Prevalence and symptoms of intracranial arachnoid cysts: a population-based study

Middle fossa arachnoid cyst fenestration for ruptured cysts associated with subdural collections: paediatric neurosurgery tertiary unit experience

INTRODUCTION

Arachnoid cysts are commonly encountered benign cystic structures and often come to attention as incidental findings following cranial imaging. Surgical intervention rates vary in different studies; however, rupture of cyst and subdural collection with mass effect are some of the indications for surgical intervention. In this study, we aimed to evaluate our operated cohort of middle fossa arachnoid cysts to determine the rate of traumatic subdural collection in this cohort and further assess outcomes.

METHODS

A retrospective review of all consecutive operated middle cranial fossa arachnoid cysts was carried out for the period 2010 to 2024. Demographics including age, sex, Galassi type, surgical technique for fenestration, preceding history of trauma, presence of papilloedema, and complications following surgery were extracted. Indication for surgery included papilloedema and headaches or increasing head circumference or rupture and subdural collections. Arachnoid cysts managed with CSF diversion as primary surgery were excluded.

RESULTS

Over the study period, 21 fenestrations of the arachnoid cysts were carried out in 19 patients with mean age of 7 years and M:F ratio of 2.2:1 (laterality: 9 right-sided and 10 left-sided). These included seven Galassi 2 and twelve Galassi 3 arachnoid cysts. At presentation, 10 had papilloedema, 5 with no papilloedema, and 4 with no available ophthalmological assessment. Fenestration of cyst included 12 microscopic, 6 endoscopic, and 3 combined approaches. Of the operated cohort, 8 were due to rupture of arachnoid cyst and subdural collections causing mass effect. Of 8 cases of ruptured arachnoid cyst with subdural collections, 75% had clear history of preceding head injury in the context of accidental or sports-related injuries. Two patients required redo-fenestration (10.5%), 1 patient required temporary lumbar drain (5.2%), and 2 patients required cysto-peritoneal shunts (10.5%).

CONCLUSION

Rupture of arachnoid cysts and subdural collections although rare can be associated with head injury in majority of cases. All operated cases belonged to grade 2 and 3 Galassi.

A Case of Subdural Hygroma due to a Ruptured Arachnoid Cyst in the Middle Cranial Fossa That Improved after Long-term Subdural Drainage: A Case Report and Review of the Literature

Arachnoid cysts have the potential to rupture, leading to the development of a subdural hygroma following minor trauma. Although surgery may be considered in cases of increased intracranial pressure (ICP) or regional neurological symptoms, the optimal approach remains unclear. We report a case of subdural hygroma due to a ruptured arachnoid cyst (SHrAC) with elevated ICP successfully treated with long-term subdural drainage for over 1 month. A 26-year-old man with persistent headache was admitted to our hospital. Magnetic resonance imaging revealed an arachnoid cyst within the left middle cranial fossa and a subdural hygroma in the left frontotemporal region. He was referred to our neurosurgery department for surgical intervention due to elevated ICP. Although burr hole surgery was initially performed, subsequent recurrence of elevated ICP necessitated the insertion of a subdural peritoneal shunt. However, the shunt was then removed following the development of postoperative meningitis, and a subdural drain was placed to control ICP. Cerebrospinal fluid (CSF) drainage gradually decreased, and the elevated ICP improved. The subdural drain was removed approximately one and a half months after drain placement. The subdural hygroma progressively reduced and completely disappeared 4 months after drain removal. The gradual reduction in the pressure difference between the arachnoid cyst and the subdural hygroma due to long-term CSF drainage and inflammation caused by meningitis may have contributed to close arachnoid membrane laceration. Although alternative approaches, such as shunt insertion and basal fenestration, should always be considered in SHrAC treatment, long-term subdural drainage can be an option.

Arachnoid cysts and epilepsy: seizures and epileptogenesis

Arachnoid cysts are sacs within the arachnoid membrane, filled with cerebrospinal fluid, and overwhelmingly asymptomatic; however, they can also lead to neurological symptoms such as epilepsy. The dependence of AC on epilepsy has been a subject of controversy because of studies with mixed results on whether AC contributes to seizure activity. This is a narrative review for the synthesis of available present research on the pathophysiological mechanisms of epilepsy, clinical presentation, and treatment options in patients with epilepsy and ACs. Some find no impactful association between ACs and seizures, while others point out the probable role of ACs in Epileptogenesis. Endoscopic fenestration and similar surgical interventions were found quite effective at reducing the frequency of seizures for selected patients, although not all of them achieve complete seizure control. Such a decision needs to be tailored on the basis of considerations such as localization and size of cysts and general health conditions. Future research should investigate the genetic and molecular basis of ACs and, based on large prospective long-term studies, define the AC-epilepsy relationship and refine treatment strategies in affected individuals.

A bibliometric analysis and visualization of normal pressure hydrocephalus

Background

Normal pressure hydrocephalus (NPH) has drawn an increasing amount of attention over the last 20 years. At present, there is a shortage of intuitive analysis on the trends in development, key contributors, and research hotspots topics in the NPH field. This study aims to analyze the evolution of NPH research, evaluate publications both qualitatively and quantitatively, and summarize the current research hotspots.

Methods

A bibliometric analysis was conducted on data retrieved from the Web of Science Core Collection (WoSCC) database between 2003 and 2023. Quantitative assessments were conducted using bibliometric analysis tools such as VOSviewer and CiteSpace software.

Results

A total of 2,248 articles published between 2003 and 2023 were retrieved. During this period, the number of publications steadily increased. The United States was the largest contributor. The University of Gothenburg led among institutions conducting relevant research. Eide P. K. was the most prolific author. The Journal of Neurosurgery is the leading journal on NPH. According to the analysis of the co-occurrence of keywords and co-cited references, the primary research directions identified were pathophysiology, precise diagnosis, and individualized treatment. Recent research hotspots have mainly focused on epidemiology, the glymphatic system, and CSF biomarkers.

Conclusion

The comprehensive bibliometric analysis of NPH offers insights into the main research directions, highlights key countries, contributors, and journals, and identifies significant research hotspots. This information serves as a valuable reference for scholars to further study NPH.

Hypoglossal Nerve Neuropathies-Analysis of Causes and Anatomical Background

The hypoglossal nerve is the last, and often neglected, cranial nerve. It is mainly responsible for motor innervation of the tongue and therefore the process of chewing and articulation. However, tumors, aneurysms, dissections, trauma, and various iatrogenic factors such as complications after surgeries, radiotherapy, or airway management can result in dysfunction. Correct differential diagnosis and suitable treatment require a thorough knowledge of the anatomical background of the region. This review presents the broad spectrum of hypoglossal neuropathies, paying particular attention to these with a compressive background. As many of these etiologies are not common and can be easily overlooked without prior preparation, it is important to have a comprehensive understanding of the special relations and characteristic traits of these medical conditions, as well as the most common concomitant disorders and morphological traits, influencing the clinical image. Due to the diverse etiology of hypoglossal neuropathies, specialists from many different medical branches might expect to encounter patients presenting such symptoms.

Large intradiploic arachnoid cyst of the skull in child-a case report and new terminology proposition

We present a rare finding of the arachnoid matter invaginating into the base of middle cranial fossa and creating an abnormal space. Presented entity was incidentally found in head CT scan of 12-year-old male. Based on the radiological characteristics in CT scans and MR images, the diagnosis of intradiploic arachnoid cyst (AC) was suggested. After surgical intervention and histopathological analysis of the specimen, the diagnosis was confirmed. We assume this is the first description of large intrasphenoid AC without any traumatic or iatrogenic cause. The literature provides many different terms for the phenomenon. We are proposing the term intradiploic arachnoid diverticulum as the more accurate for capturing the essence of the phenomenon. It provides clear differentiation of the entities from classical arachnoid cysts since they are of different anatomical localization (intradural vs. extradural) and etiopathogenesis. Management with arachnoid diverticulum is not yet established, but observation with serial imaging studies should be recommended as primary management in case of asymptomatic cyst. When cyst is symptomatic, surgical treatment may be required.

Effect of continuous drainage of cranial arachnoid cysts into the ventricular system by stereotactic placed catheters

Background: Surgical treatment of intracranial arachnoid cysts (iACs) is challenging. Microsurgical resection, endoscopic fenestration and cysto-peritoneal shunting are the most frequently used methods, each implying their own drawbacks. Stereotactic-guided cysto-ventricular drainage has been described as an alternative method. Here we describe our experience with this technique and how we conducted volumetric measurements to evaluate the effect of permanent drainage.Methods: Standardized stereotactic planning was performed. The planned trajectory included both the iAC and the ventricle system. The catheter was shortened to the defined length and was further fenestrated along its planned course through the iAC to allow drainage into the ventricular system. Clinical and radiological control was performed on outpatient basis after a mean follow-up of 2 (1-3) months. The overall mean follow-up was 32 months (6-59). The measurement of the cyst volume was conducted by the ABC/2-method.Results: Six patients with symptomatic arachnoid cysts (4 f, 2 m) were treated between 2010 and 2016. The overall postoperative reduction in cyst volume at the first follow-up was 36.04% (at the long-term follow-up: 38.57%). Decrease of the midline-shift was achieved in all cases and averaged 57.83% (long term: 81.88%). Clinical improvement of related symptoms could be achieved in all patients (4 patients were symptom free, two patients had alleviated symptoms). There was no case of over-drainage. The catheter had to be removed after 6 months in one case due to infection.Conclusions: We demonstrate successful symptom control and volume reduction in a small series of iACs by continuous drainage into the CSF-system through stereotactic placed catheters. This method may facilitate a self-regulated egress of entrapped cyst fluid in symptomatic patients without risk of over-drainage. A literature survey of the success rate and the complications of this approach is provided. It is concluded that this minimally- invasive method may be an alternative to established fenestration techniques especially for patients with arachnoid cysts that aren't directly adjacent to a cisternal or ventricular CSF space.

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.

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.

Effect comparison of neuroendoscopic vs. craniotomy in the treatment of adult intracranial arachnoid cyst

Purpose

Intracranial arachnoid cysts are common, accounting for about 1%-2% of intracranial space-occupying lesions. There is controversy over the method of surgical intervention, and in order to provide guidance for surgical decision making, this study compares the efficacy of craniotomy vs. neuroendoscopic surgery in treating arachnoid cysts.

Methods

The adult patients with arachnoid cyst admitted to our department from October 2016 to August 2021 were retrospectively analyzed. Thirteen adult patients were recruited, and divided into two groups: neuroendoscopic group (group A) and craniotomy group (group B). We compared the gender, age, clinical symptoms, preoperative and postoperative cyst sizes, symptom improvement, complications, length of hospital stay, and hospital costs between two groups to analyze the therapeutic effects of these two surgical methods.

Results

The cost of hospitalization in group A was significantly lower than that in group B (47,292.8 vs. 65,151.8 yuan, P < 0.05), and there was no difference in the length of hospital stay between the two groups. The preoperative cysts in group A were significantly larger than those in group B (6.38 vs. 2.97 cm, P < 0.05). In groups A and B, the short-term symptom improvement rates were 100% and 75.0%, respectively. The long-term symptom improvement rates were 77.78% and 75.0% (P > 0.05), respectively.

Conclusion

Both neuroendoscopic and craniotomy have good curative effects for the treatment of intracranial arachnoid cysts. There was no significant difference in the outcomes between the two surgical techniques. The cost of hospitalization can be reduced with neuroendoscopic surgery. Neuroendoscopic treatment is recommended for large intracranial arachnoid cysts, and craniotomy is suitable for small intracranial arachnoid cysts.

Ruptured Sylvian arachnoid cysts: an update on a real problem

PURPOSE

Sylvian arachnoid cysts (SACs) are the most common type of arachnoid cysts and the most prone to undergo a rupture. This event is considered rare but potentially severe. No definite information is available on its occurrence or management. The goal of the present article is to provide an update on the epidemiological, etiological, and clinical aspects and the management of this peculiar clinical condition.

METHODS

A comprehensive review of the English literature of the last 40 years on this topic has been realized. Moreover, a personal series of children investigated and treated in the last 20 years is presented. These patients were managed as follows: (1) treatment of the subdural collection; (2) identification of candidates for surgical treatment of the residual cyst (brain MRI, perfusion brain MRI, prolonged invasive ICP monitoring (selected cases), EEG, neuropsychological tests); (3) surgical treatment of the cyst in the patients with pathological perfusion MRI and/or ICP measurement and/or clear neurophysiological and neuropsychological correlations.

RESULTS

A total of 446 patients (430 from the literature and 16 from the personal series), mainly children, adolescents, and young adults, have been analyzed leading to the following results: (1) SAC rupture is rare but not negligible (yearly risk of rupture: 0.04%; overall risk up to 10% in children affected by SCAs). Prophylactic surgery in asymptomatic cases is not advisable. (2) The mechanism of rupture is not known but an impact of SAC against the sphenoid wing and/or a direct injury on SAC through a thinned temporal bone, with possible laceration of the cyst wall vessels and/or tear of the bridging veins, can be hypothesized. A head injury is often not reported (may be misdiagnosed). (3) Subdural collection (hygroma > chronic hematoma) is the most common finding followed by intracystic bleeding, extradural hematoma, and other types of bleeding. Signs or symptoms of raised intracranial pressure are the most frequent ones. (4) The complication of the rupture is usually treated in emergency or in the acute period by burr hole or craniotomic evacuation of the subdural collection, although a conservative management is possible in some cases. Following the rupture, the majority of SACs are treated (70%), often at the same time of the complication, but no specific investigations are routinely performed to select candidates. According to our protocol, only 43.7% of SACs needed to be treated.

CONCLUSIONS

The "spontaneous" or posttraumatic rupture of SACs is a rare but potentially significant complication followed by a generally good outcome. The course of the cyst is independent from the outcome of the complication, consequently requiring specific investigations for individuating those lesions interfering with CSF dynamics and/or cerebral blood flow.

The Efficacy and Tolerability of Electroconvulsive Therapy in Psychiatric Patients with Arachnoid Cysts: A Retrospective Chart Study

Electroconvulsive therapy (ECT) is an effective therapy for many psychiatric illnesses. However, intracranial occupying lesions are a relative contraindication to ECT. Arachnoid cysts are benign, congenital, and space-occupying lesions. Our study aimed to evaluate the efficacy and tolerability of ECT in psychiatric patients with arachnoid cysts. We retrospectively identified 62 psychiatric patients with arachnoid cysts; 43 of them underwent ECT and 19 did not. Their conditions were assessed by CGI-S and different scales depending on different diagnoses (PANSS for schizophrenia; HAMD for depression; YMRS for bipolar disorder). The side effect was assessed by TESS. Significant differences were shown in the reduced scores of the CGI-S between patients who underwent ECT and those who did not (p = 0.001), while, at the same time, there was no significant difference in their TESS score (p = 0.297). The current study found that ECT is an effective and tolerable therapy for psychiatric patients with arachnoid cysts.

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.

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.

The efficacy of cystoperitoneal shunting for the surgical management of intracranial arachnoid cysts in the elderly: A systematic review of the literature

Background:

Intracranial arachnoid cysts (AC) are benign, cerebrospinal fluid filled spaces within the arachnoid layer of the meninges. Neurosurgical intervention in children and young adults has been extensively studied, but the optimal strategy in the elderly remains unclear. Therefore, we performed a single center retrospective study combined with a systematic review of the literature to compare cystoperitoneal (CP) shunting with other surgical approaches in the elderly cohort.

Methods:

Retrospective neurosurgical database search between January 2005 and December 2018, and systematic review of the literature using PRISMA guidelines were performed. Inclusion criteria: Age 60 years or older, radiological diagnosis of intracranial AC, neurosurgical intervention, and neuroradiological (NOG score)/clinical outcome (COG score). Data from both sources were pooled and statistically analyzed.

Results:

Our literature search yielded 12 studies (34 patients), which were pooled with our institutional data (13 patients). CP shunts (7 patients; 15%), cyst fenestration (28 patients; 60%) and cyst marsupialisation/resection (10 patients; 21%) were the commonest approaches. Average duration of follow-up was 23.6, 26.9, and 9.5 months for each approach, respectively. There was no statistically significant association between choice of surgical intervention and NOG score (P = 0.417), COG score (P = 0.601), or complication rate (P = 0.955). However, CP shunting had the lowest complication rate, with only one patient developing chronic subdural haematoma.

Conclusion:

CP shunting is a safe and effective surgical treatment strategy for ACs in the elderly. It has similar clinical and radiological outcomes but superior risk profile when compared with other approaches. We advocate CP shunting as first line neurosurgical intervention for the management of intracranial ACs in the elderly.

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.

Late onset epilepsia partialis continua in a middle-aged patient with huge arachnoid cyst

Background:

Arachnoid cysts are congenital or acquired cerebrospinal fluid (CSF) filled intra arachnoidal lesions, included 1% of all infantile intracranial masses and were discovered incidentally in MRI or CT-scan. The vast majority of these lesions are generally asymptomatic but some patients with arachnoid cyst have headache, dizziness, seizure (or epilepsy), vestibular symptoms and cognitive impairment.

Case Presentation:

We present a case of a 43-year-old woman who has late onset epilepsia partialis continua and had right spastic cerebral palsy due to huge arachnoid cyst. Surprisingly without any history of seizure, her first seizure presents with sustained seizures (epilepsia partialis continua) and occur in the middle age for the first time.

Conclusion:

Most arachnoid cysts are asymptomatic and may not produce any symptoms throughout life. In our case, the late onset epilepsia partialis continua in the 5^th decade of life with probably a large arachnoid cyst without any history of seizure before that is unusual. Conservative approaches usually made for the management of arachnoid cysts as patients with these cysts usually maintain the vital neurological functions.

MR Brain Screening in ADPKD Patients : To Screen or not to Screen?

BACKGROUND

Adult polycystic kidney disease (ADPKD) still represents a major cause of renal failure and intracranial aneurisms (IA) have a higher prevalence in ADPKD than in the general population. Current guidelines suggest performing brain MRI only in the subjects with a positive familiar history of IAs or subarachnoid hemorrhage (SAH). This is a retrospective case-control analysis to evaluate the usefulness of a MR screening program in ADPKD patients.

METHODS

We retrospectively analyzed all ADPKD patients followed in our outpatient clinic between 2016 and 2019 who underwent a brain MRI screening. We evaluated the presence of IAs and others brain abnormalities and compared our results with a non-ADPKD population (n = 300). We performed univariate and multivariate regression analysis to evaluate if general and demographic features, laboratory findings, clinical parameters and genetic test results correlated with IAs or other brain abnormalities presence.

RESULTS

Among the patients evaluated 17 out of 156 (13.6%) ADPKD patients had IAs, compared to 16 out of 300 (5.3%) non-ADPKD controls (p < 0.005). Considering ADPKD patients presenting IAs, 12 (70.6%) had no family history for IAs or SAH. Genetic analysis was available for 97 patients: in the sub-population with IAs, 13 (76.5%) presented a PKD1 mutation and none a PKD2 mutation. We found that arachnoid cysts (AC) (p < 0.001) and arterial anatomical variants (p < 0.04) were significantly more frequent in ADPKD patients.

CONCLUSION

In our population ADPKD patients showed a higher prevalence of IAs, AC and arterial variants compared to non-ADPKD. Most of the IAs were found in patients presenting a PKD1 mutation. We found a significant number of alterations even in those patients without a family history of IAs or SAH. The practice of submitting only patients with familial IAs or kidney transplantation candidates to MRI scan should be re-evaluated.

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.

Surgical management of intracranial arachnoid cysts in pediatric patients: radiological and clinical outcome

OBJECTIVE

Congenital intracranial cysts account for a significant portion of intracranial lesions in the pediatric population. The efficiency of surgical treatment in a pediatric cohort with intracranial arachnoid cysts (ACs) at different locations regarding clinical symptoms and mass effect was evaluated.

METHODS

A retrospective study of all children who underwent surgical treatment of an intracranial AC during an 11-year period (2007-2018) was performed. Demographics, clinical symptoms, and radiological cyst size pre- and postoperatively, as well as the reoperation rate and possible treatment complications, were analyzed.

RESULTS

A total of 116 intracranial cysts at 8 different anatomical locations were surgically treated in 113 children (median age 5 years and 10 months) predominantly by endoscopic technique (84%). The complication rate was 3%, and the reoperation rate was 16%. Preoperative cyst enlargement was significantly more common in infants (p < 0.0001), as was the need for reoperation (p = 0.023). After a median radiological follow-up of 26 months, > 50% reduction of cyst volume was seen in 53 cysts (46%), and 47 cysts (40%) showed a 10%-50% reduction. Acute clinical symptoms improved: nausea and vomiting, accelerated head growth, and headaches improved at 100%, 92% and 89%, respectively. However, chronic symptoms responded less favorably after a median clinical follow-up of 26 months.

CONCLUSIONS

The strategy of predominantly endoscopic treatment with navigation planning is efficient to alleviate clinical symptoms and to significantly reduce the mass effect of pediatric intracranial cysts at different anatomical locations. The subgroup of infants requires close pre- and postoperative monitoring.

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.

Do arachnoid cysts grow? A retrospective volumetric study

OBJECTIVE

Arachnoid cysts (ACs) are frequent incidental findings and may be associated with neuropsychiatric symptoms. Usually growth of the ACs with pressure on adjacent brain tissue is regarded as cause of the symptoms. This study was undertaken to identify if and which ACs grow with time.

METHODS

We used a large database of cranial MRIs for a retrospective analysis.

RESULTS

During a period of 10 years, we collected 166 ACs of 50 persons, mean observational period was 2.5 years. Among these, only larger cysts at the temporal pole, i.e., Galassi II ACs, grew with a rate of 0.3 ml a year (β = 0.32, SE 0.07, p = 0.003); all other ACs remained constant in size or became smaller. All cysts were clinically silent.

CONCLUSIONS

Most ACs remain constant in size or become smaller.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that the majority of arachnoid cysts does not grow.

Space-occupying brain lesions, trauma-related tau astrogliopathy, and ARTAG: a report of two cases and a literature review

Astrocytes with intracellular accumulations of misfolded phosphorylated tau protein have been observed in advanced-stage chronic traumatic encephalopathy (CTE) and in other neurodegenerative conditions. There is a growing awareness that astrocytic tau inclusions are also relatively common in the brains of persons over 70 years of age-affecting approximately one-third of autopsied individuals. The pathologic hallmarks of aging-related tau astrogliopathy (ARTAG) include phosphorylated tau protein within thorn-shaped astrocytes (TSA) in subpial, subependymal, perivascular, and white matter regions, whereas granular-fuzzy astrocytes are often seen in gray matter. CTE and ARTAG share molecular and histopathologic characteristics, suggesting that trauma-related mechanism(s) may predispose to the development of tau astrogliopathy. There are presently few experimental systems to study the pathobiology of astrocytic-tau aggregation, but human studies have made recent progress. For example, leucotomy (also referred to as lobotomy) is associated with a localized ARTAG-like neuropathology decades after the surgical brain injury, suggesting that chronic brain injury of any type may predispose to later life ARTAG. To examine this idea in a different context, we report clinical and pathologic features of two middle-aged men who came to autopsy with large (> 6 cm in greatest dimension) arachnoid cysts that had physically displaced and injured the subjects' left temporal lobes through chronic mechanical stress. Despite the similarity of the size and location of the arachnoid cysts, these individuals had dissimilar neurologic outcomes and neuropathologic findings. We review the evidence for ARTAG in response to brain injury, and discuss how the location and molecular properties of astroglial tau inclusions might alter the physiology of resident astrocytes. These cases and literature review point toward possible mechanism(s) of tau aggregation in astrocytes in response to chronic brain trauma.

A large interhemispheric glioependymal cyst associated with partial defect of the corpus callosum in an elderly man

Interhemispheric cysts are congenital, and usually present symptoms during childhood. However, they are occasionally detected in adults. These cystic lesions are sometimes associated with defects of the corpus callosum. Although defects of the corpus callosum by themselves do not present clinical symptoms, they are often accompanied by other brain malformations. A man in his late 60s was found dead at the scene of a fire. At autopsy, his brain weighed 1223 g and had a large interhemispheric cyst, measuring 5.5 × 4.5 × 4.0 cm in size. The cyst contained clear fluid but was not connected to the ventricular system. On slices of the cerebrum, the corpus callosum did not connect the right and left cerebral hemispheres, and the right lateral ventricle was dilated. By the existence of the cyst, compressed by the cyst, the hemispheres were displaced on either side. Histologically, the cerebral parenchyma around the cyst was slightly edematous but structurally normal. Immunohistochemically, both glial fibrillary acidic protein and podoplanin were expressed in the cystic components. Thus, the cystic lesion was diagnosed as a glioependymal cyst. In this case, because the cyst was located at the interhemispheric space between the right and left frontal lobes, the individual experienced no obvious symptoms, despite its large size. The individual's brain malformations included the partial defect of the corpus callosum and the cyst. The dilation of the right lateral ventricle was considered to result from the location of the cyst. Under the influence of the cyst, the third ventricle was displaced downward, and one or both of the interventricular foramen were obstructed. The decedent had burns over his whole body. Burns to the epiglottis and soot in the airway were also observed. Volatile hydrocarbons, such as benzene and styrene, were detected in the blood. The percentage of carboxyhemoglobin levels in a total of hemoglobin levels were 19-25%. Therefore, the individual's cause of death was established as death by fire.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Arachnoid cysts on magnetic resonance imaging: just an incidental finding?

Objective

To determine the clinical significance of arachnoid cysts.

Methods

The scans of 6978 patients undergoing magnetic resonance imaging of the internal acoustic meatus for unilateral cochleovestibular symptoms were retrospectively reviewed. We identified the scans with arachnoid cysts, and assessed the statistical associations between the laterality, location and size of the arachnoid cyst, the laterality of symptoms, the patients’ age and gender.

Results

In a total of 37 arachnoid cysts identified in 36 patients (0.5 per cent), no associations were identified between the laterality of symptoms and the laterality of the arachnoid cyst, regardless of its size or location. There were no significant associations between the location of the arachnoid cyst and the age (p = 0.99) or gender of the patient (p = 0.13), or size (p = 0.656) or side of the cyst (p = 0.61). None of the cysts with repeat imaging scans (17 cysts) demonstrated growth.

Conclusion

Our results suggest that most, if not all, arachnoid cysts are of no clinical significance. Given their indolent behaviour, even serial imaging is not essential.

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.

Supratentorial arachnoid cysts and seizures/epilepsy: A population study in community dwellers aged ≥20 years

Literature on the association between arachnoid cysts and seizures/epilepsy is inconsistent, and most series have been flawed due to recruitment bias. In this study, we aimed to assess the prevalence of supratentorial arachnoid cysts (SACs) in Atahualpa residents aged ≥20 years, and to estimate whether these lesions were associated with seizures/epilepsy. A total of 1157 individuals were included. Computed tomography revealed SACs in 25 individuals (2.2%). Most had middle cranial fossa SACs (n = 19). Recurrent nonprovoked seizures were diagnosed in 28 individuals and a single seizure in 4. Only 1 of 25 (4%) individuals with SACs had seizures/epilepsy as opposed to 31 of 1132 (2.7%) who did not have SACs (P = 0.508). A logistic regression model showed no association between SACs and seizures/epilepsy, after taking into account the effect of relevant confounders (odds ratio [OR] 1.71; 95% confidence interval [95% CI] 0.22-13.3; P = 0.607). This study provides evidence of lack of association between SACs and seizures/epilepsy.

Resolution of unilateral upper limb action tremor after surgical treatment of a contralateral frontoparietal arachnoid cyst

PURPOSE

Arachnoid cysts (ACs) are cerebrospinal fluid-filled sacs. Although ACs are a frequent finding on neuroimaging, most remain asymptomatic during lifetime.

CASE REPORT

We report a very rare case of a 62-year-old female patient presenting with a tremor due to a giant arachnoid cyst, which completely resolved after cyst-peritoneal shunting.

Neurodevelopmental outcomes in children with large temporal arachnoid cysts

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

The Transcondylar Approach to Access Symptomatic Arachnoid Cysts of the Hypoglossal Canal

BACKGROUND AND IMPORTANCE

A direct transcondylar approach to treat symptomatic arachnoid cysts of the hypoglossal canal has not yet been described in the literature.

CLINICAL PRESENTATION

Here, we present a skull base approach in 2 female patients (68 and 38 yr) with progressive dysphagia, dysarthria, half-sided weakness, and atrophy of the tongue due to an arachnoid cyst of the hypoglossal canal. After patient informed consent, both patients were successfully operated on without complications using a transcondylar approach, and their symptoms improved 3 mo after surgery; in both patients, resection of the cyst was confirmed using magnetic resonance imaging. Review of the literature revealed 4 surgically treated cases of hypoglossal cysts operated on through a paramedian suboccipital craniotomy from a medial to lateral surgical corridor.

CONCLUSION

This is the first description of the transcondylar surgical approach to safely operate on symptomatic arachnoid cysts located in the hypoglossal canal. The isolated transcondylar approach is useful in selective cases when the pathology is located within the hypoglossal canal only and the skull base anatomy allows a direct approach.

Does subjective improvement in adults with intracranial arachnoid cysts justify surgical treatment?

OBJECTIVE

Subjective improvement of patients who have undergone surgery for intracranial arachnoid cysts has justified surgical treatment. The current study aimed to evaluate the outcome of surgical treatment for arachnoid cysts using standardized interviews and assessments of neuropsychological function and balance. The relationship between arachnoid cyst location, postoperative improvement, and arachnoid cyst volume was also examined.

METHODS

The authors performed a prospective, population-based study. One hundred nine patients underwent neurological, neuropsychological, and physiotherapeutic examinations. The arachnoid cysts were considered symptomatic in 75 patients, 53 of whom agreed to undergo surgery. In 32 patients, results of the differential diagnosis revealed that the symptoms were due to a different underlying condition and were unrelated to an arachnoid cyst. Neuropsychological testing included target reaction time, Grooved Pegboard, Rey Auditory Verbal Learning, Rey Osterrieth complex figure, and Stroop tests. Balance tests included the extended Falls Efficacy Scale, Romberg, and sharpened Romberg with open and closed eyes. The tests were repeated 5 months postoperatively. Cyst volume was pre- and postoperatively measured using OsiriX software.

RESULTS

Patients who underwent surgery did not have results on balance and neuropsychological tests that were different from patients who declined or had symptoms unrelated to the arachnoid cyst. Patients with a temporal arachnoid cyst performed within the normal range on the neuropsychological tests. Seventy-seven percent of the patients who underwent surgery reported improvement, yet there were no differences in test results before and after surgery. Arachnoid cysts in the temporal region and posterior fossa did not influence the preoperative results of neuropsychological and motor tests. The arachnoid cyst volume decreased postoperatively (p < 0.0001), but there was no relationship between volume reduction and clinical improvement.

CONCLUSIONS

The results of this study speak against objectively verifiable improvement following surgical treatment in adults with intracranial arachnoid cysts.

Ophthalmological symptoms in children with intracranial cysts

The purpose of this study was to perform an ophthalmological assessment in children with intracranial cysts and to assess the correlation between the occurrence of cysts and visual disorders. The documentation of 46 children with intracranial cysts, monitored by the Children’s Outpatient Ophthalmology Clinic, Poznan, Poland was analysed. The best corrected visual acuity (BCVA), the alignment of the eyes, visual evoked potentials (VEP), comprehensive eye examination were performed in all patients. Additional ophthalmological tests were conducted to eliminate other causes of decreased visual acuity.Included in the final analysis were 26 children (52 eyes). The average age at the last visit was 10.3 years. Sixteen children (61.5%) had arachnoid cysts located in the posterior cranial fossa, 3 children (11.5%) in the middle cranial fossa, while 7 children (27%) had a pineal cyst. Decreased BCVA was found in 13 children, abnormal VEP in 13, strabismus in 14 patients (53.9%), nystagmus in 5 patients (19.2%), and double vision in 2 patients (7.7%). Numerous visual disorders in children with intracranial cysts suggest the necessity to carry out enhanced ophthalmological diagnostics in these patients. In the examined patient group, visual disorders occurred mostly in the case of arachnoid cysts of the posterior fossa.

The association of arachnoid cysts and focal epilepsy: Hospital based case control study

OBJECTIVE

Arachnoid cysts (ACs) are common findings in brain MRI. Our aim was to examine frequency and distribution of ACs in patients with focal epilepsy, compared to healthy control subjects, and to investigate the association of AC and electro-clinical features of focal epilepsy.

PATIENTS AND METHODS

We performed a retrospective case-control study, using data from 180 patients that underwent video-EEG monitoring between 2009 and 2012, and of 114 healthy controlled subjects. Analysis of electro-clinical data and structural MRI images was conducted.

RESULTS

A significantly higher proportion of ACs in the focal epilepsy group (19/180; 10.5%) compared to healthy control subjects (3/114; 2.6%) (p=0.012) was identified. Significant congruence of semiological features or interictal and ictal EEG with AC localization was identified in only one MRI nonlesional patient with temporal cyst localization.

CONCLUSION

ACs are seen more often in patients with focal epilepsy. Explicit association between focal epilepsy and AC is possible but exceptional. More likely, focal epilepsy and AC share a common etiological ancestor but represent distant and distinct entities.