Percutaneous Treatment of Meckel Cave Arachnoid Cyst: Case Report, Surgical Strategy and Literature Review

Arachnoid cysts are benign intracranial lesions. They are usually located in the middle fossa, but can be found in other locations. We present a case of symptomatic Meckel cave (MC) arachnoid cyst - a very rare location - and a treatment strategy not elsewhere described before for this condition. A 54-year-old female with trigeminal neuralgia with previous history of radiofrequency rhizotomy treatment 6 years before admission had been experiencing pain recurrence with progression, which required successive increases in carbamazepine dosage. Magnetic Resonance Imaging (MRI) showed dilatation of the right MC with extension to the petrous apex. The lesion was compatible with arachnoid cyst, and due to the worsening of the clinical condition, surgical treatment was chosen. Percutaneous puncture of the cyst through the foramen ovale with injection of intracystic fibrin sealant was performed. The patient woke up from anesthesia with pain improvement and was discharged asymptomatic the next day. After 12 months of follow-up, she remained pain-free. In the literature review, we found only eight cases reported as MC arachnoid cyst. These are likely to progress and become symptomatic owing to their communication with the subarachnoid space and a unidirectional valve mechanism. Pain improvement with this technique is probably secondary to the interruption of these mechanisms.

Quiste aracnoidal cervical anterior en edad pediátrica / Anterior cervical arachnoid cyst in pediatric age

Los quistes aracnoidales espinales son lesiones poco comunes en la población pediátrica. La mayor parte de ellos, se ubican en los segmentos dorsales y la posición anterior respecto a la médula es rara en todos los casos. Si bien su patogenia no está aclarada, se han asociado a defectos del tubo neural y traumas previos. Clínicamente, pueden presentarse con síndrome medular que en ocasiones pueden empeorar con cambios posturales. El tratamiento, puede ser conservador o quirúrgico, el que está indicado en presencia de síntomas neurológicos secundarios a compresión medular, siendo el abordaje posterior el más frecuentemente utilizado. El propósito de la cirugía es la resección total o en su defecto, la fenestración del quiste para comunicarlo al espacio subaracnoídeo. Una potencial complicación de la vía posterior, es la herniación medular durante la durotomía, secundaria al efecto compresivo del quiste, la cual podría aumentar la morbilidad neurológica en el período postoperatorio. Se presentan 2 casos consecutivos en edad pediátrica con quistes intradurales espinales anteriores, el primero en la región cervico-dorsal cuya cirugía se vio dificultada por la presencia de herniación medular transdural y un segundo caso con un quiste exclusivamente cervical, en que mediante una punción lateral del quiste guiada por ecografía previo a la durotomía, se logró resecar la lesión sin esta complicación.

Spinal arachnoid cysts are rare lesions in pediatric population. Most of them are located posteriorly in dorsal segments ananterior position is rare. Although its pathogenesis has not been elucidated, they have been associated with neural tube defects and the presence of previous spinal traumas. Clinically, they present with a spinal cord syndrome which can sometimes worsen with postural changes. Treatment may be conservative or surgical, the latter indicated by the presence of neurological symptoms secondary to spinal cord compression, with the posterior approach being the most frequently used. The purpose of surgery is total or partial resection, or fenestration of the cyst to subarachnoid space. A potential intra-surgical complication of posterior approach in anterior cyst is spinal cord herniation during durotomy, secondary to the compressive effect of the cyst, which could increase neurological morbidity in the postoperative period (1 case with mortality is described in the literature). We present 2 consecutive cases in pediatric patients with previous spinal intradural cysts. The first in the cervico-dorsal region whose surgery was hampered by the presence of medullary transdural herniation and second case with an exclusively cervical cyst that through a side puncture cyst guided by ultrasound prior to durotomy, it was possible to resect the lesion without this complication.

Importance of Contrast-Enhanced Fluid-Attenuated Inversion Recovery Magnetic Resonance Imaging in Various Intracranial Pathologic Conditions

Intracranial lesions may show contrast enhancement through various mechanisms that are closely associated with the disease process. The preferred magnetic resonance sequence in contrast imaging is T1-weighted imaging (T1WI) at most institutions. However, lesion enhancement is occasionally inconspicuous on T1WI. Although fluid-attenuated inversion recovery (FLAIR) sequences are commonly considered as T2-weighted imaging with dark cerebrospinal fluid, they also show mild T1-weighted contrast, which is responsible for the contrast enhancement. For several years, FLAIR imaging has been successfully incorporated as a routine sequence at our institution for contrast-enhanced (CE) brain imaging in detecting various intracranial diseases. In this pictorial essay, we describe and illustrate the diagnostic importance of CE-FLAIR imaging in various intracranial pathologic conditions.

Fractura evolutiva: colocación de sistema derivativo cisto-peritoneal y corrección diferida: a propósito de un caso / Growing skull fracture: positioning system cisto-peritoneal derivative and correction deferred: report of a case

Describimos el caso de una paciente femenina de 5 años de edad, con antecedente de fractura craneal asociado a trauma directo en su segundo día de vida, posteriormente se diagnostica quistes porencefálico y aracnoideo frontoparietal izquierdo a los 3 meses de edad. Fue tratada en un primer momento con la colocación de sistema derivativo cistoperitoneal, y se le realizaron estudios de imágenes de seguimiento. A los 5 años de edad es traída a consulta de nuestro servicio de neurocirugía, por presentar deformidad calvarial en la superficie frontoparietal izquierda. El seguimiento con tomografía de cráneo demostró un cese relativo en la progresión en las dimensiones del quiste porencefálico y aumento del espacio entre los bordes óseos de la fractura. La paciente fue llevada a mesa operatoria, en la cual se realizó un abordaje hemicoronal izquierdo con resección de tejido gliótico, duroplastia con pericráneo y colocación de craneoplastía con tejido óseo craneal autólogo. El seguimiento al mes de la intervención correctiva mostró evolución satisfactoria y sin complicaciones. La cirugía correctiva de la fractura evolutiva, debe realizarse en el momento del diagnóstico para evitar su expansión. En concordancia con la teoría de Moss, se observa aumento del espacio entre los bordes de la fractura, aún con la disminución de la presión intracraneal al derivar el líquido cefalorraquídeo. En este caso, la intervención correctiva de la fractura, determinó una evolución satisfactoria, en ausencia de hidrocefalia o crisis convulsiva, posiblemente debida a la presión disminuida del quiste porencefálico sobre el parénquima subyacente.

We describe the case of a female patient of five years old, with a history of a skull fracture associated with direct trauma on his second day of life, then porencephalic left frontoparietal arachnoid cysts was diagnosed at 3 months of age. She was iniatially treated by plaing cystoeritoneal derivative system and follow-up imaging studies was performed. At 5 years of age is brought to clinic in our departmen of neurosurgery, for presenting calvarial deformity in the left frontoparietal area. The follow-p scan of the head showed a cease progression relative dimensions porencephalic cyst an increased space between the bone edges of the fracture. The patient was transferred to operating table, on which a hemicoronal left gliotico approach with resection of tissue was performed with dural graft placement craneoplasty bone tissue. Monitoring the month showed satisfactory corrective intervention and hassle evolution was performed with dural graft placement craneoplasty scalp and skull with autologous bone tissue. Corrective surgery of evolutionary fracture should be performed at the time of diagnosis to prevent its expansion. In agreement with the Moss theory, increasing the space between the edges of the fracture even with decreasing intracranial pressure deriving the cerebrospinal fluid was observed. In this case corrective intervention of the fracture produced a satisfactory outcome in the absence of hydrocephalus or seizure, possibly due to decreased pressure of porencephalic cyst on the underlying parenchyma.

Arachnoid Cyst in Oculomotor Cistern

Oculomotor cistern is normal anatomic structure that is like an arachnoid-lined cerebrospinal fluid-filled sleeve, containing oculomotor nerve. We report a case of arachnoid cyst in oculomotor cistern, manifesting as oculomotor nerve palsy. The oblique sagittal MRI, parallel to the oculomotor nerve, showed well-defined and enlarged subarachnoid spaces along the course of oculomotor nerve. Simple fenestration was done with immediate regression of symptom. When a disease develops in oculomotor cistern, precise evaluation with proper MRI sequence should be performed to rule out tumorous condition and prevent injury of the oculomotor nerve.

Hamartoma hipotalámico asociado a dos quistes aracnoideos: a propósito de un caso / Hypothalamic hamartoma associated with arachnoid cyst: report of a case

Hypothalamic hamartomas are heterotopias of the nervous tissue which are similar to the grey matter of the hypothalamus. They may cause precocious puberty and/or gelastic seizures. We present the case of a patient who began her pubertal development at the age of 9 months. Cranial magnetic resonance imaging showed a hypothalamic hamartoma associated with middle cranial fossa and pineal region arachnoid cysts, a very rare association.

Los hamartomas hipotalámicos son heterotopias de tejido nervioso que se asemejan a la sustancia gris del hipotálamo. Pueden causar pubertad precoz y/o crisis gelásticas. Presentamos el caso de una paciente que a los 9 meses de edad comenzó desarrollo puberal y que en la resonancia magnética craneal se objetivó un hamartoma hipotalámico asociado a dos quistes aracnoideos, uno en fosa craneal media y otro en región pineal, asociación que es muy infrecuente.

Spontaneous acute subdural hematoma contralateral to an arachnoid cyst

Arachnoid cysts (AC) are extra-cerebral cerebrospinal fluid collections of unknown origin. They correspond to 1 percent of all intracranial nontraumatic space-occupying lesions and appear more frequently in the middle fossa (50 percent). More than 25 percent of these cysts are incidental findings and the majority of patients are asymptomatic. Seizures, intracranial hypertension signs, neurological deficits, macrocrania, developmental delay and bulging of the skull are the main signs and symptoms of the lesion. AC rupture and bleeding are rare, usually occurring in young adults and associated with trauma. The risk of hemorrhage does not exceed 0.04 percent / year. We describe the case of a ten-year-old boy who presented with acute signs of intracranial hypertension secondary to a spontaneous acute subdural hematoma, contralateral to an AC of the middle fossa. Three factors were significant in this case: signs and symptoms occurred spontaneously; the presence of an acute subdural hematoma exclusively contralateral to the AC; successful outcome of the conservative treatment.

Os cistos aracnóideos (CA) são coleções liquóricas extra-cerebrais e intra-aracnóideas de origem desconhecida. Correspondem a 1 por cento de todas as lesões expansivas intracranianas não traumáticas e têm nítido predomínio na fossa média (50 por cento). Até 25 por cento destes cistos são achados incidentais sendo que a maioria dos pacientes é assintomática. Crises epilépticas, sinais de hipertensão intracraniana, déficits neurológicos focais, macrocrania, atraso no desenvolvimento e abaulamento da calota craniana são os principais sinais e sintomas da lesão. A ruptura dos CA, assim como seu sangramento, são situações raras, geralmente associadas a traumas e acometem adultos jovens. O risco de hemorragia em pacientes com CA não excede 0,04 por cento ao ano. É descrito caso de paciente de dez anos de idade que subitamente apresentou sinais de hipertensão intracraniana secundários a hematoma subdural agudo espontâneo, contralateral a volumoso CA de fossa média. Três fatores foram de relevância neste paciente: a ocorrência de sinais e sintomas espontaneamente, especialmente em um menino; presença de hematoma subdural agudo exclusivamente contralateral ao CA; e a boa evolução com o tratamento conservador.

Cisto aracnóide intracraniano: revisão de literatura / Arachnoid cysts: a review of the literature

Objetivo: Revisão da literatura sobre os cistos aracnóides intracranianos – formação e evolução, dados epidemiológicos e clínicos, aspectos de neuroimagem e tratamento. Método: Realizamos pesquisa bibliográfica utilizando como base de dados o MEDLINE (National Library of Medicine), abrangendo operíodo de 1980 a 2006. As palavras-chave utilizadas foram arachnoid cysts e intracranial cysts. Também realizamos pesquisa manual em jornais e revistas médicas. Artigos com dados clínicos incompletos não foram incluídos no trabalho. Conclusões: Embora haja um consenso sobre a intervenção cirúrgica para os casos sintomáticos, a abordagem ideal ainda é controversa.

Objective: To review the current literature on intracranial arachnoid cysts related to its formation,evolution, the epidemiological, clinical and neuro imaging aspects and also its treatment. Method:Bibliographic review was done using Medline data base from 1980 to 2006. The key words used were arachnoid cysts and intracranial cysts. Manual research on pertinent medical publications was also done.Articles with incomplete clinical data were not included. Conclusions: Although there is a consensus that surgery should be performed only in the symptomatic cases, there is no general agreement whichis the best surgical approach to deal with arachnoid cysts.

Achado ocasional de doenças neurológicas durante a pesquisa da surdez infantil através do BERA / Occasional finding of neurological disorders during children hearing loss evaluation using the ABR

Uma das mais importantes aplicações clínicas dos potenciais evocados auditivos de tronco cerebral (BERA) é a sua utilização na avaliação da surdez infantil. Atualmente o BERA também é utilizado na triagem das síndromes cócleo-vestibulares a procura de lesões retro-cocleares, na monitoração dos estados de coma (morte cerebral), na monitoração do tronco cerebral em cirurgias da base do crânio, etc. Uma das qualidades do BERA é a sua capacidade de avaliar a integridade neurofisiológica das vias auditivas do tronco cerebral. Desta maneira, algumas vezes durante a pesquisa dos limiares auditivos infantis, nos deparamos com BERAs que sugerem a presença de lesões retro-cocleares das vias auditivas (assimetria de traçados, aumento dos intervalos interpicos), muitas vezes comprovadas através de exames de imagem. Trata-se de achado ocasional de moléstia neurológica por ocasião da pesquisa dos limiares auditivos infantis. Neste trabalho relataremos dois casos de doenças neurológicas, diagnosticadas ocasionalmente através do BERA realizado com o intuito de se pesquisar os limiares auditivos.

One of the most important applications of the Brainstem evoked response audiometry (ABR) is in the evaluation of hearing loss in children. Today the ABR is also indicated in the screening of cochleo-vestibular syndromes to detect retrocochlear lesions, to monitor patients in a coma (brain death), in monitoring the brainstem during skull base surgery, etc. Among the many BERA qualities, is its capacity to evaluate the neurophysiologic integrity of the auditory brainstem pathway. In doing so, sometimes while evaluating hearing function in children we are faced with ABR waves that suggest the presence of retrocochlear lesions (trace asymmetry, increased interpeak intervals), many times confirmed through image studies. These cases are seen as occasional findings of neurologic disorders during children hearing loss evaluation. In this study we report 2 cases of neurologic disorders diagnosed with the use of the ABR to evaluate hearing loss in children.

Spinal intramedullary arachnoid cyst.

Spinal arachnoid cysts are a relatively uncommon lesion. They may be either intra or extradural; intradural cysts being less common. Symptomatic spinal arachnoid cysts in the pediatric age group are rare. To the best of our knowledge only 2 cases of intramedullary arachnoid cysts have been reported to date. We report an unusual case of intramedullary cyst diagnosed in a 10-year-old female who presented with progressive quadriparesis. MRI scans revealed an intramedullary cystic lesion from C4 to T2. She underwent a C3 to T2 laminectomy with partial excision of the cyst. Histopathological findings confirmed the diagnosis of an arachnoid cyst. Postoperatively the patient showed dramatic recovery with marked improvement in neurological status. Arachnoid cysts should be considered in the differential diagnosis of progressive quadri / paraparesis in the pediatric age group as surgical decompression leads to marked improvement in the symptoms.

Cistos de Tarlov: relato de quatro casos / Tarlov cysts: report of four cases

São relatados quatro casos de cistos perineurais sacrais, conhecidos por cistos de Tarlov, e é feita revisão da literatura. A partir de amostra de 88 pacientes com queixas de radiculopatia em membros inferiores, e/ ou dor lombar ou sacral que foram submetidos à ressonância magnética de coluna lombossacra quatro (4.5 por cento) tiveram o diagnóstico de cisto de Tarlov. O diagnóstico foi feito através de ressonância magnética de coluna vertebral lombossacra. Os quatro casos foram submetidos a laminectomia sacral. Todos evoluíram assintomáticos sem défices motores ou sensitivos. Os cistos de Tarlov podem apresentar manifestações clínicas semelhantes às provocadas por hérnia discal lombossacra embora, nem sempre sejam citados nos diagnósticos diferenciais. O tratamento clínico é basicamente fisioterápico. O tratamento cirúrgico visa sanar o efeito compressivo em estruturas ósseas e/ ou nervosas através de punção do cisto ou retirada dele através de laminectomia sacral.

Quiste leptomeningeo: hallazgos en TC y RM / Leptomeningeal cyst: findings in CT and MR

El quiste leptomeníngeo es una complicación de las fracturas craneales que ocurre mayoritariamente en población pediátrica. La existencia del mismo en adultos es rara. Presentamos el caso de un varón de 47 años que mostró un cuadro de acorchamiento en miembro superior derecho y desviación de la comisura bucal del que se recuperó en una hora. Los estudios de neuroimagen mostraron una destrucción irregular del hueso temporal derecho y una hipodensidad del tejido cerebral subyacente. La cirugía y el estudio histológico del hueso resecado mostraron que se trataba de un quiste leptomeníngeo asociado a un infarto cerebral.

Operative management of pediatric intracranial arachnoid cysts

In this study, 14 cases of pediatric patients with arachnoid cysts treated between 1995 and 1999 are reported. Six children with mild symptoms and small cysts that remained stable on follow-up studies have not required surgical intervention. Fenestration was done through open craniotomy for two patients and through endoscopy for another two patients. Three of these children treated initially by fenestration showed clinical and radiographic recurrence of the cysts within a period of 2 to 15 months postoperatively and have undergone cystperitoneal shunting. Thus, only one of the four patients initially treated by fenestration remained shunt-independent after a follow-up period of three years. The other four patients were initially treated by cystperitoneal shunting and all improved postoperatively. Shunt revision has been necessary because of cyst recurrence in one of these four patients. Cyst location influenced the success of shunt treatment as none of the five middle cranial fossa cysts treated by shunting required revision

Arachnoid cyst: adversity and plasticity

We report four cases of surgically treated intracranial arachnoid cysts, one with cyst-peritoneal shunt and three with craniotomy and arachnoid membrane resection. Their classification and etiopathogeny are discussed, and especially the different methods of treatment comparing the drastic complications (adversities) with the favorable solutions in severe clinical cases (plasticity) treated at our institution.

Cistos aracnóides intracranianos: tratamento pela neuroendoscopia / Intracranial arachnoid cysts: neuroendoscopic treament

O autor relata sua experiência com sete pacientes portadores de cistos aracnóides tratados cirurgicamente, todos pela técnica neuroendoscópica. Dentre os pacientes, dois portadores de cistos suprasselares haviam sido submetidos a várias cirurgias de derivaçao do líquido cefalorraquiano e um portador de cisto temporal, a derivaçoes externas de higroma subdural associado. Apenas neste caso a abordagem endoscópica nao resultou em controle dos sintomas do paciente. O tempo de acompanhamento variou de um a nove anos.