Secondary Trigeminal Neuralgia Caused by Cerebellopontine Angle Arachnoid Cyst in A 27-Year-Old Female: A Case Report

PURPOSE

Secondary (TN) caused by an arachnoid cyst in the (CPA) region is a rare finding. Based on the reported literature, there are only 5 cases of secondary trigeminal neuralgia caused by an arachnoid cyst in the cerebellopontine angle region.

CASE REPORT

A 27-year-old female presented to our neurosurgery clinic with a 2-year history of brief episodes of paroxysm pain in the left cheek. The pain was described as an electric shock-like pain triggered by simple stimuli. The magnetic resonance imaging (MRI) showed a well-confined cystic lesion in the left CPA, which compresses the left pons and the cisternal segment of the left trigeminal nerve. The patient was managed operatively to fenestrate the cyst and decompress the trigeminal nerve. The histopathological result of the cyst wall was consistent with an arachnoid cyst. Six months after surgery, the patient is in good health condition and symptom-free without medication.

CONCLUSION

Arachnoid cyst in the CPA region is one of the rare causes of secondary TN. Preoperative imaging with MRI is important to provide better results to differentiate the pathology. Surgical treatment to fenestrate the arachnoid cyst and decompress the trigeminal nerve have a good result and can improve the patient's quality of life.

Microsurgical Fenestration of Middle Fossa Arachnoid Cyst in a Pediatric Patient Through a Keyhole Approach with Endoscopic Inspection. 2-Dimensional Operative Video

In recent decades, the management of middle fossa arachnoid cysts in pediatric patients has evolved significantly through the integration of novel techniques, such as the utilization of endoscopy systems1 and implementation of minimally invasive approaches like keyhole craniotomy.2,3 These cystic formations, occurring within the arachnoid membrane, may lead to neurologic impairments and raised intracranial pressure if left untreated.4 The utilization of endoscopy to aid microsurgical techniques or as a complement to them provides a level of visualization and manipulation of the cyst walls that is significantly more precise than the isolated use of a microscope.1 The keyhole craniotomy allows for reduced surgical trauma, smaller incisions, and quicker recovery times.5 In Video 1, we present the case of a 2-year-old patient with bilateral middle fossa arachnoid cysts exerting mass effect on the adjacent parenchyma. The patient was referred to our institution due to developmental delay and cognitive issues related to language and social interactions. On the basis of imaging findings and clinical correlation, we opted for a microsurgical fenestration with endoscopic inspection using a keyhole craniotomy to minimize complications and enhance the benefits of both techniques. Throughout the surgical video, tricks and considerations that contribute to the combined procedure's efficiency and ease of execution are highlighted and discussed. Postoperative images showed no complications, and the patient was discharged 3 days after surgery.

Positive outcome after endoscopic treatment of a symptomatic convexity arachnoid cyst in an elderly

Cerebral convexity arachnoid cysts (ACs) only represent around 10-14% of the cysts. Symptomatic ACs in the elderly are rare. We present a 66-year-old woman with headache and a focal epileptic seizure. Imaging revealed a left parietal AC. Conservative management chosen but the patient's neurological condition worsened, and an endoscopic fenestration was then performed. Postoperatively, her symptoms completely resolved and MRI image showed significant shrinkage of the AC.

Spinal extradural arachnoid cysts: a rare entity and review of the literature

OBJECTIVE

Spinal extradural arachnoid cysts (SEDC) are rare primary spinal lesions, accounting for less than 1% of all spinal epidural lesions. The literature contains only case reports of this pathology, and treatment remains controversial due to its rarity. Major reported SEDC cases are caused by leaking out of cerebrospinal fluid through a dural defect in the thecal sac forming an extradural cyst. Other reports describe non-communicating SEDC cases where the dural defect was not identified. We report a literature review on SEDC and the case of a 53 year‑old female who presented with type IA extradural cyst with subarachnoid space communication.

METHODS

Literature review, preoperative imaging and surgical technique.

RESULTS

The extradural cyst was excised completely and the dural defect was repaired. After surgical decompression, neurological symptoms gradually recovered.

CONCLUSIONS

The extradural arachnoid cyst is an uncommon entity. Preoperative imaging is one of the determining elements in orienting the therapeutic management of the SEDCs. The choice of the surgical technique must be the least invasive in order to avoid postoperative complications. Subtotal or complete excision of the cyst, followed by obliteration of the communication stalk and repair of the dural defect is the gold standard treatment.

Global trends and decision-making in the management of arachnoid cysts

OBJECTIVE

In pediatric patients, middle cranial fossa (MCF) arachnoid cysts are often discovered incidentally on imaging in asymptomatic patients during workup for other indications. This study aims to describe current management gestalt and threshold for surgical intervention by surveying an international cohort of neurosurgeons.

METHODS

A web-based survey was circulated via email list of attendants of the 2019 Canadian Pediatric Neurosurgery Study Group (CPNSG) and International Society of Pediatric Neurosurgery (ISPN) mailing list. The survey consisted of 8 clinical scenarios involving patients with MCF arachnoid cysts. Demographic variables of respondents and their decisions regarding management for each scenario were analyzed using R computing software.

RESULTS

A total of 107 respondents were included. Cysts in asymptomatic patients (92%), younger age at diagnosis (81%), and presence of a mild learning delay were predominantly managed non-surgically (80.7 ± 9.4%). Patients with cyst enlargement, headaches, new seizures, or hemorrhage were divided between non-surgical (55.8 ± 3.3%) and surgical (44.2 ± 2.9%) management. Patients with contralateral hemiparesis were treated predominantly surgically (67%). For both Galassi I and II, papilledema was favored as the primary indication for surgical intervention in 54% of patients. Those inclined to surgery (n = 17) were more likely to practice and train outside North America compared to those not pro-surgical (adjusted P = 0.092).

CONCLUSION

Incidental MCF arachnoid cysts in asymptomatic patients and younger age of diagnosis are predominantly managed non-surgically. Mild learning delay was not considered an indication to intervene. In contrast, radiological progression, hemorrhagic evolution, or non-focal neurological deficits lead to uncertainty in management, while focal neurological deficits and papilledema with MCF cysts were favored to be intervened surgically. Among the provider level factors, only location of training and practice trended towards a pro-surgery approach.

Multiple spinal extradural arachnoid cysts presenting as compressive myelopathy in a teenager: case report and literature review with special emphasis on postoperative spine deformity in the current minimally invasive era

INTRODUCTION

Multiple synchronous spinal extradural arachnoid cysts are extremely rare in children and can lead to cord compression and disability. Multiple spinal extradural arachnoid cysts (SEDACs) in children with immature and growing spine need to be studied separately from multiple SEDACs in adults with mature and fully grown spine because of multiple surgical limitations in children (blood loss, surgery duration, long-term spinal stability after long segment exposure, etc.).

MATERIAL AND METHODS

We planned a non-systematic literature review of similar cases described in literature to analyse the pattern of presentation, management, and outcome of this surgically curable disease.

RESULTS

A total of 28 cases of paediatric multiple SEDACs in the age range of 5 months to 17 years and mean age of 11.54 years were analysed. Exposure was achieved by laminectomy in 9, laminoplastic laminotomy in 13, laminectomy in first surgery followed by laminoplasty in second surgery (re-exploration) in 1, hemilaminectomy in 2, and technique "not reported" in 3 children. Complete/near-complete recovery was seen in 27 (96.42%) children. Postoperative spine deformity was reported in 7 (25%) children and was progressive in 2 children during serial follow-up.

CONCLUSIONS

Symptomatic multiple synchronous SEDACs in children is a rare surgically curable condition. Sincere attempt to find out a dural defect in all cysts is a very important step in multiple SEDAC surgery. Total cyst wall excision with closure of all dural defects is the gold standard treatment for symptomatic cases. Laminoplasty is preferred for excision of multiple SEDACs in children to prevent postoperative spine deformity during long-term follow-up. Long serial follow-up for postoperative spine deformity is necessary.

Nomogram for preoperative estimation of symptomatic subdural hygroma risk in pediatric intracranial arachnoid cysts

OBJECTIVE

The occurrence and predictors of symptomatic subdural hygroma (SSH) subsequent to the fenestration of pediatric intracranial arachnoid cysts (IACs) are unclear. In this study, the authors aimed to investigate the likelihood of an SSH following IAC fenestration and the impact on operative efficacy with the ultimate goal of constructing a nomogram.

METHODS

The medical records of 1782 consecutive patients who underwent surgical treatment at the Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were reviewed. Among these patients, a training cohort (n = 1214) underwent surgery during an earlier period and was used for the development of a nomogram. The remaining patients formed the validation cohort (n = 568) and were used to confirm the performance of the developed model. The development of the nomogram involved the use of potential predictors, while internal validation was conducted using a bootstrap-resampling approach.

RESULTS

SSH was detected in 13.2% (160 of 1214) of patients in the training cohort and in 11.1% (63 of 568) of patients in the validation cohort. Through multivariate analysis, several factors including Galassi type, IAC distance to the basal cisterns, temporal bulge, midline shift, IAC shape in the coronal view, area of the stoma, and artery location near the stoma were identified as independent predictors of SSH. These 7 predictors were used to construct a nomogram, which exhibited a concordance statistic (C-statistic) of 0.826 and demonstrated good calibration. Following internal validation, the nomogram maintained good calibration and discrimination with a C-statistic of 0.799 (95% CI 0.665-0.841). Patients who had nomogram scores < 30 or ≥ 30 were considered to be at low and high risk of SSH occurrence, respectively.

CONCLUSIONS

The predictive model and derived nomogram achieved satisfactory preoperative prediction of SSH. Using this nomogram, the risk for an individual patient can be estimated, and the appropriate surgery can be performed in high-risk patients.

Intracranial arachnoid cyst in pregnancy: case report, literature review and evaluation of neuraxial anaesthesia risk

Choosing the type of intrapartum anaesthesia for pregnant women with intracranial arachnoid cysts can be challenging due to a lack of research. We report the intrapartum anaesthetic management of a 25-year-old woman with a known 10 cm arachnoid cyst. By means of a literature review and discussion of safety surrounding neuraxial techniques, this report will help to inform obstetric anaesthesia practice. Overall, in the absence of raised intracranial pressure, neuraxial analgesia and anaesthesia during the intrapartum period appears to be a safe option.

Arachnoid Cyst of the Cerebellopontine Angle: A Systematic Literature Review

OBJECTIVE

The role of surgical management of arachnoid cyst (AC) of the cerebellopontine angle (CPA) is uncertain. This topic has remained controversial with varying contradictory recommendations in the literature, which is limited to mostly case reports. We aimed to provide a comprehensive summary and analysis of symptoms, operative techniques, outcomes, and recurrence of all available surgical cases of AC of the CPA to date.

METHODS

A systematic literature search was performed in May 2022 querying several scientific databases. Inclusion criteria specified all studies and case reports of patients with AC located at the CPA for which any relevant surgical procedures were performed.

RESULTS

A total of 55 patients from the literature and 5 treated at our institution were included. Mean patient age was 29 years (range, 0.08-79 years), with nearly twice (1.7×) as many female as male patients (37 female, 22 male). Headaches (35%), hearing loss (30%), vertigo (22%), and ataxia (22%) were the most common presentations. Following surgery, 95% experienced symptom improvement, with complete resolution in 64%. Of patients with hearing loss, 44% reported a return to normal. The rate of mortality was 1.69%, and 10% of tumors recurred (mean follow-up 2.3 years [range, 0-15 years].

CONCLUSIONS

Symptomatic AC of the CPA is rare. It exhibits a proclivity for females and commonly manifests with headache, hearing loss, vertigo, and ataxia. While careful selection for surgical candidacy is needed and intervention should be reserved for patients with severe symptoms, surgical decompression is an effective tool for symptom alleviation and recovery.

Evaluation of surgical treatment strategies and outcome for cerebral arachnoid cysts in children and adults

OBJECTIVE

The best treatment strategies for cerebral arachnoid cysts (CAC) are still up for debate. In this study, we present CAC management, outcome data, and risk factors for recurrence after surgical treatment, focusing on microscopic/endoscopic approaches as compared to minimally invasive stereotactic procedures in children and adults.

METHODS

In our single-institution retrospective database, we identified all patients treated surgically for newly diagnosed CAC between 2000 and 2022. Microscopic/endoscopic surgery (ME) aimed for safe cyst wall fenestration. Stereotactic implantation of an internal shunt catheter (STX) to drain CAC into the ventricles and/or cisterns was used as an alternative procedure in patients aged ≥ 3 years. Treatment decisions in favor of ME vs. STX were made by interdisciplinary consensus. The primary study endpoint was time to CAC recurrence (TTR). Secondary endpoints were outcome metrics including clinical symptoms and MR-morphological analyses. Data analysis included subdivision of the total cohort into three distinct age groups (AG1, < 6 years; AG2, 6-18 years; AG3, ≥ 18 years).

RESULTS

Sixty-two patients (median age 26.5 years, range 0-82 years) were analyzed. AG1 included 15, AG2 10, and AG3 37 patients, respectively. The main presenting symptoms were headache and vertigo. In AG1 hygromas, an increase in head circumference and thinning of cranial calvaria were most frequent. Thirty-five patients underwent ME and 27 STX, respectively; frequency did not differ between AGs. There were two (22.2%) periprocedural venous complications in infants (4- and 10-month-old) during an attempt at prepontine fenestration of a complex CAC, one with fatal outcome in a 10-month-old boy. Other complications included postoperative bleeding (2, 22.2%), CSF leaks (4, 44.4%), and meningitis (1, 11.1%). Overall, clinical improvement and significant volume reduction (p = 0.008) were seen in all other patients; this did not differ between AGs. Median follow-up for all patients was 25.4 months (range, 3.1-87.1 months). Recurrent cysts were seen in 16.1%, independent of surgical procedure used (p = 0.7). In cases of recurrence, TTR was 7.9 ± 12.7 months. Preoperative ventricular expansion (p = 0.03), paresis (p = 0.008), and age under 6 years (p = 0.03) were significant risk factors for CAC recurrence in multivariate analysis.

CONCLUSIONS

In patients suffering from CAC, both ME and STX can improve clinical symptoms at low procedural risk, with equal extent of CAC volume reduction. However, in infants and young children, CAC are more often associated with severe clinical symptoms, stereotactic procedures have limited use, and microsurgery in the posterior fossa may bear the risk of severe venous bleeding.

A 3-Year-Old Girl with Brain Imaging Findings Suggesting Arachnoid Cyst, and Biopsy Diagnosis of Extra-Axial Multicystic Pilocytic Astrocytoma

BACKGROUND Arachnoid cysts and pilocytic astrocytomas are distinct intracranial entities with differing clinical presentations, origins, and management strategies. Arachnoid cysts are benign fluid-filled sacs associated with congenital or acquired causes, while pilocytic astrocytomas are low-grade brain tumors, primarily affecting pediatric and young adult populations, originating from astrocytes. However, diagnosing pilocytic astrocytomas can be challenging due to their radiological features, sometimes resembling more common intracranial lesions, such as arachnoid cysts. This case underscores the need for vigilance and a multidisciplinary approach when confronted with neuroimaging findings that diverge from typical patterns. CASE REPORT We present a case of a 3-year-old girl who presented with persistent headaches, vomiting, and difficulty walking. Initial radiological assessment suggested an arachnoid cyst, given the patient's symptoms and imaging characteristics. Subsequently, the patient underwent a craniotomy, with intraoperative findings revealing a cystic lesion without a solid mural nodule, which was excised completely. Postoperatively, histopathological examination confirmed a diagnosis of extra-axial pilocytic astrocytoma. The patient's symptoms resolved, and she was discharged without neurological deficits. CONCLUSIONS Diagnosing extra-axial pilocytic astrocytomas presents challenges, due to their radiological similarities with more common intracranial lesions, like arachnoid cysts. This case underscores the importance of histopathological examination to confirm the diagnosis accurately. Surgical resection remains the primary treatment for extra-axial pilocytic astrocytomas, often resulting in a favorable prognosis.

Subdural hemorrhage in middle cranial fossa arachnoid cysts: a report of two cases at two ends of the spectrum

Arachnoid cysts are usually asymptomatic, benign lesions commonly occurring in the middle cranial fossa. However, the cysts may rupture in rare cases causing intracystic or subdural hemorrhages with significant mass effect. We report two cases of middle cranial fossa arachnoid cyst with subdural hemorrhage with very different clinical course. The first case presented with significant mass effect with cerebral herniation and had significant neurological morbidity post-surgery. The second case had minimal symptoms and was managed conservatively with offer of elective surgery. The report underscores the importance of prompt diagnosis and appropriate surgical intervention in managing arachnoid cysts with hemorrhage, highlighting the potential for diverse clinical presentations and outcomes.

Does right hemisphere compensate for the left in school-age children with large left middle fossa arachnoid cysts?

BACKGROUND

To assess the cognitive function changes and brain network neuroplasticity in school-age children having large (diameter > 5 cm) left middle fossa arachnoid cyst (MFACs).

METHODS

Eleven patients and 22 normal controls (NC) between 6 and 14 years of age were included. The CNS Vital Signs (CNS VS) were administered for cognitive assessment. The differences of cognitive data and functional connectivity (FC) in resting-state functional magnetic resonance imaging (rs-fMRI) were compared between the patient group and the NC group. The correlations between the altered FC and cognitive data in the patient group were assessed.

RESULTS

Patient group had significantly poorer attention (including Complex Attention, Sustained Attention, Simple Attention, Cognitive Flexibility, and Executive Function) and memory function (Visual Memory and Working Memory) than the NC group (uncorrected p-value, p-unc < 0.05). Whole-brain local correlation (LCOR) analysis showed an extensively lower LCOR in the patient group (voxel threshold p-unc < 0.001, cluster-size threshold of false discovery rate adjusted p (p-FDR) < 0.001). Functional connectivity (FC) analysis showed that bilateral frontal and temporal lobes connectivity in the patient group was significantly lower than the NC group (p-FDR < 0.05). Seed-based FC analysis indicated that there was altered FC between the right temporal lobe and the left temporal-parietal/temporal-occipital area (p-FDR < 0.05). In the patient group, most of the altered FC had a negative correlation to the cognitive score, while the FC in the right temporal lobe-left temporal-occipital area positively correlated to Verbal/Visual Memory (r = 0.41-0.60, p-FDR < 0.05). In correlation analysis between clinical data and cognitive score, the only significant result was a low correlation between cyst size and Reaction Time (-0.30--0.36, P-FDR < 0.05).

CONCLUSIONS

School-aged children with large left MFAC showed significantly lower cognitive performance primarily in attention and memory domains. Distinct from neuroplasticity in a unilateral brain lesion, compensation in the healthy hemisphere in MFAC patients was sparse.

Follicular carcinoma of the thyroid presenting as metastasis in the wall of an arachnoid cyst

The brain is an uncommon site for metastases of differentiated thyroid carcinoma with the most common location being cerebral hemispheres, followed by cerebellum and pituitary gland. Metastasis in the wall of an arachnoid cyst is exceedingly rare with single case report available in the published literature. Arachnoid cyst metastasis from an extraneuraxial malignancy has not been published until. We present a unique case of thyroid carcinoma metastasizing to the wall of an intracranial arachnoid cyst and the most interesting fact is that it was the first clinical manifestation of her malignancy.

Clinicoradiologic Risk Stratification and Outcome Assessment in Symptomatic Intracranial Arachnoid Cyst Managed Over Fifteen Years

BACKGROUND

Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space-occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs.

METHODS

All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008-December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit.

RESULTS

A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P= 0.23).

CONCLUSIONS

ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms.

Growing and symptomatic intracranial arachnoid cyst in an elderly patient: a case report and literature review

We report an elderly patient with a symptomatic and growing arachnoid cyst. Physician should be cautious in counseling asymptomatic arachnoid cyst patients, regardless of their age, and inform them of the possibility, although rare, of growth and symptom development even in their late life.

Treatment of symptomatic sacral arachnoid cysts in the pediatric population

OBJECTIVE

Symptomatic sacral arachnoid cysts are extremely rare in pediatric patients, resulting in a lack of consensus regarding optimal treatment measures. The current study evaluated the clinical symptoms and surgical indications, techniques, and outcomes of pediatric patients who underwent treatment for sacral arachnoid cysts with the aim of developing recommendations for follow-up and treatment.

METHODS

This retrospective study included pediatric patients who underwent surgical treatment for sacral arachnoid cysts between January 2000 and December 2020 at the Department of Pediatric Neurosurgery, Acıbadem University Faculty of Medicine.

RESULTS

Thirteen patients were included in the study, 9 of whom were girls and 4 were boys. Five patients presented with urinary incontinence, 2 of whom also exhibited constipation. Other chief complaints included recurrent urinary tract infections (UTIs) and low-back pain (n = 4 patients each). Urological evaluation was performed in all patients, followed by urodynamic examination in those with urinary symptoms. Spinal MRI showed extra- and intradural sacral cysts in 12 patients and 1 patient, respectively. The latter patient exhibited recurrence during follow-up and underwent reintervention. Samples from the excised cyst walls were sent for pathological examination. Five patients with urinary incontinence, 2 with constipation, 4 with recurrent UTIs, and 3 with low-back pain exhibited resolution of symptoms after treatment. However, 1 patient with low-back pain did not show any improvement in symptoms. No postoperative complications were observed in the current study. The patients were followed-up regularly after surgery, and the mean follow-up duration was 4 years.

CONCLUSIONS

Sacral arachnoid cysts in pediatric patients may be associated with urinary system dysfunction and low-back pain. Surgery is the treatment of choice for symptomatic patients and those with enlarged cysts with radiological evidence of compression, and the morbidity and mortality rates associated with surgery are low.

Microscope neuronavigation-guided microsurgical fenestration of quadrigeminal cistern arachnoid cysts: how I do it

BACKGROUND

Management options for treatment of quadrigeminal arachnoid cysts (QAC) include microsurgical/endoscopic fenestration or shunt. There is an open debate about which method is the best. Microsurgical fenestration is well suited for treatment of QAC with predominant infratentorial component and without hydrocephalus making endoscopic procedures more challenging.

METHOD

We describe the microsurgical technique and related anatomy to fenestrate infratentorial QAC through supracerebellar infratentorial approach. We also discuss our experiences with this approach, some of the drawbacks and nuances.

CONCLUSION

Navigation-guided microsurgical fenestration of infratentorial QAC is the authors' surgical approach of choice for treating these rare challenging lesions when not associated with hydrocephalus.

An unusual cause of chronic neuropathic pain: report of a case of multiple intradural spinal arachnoid cysts and review of the literature

Spinal arachnoid cysts (SACs) arise either intra- or extradurally and are usually solitary, while cases of multiple SACs have been scarcely reported in the literature. Herein, we report on a rare case of multiple and recurring intradural spinal arachnoid cysts (SACs) causing severe spinal cord compression and neuropathic radicular pain, in a 35-year-old female with a 10-year follow-up. Two separate attempts at surgery were performed but only provided temporary relief since the cysts recurred and new ones formed along the entirety of the spinal cord. Finally, a conservative approach with physiotherapy and a combination of analgesic medications was pursued.

Scoliosis due to scar contracture caused by infection after cyst-peritoneal shunt: a case report and literature review

BACKGROUND

Cyst-peritoneal (CP) shunt is one of the most common methods for the treatment of intracranial arachnoid cysts (ACs). Infection is a common postoperative complication. We report a patient with scoliosis due to scar contracture caused by infection after CP shunt.

CASE DESCRIPTION

A 12-year-old boy underwent CP shunt surgery for the left frontoparietotemporal AC when he was 2 years old. At the age of 7 years, he underwent a shunt catheter removal procedure because of the infection caused by the fistula leading from the subcutaneous tunnel to the body surface. However, contracture of the subcutaneous scar from fistula infection caused scoliosis and limited range of motion of the right arm. At the age of 12, the patient received scar lysis and his symptoms improved.

CONCLUSION

We presented the first case of scoliosis due to scar contracture caused by infection after CP shunt. In this case, timely release of scar tissue can effectively correct scoliosis and limb movement limitation.

Arachnoid cysts in paediatrics

PURPOSE OF REVIEW

Arachnoid cysts are incidentally found on neuroimaging at an increasing rate in the paediatric population. Hence, learning their clinical implications to better inform families is important. The purpose of this review is to outline the current understanding of epidemiology, disease and clinical features based on location, imaging and management of arachnoid cysts in paediatrics.

RECENT FINDINGS

The prevalence of arachnoid cysts is 2.6% in paediatrics, with greater than 90% being asymptomatic. When they do cause symptoms, it is based primarily on their location and size. The most accurate diagnostic modality is MRI. Recent literature focuses primarily on the origin of arachnoid cysts, new approaches to treating symptomatic arachnoid cysts and long-term implications for patients.

SUMMARY

Incidental arachnoid cysts are being found most often due to the more frequent use of neuroimaging. There is a higher prevalence for arachnoid cysts in men and they are more commonly found on the left side. Despite their impressive size or location, greater than 90% of these lesions are asymptomatic and require no intervention. However, follow up with neurosurgery to help determine the clinical significance of these lesions is essential.

Familial and syndromic forms of arachnoid cyst implicate genetic factors in disease pathogenesis

Arachnoid cysts (ACs) are the most common space-occupying lesions in the human brain and present significant challenges for clinical management. While most cases of ACs are sporadic, nearly 40 familial forms have been reported. Moreover, ACs are seen with increased frequency in multiple Mendelian syndromes, including Chudley-McCullough syndrome, acrocallosal syndrome, and autosomal recessive primary ciliary dyskinesia. These findings suggest that genetic factors contribute to AC pathogenesis. However, traditional linkage and segregation approaches have been limited in their ability to identify causative genes for ACs because the disease is genetically heterogeneous and often presents asymptomatically and sporadically. Here, we comprehensively review theories of AC pathogenesis, the genetic evidence for AC formation, and discuss a different approach to AC genomics that could help elucidate this perplexing lesion and shed light on the associated neurodevelopmental phenotypes seen in a significant subset of these patients.

Clinical value of classification in the treatment of children with suprasellar arachnoid cysts

OBJECTIVE

The aim of this study is to investigate the clinical characteristics and prognostic effects of different subtypes of suprasellar arachnoid cysts (SAC) in children.

METHODS

Fifty patients with primary SAC who had undergone endoscopic treatment in our department between January 2010 and December 2020 were studied retrospectively. All patients underwent endoscopic treatment after diagnosis, including ventriculocystostomy (VC) in 23 cases and ventriculocystocisternostomy (VCC) in 27 cases. All patients were followed up regularly after the operation, including head computed tomography (CT)/magnetic resonance imaging (MRI), and Evans index (EI) and frontal and occipital horn ratio (FOHR) index were measured to assess changes in cyst volume and hydrocephalus. The prognosis was evaluated comprehensively on the data of the improvement of clinical symptoms, child growth and development correlation score, and reduction of cyst volume 12 months after surgery. According to the new classification of SAC, 50 cases of children were classified into three groups in which we compared the clinical characteristics of different subtypes of the three groups. Logistic regression was used to analyze the influencing factors of prognosis.

RESULTS

Completed success was achieved in 50 cases, including 31 cases with cyst volume reduction of more than 50% and 19 cases with cyst volume reduction of less than 50%. The median follow-up time was 55.3 months (22 ~ 113 months). According to the new classification criteria of SAC, there were 21 cases of SAC-1, 16 cases of SAC-2, and 13 cases of SAC-3. There were no statistically significant differences among the three groups in gender, birth weight, prenatal diagnosis, hydrocephalus, endocrine abnormalities, relief of postoperative symptoms, cyst wall texture, and surgical methods (P > 0.05). There was a statistically significant difference among the three groups in the change of the cyst volume and the maximum cyst diameter (P < 0.05), in which SAC-1 had the largest volume reduction, SAC-2 was more likely to cause endocrine symptoms and SAC-3 was inclined to lie in between. Multivariate logistic analysis showed that SAC classification and cyst wall texture were independent risk factors for the prognosis.

CONCLUSION

The clinical characteristics of different SAC subtypes are different, and SAC classification is one of the independent risk factors affecting prognosis.

Spinal Intradural Arachnoid Cysts in Adults: An Institutional Experience and Literature Review

BACKGROUND

Adult spinal intradural arachnoid cysts are rare pathologic entities with an unclear etiopathogenesis. These lesions can be dichotomized into primary (idiopathic) or secondary (related to inflammation, intradural surgery, or trauma) etiologies. Limited series have depicted optimal management strategies and clinical outcomes.

OBJECTIVE

To illustrate our experience with spinal intradural arachnoid cysts and to present a literature review of surgically treated cysts to elucidate the clinical and anatomic differences between etiologies.

METHODS

Institutional review revealed 29 patients. Various data were extracted from the medical record. Initial and follow-up symptomatologies of the surgical cohort were compared. The literature review included case series describing cysts managed surgically.

RESULTS

From patients treated surgically at our institution (22), there was a significant reduction in thoracic back pain postoperatively ( P = .034). A literature review yielded 271 additional cases. Overall, primary and secondary lesions accounted for 254 and 39 cases, respectively. Cysts of secondary origin were more likely localized ventral to the spinal cord ( P = .013). The rate of symptomatic improvement after surgical intervention for primary cysts was more than double than that of secondary cysts ( P < .001). Compared with primary etiologies, the rates of radiographic progression ( P = .032) and repeat surgery ( P = .041) were each more than double for secondary cysts.

CONCLUSION

Surgical intervention for spinal intradural arachnoid cysts improves thoracic back pain. The literature supports surgical intervention for symptomatic primary spinal intradural arachnoid cysts with improved clinical outcomes. Surgery should be cautiously considered for secondary cysts given worse outcomes.

Intracranial cysts: incidental or neurodevelopmental?

OBJECTIVES

Intracranial cysts are fluid-filled sacs within the brain. There is a diversity of intracranial cysts with different incidences in addition to the growing awareness about comorbidities and the consequences. The present study aimed to evaluate cystic findings in children who were admitted to the department of pediatric neurology.

METHODS

Children who were admitted to the Clinic of Pediatric Neurology and who had an MRI between 2016 and 2021 were evaluated. The MRI examination was performed with the pediatric epilepsy protocol. Children with primary intracranial cysts were enrolled in the study. Demographic and clinical findings were evaluated from the hospital's database and patients' files.

RESULTS

Among the 78 patients, 36 (46.2%) were male and 42 (53.8%) were female. The mean age was 7 ± 5.4 years. The most frequent presenting complaint was a seizure (47.4%). Approximately one-quarter (28.2%) had mental and/or motor retardation. Nine (11.5%) of the children had a neuropsychiatric diagnosis. Most of the cysts were located at the midline (41%) with the majority located extra-axial (71.8%) and supratentorial (78.2%). Arachnoid cysts were observed most frequently with a percentage of 64.1%, followed by pineal cysts (15.4%). The history of seizure, epilepsy, presence of mental retardation, and neuropsychiatric problems were evaluated according to the population ratios based on z approximation in which significantly higher rates were observed among cases with intracranial cysts.

CONCLUSION

Intracranial cysts should be taken into consideration for comorbid pathologies, especially in the childhood period. Early evaluation in patients with intracranial cysts for developmental delay and neuropsychiatric problems is important.

Comparison of Surgical Techniques for Intracranial Arachnoid Cysts: A Volumetric Analysis

AIM

To compare the volumetric changes of intracranial arachnoid cysts (IACs) in different surgical techniques.

MATERIAL AND METHODS

Sixty-six patients who underwent IAC surgery in our department between 2010 and 2020 were studied retrospectively. Based on the surgical technique, clinical and volumetric changes, postoperative complications, recurrence rates, and length of hospital stay were statistically compared.

RESULTS

Microsurgical fenestration (MF) was performed on 32 (48.5%) patients, endoscopic fenestration (EF) on 17 patients, cystoperitoneal shunt (CPS) on 11 patients, and EF + CPS in six patients. The mean IAC volume change rate was 68.54 mL, and the mean cyst volume change rate was 40.68%. The MF technique produces a significantly greater mean cyst volume change than the EF technique. The mean volume change in sylvian IAC is 4.8 times greater than in posterior fossa IAC, a significant difference. The mean cyst volume change is four times greater in patients with skull deformity than in patients with balance loss, and this difference is statistically significant. In patients with cranial deformity, the mean cyst volume change is 2.6 times greater than in patients with neurological dysfunction. This difference is also statistically significant. The volume of IAC decreased more in patients with postoperative complications, with a significant difference between the postoperative complication and the change in IAC volume.

CONCLUSION

MF can achieve better volumetric reduction in IAC, particularly in patients with sylvian arachnoid cysts. However, more volumetric reduction increases the risk of postoperative complications.

Intracranial drainage versus extracranial shunt in the treatment of intracranial arachnoid cysts: a meta-analysis

OBJECTIVE

To review the literature and analyze the efficacy and safety of two surgery procedures, intracranial drainage and extracranial shunt, for intracranial arachnoid cysts.

METHODS

We searched the online Medlars, PubMed, and Cochrane Central electronic databases and collected studies of patients with intracranial arachnoid cysts treated with two surgical methods.

RESULTS

The meta-analysis results shows that there were not statistically significant in clinical symptoms improvement, cyst reduction, the improvement of epilepsy, epidural hematoma, cerebrospinal fluid leak, and recurrence rate (P > 0.05, with RR values are 0.99, 0.94, 1.00, 0.94, 1.21, and 0.75 respectively). There was statistically significant in the occurrence rate of intracranial infection (P = 0.0004, RR = 0.28). The intracranial drainage group was lower than extracranial shunt group.

CONCLUSION

The results indicated that the efficacy and safety of two surgery procedures are similar in the treatment of intracranial arachnoid cysts, but the intracranial drainage was better than extracranial shunt in reducing the risk of intracranial infection.

Optic nerve ultrasonography in the evaluation of the relationship between arachnoid cyst and headache

AIM

This study is aimed to show the difference between optic nerve sheath diameter (ONSD) values in migraine patients with and without arachnoid cysts from migraine patients and control groups, and to evaluate the relationship with the arachnoid cyst size on magnetic resonance imaging (MRI) and their clinical severity.

METHODS

This cross-sectional study included pediatric patients who were previously diagnosed with migraine and the control group. The patients consist of 3 groups. The first group was 24 patients with arachnoid cysts on brain magnetic resonance imaging (MRI) who met the diagnostic criteria for migraine (group 1); the second group was 20 patients with only headache without arachnoid cysts or other findings on brain magnetic resonance imaging (MRI) (group 2); the third group was completely healthy 20 control group. Demographic data of the patients, the onset of headache time, clinical severity, electroencephalography (EEG) findings, optic nerve sheath diameter (ONSD) measurements by ultrasonography, and the volume of arachnoid cyst on brain MRI were determined and compared.

RESULTS

The optic nerve sheath diameter (ONSD) value was the highest in group 1 and the lowest in the control group (p: 0.001). The clinical severity was statistically different between the groups (p: 0.038). Accordingly, the majority of the clinical severity of group 1 was determined in grades 3 and 4. A weak positive correlation was found between the arachnoid cyst size on MRI and the ONSD measurement (r = 0.410, p = 0.047). The ONSD value statistically significantly increased with clinical severity in group 1 (p: 0.003).

CONCLUSION

The reliability of the optic nerve sheath diameter (ONSD) measurements in determining the increase of the intracranial pressure was shown in previous studies. This is the first study in the literature presenting that the intracranial pressure effects of arachnoid cysts can be demonstrated by ONSD. We have considered that arachnoid cysts detected in headaches can create a compression effect and cause the pain to intensify.

Intracranial arachnoid cysts and epilepsy in children: Should this be treated surgically? Our 29-year experience and review of the literature

INTRODUCTION AND OBJECTIVE

Arachnoid cysts (ACs) are relatively frequent lesions related to different neurological symptoms, being mostly incidentally diagnosed. This study aims to clarify whether AC surgery in epileptic patients is useful in their treatment.

MATERIAL AND METHODS

The patients registered in the database of the Neuropediatrics Section from May 1990 to August 2019 are analyzed retrospectively. Patients in whom the diagnosis of ACs and epilepsy coincide are studied. The location, size and number of ACs, neurological development, age at diagnosis, follow-up time, the performance of surgery on the cyst, evolution, anatomical relationship between brain electrical activity and location of AC, and type of epilepsy are analyzed.

RESULTS

After analyzing the database, we found 1881 patients diagnosed with epilepsy, of which 25 had at least one intracranial AC. In 9 of the patients, cerebral or genetic pathologies were the cause of epilepsy. Of the other 16, only 2 patients showed that the type of epilepsy and the epileptogenic focus coincided with the location of the AC; one of them was surgically treated without success, and the other one remained asymptomatic without receiving medical or surgical treatment.

CONCLUSIONS

Although it is necessary to design a prospective study to establish causality, the results of our research and the available literature suggest that there is no causal relationship between the presence of ACs and epilepsy. The study and treatment of these patients should be carried out in a multidisciplinary epilepsy surgery unit, without initially assuming that the AC is the cause of epilepsy.

Cine MRI Is Useful for the Diagnosis of Intradural Arachnoid Cyst with Spinal Arachnoid Web: A Case Report

CASE

A 28-year-old woman developed gait disturbance due to lower limb weakness 3 years before presentation. Conventional magnetic resonance imaging (MRI) findings were inconclusive; therefore, we performed cine MRI, which confirmed the presence of a pulsatile cyst on the posterior thoracic spinal cord. The cyst compressed the spinal cord, and its pulsations synchronized with the patient's heartbeats. We resected the intradural arachnoid cyst and thickened arachnoid membrane. The gait disturbance improved after surgery.

CONCLUSIONS

Cine MRI can be used to identify a pulsating arachnoid cyst that cannot be visualized with a conventional MRI. Cine MRI is useful in patients with unexplained spinal symptoms.

Concomitant chronic subdural hematomas and arachnoid cysts in young adults

Objective: This study aimed to evaluate the correlation between arachnoid cysts and chronic subdural hematomas in young adults. Methods: This retrospective study evaluated ten patients having concomitant chronic subdural hematomas and arachnoid cysts. Patients were evaluated with the data of age and gender, location of hematoma and arachnoid cyst, trauma history, symptoms at admission, maximum hematoma diameter, contiguity between arachnoid cyst and hematoma, and treatment  methods. Results: We treated 285 patients who were diagnosed with cSDH between January 2013 and December 2019. 22 patients were under the age of 40 years. Ten of them had both cSDH and arachnoid cysts. The mean age of patients was 24.8±3.9 years. Patients with only chronic subdural hematoma had higher mean age than the patients with arachnoid cyst-related chronic subdural hematoma. In four patients, the onset of chronic subdural hematoma was reported after arachnoid cyst diagnosis. Four of the patients did not have causative trauma history, and two patients suffered minor sports-related traumas. All patients had headache, and only two patients had hemiparesis. The location of arachnoid cysts were in the middle fossa in eight patients. All patients had chronic subdural hematomas on the ipsilateral side of arachnoid cyst. Four patients who had smaller than 10 mm maximal cSDH diameter underwent conservative management. They were followed by serial neuroimaging studies and it was noted that the hematoma disappered and the size of the arachnoid cysts decreased over time without any neurological complication. In six cases, craniotomy was required, and all recovered completely. cSDH did not recur during 5–60 months of follow-up period (median 12 months). Conclusions: It seems that presence of an arachnoid cyst in young adults is a predisposing factor for the formation of chronic subdural hematoma. Coincidentally diagnosed arachnoid cyst patients may be followed up with periodical clinical examinations and neuroimaging studies.

Pulsating Spinal Arachnoid Cyst as a Hidden Aggravating Factor for Thoracic Spondylotic Myelopathy: A Report of 3 Cases

CASE

We report 3 cases of thoracic myelopathy caused by vertebral osteophytes and coexisting intradural spinal arachnoid cyst (SAC), which was difficult to diagnose on preoperative magnetic resonance imaging. Intraoperative ultrasound sonography revealed spinal cord impingement because of osteophytes and a pulsating intradural SAC. Repeated pincer compression on the spinal cord seemed to be associated with their paraparetic symptoms.

CONCLUSION

In treating patients presenting with unexplained progressive myelopathy with small ossified lesion in the thoracic spine, close attention should be paid to a coexisting SAC as a hidden aggravating factor for thoracic myelopathy.

[Clinical effect of endoscopic transnasal sphenoidal approach with simple muscle packing for intrasellar arachnoid cyst]

Objective: To examine the clinical effect of simple muscle packing through transnasal sphenoid approach in the treatment of intrasellar arachnoid cyst. Methods: The clinical data of 11 patients with intrasellar arachnoid cyst treated by transnasal sphenoidal approach with simple muscle packing at the Neurosurgery Department of the First Affiliated Hospital of Zhengzhou University from January 2014 to February 2020 were retrospectively analyzed. There were 5 males and 6 females, with a median age of 48 years (range: 23 to 75 years). The clinical manifestations included headache in 6 cases, dizziness in 4 cases, hypo-libido in 1 case, disturbance of consciousness in 1 case, visual impairment in 7 cases and mixed pituitary dysfunction in 5 cases. The enlargement of the sellar fossa was seen in the preoperative MRI images. The enhanced MRI images showed that the cyst wall of the intrasellar arachnoid cyst was not enhanced, and the compression and thinning of the sellar base was seen in the CT images. In 9 cases, the cyst extended suprasellar and the sellar septum was "arched". In 7 cases, the cyst compressed the optic chiasm upward. The cyst walls of all patients were incised through the nasal sphenoid approach under the endoscope, and the muscle was packed after sufficient drainage. The postoperative symptoms, pituitary endocrine function and recurrence of patients were followed up. Results: MRI images of the sellar region in all patients showed significant reduction or disappearance of cysts. Intracranial infection occurred in 1 case and electrolyte disorder in 2 cases, which were relieved after symptomatic treatment. No cerebrospinal fluid rhinorrhea occurred. Postoperative clinical symptoms were completely relieved in 6 cases and partially relieved in 5 cases. Pituitary endocrine function recovered completely in 2 cases and improved significantly in 4 cases. All patients were followed up for 10 to 40 months. One patient found to have a partial recurrence of the cyst 3 months after surgery. Because there were no new symptoms appeared, the follow-up was continued without second operation. Conclusion: Transnasal sphenoidal approach is a feasible method for the treatment of intrasellar arachnoid cyst.

[Arachnoid cysts can be associated with cognitive and affective symptoms]

Arachnoid cysts are frequent incidental findings on brain scans. Traditionally, they are regarded as harmless, congenital structures which do not require surgical treatment. In the rare cases where surgery is indicated it can be due to haemorrhage, hydrocephalus or cranial nerve affection caused by the cyst. However, recent literature suggests a correlation between arachnoid cysts and cognitive and affective symptoms. The hypothesised pathomechanisms include pressure, affected neuronal or glial metabolism and inflammation. If this is correct a more active approach might benefit the patients as suggested in this review.

A Single Vertebral Surgical Approach for Spinal Extradural Meningeal Cysts Spanning Multiple Vertebral Segments by Auxiliary Neuroendoscope

BACKGROUND

Spinal extradural meningeal cysts (SEMCs) are rare lesions, especially those spanning multiple vertebral segments, and the surgical strategy has remained controversial. In the present study, we have described the outcomes of 4 patients with SEMCs treated with dural defect repair alone assisted by neuroendoscopy.

METHODS

From January 2018 to January 2020, 4 patients with SEMCs spanning multiple vertebral segments had undergone single-vertebral laminectomy or hemilaminectomy.

RESULTS

The SEMCs in all 4 patients had spanned multiple vertebral segments, from T11 to L2. Using magnetic resonance imaging, the location of the dural defect was predicted correctly for 3 patients. Single-vertebral laminectomy was used in 2 patients and single-vertebral hemilaminectomy in 2 patients. Intraoperatively, the entire cyst, including the upper pole, lower pole, and middle segment of the cyst, was explored using neuroendoscopy. In each patient, only 1 dural defect was found, which had been located in the middle segment of the cyst (T12-L1). All cyst dural defects had been sutured under a microscope. In all cases, the cyst wall was not removed. Postoperatively, the symptoms for all the patients had improved significantly, and subsequent magnetic resonance imaging studies showed obvious cyst regression. During the follow-up period of 15-44 months, no recurrence was observed.

CONCLUSIONS

For SEMCs spanning multiple vertebral segments, dural defect repair without cyst wall resection through single-vertebral hemilaminectomy or laminectomy can be effective. Intraoperative neuroendoscopy can assist, not only in finding the dural defect, but also in avoiding the omission of multiple dural defects as much as possible.

Spinal Arachnoid Web: A didactic report of two cases with clinical, radiological, surgical and pathological correlations

BACKGROUND

Arachnoid web (AW) is a rare but probably underestimated cause of spinal cord injury that is complex to diagnose due to subtle MRI findings and similarities to other better-known diseases such as arachnoid cyst (AC) or transdural spinal cord herniation (TSCH). Increased recognition of AW is mandatory since delay in diagnosis can lead to potentially serious neurological sequelae.

CASE PRESENTATIONS

We report two additional cases of AW for didactic purposes, with special emphasis on the distinctive MRI and intraoperative findings. Both patients presented with progressively worsening neurological symptoms, including proprioceptive ataxia, motor weakness, numbness and neuropathic pain. The diagnosis of AW was suspected on the basis of specific MRI criteria, especially the so-called "scalpel sign". Formal confirmation of the diagnosis was obtained in two patients that were managed surgically. Postoperative follow-up demonstrated significant functional recovery.

DISCUSSION

There is a need for better recognition of AW by the medical community. Careful analysis of MRI semiology is crucial for the distinction between AW, AC and TSCH. Prompt and accurate diagnosis is mandatory to conserve functional prognosis, since appropriate surgical treatment with AW resection is curative, halting or even resolving the neurological symptoms.

Subdural Hygroma: A Rare Complication of a Common Brain Malformation

INTRODUCTION

Arachnoid cysts are a common incidental finding on head imaging. While the natural history of these cysts in poorly described, hemorrhage with subdural hygroma formation is rare. We review the clinical course of a patient who developed a subdural hygroma following trauma.

CASE

The patient was a previously healthy 14-month-old male who presented to the Emergency Department with vomiting after a fall and was found to have esotropia without other focal neurological deficits and a CT scan consistent with a subdural cerebrospinal fluid collection with midline shift. The patient was treated conservatively and his symptoms resolved.

DISCUSSION

Arachnoid cyst rupture is a rare complication which can lead to increased intracranial pressure with devastating consequences. Clinical manifestation can be similar to that of other intracranial pathologies. Prompt diagnosis is required to avoid life-threatening symptoms.

CONCLUSION

Arachnoid cyst rupture should be considered when evaluating patients with non-specific neurological symptoms following trauma.

Spontaneous rupture of middle fossa arachnoid cysts: surgical series from a single center pediatric hospital and literature review

PURPOSE

Arachnoid cysts may present with symptoms deriving from cyst rupture, usually causing intracystic hemorrhage and subdural hematoma or hygroma. Rupture is usually caused by minor trauma, spontaneous rupture is an exceptional event, and 57 cases have been described in literature. We here present and discuss the largest series of spontaneously ruptured middle fossa arachnoid cysts in order to investigate clinical presentation and best treatment available.

METHODS

We report a retrospective series of 17 pediatric patients surgically treated for middle fossa arachnoid cyst with signs of cyst rupture without a history of trauma in the previous 90 days. We describe clinical presentation, treatment, and outcome at follow-up discussing our results with a literature review including all reported cases of spontaneous rupture of middle fossa arachnoid cysts.

RESULTS

In our experience patients most frequently presented with subdural hygroma, in literature, a chronic hematoma was most frequently reported. Headache is the most reported symptom at presentation. Neurological deficits and consciousness alterations are rare. Surgical treatment may resolve brain compression only or reduce rupture recurrence risk. Conservative treatment has also been proposed. Different treatments are reported and discussed focusing on indications, contraindications, risks, and expected benefits.

CONCLUSION

We propose, when safely possible, microsurgical cyst fenestration in skull base cisterns as the treatment of choice for these patients as long as it addresses both immediate decompression and risk of rupture recurrence. We report good outcomes and low incidence of complications from our series with a mean postoperative follow-up of 30 months.