Craniospinal and spinal enterogenous cysts--report of three cases

Huge Ventral Cervicomedullary Neurenteric Cyst: A Rare Entity with Good Surgical Outcome and Appraisal

Neurenteric cysts are rare congenital lesions of benign nature that can be encountered at any level of the neuraxis, starting from the cranium down to coccyx. Rewarding outcome can be achieved with early diagnosis and complete removal of these benign lesions. Here, we report a case of a huge neurenteric cyst in an 11-year-old boy at the ventral craniocervical junction, a rarely reported entity with literature review. In this article, we focus on the clinical presentation, pathogenesis, radiological findings, surgery, and surgical outcome of this benign lesion, as we succeeded to have gratifying result following surgery in our instance.

Therapeutic Strategies and Prognostic Factors Based on 121 Spinal Neurenteric Cysts

BACKGROUND

Limited data existed to guide the management of intraspinal neurenteric cysts (ISNECs).

OBJECTIVE

To evaluate the risk factors for progression-free survival (PFS), elucidate the radiological features of ISNECs, and propose a treatment protocol.

METHODS

From 2003 to 2015, 121 patients with pathologically confirmed ISNECs treated at our institute were included in this study. Pertinent risk factors were evaluated.

RESULTS

Gross total resection (GTR) was achieved in 55 (44.6%) patients; 106 (87.6%), 12 (9.9%), and 3 (2.5%) ISNECs were classified as Wilkins A, B, and C, respectively. After a median follow-up duration of 64.2 mo, recurrence occurred in 25 (22.7%) patients, with a median PFS time of 43.1 mo. The actuarial PFS rates at 5 and 10 yr were 73.2% and 66.2%, respectively. The actuarial overall survival rates at 5 and 10 yr were 100% and 97.6%, respectively. Non-GTR (hazard ratio [HR], 5.836; 95% confidence interval [CI], 1.698-20.058; P = .005), Wilkins B/C (HR, 3.129; 95% CI, 1.009-9.702; P = .048), and a history of surgical resection (HR, 3.690; 95% CI, 1.536-8.864; P = .004) were adverse factors.

CONCLUSION

GTR and Wilkins A were favorable factors for PFS. If tolerable, GTR alone was advocated as an optimal treatment. Because of the benign nature and favorable prognosis, non-GTR was an alternative if GTR failed. Close follow-up was needed because of the recurrent tendency of ISNEC. Future study with a large cohort is necessary to verify our findings.

Congenital Spinal Cysts: An Update and Review of the Literature

Congenital spinal cysts are rare and encompass a wide variety of diseases including arachnoid, enterogenous, teratomatous, neurenteric, foregut, bronchogenic, epithelial, ependymal, dermoid, and epidermoid cysts. Here, we elucidate the epidemiology, pathology, pathogenesis, and diagnostic findings of the most common congenital spinal cysts, followed by a discussion of their presentation and treatment options. Differentiating the cause of each lesion is crucial for targeted clinical and surgical management for the patient. Our review describes how arachnoid cysts can be observed, fenestrated, percutaneously drained, or shunted; however, the primary goal for neurenteric, dermoid, and epidermoid cysts is removal. Further, we discuss how patient presentation is dependent on the rate of growth and location of compression on the spinal cord and nerve roots. However, although many of these lesions are discovered incidentally on imaging, the spectrum of possible symptoms include pain, weakness, ataxia, bladder incontinence, and progressive or acute neurologic deficits. We present and review the histology and imaging of a variety of cysts and discuss how although the goal of treatment is resection, the risks of surgery must be considered against the benefits of complete resection in each case.

Changes in Cervical Neurenteric Cyst Size

Spinal neurenteric cysts are rare congenital anomalies and the natural history of the cyst is not fully understood. We evaluated a case of spontaneous absorption of a cyst. The patient was a 5-year-old boy who had experienced pain in the bilateral upper extremities 3 days before his admission. Neurological examination revealed severe motor weakness of the upper extremities and mild motor weakness of the lower extremities. Magnetic resonance imaging (MRI) revealed an extramedullary cystic lesion with a fluid-fluid level in the cervical region. One week later, the pain spontaneously improved with bed rest, and the patient showed good neurological recovery. MRI performed 6 months later revealed spontaneous reduction of the cyst. Enlargement and contraction of the cyst were observed over 3 years on MRI. Since the size of the cyst changes, MRI should be performed annually for patient follow-up.

A rare case of solid calcified intramedullary neurenteric cyst: Case report and technical note

Neurenteric cysts are rare lesions of the spinal cord, constituting less than 1.3% of all spinal cord tumors. Approximately 90% of neurenteric cysts are located in the intradural extramedullary compartment, while the remaining 10% are divided between an intradural intramedullary or extradural location. They are usually extramedullary and found in the lower cervical and thoracic spine. We report a case of 8 year old child with totally solid calcified intramedullary cyst which has hitherto not been reported in literature. We discuss the challenges faced in the diagnosis and surgical management of such lesions and a brief review of pertinent literature.

Clinical features and MRI manifestations of intraspinal enterogenous cysts

AIM: To explore the clinical features and magnetic resonance imaging (MRI) manifestations of intraspinal enterogenous cysts.

METHODS: Case reports concerning intraspinal enterogenous cysts were retrieved from CNKI and WanFang Data and screened according to the inclusion and exclusion criteria. The clinical features and MRI manifestations of intraspinal enterogenous cysts were analyzed.

RESULTS: A total of 60 case reports with 80 patients were included. The male to female ratio was 46:33. The mean age was 19.9 years ± 14.6 years. The mean course of disease was 2.87 years ± 5.00 years. There were 37.50% of patients with chief complaint or first symptom of neck-shoulder-back pain or discomfort. Most of the patients (82.50%) had motor dysfunction, and 13 patients had complications. The lesions were mostly located in the cervical (45.00%), ventral (83.33%) and subdural (94.87%) spinal cord. The signal was mostly hypointensity (67.35%) on T1 weighted imaging and hyperintensity (91.84%) on T2 weighted imaging in MRI examination. No enhancement was observed in most post-contrast images. Thinning and displacement can be observed in the corresponding spinal segments due to compression of cysts. All patients underwent surgery, and 95.74% of them recovered well. There were three cases of recurrence.

CONCLUSION: Intraspinal enterogenous cyst is a rare congenital disease. It can be diagnosed early and treated timely based on the clinical features and MRI manifestations. MRI examination provides an important tool for preoperative diagnosis, surgical planning and prognosis evaluation of intraspinal enterogenous cysts.

Solitary cervical neurenteric cyst in an adolescent patient

Spinal neurenteric cysts are uncommon congenital lesions, furthermore solitary neurenteric cysts of the upper cervical spine are very rare. A 15-year-old boy having an intraspinal neurenteric cyst located at cervical spine presented with symptoms of neck pain and both shoulders pain for 2 months. Cervical spine magnetic resonance (MR) imaging demonstrated an intradural extramedullary cystic mass at the C1-3 level without enhancement after gadolinium injection. There was no associated malformation on the MR imaging, computed tomography, and radiography. Hemilaminectomy at the C1-3 levels was performed and the lesion was completely removed through a posterior approach. Histological examination showed the cystic wall lined with ciliated pseudostratified columnar epithelium containing mucinous contents. Neurenteric cyst should be considered in the diagnosis of spinal solitary cystic mass.

Silent neurenteric cyst with split cord malformation at conus medullaris: Case report and literature review

Split cord malformations (SCM) are a common pediatric abnormality where children present with features of tethering and backache along with varying neurological deficits. Multiple neural tube defects may co-exist in children having defects of primary and/or secondary neurulation. Co-existent neurenteric cysts along with type 1 SCM have been described very rarely in the literature. We report a case of silent neurenteric cyst at conus medullaris with SCM type 1 where the cyst was missed in the preoperative imaging. Until date, only 8 such cases of neurenteric cysts with SCM at lumbar region have been reported. We review the literature regarding co-existing dual pathologies of neurenteric cysts and type 1 SCMs in light of limited capacity of imaging modalities to detect small neurenteric cysts in presence of co-existent neural tube defects. Multiple spinal neural tube defects in children need more attention and precise microneurosurgical skills as management differs in each of them. Co-existence of such pathologies detected intra-operatively may need modifications in preoperative planning to achieve the best possible outcomes.

Upper cervical cord enterogenous cyst mimicking transient ischaemic attacks

A 76-year-old woman presenting with tetraparesis, left-sided hemisensory loss and occasional neck pain was urgently admitted to our department. A cervical spine MRI scan revealed a partially cystic lesion compressing the cord at the C2-4 level. The lesion was surgically excised. The histopathological diagnosis was that of an enterogenous cyst. No postoperative complications were noted and the patient significantly recovered from the preoperative tetraparesis. Eleven months before surgery, a waxing and waning presentation of the myelopathic signs with normal neuroradiological findings on a non-contrast-enhanced head CT scan, had unfortunately led to the misdiagnosis of transient ischaemic attacks and ischaemic stroke which delayed the treatment of an essentially benign disease the total surgical excision of which not only is usually curative but also improves the preoperative signs and symptoms.

Neurosurgical management of neurenteric cysts in children

OBJECT

Neurenteric cysts (NCs) are endothelium-lined structures of presumed endodermal origin. There have been few pediatric series of intracranial NCs reported previously. The authors present their experience in the management of these lesions.

METHODS

A retrospective chart review of all cases of NCs identified between 1977 and 2007 was carried out. Demographics, details of clinical presentation, surgical therapy, and outcome data were extracted.

RESULTS

Eleven cases were identified, involving 6 girls and 5 boys. The patients' average age was 4.6 years (range 1 day-14 years). Limb weakness was the most common presenting symptom. The location of the cysts was cervical in 2 cases, cervicothoracic in 4 cases, and thoracic in 3 cases. One cyst was anterior to the pons with extension to the left cerebellopontine angle and 1 cyst was at the craniocervical junction. Five patients had an apparently complete initial excision, with 1 recurrence. Four patients were initially treated with incomplete excision and/or cyst drainage, usually into an Ommaya reservoir. A neonate with a large cervicothoracic cyst died of multiple congenital anomalies without any intervention. All other patients were alive at last follow-up. One patient with a radiologically identified presumed cyst, which remained stable, was simply followed up. Several patients required multiple procedures and 1 patient developed hydrocephalus after aseptic meningitis and was treated with CSF shunting.

CONCLUSIONS

Neurenteric cysts are rare in the pediatric population. Total resection, if possible, provides the best long-term outcome. Incomplete excision may lead to multiple procedures, including cyst drainage, but can lead to long-term stability.

Microsurgical excision of the craniocervical neurenteric cysts by the far-lateral transcondylar approach: case report and review of the literature

Neurenteric cysts in the anterior craniocervical junction (CCJ) region can be found in extremely rare cases. We report one case with craniocervical neurenteric cyst that was excised by the far-lateral transcondylar (FLT) approach. A 43-year-old man presented with a history of recurrent episodes of mild neck pain and dysesthesia in his bilateral hands of 2 years' duration with rapid deterioration 3 weeks prior to admission. Magnetic resonance imaging (MRI) of the CCJ region revealed a well-defined intradural cystic lesion located ventral from the pontomedullary junction to C1 vertebra with medulla and C1 cord compression. This patient underwent total excision of the lesion via the FLT approach without any postoperative neurological deficits, and the histopathologic diagnosis was neurenteric cyst. Follow-up MRI has revealed no evidence of recurrence. The clinical features, imaging studies, and surgical approach options involved in resecting craniocervical neurenteric cysts are discussed, along with a review of the literature.

Intramedullary enterogenous cyst of the conus medullaris presenting as lower limb pain

Enterogenous cysts account for 0.7-1.3% of spinal axis tumors. Cervical and thoracic segments are most often affected and they are rare in the lumbar region. Intramedullary variant which comprises less than 5% of enterogenous cysts are densely adherent to the surrounding tissue and preclude total excision. Partial excision is associated with recurrence and is the most common unfavorable outcome in these cysts. Hence, such patients need follow-up with serial imaging. We describe a case of conus medullaris enterogenous cyst presenting as lower limb pain. Due to dense adhesion of the cyst to the surrounding neural tissue, subtotal excision was done. The patient is symptom and tumor free at one year interval. We describe our case, discuss its uniqueness and review the literature on this rare but difficult to cure tumor.

Neurenteric cysts of the spine

Neurenteric cysts account for 0.7-1.3% of spinal axis tumors. These rare lesions result from the inappropriate partitioning of the embryonic notochordal plate and presumptive endoderm during the third week of human development. Heterotopic rests of epithelium reminiscent of gastrointestinal and respiratory tissue lead to eventual formation of compressive cystic lesions of the pediatric and adult spine. Histopathological analysis of neurenteric tissue reveals a highly characteristic structure of columnar or cuboidal epithelium with or without cilia and mucus globules. Patients with symptomatic neurenteric cysts typically present in the second and third decades of life with size-dependent myelopathic and/or radicular signs. Magnetic resonance imaging and computed tomography are essential diagnostic tools for the delineation of cyst form and overlying osseous architecture. A variety of approaches have been employed in the treatment of neurenteric cysts each with a goal of total surgical resection. Although long-term outcome analyses are limited, data available indicate that surgical intervention in the case of neurenteric cysts results in a high frequency of resolution of neurological deficit with minimal morbidity. However, recurrence rates as high as 37% have been reported with incomplete resection secondary to factors such as cyst adhesion to surrounding structure and unclear dissection planes. Here we present a systematic review of English language literature from January 1966 to December 2009 utilizing MEDLINE with the following search terminology: neurenteric cyst, enterogenous cyst, spinal cord tumor, spinal dysraphism, intraspinal cyst, intramedullary cyst, and intradural cyst. In addition, the references of publications returned from the MEDLINE search criteria were surveyed in order to examine other pertinent reports.

Diagnosis and management of adult intracranial neurenteric cysts

BACKGROUND

Intracranial neurenteric cysts are rare, benign lesions of the central nervous system.

OBJECTIVE

To analyze our experience with these lesions and conduct a review of the literature with the aim of identifying a rational approach to diagnosis and management.

METHODS

Seven patients underwent surgical treatment for intracranial neurenteric cysts from July 2000 to December 2008. The general strategy was to perform complete resection whenever possible. The clinical, radiological, operative, and pathological findings of the patients were reviewed retrospectively.

RESULTS

This series included 3 women and 4 men. The age of hospitalized patients ranged from 19 to 55 years, with an average age of 34 years. Headache and dizziness were the most common chief symptoms. The imaging spectrum for these lesions is broad, leading to several preoperative misdiagnoses. All 7 lesions were resected by a far lateral transcondylar or retrosigmoid approach. Total tumor resection was achieved in 3 patients. Four patients presented transient fever postoperatively. All patients were healthy and showed no signs of tumor recurrence at their latest follow-up.

CONCLUSION

Intracranial neurenteric cysts ventral to the brainstem are rare lesions occurring in young adults. These lesions should be considered in the differential diagnosis for intracranial extra-axial cystic lesions anterior to the brainstem. Total surgical resection seems to be the most effective therapeutic method, although radical resection at the risk of impairing the brainstem is not recommended. This benign lesion has a favorable overall prognosis.

Huge intramedullar neurenteric cyst with intrathoracic development in a 1 month-old boy: excision though the anterior approach. A case report and review of the literature

Spinal neurenteric cyst is a rare congenital lesion that may occur either alone or in the context of a complex malformative disorder. Our case is unusual because of its rare intramedullary location, the association with an important intrathoracic development, and the age of the child at presentation (1 month). An anterior approach through a right-sided lateral thoracotomy was performed for a total resection of the intrathoracic part and a subtotal resection for the intramedullar portion. During 2 years of follow-up, the child presented no neurological deficit and post-operative magnetic resonance imaging found a small residue fixed on the anterior spinal cord without progression.

Is total excision of spinal neurenteric cysts possible?

Spinal neurenteric cysts are intradural cystic lesions. These represent a part of the spectrum of developmental anomalies. These are rare lesions. Most of the data in literature is review of case reports. This made us evaluate our results of 23 cases and review the literature. This is a retrospective study of 23 patients managed at our institute over 20 years. The slides were retrieved and histopathological features studied. Twenty patients were less than 30 years old and 21 were males. Follow-up was available for 21 patients with mean duration of 71 months (range 2 months to 23 years). The typical presentation was backache with progressive neurological deficits pertaining to the level. Atypical presentations as acute onset, recurrent episodic events and aseptic meningitis were also noted. The cervicothoracic region was the most common site. 16 patients had cyst in intradural extramedullary plane and seven had intramedullary location. Associated vertebral anomalies as hemivertebrae, Klippel-Feil and spina bifida were noted in seven patients. There were two histological types of cysts with no correlation between the type of cysts and associated vertebral anomalies and extent of outcome. Partial excision though had higher risk of recurrence, was not associated with poorer outcome. Dorsal approach is an acceptable route with reasonably good results for this lesion. Spinal neurenteric cysts present at younger age with varied clinical presentations. These are commonly located intradurally ventral to the cord. Histological types have no effect on the outcome. Total excision is the choice of treatment. However, partial excision is a feasible option in intramedullary lesions and when significant adhesions occur. Although associated with higher risk of recurrence, the outcome is still good in these patients on re-excision.

Resolution of a fourth ventricle epithelial cyst after ventriculoperitoneal shunting: case report

BACKGROUND

Symptomatic cysts of epithelial origin occurring in the fourth ventricle are very rare. When such a cyst is encountered, the treatment strategy includes surgical removal or fenestration of the cyst into subarachnoid space. CASE 1: A 23-year-old male was diagnosed as having a cyst located in the fourth ventricle causing hydrocephalus; the patient underwent cyst removal via craniotomy. The histopathologic diagnosis was neuroepithelial cyst. Because clinical and neuroradiological findings persisted, he underwent VP shunting. The cyst disappeared and did not recur. CASE 2: A 54-year-old woman was diagnosed as having a cystic mass in the fourth ventricle and dilatation of the ventricles. Magnetic resonance imaging showed the same findings as those of the first case. The patient refused craniotomy for total mass excision. Therefore, a VP shunt was applied. Postoperatively, the clinical findings and hydrocephalus improved, and complete disappearance of the cystic mass was observed unexpectedly. Both cases had 2 years of follow-up.

CONCLUSION

There is no proven mechanism to explain resolution of fourth ventricle cysts after a supratentorial VP shunting. We hypothesize that disappearance of the cyst could result from rupture of its wall because of pressure gradient, which might be facilitated by a VP shunt. The current report should not be taken as an argument against cyst removal, which is the established way of treatment. However, considering that the pathogenesis and pathophysiology of these cysts are unclear, VP shunting should be considered especially for recurrent cases accompanied by hydrocephalus.

Intramedullary neurenteric cysts of the spine. Report of three cases

Neurenteric spinal cysts are infrequently occurring dysraphic lesions that are caused by persistent or abnormal communication among neuroectoderm, notochord, and endoderm. They are generally located at the intradural, extramedullary compartment of the low cervical or upper spinal canal. They occur primarily in infants and in young adults in combination with other congenital abnormalities. The authors report on three cases of lower-thoracic and thoracolumbar intramedullary neurenteric cysts that atypically presented in adult patients in whom there was no concomitant malformation. These lesions appear notable for location, clinical presentation, intraoperative findings, and imaging features.

Presacral neurenteric cyst in an infant

Intraspinal neurenteric cysts are rare congenital cystic lesions, formed due to displacement of elements forming the alimentary canal. We report an 11-month-old infant presenting with a soft, fluctuant and transilluminant swelling posterior to the anus since birth; the size of the swelling varied with alterations in intraspinal pressure subsequent to crying, coughing, or sneezing. MRI showed a multiloculated lesion anterior to the sacrum and coccyx. Near total excision was carried out without any worsening in the neurological status.

Intraventricular congenital lesions and colloid cysts

Intraventricular congenital lesions and colloid cysts comprise a rather large spectrum of different pathologic conditions. In most cases, treatment in not warranted unless there is progressive ventricular obstruction with hydrocephalus or growth of the lesion itself, making tissue biopsy and histopathologic diagnosis necessary. Accordingly, a precise neuroradiologic evaluation is of the utmost importance, because most lesions, if not symptomatic, only require clinical and radiologic follow-up.

Iso-intense neuroenteric cyst in the lower cervical spine treated with ventral resection and anterior fusion utilising sternal notch exposure: case report, technical note and literature review

A 36-year-old female patient with a long-standing asymptomatic lower thoracic scoliosis presented with sensory symptoms involving all limbs. MRI scan demonstrated a rounded ventral intradural mass causing major deformity of the cervical cord at C6 and C7 levels. Unlike most previously reported neurenteric cysts, the MRI signal characteristics of this mass were such that it could not be determined if it is cystic or solid, being iso-intense on T1- and hyperintense T2-weighted images. Resection was performed through a median corporectomy of C6 and C7, the lesion being found to be a neurenteric cyst with an attachment to the anterior median fissure of the cord. Strut graft and cervical locking plate fixation from C5 to C6 was facilitated by extending the cervical incision into the sternal notch, with detachment of left-sided strap muscle insertion. The patient made an excellent recovery with complete resolution of neurological symptoms and solid fusion. The postoperative course was complicated by an anterior cervical CSF collection which resolved spontaneously within 2 months. The literature regarding this rare condition and its management is reviewed. Although the majority of intraspinal neurenteric cysts are situated ventral to the cord, most reports of excision have been from a dorsal approach. Drainage and subtotal excision of neurenteric cysts have been previously advocated; however, the recurrence rate is such that complete excision is advocated. This is facilitated by a ventral approach. A simplified method of utilising the sternal notch exposure is reported. The literature regarding the anatomical peculiarities pertinent to the sternal notch approach, and the reported literature regarding spinal neurenteric cysts is reviewed.

Unusual neuroenteric cysts: diagnosis and management

Six cases of unusual neuroenteric (NE) cysts, occurring in children aged 15 months to 18 years, are reported here. Three of the cysts were extramedullary, while the other three were intramedullary. Two of the extramedullary cysts were located at the lumbosacral region, an unusual site. Only one patient had the cyst located in a ventral relation to the cord in the cervicothoracic region. None of the patients had communication with the mediastinum or intraabdominal viscera. Stigmata of spinal dysraphism were seen in three patients. All the children had variable neurological involvement and it was difficult to differentiate NE cyst from other causes of spinal cord or cauda equina lesion, particularly in the absence of some dysraphic marker. One patient presented with minimal neurological deficits and painful torticollis; this patient was suspected to have an atlantoaxial dislocation. All patients were investigated with MRI, and the only diagnostic feature of an NE cyst was an intradural cyst with an anterior vertebral body anomaly in a single case. It was not possible to radiologically differentiate NE cyst from other intraspinal cysts in the rest of the patients. All patients were operated on by the posterior route; an attempt to excise the cyst nearly in toto was made. Evidence of neural tethering most probably due to cyst contents was seen in three patients. All patients improved after surgery. None showed recurrence of the cyst at follow-up of 3 months to 2 years.

Intramedullary neurenteric cyst presenting as infantile paraplegia: a case and review

The authors report a case of a 3-month-old male child with paraplegia in whom magnetic resonance imaging (MRI) revealed a nonenhancing intramedullary cystic lesion extending from the level of D1 to D7 without any other associated anomaly. Intraoperatively, these findings were confirmed and the spinal cord was found to have splayed circumferentially into a papery thin rim. The patient underwent marsupialization of the cyst with subtotal excision of the cyst wall. Histopathological examination revealed ciliated pseudostratified columnar epithelium consistent with the diagnosis of a neurenteric cyst. Intramedullary neurenteric cysts are rare developmental malformations, and out of the 13 previously reported cases, only 3 were evaluated by MRI. This is the first case report in the literature of an intramedullary neurenteric cyst presenting as infantile paraplegia. In the present report, the embryology, etiopathogenesis, radiological imaging and management of this rare clinical entity are discussed and a detailed literature review is presented.

Intramedullary neurenteric cysts of the spine. Case report and review of the literature

This case of a 68-year-old woman with a low-thoracic intramedullary neurenteric cyst is notable for clinical presentation, cyst location, intraoperative findings, and imaging characteristics. The patient's postoperative course was complicated by neurological deterioration and a neuropathic pain syndrome. Potential causes of these complications are discussed, as are possible ways to reduce the risk of their occurrence.