.

DISCUSSION

Our results suggest that "pure neuroendoscopic" approach can be used safely in the management of SACs in children. We recommend at least two fenestration sites for an effective marsupialization of the cyst within the basal cisterns. In pediatric cases, the use of a small diameter rigid endoscope allows to reach safely the planned target areas.

Cognition and resective surgery for diffuse infiltrative glioma: an overview

Compared to classical oncological outcome measures such as time to progression and survival, the importance of cognitive functioning in patients with diffuse infiltrative brain tumors has only recently been recognized. Apart from the relatively low incidence and the invariably fatal outcome of gliomas, the general assumption that cognitive assessment is time-consuming and burdensome contributes to this notion. Our understanding of the effects of brain surgery on cognition, for instance, is largely based on studies in surgical patients with refractory epilepsy, with only a limited number of studies in surgical patients with gliomas. The impact of other factors affecting cognition in glioma patients such as direct tumor effects, radiotherapy and chemotherapy, and medical treatment, including anti-epileptic drugs and steroids, have been studied more extensively. The purpose of this paper is to provide an overview of cognition in patients with diffuse infiltrative gliomas and the impact of resective surgery as well as other tumor and treatment-related factors.

Language impairment associated with arachnoid cysts: recovery after surgical treatment

Supporting data from the literature, we observe that large arachnoid cysts may affect cognitive function. Neuropsychologic assessment plus magnetic resonance imaging allowed for documentation of associations between left temporal arachnoid cysts, language impairment, and other cognitive dysfunctions. Significant cognitive improvements were evident soon after cysto-peritoneal shunting. These observations reinforce the rationale for neuropsychologic assessments of patients with developmental delay and arachnoid cysts, and support the potential benefit of surgical decompression for arachnoid cysts associated with neurologic deficits, even if surgery is performed well after the occurrence of neurologic deficits.

Temporo-sylvian arachnoidal cyst and an extreme pneumatization of the cranial sinuses: a case report

We present a patient who showed MRI evidence of a giant temporo-sylvian arachnoidal cyst of the left hemisphere and an extreme pneumatization of the sphenoid and frontal sinuses. No sign of mass effect or cerebral atrophy was detected. This patient presented a deficit of memory and control functions, but quality of life was not affected. Surgery was not performed. Arachnoidal cyst and anatomic variants of the sinus region have not a common etiology. This is the first report that describes a giant temporo-sylvian arachnoidal cyst with anatomic variants of the paranasal sinuses.

Location, sidedness, and sex distribution of intracranial arachnoid cysts in a population-based sample

Object

The aim of this study was to examine the distribution of intracranial arachnoid cysts in a large and unselected patient population with special emphasis on sidedness and sex distribution.

Methods

In total, 299 patients with 305 arachnoid cysts were studied. These patients were consecutively referred to our department during a 20-year period from a well-defined geographical area with a stable population.

Results

There was a strong predilection (198 patients [66.2%]) for intracranial arachnoid cysts in the temporal fossa. Forty-two patients had cysts overlying the frontal convexity, 36 had cysts in the posterior fossa, and 23 patients had cysts in other, different locations. Of 269 cysts with clearly unilateral distribution, 163 were located on the left side and 106 on the right side. This difference resulted from the marked preponderance of temporal fossa cysts on the left side (left-to-right ratio 2.5:1; p < 0.0001 [adjusted < 0.0005]). For cysts in the cerebellopontine angle (CPA), there was preponderance on the right side (p = 0.001 [adjusted = 0.005]). Significantly more males than females had cysts in the temporal fossa (p = 0.002 [adjusted = 0.004]), whereas in the CPA a significant female preponderance was found (p = 0.016 [adjusted = 0.032]). For all other cyst locations, there was no difference between the 2 sexes.

Conclusions

Arachnoid cysts have a strong predilection for the temporal fossa. There is a sex dependency for some intracranial locations of arachnoid cysts, with temporal cysts occurring more frequently in men, and CPA cysts found more frequently in women. Furthermore, there is a strong location-related sidedness for arachnoid cysts, independent of patient sex. These findings and reports from the literature suggest a possible genetic component in the development of some arachnoid cysts.

Acute respiratory failure as a manifestation of an arachnoid cyst

Arachnoid cysts are the most common congenital cystic lesions in the brain occurring in the middle fossa, suprasellar region and occasionally in the posterior fossa. Conventionally all cysts are considered as benign and symptoms are attributed to expansion of cysts causing compression of adjacent neurological structures, bleeds within the cyst or due to the development of acute hydrocephalus. We are reporting this case of a 15-year-old female patient with non-progressive weakness in the limbs since the age of seven years who presented with acute onset syncopal attacks and respiratory failure. She was intubated and ventilated. An magnetic resonance imaging scan showed large posterior fossa cyst extending up to mid second cervical vertebra causing compression of the medulla and pons, with mild hydrocephalus. After a failed attempt to wean her from the ventilator a cysto peritoneal shunt surgery was performed following which she was weaned from the ventilator successfully. Weakness in the upper and lower limbs, which had increased in the preceding month, also improved following the surgery.

Prevalence and natural history of arachnoid cysts in children

OBJECT

Arachnoid cysts are a frequent finding on intracranial imaging in children. The prevalence and natural history of these cysts are not well defined. The authors studied a large consecutive series of children undergoing MR imaging to better define both the MR imaging-demonstrated prevalence and behavior of these lesions over time.

METHODS

The authors reviewed a consecutive series of 11,738 patients who were 18 years of age or younger and had undergone brain MR imaging at a single institution during an 11-year period. In the patients in whom intracranial arachnoid cysts were identified, clinical and demographic information was recorded and imaging characteristics, such as cyst size and location, were evaluated. Prevalence data were analyzed using univariate and multivariate logistic regression, linear regression, and ANOVA. All patients with sufficient data (repeat MR imaging studies as well as repeated clinical evaluation over at least 5 months) for a natural history analysis were identified. This group was assessed for any change in symptoms or imaging appearance during the follow-up interval.

RESULTS

Three hundred nine arachnoid cysts (2.6% prevalence rate) were identified. There was an increased prevalence of arachnoid cysts in males (p < 0.000001). One hundred eleven patients met all criteria for inclusion in the natural history analysis. After a mean follow-up of 3.5 years, 11 arachnoid cysts increased in size, 13 decreased, and 87 remained stable. A younger age at presentation was significantly associated with cyst enlargement (p = 0.001) and the need for surgery (p = 0.05). No patient older than 4 years of age at the time of initial diagnosis had cyst enlargement, demonstrated new symptoms, or underwent surgical treatment.

CONCLUSIONS

Arachnoid cysts are a common incidental finding on intracranial imaging in pediatric patients. An older age at the time of presentation is associated with a lack of clinical or imaging changes over time.

Neurocognitive and psychological profiles in pediatric arachnoid cyst

OBJECTIVE

This study aims to investigate whether intracranial arachnoid cysts (AC) compromise neurocognitive function and psychological profiles in pediatric patients, depending on various clinical factors.

METHODS

We assessed neurocognitive functions and psychological tests in 35 AC patients and 35 healthy control subjects between October 2007 and April 2008. AC patients ranged in age from 3 to 15 (7.94 +/- 3.12) years old and control patients from 5 to 13 (8.84 +/- 2.17) years old. The location of the AC were temporal (n = 22), frontal (n = 6), suprasellar (n = 4), and posterior fossa (n = 3). Patients underwent neurocognitive and psychological assessments before surgery. To investigate which AC impair neurocognitive function and psychological profile, we assessed intelligence, memory, attention, executive function, behavioral problems, emotional distress, and parenting stress.

RESULTS

AC caused some demonstrated impairment by both neurocognitive function and psychological assessments. Left hemisphere AC tended to have more anxiety; mood changes can be detected depending on cyst grade. An incidental finding of AC after trauma is more intelligent, well-reserved executive function. Frontal locations tended to cause more anxiety than temporal locations.

CONCLUSIONS

Our results imply that intracranial AC impairs some neurocognitive and psychological functions. An incidental finding of AC after trauma was a more intelligent, well-reserved executive function. AC in the left hemisphere, frontal location tended to cause more anxiety. The AC itself did not cause differences in neurocognitive function from the control group. However, parenting stress in the AC group was much higher than in the control group.

Psychosis-like syndrome associated with intermittent intracranial hypertension caused by a large arachnoid cyst of the left temporal lobe

Lesions on certain brain areas can cause psychiatric signs. Symptomatic arachnoid cysts can produce a variety of symptoms like headache, seizures, increased ICP, and rarely psychiatric disorders. We report a case of a young woman with a left temporal lobe arachnoid cyst, presented with headache and an atypical psychosis. A 72-h epidural ICP recording revealed incidental elevation of ICP. After a permanent shunt was placed, patient's symptoms improved substantially, and antipsychotic medication was significantly reduced.

Sylvian fissure arachnoid cysts: a survey on their diagnostic workout and practical management

BACKGROUND

The management of Sylvian arachnoid cysts in children is still a matter of debate. Diagnosis is often incidental, and symptoms are frequently aspecific in symptomatic cases. Suggested diagnostic investigation results have been often unclear. Surgical treatment is also controversial, pure, and assisted endoscopic cyst marsupialization having entered in the traditional debate between craniotomic and shunting approach

PURPOSE

The objective of the present study was to survey if (and, eventually, which) agreement points do actually exist between internationally recognized pediatric neurosurgery centers in the management of children with a controversial type of Sylvian arachnoid cyst (Type II cyst).

METHODS

Contributors were asked to answer to a six-separate-part multiple choice questionnaire related to the case of a 2.7-year-old boy with a Type II left Sylvian arachnoid cyst presented in different clinical situations. If surgery was indicated, it was asked which surgical procedure the authors would have suggested as first option.

RESULTS AND CONCLUSIONS

The option of the mere clinical observation was chosen by the majority of surgeons in case of asymptomatic clinical discovery. On the other hand, a constantly high percentage of participants suggested direct surgical treatment based on clinical manifestations or as a preventive measure justified by the risk of spontaneous or traumatic intracranial bleeding. The only diagnostic investigation result which significantly influenced the surgical indication was a localizing electroencephalography, if the child presented with seizures. The result is that in most cases the surgical indication was based on aspecific clinical manifestations and laboratory data. Craniotomy and arachnoid cyst marsupialization represented the preferred surgical option (66.6%), 28.8% of the participants suggesting pure or assisted endoscopic cyst marsupialization as primary surgical procedure. Cyst shunting was suggested by only three centers.