Stereotactic cyst/ventricular-peritoneal shunting for the treatment of prepontine arachnoid cyst: case report

BACKGROUND: Prepontine (suprasellar) arachnoid cysts are uncommon in clinical practice, so experiences in their management are limited and the best method of treatment for them remains unclear. Here we report our experience in using stereotactic cyst/ventricular-peritoneal shunting for the treatment of prepontine arachnoid cyst. CASE DESCRIPTION: A 42-year-old woman with prepontine arachnoid cyst was treated with cyst/ventricular-peritoneal shunting: the ventricular catheter was precisely inserted at a point where it could drain from the cyst and the ventricle at the same time. The postoperation CT scan showed that the cyst and the enlarged ventricle shrunk markedly. During a 1-year follow-up period, she remained symptom-free and had returned to full-time work. CONCLUSION: Stereotactic cyst/ventricular-peritoneal shunting appears to be an effective method for treating prepontine arachnoid cyst.     

Shunting procedures in the management of intracranial cerebrospinal fluid cysts in infancy and childhood

Summary Widely diverging opinions on the optimal therapy for intracranial cerebrospinal fluid cysts (CSF), mainly arachnoid cysts and the Dandy-Walker cysts, exist. Excision of the cyst walls in the treatment of the Dandy-Walker cyst has been replaced by shunting procedures, but the recommended method for primary treatment of arachnoid cysts in childhood is still cyst wall excision. Membrane excision is, however, often complicated by recurrence, subsequently requiring shunting-procedures. In a series of 19 cases primary shunting of intracranial CSF cysts proved to be a reliable method. In those cases where hydrocephalus (ventricular dilatation) is present at the time of the primary operation the ventricles should be shunted as well as the cyst. The catheter from the ventricle and that from the cyst should be connected to the same valve, otherwise an increased risk of intracranial herniation exists. The prognosis for infants and children suffering from intracranial CSF cysts is in general good; in 17 out of 19 cases mental development was normal and in 15 out of 19 motor development was normal. The risk of permanent motor damage seems to be particularly high when an arachnoid cyst is located on the quadrigeminal plate.     

Double-endoscopic approach for management of convexity arachnoid cyst: case report

BACKGROUND: Controversy exists about the best treatment modality for arachnoid cysts. Widely accepted neurosurgical options include craniotomy with open resection of the cyst walls, shunting procedures and stereotactic fenestration of the cyst cavity. Recently, neuroendoscopic approach showed its effectiveness for treatment of these lesions. CASE DESCRIPTION: In the presented case the large convexity arachnoid cyst was diagnosed in a 22-year-old woman with head dullness and local bone bulging. No neurologic signs were found. Surgery was performed by double-neuroendoscopic approach with simultaneous use of two flexible ventriculofiberscopes, which permitted wide resection of the inner cyst wall. Complete resolution of symptoms was noted soon after surgery. CONCLUSION: Double-endoscopic approach might be useful for complex neuroendoscopic procedures that need different simultaneous surgical actions, particularly for cases of large arachnoid cysts.     

症状性骶管内囊肿的诊断与治疗

目的：探讨症状性骶管内蛛网膜囊肿的诊断与治疗方法.方法：对12例以骶管内神经受压表现为主,如腰骶部疼痛、下肢痛、会阴部疼痛,鞍区麻木不适,大小便障碍,下肢无力患者,行MRI检查.结合临床症状、体征及MRI表现明确诊断为症状性骶管内囊肿后行手术治疗.手术均在显微镜下操作.对未见明显交通孔的7例中5例行囊壁大部切除后残存囊壁修补缝扎,2例因硬脊膜缺如,无法修补而行囊肿部分切除旷置;5例有交通孔的患者中,2例囊肿大部切除后用肌肉填塞交通孔,2例因交通孔处理困难未作特殊处理,1例囊肿大部切除后,切开交通孔处硬脊膜以扩大交通孔至脑脊液通畅流出,消除交通孔的单向阀门作用.严密缝合切口,术后采取头低臀高俯卧位.结果：骶管内囊肿在MRI上表现为骶管内单发或多发类圆形或椭圆形的软组织影,呈长T1、长T2表现,信号与脑脊液相同.术后2例出现少量皮下积液,加压包扎2～3个月后自行吸收,无1例脑脊液漏.随访3个月～4年6个月,平均18.3个月,症状完全缓解8例,部分缓解3例,1例3个月后症状复发,MRI检查示囊肿较术前轻微扩大,未再次手术.结论：MRI检查是正确诊断骶管内蛛网膜囊肿的有力手段,伴有临床症状、体征者应考虑手术治疗.对囊肿的处理以囊肿大部切除为主,严密缝合切口各层及术后合理体位可以有效防止并发症的发生.     

Two cases of symptomatic arachnoid cysts in elderly patients--a comparison and analysis with child cases

A symptomatic arachnoid cyst in an elderly patient is rare. We report two cases of symptomatic arachnoid cysts in elderly patients. The first case is that of a 73-year-old woman complaining of headache and speech disturbance. She had an arachnoid cyst in the left interhemispheric fissure. This is rare. Only two interhemispheric arachnoid cysts in the elderly have ever been reported. The other case is that of a 64-year-old woman, having right hemiparesis and dementia and a cyst is shown in her left temporal lobe. Both patients underwent a cystectomy which resulted in the disappearance of their symptoms. Only 56 cases of symptomatic arachnoid cyst over the age of 60 years have ever been reported. We made an analysis of 58 cases, including our two cases, and compared it with child cases. In cases of the elderly, the symptoms are usually headache, hemiparesis, gait disturbance and dementia, which are similar to symptoms of chronic subdural hematoma and normal pressure hydrocephalus. On the other hand, child cases usually reveal signs of intracranial hypertension. Several authors have reported their therapeutic method for child symptomatic arachnoid cysts. However, it is difficult to determine the best method for treating child cases at this time. We think a cystectomy is the first choice of operative procedure for symptomatic arachnoid cyst in the elderly.     

Surgical therapy of symptomatic arachnoid cysts - an outcome analysis

BACKGROUND: Arachnoid cysts may present with various symptoms and in different locations. Optimal treatment is still controversial, although cyst fenestration or shunt insertion are recognized as standard procedures. In this retrospective analysis the authors sought to determine which factors influence the outcome after surgery of symptomatic arachnoid cysts. METHODS: 37 patients (24 male, 13 female, mean age 40.2 years) were treated within a ten year period in our institution. Mean follow-up was 39 months; follow-up was done on an ambulatory basis. For analysis patient charts were reviewed and cranial CT scans or MR investigations were examined to determine pre- and postoperative cyst volumes. Clinical outcome was graded into four subgroups using a scale based on the patients self-rating of success. Different factors were studied concerning their influence on outcome. FINDINGS: Fenestration was performed in 28 cases, cysto-peritoneal or cysto-atrial shunting in 9 cases. A favourable outcome (subgroups 3 and 4) was achieved in 19 of 28 patients (fenestration) and in 6 of 9 patients (shunting), respectively. Mean reduction of the cyst volumes was 58% after fenestration and 74% after shunting revealing both methods to be effective. Degree of cyst volume reduction correlated significantly with clinical outcome. Patients with infratentorial cysts had more often a favourable outcome. Headache as the only symptom did not influence outcome. CONCLUSIONS: Surgery of symptomatic arachnoid cysts resulted in favourable outcome in two thirds of the patients. Both standard procedures, fenestration and shunting, are equally effective for treatment. Factors that influence outcome are the rate of volume reduction and cyst location.     

Endoscopic treatment of intracranial lesions. Apropos of 8 cases

The authors describe their initial experience involving endoscopic techniques used in the treatment of eight patients with varied brain lesions. Two tumours and a colloid cyst of the third ventricle, two paraventricular symptomatic cysts, one arachnoid cyst, one chronic intracerebral hematoma and one case of free catheter extraction in the lateral ventricle. The common characteristics of all these lesions were their liquid character and/or intraventricular location. Rigid endoscopes were used, with 9 and 6 mm work channels and independent aspiration and irrigation systems. The optic elbow makes direct visualization and adaptation to the TV monitor possible. The endoscope was manually directed at the lesion through a 12 mm burr hole in five cases and by means of a stereotactic frame in three cases. Biopsies were obtained in six cases. In three cases a communication between the cyst and the ventricular system or adjacent cisterns was established and in two cases vaporization of the lesion using a CO2 laser was performed. Tolerance to the endoscopic procedures was good in all cases. In the authors' opinion, endoscopic techniques constitute a low risk method, midway between stereotactic techniques and the microsurgical approach, and are especially indicated in the treatment of cystic brain lesions or those situated in or near the ventricular system. Their most notable advantages are: providing direct visualization of the lesion without interference from the instruments in the operating field; non-repercussion of the spatial changes derived from the liquid outlet and possibility of lesion coagulation and manipulation. Their disadvantages, related to the use of very long instruments and from a reduced work channel, must be overcome by specialized training.     

The diagnosis and neuroendoscopic treatment of noncommunicating intracranial arachnoid cysts

BACKGROUND: The aim of this study was to explore the CTC classification, establish surgical indication, and evaluate neuroendoscopic treatment of IAC. METHODS: Computed tomographic cisternography was applied to screen NCIAC cases out of 22 patients with IAC. Noncommunicating intracranial arachnoid cyst cases were treated with neuroendoscopic fenestration between IAC and cerebral cistern/ventricle with rigid neuroendoscope. RESULTS: All the NCIAC patients had definite neurologic findings. Postoperatively, the clinical status and situations of all the patients were improved, and some patients were even cured. Only 1 case suffered complicated chronic subdural hematoma and was cured by burr hole drainage. Follow-up CT scan of 9 cases showed that the cysts decreased markedly in size; most of the surrounding spaces were filled by normal cerebral tissue. CONCLUSION: (1) CTC is specific for the differential diagnosis of IAC, which can be classified into CIAC and NCIAC with CTC. (2) NCIAC with definite neurologic findings have surgical indication. (3) Compared with traditional treatments, neuroendoscopic cystic fenestration is more effective and minimally invasive with less mortality and morbidity.     

Surgical treatment for symptomatic arachnoid cysts

During the period from 1983 to 1999, 12 patients with symptomatic arachnoid cyst were treated. The mean patient age was 20.6 years. The most common location was the middle fossa (10 cases). Initial CT scan revealed associated subdural hygroma in 7 patients and hydrocephalus in one. Clinical symptoms were related to increased intracranial pressure, cranio-megaly and seizure. One infant with a huge arachnoid cyst was treated, using a cystoperitoneal (CP) shunt. Four patients underwent membraectomy. Combination CP shunt and membraectomy was performed in 5 patients. The remaining 2 arachnoid cysts were complicated with subdural hygroma and, initially, they were observed conservatively, but hygroma gradually changed to hematoma. One was treated by irrigation and the other hematoma was spontaneously absorbed. Significant complications included extensive subdural effusion in one patient, contralateral chronic subdural hematoma in two, intracranial hypotension in two, and shunt dependency in one. There were no recurrences during the follow-up period (mean 3.6 years).     

Acute intracranial hypertension and shunt dependency following treatment of intracranial arachnoid cyst in a child: a case report and review of the literature

Arachnoid cysts are developmental anomalies that represent 1% of all intracranial space occupying lesions. Treatment of symptomatic cases may include shunting of the cyst or an open fenestration of it, among other less acceptable surgical procedures. Each procedure has its own pros and cons. We present a case of the development of an acute intracranial hypertension during cysto-peritoneal shunt malfunction in a child. We describe the possible mechanism of these phenomena and, based on this report and by reviewing other case series in the literature, we raise the possibility that acute increase in intracranial pressure and the development of shunt dependency, although rare, are important complications of shunting an arachnoid cyst.     

Treatment of supratentorial primary arachnoid cysts

Summary Twenty-four cases of supratentorial primary arachnoid cysts operated with different techniques are reviewed: both cyst shunting or extirpation may lead to a good early clinical result, but the former is less dangerous and more indicated in a particular group of patients; late results are better in the shunted patients. CT scan is almost always diagnostic and is mandatory postoperatively to assess the late results.     

Arachnoid cyst is a risk factor for chronic subdural hematoma in juveniles: twelve cases of chronic subdural hematoma associated with arachnoid cyst

Chronic subdural hematoma (CSDH) tends to occur in elderly patients with a history of mild head injury at a few months prior to the onset of symptoms. Intracranial arachnoid cyst is believed to be congenital and sometimes becomes symptomatic in pediatric patients. These two distinct clinical entities sporadically occur in the same young patient. Twelve of 541 cases of CSDH surgically treated in our institution had associated arachnoid cyst. The clinical and radiological characteristics of the cases of CSDH associated with arachnoid cyst were retrospectively analyzed and compared with those of CSDH without arachnoid cyst. Arachnoid cysts were located in the middle fossa (eight cases), convexity (two cases), and posterior fossa (two cases). Three cysts were less than 20 mm in diameter. The 12 patients with CSDH and arachnoid cyst (mean age 27.8 +/- 19.7 years) were significantly younger (p < 0.001) than the patients with CSDH without arachnoid cyst (69.5 +/- 13.7 years). Five of the 12 patients were pediatric cases (< 15 years old). The clinical symptoms were also significantly different. The most frequent symptom was headache followed by vomiting in the patients with arachnoid cyst, while gait disturbance and hemiparesis predominated in patients without arachnoid cyst. Hematoma evacuation through burr holes improved the symptoms in all patients with arachnoid cyst. We conclude that even a small arachnoid cyst can be a risk factor for CSDH after mild head injury in young patients and symptoms of increased intracranial pressure are common. Hematoma evacuation is adequate at first operation. If the preoperative symptoms persist, additional arachnoid cyst surgery should be considered. The present results also suggest that CSDH formation may be preceded by subdural hygroma caused by the rupture of arachnoid cyst.     

Intracranial arachnoid cysts in children

The clinical and radiographic findings, surgical treatment, and outcome in 16 pediatric patients with intracranial arachnoid cysts are reviewed. The clinical presentation reflected the anatomical location of the lesions. Computerized tomography or magnetic resonance imaging scans were diagnostic in all cases. Of the nine cysts treated primarily or secondarily by craniotomy for fenestration and drainage into the basilar cisterns, five recurred. Cyst-peritoneal shunting led to diminished cyst size and clinical improvement in all seven cases in which it was used as the initial treatment and in all four cases in which fenestration had been unsuccessful. The results in this series show that cyst-peritoneal shunting is the treatment of choice for most intracranial arachnoid cysts in children.     

Middle fossa arachnoid cyst presenting an interesting clinical course: a case report

The mechanism of the disappearance of arachnoid cysts is not fully understood. We report a case of arachnoid cyst which disappeared after head injury. A 28-year-old male was found to have an arachnoid cyst in the left middle fossa following head injury. We followed him up, because he had no symptoms. Two weeks later, he suffered from severe headache. CT image showed a dilatation of the subdural space, and his symptom deteriorated. We performed subdural-perifocal shunt, but one month after, he developed a subdural hematoma. The subdural hematoma was irrigated through a burr hole. His symptom disappeared post operatively. Two months later, CT image showed the disappearance of subdural hematoma and the arachnoid cyst. This case suggested one of the mechanisms involved in the disappearance of arachnoid cyst after head injury.     

骶管内蛛网膜囊肿的外科治疗

目的 :探讨骶管内蛛网膜囊肿的诊断及治疗方法。方法 :2 3例骶管内蛛网膜囊肿病人行椎板减压后 ,对囊肿的处理有 3种方法 :13例行囊肿大部分切除后 ,重新缝合残余的囊肿以包绕囊内神经根 ;8例囊肿大部分切除后用肌肉填塞交通孔 ;2例囊肿切开旷置。平均随访 3 0 2个月 ,观察疗效。并对其临床表现 ,手术中的病理特点 ,手术后的并发症 ,以及X线片 ,CT ,CTM ,MRI等影像学资料进行分析。结果 :MRI可清楚显示囊肿呈长T1及T2信号 ,信号强度与脑脊液一致。临床症状以骶管内神经受压表现为主 ,囊肿与硬膜囊一般有交通孔。囊肿切除后重新缝合包绕神经组与囊肿切除肌肉填塞组优良率并无统计学差异。术后并发症有皮肤糜烂和颅内感染。结论 :MRI是最好的影像学诊断方法 ;骶管内蛛网膜囊肿的发生是由于先天的硬膜缺隐所致。对囊肿的处理以囊肿切除 ,肌肉填塞封堵交通孔最为合理。术后不宜放引流及平卧。     

Symptomatic arachnoid cyst at the clivus drained stereotactically through the vertex

A 40-year-old man had an acute ischemic event affecting the pons. He had no cardiac illness or vasculities and was not diabetic or hypertensive. The contrast-enhanced computed tomographic scan disclosed nothing abnormal, and a vertebral angiogram showed an avascular mass markedly displacing the basilar artery and pons posteriorly and toward the right. A magnetic resonance image clearly delineated a homogeneous arachnoid cyst containing cerebrospinal fluid. To avoid manipulating posterior fossa arteries, after the recent pontine stroke, this arachnoid cyst with unusually favorable anatomical landmarks was approached stereotactically through the vertex. Fenestration and drainage of the cyst was accomplished under local anesthesia and benzodiazepine sedation with low morbidity. The procedure was well tolerated, and the patient returned to gainful employment shortly afterward. He remains asymptomatic at 3 years' follow-up. The successful outcome of this case suggests that in carefully selected symptomatic arachnoid cysts, stereotactic interventions could become a useful surgical alternative. Stereotaxis may also be helpful in other cumbersome surgical cases in which a second port for contrast injection or simple manipulation would be advantageous.     

Spontaneous disappearance of cerebellopontine angle arachnoid cyst: report of a case

A case of a cerebellopontine angle arachnoid cyst spontaneously disappeared is reported. A 1-year-and-11-month old boy was suffered from sudden onset of left facial palsy. CT scan demonstrated dilatation of left internal auditory canal and a cystic lesion in the left cerebellopontine angle. Neurological examination disclosed only left facial palsy and left hearing loss. There was no signs and symptoms of increased intracranial pressure. He was followed up by CT scan. Repeated CT scan showed non-enhanced cystic lesion, the attenuation value of which was similar to that of cerebrospinal fluid. The cyst expanded gradually, and the brain stem was severely compressed. Then operation was planned under the diagnosis of left cerebellopontine angle arachnoid cyst about 2 years after the onset. But CT scan performed before operation showed disappearance of the cyst. Without operation the patient was followed by CT scan. There is no recurrence of the cyst. Natural history of arachnoid cyst will be well understood with repeated CT scan.     

Intracranial arachnoid cysts and obstetric anesthesia: Two case reports

Two cases of patients in whom neuraxial anesthesia was planned for labor and delivery and who had a pre-existing intracranial arachnoid cyst are reported. Anesthesia was used in one patient and was uneventful. The pathophysiology of these cysts and factors which can precipitate the occurrence of symptoms, are reviewed and cases previously described in the literature are examined. Management should be individualized and based on evaluation of preexisting neurological symptoms. In most cases and although CT scan and MRI images may show an intracranial cyst with impressive development, patients remain asymptomatic and neuraxial regional anesthesia can be used safely, provided the patient has agreed and the neurologist in charge has been informed.     

Surgical therapy of symptomatic arachnoid cysts – an outcome analysis

Summary. Background. Arachnoid cysts may present with various symptoms and in different locations. Optimal treatment is still controversial, although cyst fenestration or shunt insertion are recognized as standard procedures. In this retrospective analysis the authors sought to determine which factors influence the outcome after surgery of symptomatic arachnoid cysts.Methods. 37 patients (24 male, 13 female, mean age 40.2 years) were treated within a ten year period in our institution. Mean follow-up was 39 months; follow-up was done on an ambulatory basis. For analysis patient charts were reviewed and cranial CT scans or MR investigations were examined to determine pre- and postoperative cyst volumes. Clinical outcome was graded into four subgroups using a scale based on the patients self-rating of success. Different factors were studied concerning their influence on outcome.Findings. Fenestration was performed in 28 cases, cysto-peritoneal or cysto-atrial shunting in 9 cases. A favourable outcome (subgroups 3 and 4) was achieved in 19 of 28 patients (fenestration) and in 6 of 9 patients (shunting), respectively. Mean reduction of the cyst volumes was 58% after fenestration and 74% after shunting revealing both methods to be effective. Degree of cyst volume reduction correlated significantly with clinical outcome. Patients with infratentorial cysts had more often a favourable outcome. Headache as the only symptom did not influence outcome.Conclusions. Surgery of symptomatic arachnoid cysts resulted in favourable outcome in two thirds of the patients. Both standard procedures, fenestration and shunting, are equally effective for treatment. Factors that influence outcome are the rate of volume reduction and cyst location.     

Roller coaster headaches revisited

BACKGROUND: Roller coasters are probably one of the more popular rides at amusement parks around the world. Despite their relative safety, nontraumatic intracranial injuries have been reported following roller coaster rides. The presence of an intracranial arachnoid cyst may increase the risk of nontraumatic injury in this setting. CASE DESCRIPTION: We describe a 33-year-old female with a left middle fossa arachnoid cyst who presented with increasing headaches from bilateral subdural hygromas after a roller coaster ride. The patient underwent bilateral burr hole drainage of her subdural hygromas with resolution of her symptoms. CONCLUSION: This case demonstrates the potential risks of intracranial injury in patients with an underlying arachnoid cyst who engage in certain types of recreational activity.