Cyst-ventricle stent as primary or salvage treatment for posterior fossa arachnoid cysts

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.

A Case of Torticollis in an 8-Month-Old Infant Caused by Posterior Fossa Arachnoid Cyst: An Important Entity for Differential Diagnosis

Torticollis is a clinical diagnosis with heterogeneous causes. We present an unusual case of acquired torticollis in an 8-month-old female infant with a large cerebellopontine angle arachnoid cyst. Symptoms resolved after surgical fenestration. Non-traumatic acquired or new-onset torticollis requires brain imaging, and posterior fossa lesions are an important entity in the differential for pediatric clinicians.

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

INTRODUCTION

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

CASE REPORT

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

DISCUSSION/CONCLUSION

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

Cognition in Children with Arachnoid Cysts

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

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

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSION

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

Intracranial arachnoid cysts: Pediatric neurosurgery update

Background:

With the greater worldwide availability of neuroimaging, more intracranial arachnoid cysts (IACs) are being found in all age groups. A subset of these lesions become symptomatic and requires neurosurgical management. The clinical presentations of IACs vary from asymptomatic to extremely symptomatic. Here, we reviewed the clinical presentation and treatment considerations for pediatric IACs.

Case Description:

Here, we presented three cases of IAC, focusing on different clinical and treatment considerations.

Conclusion:

IACs can be challenging to manage. There is no Class I Evidence to guide how these should be treated. We suggest clinical decision-making framework as to how to treat IACs based on our understanding of the natural history, risks/benefits of treatments, and outcomes in the future, require better patient selection for the surgical management of IACs will be warranted.

Rare case of a rapidly enlarging symptomatic arachnoid cyst of the posterior fossa in an infant: A case report and review of the literature

Background:

Intracranial arachnoid cysts are space-occupying lesions that typically remain stable or decrease in size over time. Cysts in infants younger than 1 year of age are remarkably different from those in older children and adults in terms of cyst localization and enlargement. Arachnoid cysts of the posterior fossa (PFACs) are very rare in infants and do not typically grow or present with clinical symptoms, such that surgical treatment is generally considered to be unnecessary. Here, we describe an extremely rare case of an infant with a rapidly enlarging symptomatic PFAC that was successfully treated with surgery.

Case Description:

A 4-month-old boy presented with increasing head circumference and a rapidly enlarging arachnoid cyst in the left posterior fossa with ventriculomegaly, which was documented using serial imaging over the preceding 2 months. We performed a microscopic resection of the cyst membrane to remove the mass effect as soon as possible and facilitate normal development. To confirm dural closure and prevent cerebrospinal fluid leakage, we also performed short-term (7 days) percutaneous long-tunneled external ventricle drainage after the surgery. Magnetic resonance imaging over a 4-year follow-up period revealed adequate reduction of the ventricle and cyst. The patient no longer exhibited progressive macrocrania and showed normal development.

Conclusion:

To our knowledge, this is the second successful case of surgical treatment of an enlarging symptomatic PFAC in an infant. Our surgical strategy for the treatment of this rare case can serve as a guide for surgeons in similar future cases.

Posterior fossa arachnoid cyst causing torticollis and gastro-oesophageal reflux in an infant

INTRODUCTION

Arachnoid cysts (ACs) account for a small proportion of all intracranial lesions. They are often incidental but can become symptomatic and even cause a threat to life. Symptoms are usually due to direct compression of neural elements and/or raised intracranial pressure.

CASE REPORT

We report the case of an infant with an enlarging posterior fossa arachnoid cyst (PFAC) causing torticollis and gastro-oesophageal reflux (GOR), the combination of which had been previously unreported in this context. Endoscopic fenestration and cyst decompression were followed by complete resolution of the symptoms. We discuss the possible mechanisms of torticollis and GOR in this context.

Management of quadrigeminal arachnoid cyst associated with obstructive hydrocephalus: report on stereotactic ventricular - cystic stenting

Quadrigeminal arachnoid cysts (QAC) are usually accompanied by a symptomatic obstructive hydrocephalus. Several endoscopic and surgical treatments exist; however, the critical location of these cysts further complicates treatment and usually more than one procedure is required. In this report, a 31 year old female with QAC and associated obstructive hydrocephalus was successfully treated with stereotactic placement of a permanent ventricular - cystic stent (intraventricualr - cystic catheterization) in single - session. Intraventricular - cystic stenting provides a long lasting communication between these two compartments, allowing persistent "physiologic" solution to this challenging condition.

Neuroendoscopic stent placement for cerebrospinal fluid pathway obstructions in adults

OBJECTIVE Since its revival in the early 1990s, neuroendoscopy has become an integral component of modern neurosurgery. Endoscopic stent placement for treatment of CSF pathway obstruction is a rarely used and underestimated procedure. The authors present the first series of neuroendoscopic intracranial stenting for CSF pathway obstruction in adults with associated results and complications spanning a long-term follow-up of 20 years. METHODS The authors retrospectively reviewed a prospectively maintained clinical database for endoscopic stent placement performed in adults between 1993 and 2013. RESULTS Of 526 endoscopic intraventricular procedures, stents were placed for treatment of CSF disorders in 25 cases (4.8%). The technique was used in the management of arachnoid cysts (ACs; n = 8), tumor-related CSF disorders (n = 13), and hydrocephalus due to stenosis of the foramen of Monro (n = 2) or aqueduct (n = 2). The mean follow-up was 87.1 months. No deaths or infections occurred that were related to endoscopic placement of intracranial stents. Late stent dislocation or migration was observed in 3 patients (12%). CONCLUSIONS Endoscopic intracranial stent placement in adults is rarely required but is a safe and helpful technique in select cases. It is indicated when reliable and long-lasting restoration of CSF pathway obstructions cannot be achieved with standard endoscopic techniques. In the treatment of tumor-related hydrocephalus, it is a good option to avoid reclosure of the restored CSF pathway by tumor growth. Currently, routine stent placement after endoscopic fenestration of ACs is not recommended. Stent placement for treatment of CSF disorders due to tumor is a good option for avoiding CSF shunting. To avoid stent migration and dislocation, and to allow for easy removal if needed, the device should be fixed to a bur hole reservoir.

Symptomatic foramen of Magendie arachnoid cyst in an elderly patient

Background:

Arachnoid cysts (ACs) are congenital anomalies of the central nervous system and arise in virtually all locations where the arachnoid membrane exists. Posterior fossa ACs are considered to develop in the posterior aspect of the rhombencephalic roof plate and do not communicate freely with the fourth ventricle or perimedullary subarachnoid space. Although posterior fossa ACs have been reported a number of times, ACs arising from the foramen of Magendie are very rare.

Case Description:

We report here on a 76-year-old female who presented with progressive gait disturbance. Magnetic resonance imaging of the head showed a large AC in the foramen of Magendie that was compressing the inferior vermis and medial aspects of the cerebellar hemisphere without causing hydrocephalus. Neurological examination revealed cerebellar ataxia without Romberg's sign. A nearly total excision of the cyst was safely performed via a median suboccipital approach. The patient's postoperative course was excellent and her neurological recovery was remarkable.

Conclusion:

Most cases of ACs located in the foramen of Magendie are reported in children, and it is extremely rare to observe such ACs in the elderly. In fact, to our knowledge, a symptomatic foramen Magendie AC has never been reported previously in an elderly person. Our results indicate that proper surgical intervention can yield highly positive outcomes in such cases.