Temporal fossa arachnoid cyst presenting with bilateral subdural hematoma following trauma: two case reports

Arachnoid Cysts in Athletes with Sports-Related Concussion: A Case Series and Literature Review

BACKGROUND

Arachnoid cysts (AC) are associated with a risk of rupture or haemorrhage following head impact and pose a potential predisposing factor for significant complications of sport-related concussion. Despite a recognised association between ACs and intracranial haemorrhage/cyst rupture, the risk profile of participating in contact sports with AC is not well defined. We report a retrospective case series of players presenting to the Birmingham Sports Concussion Clinic between 2017 and 2023 and underwent MRI head, with a comprehensive review of the prior literature.

RESULTS

432 athletes underwent MRI of which 11 were identified to have AC (middle fossa n = 8; posterior fossa n = 2, intraventricular n = 1). Average maximal diameter was 4.1 ± 1.2 cm. 64% had a protracted recovery (≥ 3 months). 9% experienced an AC specific complication (cyst rupture, complete neurological recovery, maximal diameter 6.5 cm, Galassi II, 4 previous concussions). 91% of patients (mean maximal diameter 3.9 ± 1.0 cm) experienced no complications despite multiple previous accumulated sports-related concussions (mean 3.3, range 1-9). Case studies from the literature are summarised (n = 63), with 98% reporting complications, none of which resulted in adverse or unfavourable neurological outcomes. Across prospective and retrospective cohort studies, 1.5% had a structural injury, and (where outcome was reported) all had a favourable outcome.

CONCLUSIONS

AC is an incidental finding in athletes, with the majority in our cohort having sustained serial concussions without AC complication. The single complication within this cohort occurred in the largest AC, and AC size is proposed as a tentative factor associated with increased risk of contact sports participation. Complications of AC appear to be a rare occurrence. This case series and review has not identified evidence to suggest that participation in sports with AC is of significant risk, though individualised assessment and discussion of the potential risks of contact sports participation should be offered.

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.

A Rare Triad of Lateral Rectus Palsy, Sylvain Fissure Bleed, and Bilateral SDH Shrouding a Benign Pathology

BACKGROUND

Arachnoid cysts are benign extra-cerebral congenital lesions that are thought to arise from the splitting of the arachnoid membrane. Although most arachnoid cysts remain static with advancing age, occasionally they can become symptomatic due to cyst enlargement or hemorrhage. Hemorrhage into the arachnoid cysts (intra-cystic hemorrhage) with or without associated subdural hematoma is of rare occurrence.

CASE DISCUSSION

A 23-year-old male presented with a history of sudden onset severe headache while sleeping. The patient also noticed double vision, especially when looking towards the left side. Non-contrast computed tomography (NCCT) scan of the head showed left temporal pole hematoma with left Sylvian fissure bleed and bilateral fronto-temporoparietal (FTP) subacute SDH.

CONCLUSION

Every patient with incidentally detected AC, especially in the middle cranial fossa, should be counseled regarding the risk of possible complications including hemorrhage and regular follow-up.

Arachnoid cyst with spontaneous intracystic hemorrhage and associated chronic subdural hematoma: A case report

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Spontaneous hemorrhage of arachnoid cyst accompanying subdural hematoma was rare.

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Surgery was the most common and effective treatment.

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Endoscopic/microsurgical fenestration or membranectomy was recommended to prevent a recurrence.

Introduction and importance

Spontaneous hemorrhage of the arachnoid cyst was rare, especially associated with chronic subdural hematoma (CSDH). In this paper, we reported successful surgical management of arachnoid cyst with spontaneous hemorrhage and associated subdural hematoma.

Case presentation

A 33-year-old female with no medical history was presented with a headache for one month prior to admission. Head computed tomography and magnetic resonance imaging showed a left hypodense middle cranial fossa arachnoid cyst and ipsilateral CSDH. The multiple-slice computed tomography with contrast showed no vascular abnormality. The patient was indicated for surgical hematoma evacuation, membranectomy, and fenestration of the arachnoid cyst. At the one postoperative month, the computed tomography showed a middle fossa arachnoid cyst with no hemorrhage. Until a postoperative year, the patient had no headache and no neurological deficits. She returned to daily activities and her work.

Clinical discussion

This event's pathogenesis was thought of as a result of tearing of the outer wall of an arachnoid cyst. The most common cause was mild head trauma; however, spontaneous rupture of the cyst wall also occurred. Surgery was the most common and effective treatment. Evacuation of CSDH was mandatory, but the strategies treatment for arachnoid cysts varied. Surgical options for arachnoid cyst included endoscopic/microsurgical fenestration, membranectomy, and even the cysto-peritoneal shunting.

Conclusion

Arachnoid cyst with spontaneous intracystic hemorrhage accompanying CSDH was an uncommon condition. Surgery was the most common and effective treatment. Besides evacuation of CSDH, endoscopic/microsurgical fenestration or membranectomy was recommended to prevent the recurrence.

Ruptured intra-cranial arachnoid cysts: a case series from a single UK institution

INTRODUCTION

Intracranial arachnoid cysts are a common incidental finding; however presentation with cyst rupture is a recognised complication. Patients are advised to avoid contact sports to reduce the risk of cyst rupture but the risk of rupture is not currently known. The aim of this study is to describe a single institution's experience of managing ruptured intra-cranial arachnoid cysts.

METHOD

A retrospective case note review of all patients admitted to a single institution with a ruptured intra-cranial arachnoid cyst between 2005 and 2016 (inclusive). Medical records were reviewed for demographics, history of trauma, surgical treatment and radiological evidence of cyst rupture.

RESULTS

Fourteen patients were identified for inclusion with an average age of 23.4 years (range 7-57) and 10 (71%) were male. Nine patients (64%) had a documented history of head trauma. Eleven patients (78.6%) required neurosurgical intervention which included hygroma/haematoma evacuation only (n = 5), haematoma evacuation with cyst fenestration (n = 4) and cyst fenestration/shunting only (n = 2). Twelve patients (85%) experienced full recovery and the remaining two had persisting headaches or neurological symptoms.

DISCUSSION

Cyst rupture remains an uncommon cause for presentation with arachnoid cysts. However the majority are associated with head trauma and thus current advice to avoid contact sports seems justified.

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.

Spontaneous chronic subdural hematoma associated with arachnoid cyst in children and young adults

Arachnoid cysts are clear, colorless fluid-filled cysts that arise during brain and skull development from the splitting of the arachnoid membrane. Chronic subdural hematoma (CSDH) is an encapsulated collection of old blood, mostly or totally liquefied and located between the dura mater and the arachnoid mater. Trauma is an important factor in the development of CSDH. Here, we report four patients, previously asymptomatic, revealing CSDH with AC on computed tomography (CT) and magnetic resonance imaging (MRI) of the brain. All patients underwent craniotomy with evacuation of hematoma and resection of the cystic membrane that was then connected to the basal cistern under the operating microscope. Postoperatively, all patients were symptom-free. Presentation of an AC with chronic subdural hematoma in the absence of preceding head trauma is considered to be rare in children and young adults.

Arachnoid cysts confined to the internal auditory canal or facial nerve canal

OBJECTIVE

To illustrate the morphological characteristics and pathological significance of arachnoid cysts confined to the internal auditory canal or facial nerve canal.

DESIGN

Retrospective case series.

SUBJECTS

Three patients' cases were reviewed, and temporal bone sections examined histologically.

RESULTS

In this series, three intracanalicular arachnoid cysts were found in the internal auditory canal and one in the facial nerve canal. All lesions consisted of distinct, space-occupying cysts with a sharp boundary with surrounding tissues. They were thin-walled and compressed the surrounding nerve trunks to a variable degree. However, there was no indication that patients suffered meatal nerve dysfunction.

CONCLUSION

Arachnoid cysts can develop within the internal auditory canal or facial nerve canal. In our series, they were asymptomatic, which is quite different from most intracanalicular arachnoid cysts encountered in clinical practice.