Prevalence and natural history of arachnoid cysts in children

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.

Acetazolamide to treat symptomatic ruptured arachnoid cysts: illustrative cases

BACKGROUND

Arachnoid cysts are benign, often asymptomatic intracranial mass lesions that, when ruptured, may cause seizures, raised intracranial pressure, hemorrhage, and/or loss of consciousness. There is no widely agreed upon treatment, and there is debate as to whether a nonoperative or surgical approach is the best course of action. The carbonic anhydrase inhibitor acetazolamide may be an effective nonoperative approach in treating ruptured arachnoid cysts.

OBSERVATIONS

The Pediatric Neurosurgery Clinical Database at BC Children’s Hospital from 2000 to 2020 was queried, and four pediatric patients who were treated with acetazolamide after presentation with a ruptured middle cranial fossa arachnoid cyst were identified. All patients showed some degree of symptom improvement. Three of the patients showed complete reabsorption of their subdural collections in the ensuing 6 months. One patient had an inadequate response to acetazolamide and required surgical management.

LESSONS

Acetazolamide is a safe and reasonable primary treatment option in pediatric patients with ruptured middle cranial fossa arachnoid cysts, and it may help avoid the need for surgery.

Supratentorial Pediatric Midline Tumors and Tumor-like Lesions: Clinical Spectrum, Natural History and Treatment Options

Childhood Central Nervous System tumors account for 25% of all pediatric tumors. Large availability and broadening of indications to imaging has made incidental findings more common. Among these, midline lesions have different clinical relevance depending on their intrinsic pattern of behaviour and on their specific location. In this narrative review we describe the natural history and treatment options of midline lesions in children.

Reversible hearing loss after 3D video-assisted marsupialization of several posterior fossa arachnoid cysts: A case report

Very few pediatric cases of arachnoid cyst of ponto-cerebellar angle are described in the literature. Only 4 are described with hearing loss. It is a pathology which poses especially a problem of early diagnosis. In this paper we describe the management of a 16-year-old patient with an arachnoid cyst of the cerebellopontine angle with an isolated auditory deficit that was treated surgically. The follow up was marked by a Full recovery of hearing after surgical treatment. Arachnoid cyst of the cerebellopontine angle is rare in the pediatric population. early surgical management help to increase the chances of recovery.

Surgical management of quadrigeminal cistern arachnoid cysts: case series and literature review

OBJECTIVE

Quadrigeminal cistern arachnoid cysts (QACs) are congenital lesions that can cause pineal region compression and obstructive hydrocephalus when sufficiently large. Management of these cysts is controversial and rates of reintervention are high. Given the limited data on the management of QACs, the authors retrospectively reviewed 20 years of cases managed at their institution and performed a literature review on this topic.

METHODS

The authors performed a retrospective analysis of patients treated for QAC at their institution between 2001 and 2021. They also performed a literature review of studies published between 1980 and 2021 that reported at least 5 patients treated for QACs. Patient characteristics, radiographic findings, management course, and postoperative follow-up data were collected and analyzed.

RESULTS

A total of 12 patients treated for a QAC at the authors' institution met the inclusion criteria for analysis. Median age was 9 months, mean cyst size was 5.1 cm, and 83% of patients had hydrocephalus. Initial treatment was endoscopic fenestration in 92% of these patients, 27% of whom had an endoscopic third ventriculostomy (ETV) performed concurrently. Reintervention was required in 42% of patients. Cases that required reintervention had a statistically significant lower median age at the initial intervention (5 months) than the cases that did not require reintervention (24.33 months; p = 0.018). There were no major complications. At a mean follow-up of 5.42 years, 83% of patients had improvement or resolution of their symptoms. A literature review revealed 7 studies that met the inclusion criteria, totaling 108 patients with a mean age of 8.8 years. Eighty-seven percent of patients had hydrocephalus at presentation. Ninety-two percent of patients were initially treated with endoscopic fenestration, 44% of whom underwent concurrent ETV. Complications occurred in 17.6% of cases, and reintervention was required in 30.6% of cases. The most frequent reason for reintervention was untreated or unresolved hydrocephalus after the initial procedure.

CONCLUSIONS

Endoscopic fenestration is the most common treatment for QACs. While generally safe and effective, there is a high rate of reintervention after initial treatment of QACs, which may be associated with a younger age at the first intervention. Additionally, identifying patients who require initial treatment of hydrocephalus is critically important, as the literature suggests that untreated hydrocephalus is a common cause of reintervention.

Impaired visual acuity as an only symptom of shunt malfunction, long time after initial cyst-peritoneal shunting for arachnoid cyst: A case report

Background:

Long-term outcomes after surgical treatment of arachnoid cysts (ACs) have not been reported adequately. Impaired visual acuity is not a common symptom of shunt dependency syndrome due to cyst-peritoneal (CP) shunt malfunction for ACs. We report a case of CP shunt malfunction, who presented only impaired visual acuity as a symptom, long after the initial surgical treatment.

Case Description:

A 16-year-old boy was surgically treated for the left frontal AC with CP shunting at 2 years of age. Extension of the peritoneal shunt catheter was performed at 15 years of age. A year later, he started experiencing impairment of visual acuity without headaches, which worsened to bilateral light perception. The presence of bilateral optic atrophy was confirmed. The AC in the left frontal lobe had enlarged very slightly, with shortening of the intracystic catheter, and the cerebrospinal fluid pressure was elevated to 30 cmH2O. He was treated with lumboperitoneal shunting. The visual acuity showed limited improvement.

Conclusion:

The possibility of CP shunt malfunction and shunt dependency syndrome should be considered, even if the patient presented only impaired visual acuity and no significant changes in the size of the ACs are observed.

Classification of pediatric headache cases referred to a neurology department

BACKGROUND

Headaches are very common in children. The patients often have mild symptoms, but on occasion may have severe, secondary headaches. The present study aimed to clarify the details of children with headaches seen at the outpatient clinic of a pediatric neurological department.

METHODS

The present, retrospective observational study was conducted at a tertiary pediatric hospital in Japan and enrolled children referred to the neurology department outpatient clinic for headache between April 2018 and March 2021.

RESULTS

In total, 113 cases of headache were examined; of these, 99 (87.6%) were primary headaches, one case (0.9%) was a secondary headache, and 13 (11.5%) were unclassified or unspecified. There were 46 cases (40.7%) of tension-type headache (TTH), both confirmed and suspected, 30 cases (26.5%) of migraine, and 23 cases (20.4%) of a combination of the TTH and migraine. One case of secondary headache was attributed to an infection. Arachnoid cysts were found in seven patients (7.8%). Acute drug treatments were administered to 93 patients (82.3%), with acetaminophen being the most common drug, followed by ibuprofen. Prophylactic drug treatments were administered to 39 patients (34.5%), with goreisan (a Chinese herbal medicine containing Alisma orientale, Poria cocos, Polyporus umbellatus, Atractylodes lancea, and Cinnamomum cassia) being the most common (41%).

CONCLUSIONS

Few cases of secondary headache and none of emergency headache were diagnosed. The prevalence of arachnoid cysts was higher than in the general pediatric population, suggesting that arachnoid cysts might be associated with headache.

Non-Operative Management of a Pediatric Patient With Bilateral Subdural Hematomas in the Setting of Ruptured Arachnoid Cyst

Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.

Neuro-Ophthalmologic Monitoring in the Management of Increased Intracranial Pressure From Leaking Arachnoid Cysts

BACKGROUND

Intracranial arachnoid cysts are common incidental imaging findings. They may rarely rupture, leading to the development of subdural hygromas and high intracranial pressure (ICP). Neurosurgical intervention has been advocated in the past, but recent evidence indicates that most cases resolve spontaneously. The role of neuro-ophthalmologic monitoring in identifying the few cases that have persisting vision-threatening papilledema that justifies intervention has not been emphasized.

METHODS

Retrospective review of 4 cases of leaking arachnoid cysts drawn from the files of the University of Michigan Medical Center (Michigan Medicine) between 2007 and 2018.

RESULTS

In 1 case, surgery was avoidable as papilledema resolved over time despite lingering imaging features of mass effect. In 3 cases, papilledema persisted with the threat of permanent vision loss, prompting neurosurgical intervention. In one of those cases, the fluid collection was thinly but extensively spread across both hemispheres without brain shift; yet, papilledema was pronounced. Emergent evacuation led to rapid resolution of papilledema and encephalopathy, but with residual optic nerve damage.

CONCLUSIONS

Because constitutional symptoms and even imaging are not always reliable indicators of high ICP in leaking arachnoid cysts, neuro-ophthalmologic monitoring of papilledema is valuable in identifying the cases when neurosurgical intervention is necessary.

Acute communicating hydrocephalus after intracranial arachnoid cyst decompression: A report of two cases

Background:

Arachnoid cysts (AC) may cause hydrocephalus and neurological symptoms, necessitating surgical intervention. Cyst drainage may result in postoperative complications, however, these interventions are not normally associated with the subsequent development of acute hydrocephalus. Herein, we present two unique cases of AC drainage with postoperative development of acute communicating hydrocephalus.

Case Description:

Case 1. A 75-year-old female presented with progressive headaches, cognitive decline, and questionable seizures. Her neurological examination was non-focal, but a head computed tomography scan (CT) identified a large right frontal AC with mass effect. She subsequently underwent craniotomy and decompression of the cyst. Postoperatively, her neurological examination deteriorated, and a head CT demonstrated new communicating hydrocephalus. The opening pressure was elevated upon placement of an external ventricular drain. Her hydrocephalus improved on follow-up imaging, but her neurological examination failed to improve, and she ultimately expired. Case 2. A 61-year-old female presented with headache and seizures attributed to a left parietal AC. She underwent open craniotomy for fenestration of the cyst into the Sylvian fissure. Postoperatively, her neurologic examination deteriorated, and she developed acute communicating hydrocephalus. She was initially managed with external ventricular drainage (EVD). The hydrocephalus resolved after several days, and the EVD was subsequently removed. Late follow-up imaging at 2 years showed that the regression of the AC was maintained.

Conclusion:

Acute development of hydrocephalus is a potential complication of intracranial AC fenestration. A better understanding of intracranial cerebrospinal fluid flow dynamics may better inform as to the underlying cause of this complication.

Endoscopic management of periventricular and intraventricular arachnoid cysts

Introduction

The most successful surgical management of periventricular and intraventricular cysts is still a matter of debate. Up to the early 1990s, open cyst fenestration and cystoperitoneal shunts were the only options available. Recently, different endoscopic approaches to these lesions have gained popularity.

Methods

Eighteen endoscopic procedures were performed for the treatment of arachnoid cysts in 18 patients. Sylvian fissure arachnoid cysts were excluded from this study. Ten of them were females and eight were males with their ages ranging from 6 months to 50 years with a mean of 16 years. All patients were prospectively observed.

Results

Seven of the arachnoid cysts were in the suprasellar region, 5 in the quadrigeminal region, 2 in the posterior fossa, 2 parietal, and 2 intraventricular. Seventeen cases (94%) had hydrocephalus. The main presenting manifestations were those of increased intracranial pressure. All fenestrations were done in the lateral ventricle except for the 2 cases with posterior fossa arachnoid cysts, the fenestrations were done to the fourth ventricle. Endoscopic ventriculocytostomies (VC) were performed in 14 cases without operative complications and no stents were placed. Endoscopic cystocisternostomies (C) were done in all suprasellar cases. Endoscopic cystoventriculostomies (CV) were done in 4 cases. The mean surgical time was 1 h. The mean follow-up period was 15 months. Symptoms improved in 17 cases. Seventeen cases demonstrated a significant decrease of the cysts’ size in the postoperative computed tomography (CT) and magnetic resonance imaging (MRI). A single case developed a complication in the form of subdural hygroma which required no intervention and was managed conservatively.

Conclusion

Endoscopic management of periventricular and intraventricular arachnoid cysts is a useful safe option in the management of arachnoid cysts related to the ventricular system.

Incidental Intracranial Cysts in Children

With increasing use of intracranial imaging, the diagnosis of benign intracranial cysts is becoming more frequent in the pediatric population. These lesions are usually incidentally discovered during the work-up of unrelated symptoms. Most do not require treatment and many do not even require imaging follow-up. When symptomatic, symptoms of these lesions are usually caused by local mass effect. Symptomatic lesions warrant neurosurgical evaluation, and may require surgical intervention in rare, well-selected cases. This article describes three common benign intracranial cysts found in the pediatric population: arachnoid cysts, choroid cysts, and pineal cysts.

Are arachnoid cysts actually clinically mute in relation to neuropsychological symptoms? Cognitive functioning in children with AC of middle and cranial fossa

Aiming at being part of the discussion about the cognitive functioning of patients with arachnoid cysts (AC) and the value of neuropsychological testing in these patients, we present our study in which we investigated the cognitive functioning of 32 children with ACs of the middle cranial fossa. We compared the Stanford Binet 5 (SB 5) results obtained by the patients with the population mean values and analysed the relation between the patients' clinical details and the results of SB 5. The main conclusions of this research are: (1) In SB 5 tasks, the tested group performed worse than the population mean, which could be related to AC of the middle cranial fossa. Deficits concern especially visuospatial reasoning, quantitative reasoning, and knowledge. The obtained results indicate the coexistence of cognitive impairment and AC of the middle cranial fossa. (2) In patients with AC, neuroimaging information has only limited predictive ability regarding cognitive syndromes. (3) The complaints reported in the interview are not necessarily objectively reflected in the clinical assessment. Neuropsychological assessment should be part of the management of all patients with AC. (4) Cognitive deficits in patients with AC may become more pronounced with age. Accordingly, increasing school difficulties in these patients should be expected. In light of the above, there is a clear indication of the need for neuropsychological support and support in school functioning for patients with AC. (5) Neuropsychological control in patients with AC is crucial not only with regard to treatment decisions but primarily for monitoring school performance and providing these patients with adequate neuropsychological and psychological support.

A Neuronavigation-Assisted Endoscopic Ventriculocystocisternostomy of a Suprasellar Arachnoid Cyst: A 2D Video Case Presentation

Background and Importance: Suprasellar arachnoid cysts are insidious and progressive ventricular cysts that cause hydrocephalus, ataxia, optic, and endocrinological symptoms. These cysts can be successfully treated via an endoscopic ventriculocystocisterostomy (VCC).

Clinical Presentation: A three-year-old patient presented with emesis and bobble-head doll syndrome with a suprasellar arachnoid cyst. Through our video, we present our neuronavigation-assisted endoscopic VCC without cautery and the relevant neuroanatomy.

Conclusion: Neuroendoscopic fenestration is a preferred approach over resection or shunting for a suprasellar arachnoid cyst. In addition, VCC has decreased recurrence and increased radiologic improvement over a ventriculocystostomy (VC).

Pediatric cerebral cysts: comparison of early complications following fenestration versus shunting procedures

Objective: Characterize practice patterns and acute (30-day) surgical complications following fenestration and shunt procedures for the treatment of cerebral cysts in pediatric patients.Methods: This study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients were identified by International Classification of Disease codes for cerebral cysts and Current Procedural Terminology codes for shunting or fenestration. Demographic data, preoperative comorbidities, and postoperative complications were compared between the two procedures.Results: 741 patients were included in the data analysis, with a majority aged 4 years or younger (55.9%) and a male predominance (62.6%). Fenestration was performed in 590 (79.6%) patients. Primary shunting was performed in 151 (20.4%) patients. Patients who received shunts were more commonly aged 0-4 years and had proportionately worse preoperative health status. No statistically significant differences in postoperative complications were detected. Reoperation rate was 7.9% and 8.6% in the shunt and fenestration groups, respectively. Common reasons for reoperation were shunt revision or replacement and shunt placement after fenestration. Patients requiring shunting after a failed fenestration tended to be younger with higher American Society of Anesthesiologists (ASA) classification.Discussion: Fenestrations are performed more often than shunting. Generally, children who receive shunts are younger than those who undergo fenestration. Acute surgical risk appears to be similar for both operations.

The health-related quality of life in children with arachnoid cysts. Clinical predictors and parent-child perspectives

BACKGROUND

In clinical practice, arachnoid cysts are usually detected by coincidence and are frequently considered as clinically mute. Even though an AC does not usually result in serious symptoms, the diagnosis itself can have a significant impact on the patients and their families, especially in terms of psychological functioning and quality of life.

METHODS

Participants were 22 pairs of children diagnosed with AC and their parents. We analysed patients' medical records and assessed them using the Stanford Binet Intelligence Scale ed. 5th. Additionally, both children and parents filled in the Polish version of the PedsQL™ 4.0 generic core module.

RESULTS

The HRQOL is not related to objective predictors such as radiological predictors and SB 5 results. However, there is a correlation between the HRQOL, and symptoms given in the interview. Secondly, parents assess the HRQOL of their children worse compared to the children's own ratings. Lastly, children with AC assess the HRQOL in a way that is similar to the assessment done by healthy children in the original study describing PedsQL™, whereas parents assess children's HRQOL in a way rather similar to the assessment done by parents of patients.

CONCLUSIONS

The results show the impact of the disease's image and understanding on the HRQOL. Basing on our results we conclude the important role of psychological support for patients with AC. We furthermore conclude that parents of children with AC assess the HRQOL of children worse compared to the children's own ratings.

Intracranial arachnoid cysts in an infant: A technical note on the innovative use of navigation and flexible endoscopy for cyst fenestration

Background:

Intracranial arachnoid cysts (ACs) are a cerebral spinal fluid (CSF) collection within the meninges. They typically arise during embryologic development. Some are stable overtime with little consequence, but large or growing cysts may require surgical intervention. The optimal surgical technique is debated and may be more technically challenging in the infant age group.

Case Description:

Our unique case report details a 10-month-old (6 months corrected age) infant who presented with a drastic increase in head circumference and was found to have midline shift and three cysts – one large and two smaller ones. He was treated with an innovative surgical approach combining stereotactic introduction of a catheter to facilitate subsequent flexible endoscopy allowing three separate cysts to be treated through one small surgical incision with no complications and a stable examination on 2-year follow-up.

Conclusion:

Symptomatic ACs in the infant population that require treatment can be addressed with open surgery to fenestrate the cyst, endoscopic cyst fenestration, or cystoperitoneal shunting. Typically, surgeons must choose between a rigid endoscope which allows stereotactic navigation or a flexible endoscope which allows multiple trajectories but precludes navigation. Our case demonstrates that combining stereotactic ventricular placement before flexible endoscopy provides the benefit of both approaches and allows for successful endoscopic treatment in a young patient with durable results.

Resolution of the large middle fossa arachnoid cyst without any identifiable cause: Case report

Although the possibility of spontaneous regression of intracranial arachnoid cysts (AC) during observational follow-up is widely recognized, the number of reports documenting such clinical course, often associated with the mild head trauma, is rather limited. We present a case of nearly complete resolution of the large middle fossa AC in a 5-year-old boy without any identifiable cause in 2.3 years after the initial diagnosis. It once again justifies observational strategy for AC not accompanying by mass effect and manifesting with minimal symptoms or diagnosed incidentally.

Surgical fenestration might not be the best option for very young patients with middle fossa arachnoid cysts

PURPOSE

Surgical fenestration is widely accepted as a primary treatment for middle fossa arachnoid cysts (MFACs) in pediatric patients. However, postoperative subdural effusion and/or hydrocephalus always affect treatment outcomes. In this study, we presented our experience of treating MFACs with surgical fenestration in pediatric patients and analyzed the cases complicated by postoperative subdural effusion and/or hydrocephalus, to give insight into the clinical characteristics predisposing the complications.

METHODS

We retrospectively analyzed 21 pediatric cases with MFACs treated by surgical fenestration suffering postoperative subdural effusion and/or hydrocephalus in our department from November 2011 to April 2019. We reviewed the clinical characteristics and treatment outcomes.

RESULTS

A total of 21 patients, among a total of 53 pediatric patients with MFACs treated by surgical fenestration, developed subdural effusion and/or hydrocephalus postoperatively. The mean age at the time of the initial surgery was 49 months. A total of 75% (6/8) of the patients under 2 years old and 13.3% (6/45) of the older patient group sustaining postoperative subdural effusion and/or hydrocephalus required further surgeries, respectively (Fisher's exact test, p = 0.001). Notably, among the 21 cases with postoperative subdural effusion and/or hydrocephalus, all the 6 patients under 2 years old needed additional surgeries, while of the other 15 older patients, only 40% (6/15) needed further surgical interventions (Fisher's exact test, p = 0.019).

CONCLUSION

The immature CSF absorption in MFAC patients younger than 2 years old might predispose them to the relatively serious postoperative subdural effusion and/or hydrocephalus. For very young patients with giant MFACs, surgical fenestration might not be the best option.

Head Injury without Head Blow? A Rare Case of Subdural Hematoma Associated with Minute Arachnoid Cyst in a Teenage Skater

BACKGROUND

 Skateboarding has been reported to cause diverse kinds of injuries, including head trauma. However, the risk of brain injury without direct blow to the head seems to be underestimated. In particular, the impact of the inertial forces related to the vigorous character of skateboarding tricks is not sufficiently recognized.

CASE DESCRIPTION

 In our report, we demonstrate a case of chronic subdural hematoma developing without previous blow to the head in a 17-year-old skater bearing small frontal convexity arachnoid cyst.

CONCLUSION

 Based on the described case, the possibility of acceleration and angular forces related to skate park leisure activities resulting in subdural hematoma needs to be discussed. This risk should be critically appraised in patients carrying arachnoid cyst as a malformation predisposing to develop subdural bleeding.

A Rare Case of Spontaneous Arachnoid Cyst Rupture Presenting as Right Hemiplegia and Expressive Aphasia in a Pediatric Patient

This study examines an 11-year-old boy with a known history of a large previously asymptomatic arachnoid cyst (AC) presenting with acute onset of right facial droop, hemiplegia, and expressive aphasia. Shortly after arrival to the emergency department, the patient exhibited complete resolution of right-sided hemiplegia but developed headache and had persistent word-finding difficulties. Prior to symptom onset while in class at school, there was an absence of reported jerking movements, headache, photophobia, fever, or trauma. At the time of neurology consultation, the physical exam showed mildly delayed cognitive processing but was otherwise unremarkable. The patient underwent MRI scanning of the brain, which revealed left convexity subdural hematohygroma and perirolandic cortex edema resulting from ruptured left frontoparietal AC. He was evaluated by neurosurgery and managed expectantly. He recovered uneventfully and was discharged two days after presentation remaining asymptomatic on subsequent outpatient visits. The family express concerns regarding increased anxiety and mild memory loss since hospitalization.

Paediatric arachnoid cysts: Surgical outcomes from a Singapore children's hospital

Arachnoid cysts (AC) are reported to have a prevalence of up to 2.6% in children. Most AC remain indolent, but others may expand or rupture to cause life-threatening symptoms of raised intracranial pressure. Currently, there are 2 controversial topics with regards to the management of ACs: the indications for surgery and the choice of surgical procedure. We therein report our institution's neurosurgical experience for symptomatic AC over a 22-year period and corroborate our results with published literature. This is a single institution, retrospective study conducted at KK Women's and Children's Hospital from 01 January 1998 to 31 December 2019. A total of 38 patients with ACs that required surgery were recruited. The 3 most common anatomical locations were in the middle cranial fossa (40.5%), posterior fossa (24.3%) and interhemispheric (13.5%). Typical clinical presentations included symptoms of raised intracranial pressure (34.2%), obstructive hydrocephalus (28.9%) and AC rupture (21.1%). Surgical approaches included 17 craniotomy-based procedures, 7 endoscopic fenestrations, 11 cystoperitoneal shunts, 2 burrhole drainage operations and 1 excision of spinal AC. Thirteen patients (34.2%) underwent either another operation due to the lack of resolution of their AC-related symptoms or secondary to complications directly related to their initial surgery. Average length of followup from time of first operation was 84.1 months. Overall, our results demonstrate similarities in epidemiology, clinical presentation and surgical experience, in comparison to larger cohort studies. We advocate collaborative efforts to better understanding of the pathophysiology of paediatric ACs, particularly for deciding between the various surgical treatment modalities.

Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More?

Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.

Giant Arachnoid Cyst Associated with an Orbital Meningocele: A Case Report and Cystoperitoneal Shunt Management

INTRODUCTION

Intracranial arachnoid cysts (ACs) are space-occupying lesions that typically remain stable in size and clinically silent over time.

CASE REPORT

We describe an unusual pediatric case of enlarged AC impressive by its compressive phenomena. An 11-month-old girl presented with remarkable macrocephaly associated with a cystic orbital tumor. CT scan and MRI studies revealed a large intracranial ACs extending in the orbit with an orbital meningocele (OM). The intracranial cyst did communicate with the orbital one into a bony defect in the right inner region of the orbital roof and represses the globe outward. A cystoperitoneal shunting procedure was performed to remove the mass effect as soon as possible and facilitate normal development.

DISCUSSION/CONCLUSION

Cysts in infants younger than 1 year of age are remarkably different from those in older children and adults in terms of cyst localization and enlargement. Classically described complications result from compression of adjacent structures and include focal neurologic involvement, headaches and seizures and developmental deficits, or macrocephaly in younger children. There are few cases of ACs with ophthalmic manifestations reported in the literature. The paucity of literature prompted us to analyze the case. To the best of our knowledge, an AC accompanying OM has not been reported. The pathogenesis and management of the case will be discussed.

Postsurgical Size-Changing Temporal Lobe Arachnoid Cysts in Patients with Trigonocephaly Who Underwent Reconstructive Surgery: A Two-Case Report

INTRODUCTION

Trigonocephaly (TC), the tapering of the metopic suture toward the anterior, lateral inadequacy of supraorbital bar, hypoplasia of the ethmoid bone, and hypotelorism due to orbital medialization leads to a triangular shape in the head together with frontotemporal stenosis and widening of the biparietal diameter. Arachnoid cysts (ACs) are benign cysts, which are formed by cerebrospinal-fluid entrapment into the arachnoid membrane due to duplication or separation of the arachnoid membrane layers. ACs are typically located in the middle cranial fossa and Sylvian fissure region. They are mostly detected incidentally through neuroimaging. The coexistence of TC and AC is considerably rare; hence, its actual incidence is unknown. To our knowledge, the coexistence of nonsyndromic TC and AC has been revealed in only 2 publications in the literature. In this case study, 2 patients, one of whom were with unilateral and the other with bilateral temporally localized ACs, sizes of which increased following the reconstructive surgeries, and who underwent reconstructive surgery for TC, were presented.

CASE REPORT

Both of the 2 patients that we have presented in our study are 7 months old and male. Fronto-orbital advancement and calvarial remodeling operations were performed on both. ACs of the patients were not intervened. However, in the post-op follow-ups, the left temporal cyst of the 1st case and the right cyst of the 2nd case grew radiologically, and the left cyst became very small.

DISCUSSION/CONCLUSION

TC must be treated surgically. ACs may show changes in size secondary to the increase in intracranial volume following reconstructive surgery for TC. However, if it does not give rise to any complaints, it can be followed-up clinically and radiologically. Patients should be followed-up for many years, given that neurodevelopmental and behavioral problems may occur later in both pathologies.

Endoscopic Fenestration of Arachnoid Cysts Through Lateral Pontomesencephalic Membranotomy: Technical Note and Case Series

BACKGROUND

The ideal treatment method for cranial arachnoid cysts stills controversial, each of endoscopic and microscopic techniques has its pros and cons.

METHODS

We described cystocisternostomy technique for arachnoid cysts through fenestration medial to the edge of tentorium through lateral pontomesencephalic membrane and illustrated it's outcomes. We performed endoscopic lateral pontomesencephalic membranotomy in nine children with zero angled rigid endoscope (STORZ).The age ranged from eight months up to nine years. The cysts were Galassi type III in eight cases (five of them giant hemispheric) and Galassi type II in one case. Clinical presentations were delay in milestones, seizures, loss of consciousness, unsteady gait, and persistent headache.

RESULTS

The cysts decreased in size in five cases after three months and nearly disappeared after three and 15 months in two cases, and in 18 months in the other two. Preoperative symptoms improved in all cases. Insignificant subdural hygroma was found in five cases, one case developed hydrocephalus four months later treated with a ventriculoperitoneal shunt; contralateral massive subdural hematoma occurred in one case four months after surgery evacuated with two burr holes with good clinical outcome. There was neither cerebrospinal fluid leakage, cranial nerve palsy nor mortality.

CONCLUSIONS

The fenestration through the lateral pontomesencephalic membrane created a shortcut of cerebrospinal fluid flow to the basal cisterns especially cerebellopontine cistern and represents a reliable option with an acceptable success rate. It creates a good drainage to the large cysts.

Infection of arachnoid cyst associated with vasospasm and stroke in a pediatric patient: case report

Arachnoid cysts are relatively common and benign intraarachnoid membrane outpouchings containing CSF-like fluid. The majority of arachnoid cysts remain stable and asymptomatic and do not require intervention in the pediatric population. Here, the authors present the first reported case of an infected arachnoid cyst in a pediatric patient resulting in severe vasospasm of the left terminal internal carotid artery, left A1 segment, and left M1 branches with a left middle cerebral artery infarct. Their experience suggests that close monitoring is warranted for this condition and that the pediatric population may be at higher risk for vasospasm.

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.

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?

Coexisting arachnoid cyst and tentorial sinus: A therapeutic dilemma

A 4-year-old male presented with a large arachnoid cyst over the left temporal region causing displacement of adjacent structures. Cerebral angiography showed dilatation of the tentorial sinus without other apparent vascular alterations. The association of these two anomalies raises a therapeutic dilemma as no information is available about how the variants of the venous system can modify cerebrospinal fluid hydrodynamics and thus affect arachnoid cyst’s prognosis. In this case, the patient was treated conservatively and has remained stable for 2 years.

Temporal crescent syndrome caused by a lateral ventricular glioependymal cyst: case report

Temporal crescent syndrome is a monocular visual field defect involving the temporal crescent of one eye caused by a retrochiasmal lesion. The most anterior portion of the striate cortex is the only area where the retrochiasmal lesion produces a monocular visual field defect. The authors present the case of a 9-year-old boy who presented with mild headache. MRI revealed a cyst with cerebrospinal fluid signal intensity, occupying the body and trigone of the right lateral ventricle. Conservative treatment with regular clinical and radiological follow-up was chosen because neurological examination findings were normal. Three years later, the patient experienced blurred vision with a temporal crescent defect in the left eye. Endoscopic cyst fenestration was performed, and the pathological findings indicated a glioependymal cyst. After surgery, the monocular temporal crescent disorder was resolved. MRI indicated shrinkage of the cyst and improvement in the narrowing of the anterior calcarine sulcus. These findings suggested that the temporal crescent syndrome was caused by a lateral ventricular glioependymal cyst. This is the first known report of temporal crescent syndrome caused by a lateral ventricular glioependymal cyst. In patients with monocular temporal crescent disorder without intraocular disease, a retrochiasmal lesion in the most anterior portion of the striate cortex should be considered.

Ruptured intracranial arachnoid cysts in the subdural space: evaluation of subduro-peritoneal shunts in a pediatric population

PURPOSE

Rupture of arachnoid cysts (AC) in the subdural space after trauma may cause a subacute/chronic subdural hematoma or a hygroma. Treatment of this complication still remains controversial, and no consensual strategy is to date clearly proposed. In this study, the authors evaluated the clinical and radiological evolution of patients treated by a subduro-peritoneal shunt for symptomatic subdural collections complicating ruptured AC.

METHODS

Medical records of the 10 patients treated at our institution between January 2005 and December 2018 for a subdural collection associated with an intracranial AC were reviewed. Subduro-peritoneal shunts consisted of low-pressure valves from 2005 to 2012 (6 cases) and medium-pressure valves after 2012 (4 cases).

RESULTS

A benign head trauma was retrospectively found in the history of 8 patients. The mean time to diagnosis ranged from 15 days to 5 months. Symptoms resulted mainly from intracranial hypertension. Six patients had an ipsilateral hygroma to the AC, 2 patients had a bilateral hygroma predominantly to the AC side, and 2 patients presented an ipsilateral chronic subdural hematoma. Arachnoid cysts were classified as Galassi I in 5 cases and Galassi II in 5 cases. Patients with chronic subdural hematoma were given a medium-pressure valve. Patients with subdural hygroma received a low-pressure valve in 6 cases and a medium-pressure valve in 2 cases. There were no complications during surgical procedures. All patients were rapidly free of symptoms after surgery and were discharged from hospital 1 to 4 days postoperatively. The subdural collection completely disappeared in all cases. In the long term, only 2 patients with low-pressure valves underwent shunt removal without any consequences, while a second surgical procedure was necessary to treat recurrence of intracranial hypertension in the 4 remaining cases. All the medium-pressure valves were removed without problems. The size of the AC was reduced in 3 cases, remained stable in 4 cases, and increased in 3 cases. No patients experienced recurrence of subdural collection during follow-up.

CONCLUSIONS

Medium-pressure subduro-peritoneal shunts should be considered as part of the arsenal of surgical strategy in symptomatic ruptured AC in the subdural space. The procedure is simple with a very low morbidity, and it allows rapid improvement of symptoms. Although the shunt is located in the subdural space, we strongly recommend avoiding devices which may create an overdrainage and expose the patient to shunt dependency such as low-pressure shunts.

Long-term outcome of large sylvian arachnoid cysts: the role of surgery has been exaggerated

OBJECTIVE

The surgical indications for some arachnoid cysts (ACs) are controversial. While surgical procedures can be effective when an AC is a definite cause of hydrocephalus or papilledema, most ACs do not cause any symptoms or signs. Some surgeons perform several procedures to treat ACs because of their large size. The purpose of this study was to compare the long-term outcomes of Galassi type III ACs between surgery and nonsurgery groups.

METHODS

The medical records of 60 patients diagnosed with sylvian ACs (Galassi type III) who visited Seoul National University Children's Hospital from July 1990 to March 2018 were analyzed. The authors compared the outcomes between those treated with surgery and those not treated with surgery.

RESULTS

Of the 60 patients, 27 patients had no symptoms, 19 patients had vague symptoms and signs associated with ACs, and the remaining 14 patients had definite AC-related symptoms and signs. Thirty-eight patients underwent surgery, and 22 patients underwent observation. Some operations were accompanied by complications. Among the 33 patients in the surgery group, excluding 5 with hydrocephalus or papilledema, 8 patients needed 18 additional operations. However, there were no patients in the nonsurgery group who needed surgical intervention during the follow-up period (mean 67.5 months), although the size of the AC increased in 2 patients. Changes in AC size were not correlated with symptom relief.

CONCLUSIONS

When patients with hydrocephalus or papilledema were excluded, there was no difference in the outcomes between the surgery and nonsurgery groups regardless of the size of the sylvian AC. Surgeons should be cautious when deciding whether to operate.

Cerebrospinal fluid hydrodynamics in arachnoid cyst patients with persistent idiopathic intracranial hypertension: A case series and review

Background:

A clear connection has been established between arachnoid cysts (ACs) and the evolution of idiopathic intracranial hypertension (IIH), a connection, which is presently not well understood. Cerebrospinal fluid (CSF) is an integral element of this condition. Little is known about either the influence of AC on CSF hydrodynamics or the specific nature of CSF, which contributes to the complex pathology of IIH.

Case Description:

This study aimed to chronicle in detail four patients with previously treated intracranial ACs, who developed persistent IIH. This series and review aims to identify and qualitatively analyze the multiple constituents, which could possibly elucidate the intrinsic relationship between arachnoid cyst-induced IIH and CSF hydrodynamics. A retrospective analysis of the medical records of four patients admitted to the institution’s neurosurgery department during the period of 1994–2013 was completed. This study investigated discernible aspects linking CSF pathophysiology with the development of IIH in AC patients. Four male patients, ranging from 3 to 44 years of age at presentation, had a left-sided arachnoid cyst treated surgically. All four patients subsequently developed IIH. Three patients remain persistently symptomatic.

Conclusion:

IIH associated with AC is a hydrodynamic disorder. The full discovery of its fluctuant pathophysiology is the only way to identify an effective standard for the management and treatment of this condition.

Prenatal diagnosis of arachnoid cysts: a case series and systematic review

INTRODUCTION

Primary cysts are believed to arise from the splitting of the arachnoid membrane during prenatal development and can be diagnosed in utero. Prenatal diagnosis is uncommon; therefore, the evidence base for counselling expectant mothers is limited. The purpose of this article is to present a case series and review the current literature on prenatally diagnosed arachnoid cysts.

METHOD

A keyword search of hospital electronic records was performed for all patients with a prenatally diagnosed arachnoid cyst at a tertiary neurosurgical centre. Case notes were reviewed for all patients diagnosed between 2005 and 2017. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to structure a systematic review of all English language articles published up to May 2018.

RESULTS

A total of eight eligible patients were identified from our own records and 123 from the literature. Sixty-eight per cent of patients had a normal outcome. Sixty-three per cent of patients underwent surgical intervention which was not associated with abnormal outcome. The diagnosis of syndromic/genetic diagnosis (p < 0.001) and the presence of other intra-cranial anatomical abnormalities (p = 0.05) were significant predictors of abnormal outcome.

CONCLUSION

The pathogenesis and prognosis of a prenatal arachnoid cyst diagnosis remain unclear. These results suggest favourable outcomes from simple cysts without associated abnormalities and expectant mothers should be counselled accordingly. A wider prospective review is required to better established evidence-based practice.

Arachnoid cyst in young soccer players complicated by chronic subdural hematoma: personal experience and review of the literature

Arachnoid cysts (ACs) are congenital intracranial benign cavities originating from the meninges during embryological development. Several studies have shown the existence of a relationship between AC and a higher risk to develop ipsilateral chronic subdural hematoma (CSH) especially in a young population. In the presence of an AC, the practice of sport activities may expose young patients to minor head trauma and to an increased risk of developing CSH. We describe three cases of young soccer players with AC associated with CSH. Then, we performed a literature review of all the reported cases in the literature of patients younger than 18 years with AC-associated CSH related to sport practice. A total of 33 cases, including the three cases reported by us, are analyzed. Soccer is the most represented sport activity in this association (39% of cases). The treatment of choice is surgical in all patients, with burr hole or craniotomy in similar proportions. In one-third of patients, the AC has been fenestrated. Outcome is good in all the reported cases. We reviewed the main pathogenic theories, the main surgical strategies described in literature, as well as recurrence rate of CSH, the association of AC and cranial deformities, and the clinical outcome. AC might be associated with skull deformities, but their real incidence remains unclear. The clinical detection of such anomalies should suggest performing further radiological investigations. If the presence of AC is confirmed, the practice of sport activities should not be avoided, as the real incidence of AC-associated CSH is not clear yet and the reported outcomes in literature are good. Surgical treatment of AC-associated CSH should be hematoma removal through burr hole, reserving AC fenestration only for cases with intracystic bleeding or recurrences. The surgeon should adequately advise and inform the young patients and their families that they could have an increased risk of developing CSH given by the presence of the AC, and that they should be referred to a neurosurgical center if they become symptomatic.

Cognition in Children with Arachnoid Cysts

Background: This study aims to evaluate if children with temporal arachnoid cysts (AC) have cognitive symptoms and if neurosurgery improves these. Methods: A prospective case series study including consecutive pediatric patients with temporal AC. The children underwent neuroradiology, neuroopthalmologic evaluation, and a standard electroencephalography (EEG). Additionally, a neuropsychologist performed a standardized set of evaluations, with a one-year follow-up consisting of Weschler Intelligence Scale for Children version IV (WISC-IV), FAS (for verbal fluency), Boston Naming Test (BNT, for visual naming ability) and NEPSY-II (Developmental NEuroPSYchological Assessment) for verbal memory. Results: Fifteen children, 9 boys and 6 girls, were evaluated and 11 underwent surgery. The Full Scale IQ subscore (FSIQ) improved from M = 84.8 to M = 93.0 (p = 0.005). The preoperative Verbal Comprehension Index (VCI) was in the low average range (M = 86.7), improving to a level within the average range (M = 94.7, p = 0.001). Preoperative Perceptual Speed Index (PSI) was in the below average range (M = 81.5), improving to a level within the average range (M = 92.5, p = 0.004). Conclusion: ACs are a common finding in a pediatric neurosurgical setting. Our data suggest that some temporal AC have a negative effect on general cognitive ability and that this impairment can be improved by surgery. We suggest a standardized evaluation, including comprehensive and validated neuropsychological assessment tools, to thoroughly assess symptoms as well as the postoperative outcome.

Sporadic Meningioangiomatosis Presenting as a Middle Cranial Fossa Arachnoid Cyst

BACKGROUND

Meningioangiomatosis is an extremely rare meningovascular disease of the central nervous system that is characterized by the proliferation of leptomeninges, cortical vessels, and perivascular spindled cells. Although it is a benign, neoplastic disorder that carries a good prognosis after surgical excision, initial diagnosis may be challenging as radiologic findings are often variable and nonspecific.

CASE DESCRIPTION

In this report, we describe an unusual presentation of meningioangiomatosis presenting as a symptomatic middle cranial fossa arachnoid cyst.

CONCLUSIONS

In view of the unexpected diagnosis and infrequency of this condition, the case is discussed in collaboration with current literature and management strategies.

Spontaneous Resolution of Asymptomatic Pediatric Suprasellar Arachnoid Cysts: Report of 2 Cases and Review of the Literature

INTRODUCTION

Sellar/suprasellar arachnoid cysts are infrequent nonneoplastic cystic lesions that account for approximately 1% of all arachnoid cysts. While various surgical treatment options have been proposed for symptomatic lesions, treatment guidelines regarding the management of asymptomatic sellar/suprasellar arachnoid cysts remain to be elucidated. This case series aims to provide a better insight into the management and outcomes of such lesions.

CASE PRESENTATION

We discuss 2 pediatric patients diagnosed with sellar/suprasellar arachnoid cysts who remained asymptomatic and demonstrated spontaneous gradual resolution of their arachnoid cysts on subsequent imaging studies.

CONCLUSION

Review of the literature identified only a handful of previously reported cases of spontaneously disappearing suprasellar arachnoid cysts. There might be a role for conservative management of sellar/suprasellar arachnoid cysts in certain patients who remain asymptomatic.

Quadrigeminal arachnoid cyst with perinatal encephalocele

INTRODUCTION

Quadrigeminal arachnoid cyst (QAC) associated with encephalocele is rare; and while some treatments have been developed in recent years, no definite therapeutic approach for QAC has been established. Endoscopic treatment for arachnoid cyst is gaining popularity because it is relatively less invasive to the normal brain tissues.

CASE PRESENTATION

The patient, a 4-year-old girl, presented with QAC associated with congenital occipital encephalocele. At the age of 1 month, repair of the perinatal encephalocele had been performed at another institute. An asymptomatic arachnoid cyst remained in the posterior fossa, which was closely monitored with follow up. At age 4 years, the patient started to complain of headache, which gradually increased in both strength and frequency. Magnetic resonance imaging (MRI) revealed cerebellar compression due to cyst enlargement. We performed neuroendoscopic cyst fenestration with an occipital bone approach. Post-operative MRI showed reduced size of the cyst, and the headache dramatically improved and resolved.

DISCUSSION

The standard treatment of QAC is still controversial; however, our successful use of endoscopic fenestration toward the third ventricle indicates its efficacy and safety. QACs have been classified into 3 types based on their expansion mechanisms; our case might suggest another possible mechanism of QAC development.

CONCLUSION

In our case, endoscopic cyst fenestration was successful for QAC with perinatal encephalocele. However, long-term follow-up and analysis of similar cases are needed to determine its effectiveness.

Progressively Enlarged Convexity Arachnoid Cysts in Elderly Patients: A Report of 2 Cases

BACKGROUND

Generally, enlargement of arachnoid cysts (ACs) has been found mostly in cases occurring during early childhood. Therefore, progressively enlarged ACs found to be symptomatic in elderly patients are extremely rare, and the mechanisms have remained unexplored.

CASE DESCRIPTION

Our first patient was a 72-year-old woman with memory disturbance, who had presented with a large cyst beneath the right temporal convexity 9 years previously. The annual follow-up magnetic resonance imaging (MRI) studies had revealed that the cyst had progressively enlarged. In addition, her memory disturbance had become advanced. Endoscopic cyst fenestration was performed between the cyst and lateral ventricle, resulting in a reduction of her symptoms. Our second patient was a 79-year-old woman with unsteadiness, who had presented with a large cyst under the right parietal convexity 6 years previously. The annual follow-up MRI studies had shown that the cyst had gradually enlarged. She subsequently developed left hemiparesis. Because the pyramidal tract was located between the cyst and ventricle, a cyst-ventricle shunt was placed to allow the cystic fluid into the lateral ventricle, with complete resolution of her symptoms. In both cases, MRI showed obliteration of the subdural spaces around the cysts. Endoscopic observations revealed that the arachnoid membrane was lined under the surrounding brain, leading to the diagnosis of an AC.

CONCLUSION

The establishment of stable communication between a cyst and the normal cerebrospinal fluid space is important to treat symptomatic ACs characterized by progressive enlargement, even in elderly patients. The 1-way entry of the cerebrospinal fluid into the cyst and the closure of the surrounding subdural space might result in AC enlargement internally.

Treatment of Arachnoid Cyst With Spontaneous Hemorrhage With Atorvastatin

As one of the common neurological diseases, pediatric middle fossa arachnoid cysts(MFACs) can develop intracystic hemorrhage and subdural hematoma. Risk factors for pediatric arachnoid cyst rupture/hemorrhage is very complicated in mechanism. Although surgery is the first choice for children with MFACs and subdural hematoma, the rate of recurrence of the subdural hematoma is very high after 1 or more surgeries. Atorvastatin has proven to be a bold and safe choice in the management of subdural hematoma with mild symptoms. The present study has described a 7-year-old child with a recurrent rupture of arachnoid cyst develops into a subdural hematoma. We demonstrate that atorvastatin is safe and effective in pediatric patient who has failed surgical treatment of middle fossa arachnoid cyst and subdural hematoma. The patient received atorvastatin monotherapy, once daily for the first week, with an initial dose of 5 mg, followed by 10 mg once daily for 7 weeks. In the third month after the initial treatment, the neurological function recovered, and the hematoma completely resolved. This case report supports the concept that atorvastatin can promote the absorption of subdural hematoma.

Spontaneous Disappearance of an Arachnoid Cyst after Burr Hole Drainage of Chronic Subdural Hematoma

It is well known that the presence of arachnoid cysts (ACs) in young patients is a risk factor for developing a chronic subdural hematoma (CSDH) after a minor head injury. Although there have been controversies with the treatment, most authors recommend only draining the CSDH if the AC is asymptomatic. This judgement is based on the facts that this surgical approach has shown good clinical outcomes, and the AC usually remains unchanged after the surgery. Our case demonstrates that the AC of a young patient who developed a CSDH after a minor head injury completely disappeared after a burr hole drainage of the CSDH. Although the chances of an AC disappearing are low, this case shows that an AC might disappear after only draining a CSDH when a rupture of the AC membrane is identified. In such cases, we recommend first draining only the CSDH for the treatment of AC-associated CSDHs.

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.

Microsurgical, endoscopic, and shunt management of pediatric temporosylvian arachnoid cysts: a comparative study

OBJECTIVE

Arachnoid cysts (ACs) are most frequently located in the middle cranial fossa. Some patients are asymptomatic whereas others exhibit signs of increased intracranial pressure, seizures, or cognitive and behavioral symptoms. When ACs do require treatment, the optimal surgical technique remains controversial. This study was conducted to assess the most effective surgical treatment for these cysts.

METHODS

The authors retrospectively reviewed 240 temporal intracranial ACs managed over a 25-year period in their pediatric neurosurgical unit. Pre- and posttreatment results were clinically and radiologically assessed.

RESULTS

A majority of male patients (74.6%) with an overall median age of 6.9 years were included. The mean cyst size was 107 cm3; the Galassi classification showed 99 (41.3%) type I, 77 (32.1%) type II, and 64 (26.7%) type III cysts. Forty-four ACs (18.3%) were diagnosed after rupture. Surgical management was performed by microsurgery (28.3%), endoscopic cyst fenestration (14.6%), cystoperitoneal shunting (CPS; 16.2%), or subdural shunting (10%). Furthermore, 74 children (30.8%) did not undergo operations. After a mean follow-up of 4.1 years, the mean percentage decrease in cyst volume and the overall rate of clinical improvement did not significantly differ. The endoscopy group had earlier complications and a shorter event-free survival (EFS) time (EFS at 3 years = 67.7%, vs 71.5% and 90.5% for CPS and microsurgery, respectively; p < 0.007) and presented with more subdural hematomas compared to the microsurgery group (p < 0.005). The microsurgery group also showed a tendency for longer cystocisternostomy permeability than the endoscopy group.

CONCLUSIONS

Concerning the management of unruptured symptomatic temporal ACs, microsurgery appears to be the most effective treatment, with longer EFS and fewer complications compared to shunting or endoscopy.