Arachnoid Cyst Causing Depression and Neuropsychiatric Symptoms: a Case Report

Arachnoid cysts are benign space-occupying brain lesions that contain cerebrospinal fluid. Most cases are congenital in origin, caused by failed fusion of the arachnoid membrane early in fetal development. Cases are often incidentally detected on neuroimaging; however, rarely patients present with neuropsychiatric manifestations when cysts expand and cause a midline shift, compression of nearby brain tissue or cerebrospinal fluid compartments or both. We report a case of a 56-year-old woman with no past history or family history of psychiatric illness who developed acute-onset right-sided weakness, depressive symptoms, and other neuropsychiatric deficits. A diagnosis of organic mood disorder caused by an arachnoid cyst was made. Her symptoms and neuropsychiatric deficits remitted after cyst marsupialisation by open craniotomy. Therefore, it is important to investigate the organic aetiology in elderly patients who present with simultaneous mood disorder and cognitive dysfunction.

Quality of life in adult patients with primary intracranial arachnoid cysts

BACKGROUND

Primary arachnoid cysts are benign developmental lesions of arachnoid mater. Arachnoid cysts may be detected due to various neurological symptoms, or they may be encountered as incidental findings of neuroimaging. Consequently, a significant share of the patients seems asymptomatic. There are diverging opinions about the clinical importance of cyst sizes, cyst location and degree of volume reduction after surgery, hence contributing to controversies regarding indications for surgical treatment. We present the first study assessing internationally established parameters of quality of life and mental health in a clinical-outcome analysis of adult patients with arachnoid cysts.

METHOD

Ninety-two adult patients with arachnoid cysts who had been referred to our department over the last 16 years were included. Forty-seven patients had undergone surgery and 45 patients had not been operated on. Data for analysis was based on both medical records and questionnaires sent out by mail. Quality of life was assessed by the Short Form 36 Health Survey (SF-36), and mental health was further evaluated by the Hospital Anxiety and Depression Scale (HADS). Seventy-one percent of patients responded to our questionnaires.

FINDINGS

There was a great variation in the presenting symptoms, seemingly without any relation to cyst localisation. Patients with arachnoid cysts seem to have a reduced quality of life and a very high prevalence of anxiety compared to a healthy normal population. Men presented lower outcome scores than women. Subjects with symptoms, that we retrospectively labeled biologically comprehensible, tended to have higher quality of life, less anxiety and better subjective symptom relief after surgery.

CONCLUSION

Our arachnoid cyst population had a low employment status, decreased quality of life scores and prevalent symptoms of anxiety. We argue that the arachnoid cysts are, in most cases, not directly related to these studied parameters. We speculate that our findings may reflect the demographic characteristics of adults likely of being diagnosed with incidental cysts. A better clinical outcome for patients with biologically plausible symptoms supports a neurobiological approach in the selection of patients suited for surgery.

Neurocognitive sequelae of a giant arachnoid cyst: case study

We conducted a comprehensive neuropsychological evaluation of a normally functioning man with a giant arachnoid cyst encompassing much of the space normally occupied by the left hemisphere. Although of solidly average intellectual ability, the patient demonstrated neurocognitive deficits only revealed upon neuropsychological assessment. Despite the remarkable left hemisphere lesion, the pattern of cognitive dysfunction suggested right hemisphere pathology. We review the arachnoid cyst literature and discuss the possibility of a crowding phenomenon by which language function relocates to the more viable hemisphere. This case illustrates striking preservation of higher cognition in the presence of substantial structural abnormality.

Assessment of Memory and New Learning Ability following Stereotaxy-Guided Transcortical Resection of Anterior Third Ventricular Colloid Cysts

In a prospective study, memory and new learning ability functions were assessed pre-operatively (17 patients) and in the early post-operative period (22 patients) at 7-26 days following surgery in patients undergoing stereotactic transcortical excision of their colloid cysts. Pre-operative assessment detected impaired memory in 5 patients, 2 of whom had no memory-related complaints. Impaired new learning ability was detected pre-operatively in 7 patients. There was a statistically non-significant trend towards improvement in the dysfunction scores post-operatively in most patients. No correlation was detected between the cyst size, presence of raised intracranial pressure at presentation, hydrocephalus and the pre-operative dysfunction scores. Stereotactic transcortical resection of colloid cysts does not impair these functions in the majority of patients and might improve these functions in some. In the absence of clinical or radiological predictors of dysfunction of memory and new learning ability, pre-operative neuropsychological assessment has a role in detecting impaired memory and new learning ability in patients with anterior third ventricular colloid cysts who may not even complain of them.

Neuroendoscopic management of interhemispheric cysts in children

OBJECT

Interhemispheric arachnoid cysts are very rare, and they are often associated with complex brain malformations such as corpus callosum agenesis and hydrocephalus. Debate remains concerning the proper management of these lesions. Placement of shunts and microsurgical marsupialization of the cyst are the traditional options. Using endoscopic methods to create areas of communication between the cyst, the ventricular system, and/or the subarachnoid space is an attractive alternative to the use of shunts and microsurgery.

METHODS

Between 2000 and 2005, seven consecutive pediatric patients with interhemispheric arachnoid cysts underwent neuroendoscopic treatment involving cystoventriculostomy in two patients, cystocisternostomy in two, and cystoventriculocisternostomy in three. There were three cases of associated hydrocephalus, six cases of corpus callosum agenesis, and one case of corpus callosum hypogenesis. The follow-up period ranged from 12 to 49 months (mean 31.6 months). Endoscopic procedures were completely successful in all but two patients. In one of the remaining two patients, a repeated endoscopic cystocisternostomy was performed with success because of closure of the previous stoma. In the other, a subcutaneous collection of cerebrospinal fluid (CSF) was managed by insertion of an lumboperitoneal shunt. A subdural collection of CSF developed in three patients; it was treated with insertion of a subduroperitoneal shunt in one patient and managed conservatively in the other two patients, resolving spontaneously without further treatment. Neurodevelopmental evaluation performed in six patients showed normal intelligence (total intelligence quotient [IQ] > 80) in three patients, mild developmental delay (total IQ 50-80) in two, and severe developmental delay (total IQ < 50) in one.

CONCLUSIONS

Endoscopic treatment of interhemispheric cysts can be considered a useful alternative to traditional treatments, even if some complications are to be expected, such as subdural or subcutaneous CSF collections and CSF leaks due to thinness of cerebral mantle and to the often-associated multifactorial hydrocephalus.

A case of brief psychosis associated with an arachnoid cyst

Little is known about the arachnoid cyst and there have been few reports of it accompanying psychiatric disturbances. A 57-year-old patient was admitted due to sudden headache, auditory hallucination, and delusion of persecution. An arachnoid cyst was found in the anteromedial aspect of middle cranial fossa on his magnetic resonance image. This was his first psychotic episode and he was also negative to other clinical evaluations including endocrine system. His psychotic symptoms were suspected to be induced by the arachnoid cyst and it was well controlled by low-dose risperidone administration. He left hospital free from psychotic symptoms on 14th hospital day.

Symptomatic arachnoid cyst of the left frontal convexity presenting with memory disturbance--case report

A 48-year-old female presented with vertiginous feeling and behavior disturbance. Computed tomography showed an arachnoid cyst on the left cerebral convexity. Single photon emission computed tomography revealed decreased cerebral blood flow (CBF) in the left frontal lobe. The Wechsler Memory Scale-Revised test demonstrated memory dysfunction. The arachnoid cyst was partially removed. Disturbances in CBF and behavior disappeared postoperatively. Local ischemia induced by compression due to arachnoid cyst may cause memory dysfunction and behavior disturbance. Neuropsychometric examination is useful for the evaluation of such symptoms.

Relevance of the cerebellar hemispheres for executive functions

The aim of the present study was to elucidate the role of the cerebellar hemispheres in executive functions. The findings are relevant because of the large number of children who survive cerebellar tumors. Neuropsychologic assessments of four patients (8-21 years of age) who had undergone neurosurgery for removal of tumors in the cerebellar hemispheres were conducted and compared with the assessments of six children who had been diagnosed with temporal lobe tumors or cysts. The executive functions were assessed using the Wisconsin Card Sorting Test. IQs were average in both groups. As expected, patients with cerebellar hemispheric lesions had impaired executive functions. In particular, they appeared to have difficulty generating and testing hypotheses regarding the matching rules on the Wisconsin Card Sorting Test. Patients with temporal lesions had a different pattern of deficits on this test. The findings are consistent with the theories that propose that the cerebellar hemispheres are involved in cognitive processes. The findings also demonstrate that subtle deficits in executive functions can be masked by a normal IQ in survivors of cerebellar tumors and highlight the need to design interventions targeted toward problem-solving skills.

[Intracranial arachnoidal cysts--some neuropsychological experiences]

Arachnoid cysts may cause neurological symptoms. The aim of this study was to investigate whether they also affect cognition. 31 patients (26 males and five females) underwent decompressive surgery for a symptomatic cyst in the left temporal fossa, with craniotomy and fenestration or with a cystosubdural shunt. The patients were tested for asymmetries in verbal perception and verbal memory before and after surgery, using dichotic listening techniques with different auditory stimuli presented simultaneously to the two ears. In the preoperative perception (dichotic listening-DL) test, the patients failed to show the normal advantage for auditory input to the right ear. After decompression, their DL performance normalised, as they now had a right ear advantage. In the preoperative dichotic memory test, the patients differed significantly from a normal reference group in two respects: they remembered fewer words, and they exhibited a clear left ear advantage, in contrast to the normal right ear advantage seen in the reference group. Postoperatively, overall memory performance was enhanced, and the preoperative superiority of the left ear had changed to a normal right ear advantage. The results indicate that arachnoid cysts in the left temporal fossa impair cognition, that neuropsychological tests are required to disclose such impairments, and that decompressive surgery improves cognition.

Cognitive improvement despite minimal arachnoid cyst decompression

There are relatively few reports that evaluate the cognitive functions of patients with arachnoid cysts. Presumably, these 'silent cysts' are regarded as incidental findings with no functional significance. Although postoperative clinical improvement is well documented in patients with significant reduction in cystic volume, the current report describes a patient who underwent cystoperitoneal shunting due to mass effect, with minimal postoperative decompression. Neuropsychological testing indicated significant cognitive improvement in verbal learning, memory, visual-perceptual abilities, constructional skills, conceptual shifting, and psychomotor speed after shunt placement, despite marginal evidence of decompression. These findings suggest that (1) significant cognitive changes can occur in these patients, despite minimal postoperative regression of the lesion, (2) cognitive measures may provide an alternative, functional index of outcome efficacy, and (3) reliance on traditional outcome measures (i.e. anatomical decompression or resolution of clinical symptoms) may underestimate the efficacy of surgical intervention for these patients.

[Parasitic delirium in patient with multiorganic pathology: a complex situation]

Delusion of parasitosis is often observed in people who usually take psychoactive drugs. Moreover, it can be present in infectious diseases or tumours of the central nervous system, metabolic disorders, deficiency and states systemic disorders, such as Systemic Lupus Erythematosus (SLE). The neuropsychiatric manifestations in SLE patients are common and constitute one of the criteria for the classification of SLE. Presentation as an acute organic mental syndrome is a clinical emergency and it is usually required the admission in the hospital. We report a case of delusion of parasitosis in a middle age woman diagnosed of SLE several years before and with previous corticosteroid therapy, right temporal arachnoid cyst, chronic Lyme disease and hypothyroidism. We analyse the different role of each pathology and the clinical practice difficulties in the management of these disorders.

Cerebellar arachnoid cyst in a firesetter: the weight of organic lesions in arson

A 52-year-old female patient was accused of arson; the patient had had an arachnoid cyst of the cerebellar vermis. Even after surgery, she showed marked instability of mood and pseudologia fantastica, but did not suffer from cognitive impairment. Possible associations of the presence of this cerebellar arachnoid cyst and behavioral disturbances are discussed.

Arachnoid cysts of the left temporal fossa: impaired preoperative cognition and postoperative improvement

Thirteen adult patients were operated on for symptomatic arachnoid cysts in the left temporal fossa; seven with an internal shunt procedure during local anaesthesia, and five with a craniotomy with fenestration of the cyst to the basal cisterns. In one patient, an initial internal shunt was transformed to a cystoperitoneal shunt. After surgery, all patients experienced relief of symptoms. Reduction of cyst volume occurred in 11 patients. The patients were tested for brain asymmetries related to language and verbal memory before and after operation, with a dichotic listening technique with simultaneous presentation of different auditory stimuli to the two ears. In the preoperative memory test, the patients showed impaired total recall compared with healthy control subjects, and recall from the right ear was significantly impaired. The patients also performed poorly in a forced attention task consisting of dichotic presentations of consonant-vowel syllables. In addition to clinical improvement, the surgical procedures led to improvements in both dichotic perception and memory. Overall memory performance was enhanced, mainly because of improved recall from the right ear. This normalisation of memory function was found as early as four hours after the operation. The results indicate that arachnoid cysts in the left temporal fossa may impair cognitive function, that neuropsychological tests are necessary to disclose these impairments, and that cognitive improvement occurs after surgery.

[Psychiatric and neuropsychological symptoms in children with arachnoid cysts--a case report]

Arachnoid cysts (AC) are intracranial, extracerebral cysts. They can produce a wide variety of neurological symptoms, but they can also be asymptomatic or produce psychological or psychiatric symptoms. First, a short overview of the clinical manifestations of AC is given. There is an astonishing lack of literature dealing with psychological problems in children with AC. The case of a 12-year-old boy with a large left temporofrontal AC without increased intracranial pressure is presented. The psychiatric symptoms, which had begun only a few months earlier, included lack of interest, attention deficit, difficulties in contact and communication, severe outbursts of aggression and obsessive-compulsive, inhibited behavior. The main neuropsychological finding was slow and hesitant expression of thoughts despite an intelligence level in the upper normal range. The findings and course are described in detail. They are discussed as signs of an organic psychosyndrome due to the AC.