Spinal Arachnoid Cysts: Presentation, management and pathophysiology.

OBJECTIVE: Evaluation of the presentation and outcomes associated with surgical marsupialisation of spinal arachnoid cysts and formulation of a putative hypothesis explaining their pathogenesis. PATIENTS AND METHODS: Cases were identified from electronic and theatre records at a single centre. All patients underwent pre-operative assessment and radiographic evaluation with subsequent spinal multidisciplinary discussion. Following surgery patients were reviewed at 6, 12 weeks, 6-months and beyond. RESULTS: A total of 17 patients with dorsal thoracic arachnoid cysts with a mean age at time of surgery of 58 years with a male to female ratio of 1.8:1 were identified. Paraesthesia (76%), neuropathic pain (76%), weakness (47%) and unsteadiness (53%) were the commonest presenting complaints. Abnormal gait (76%), altered sensation (71%) and weakness (47%) were the most commonly observed signs. Average cyst volume was observed to be 2570 mm3 (sd ±1682, range 544 to 7644 mm3), spanning a median of 2 thoracic levels, with a resultant reduction of cord volume of 33% (sd 12%). A syrinx was associated with 35% of SAC. All cases underwent marsupialisation of the arachnoid cyst. Six months following surgery all patients experienced improvement in at least of one their presenting symptoms and or clinical signs. Weakness, gait and paraesthesia were most likely to improve following surgery. Only 29% of cases had resolution of neuropathic pain, with 13% of the rest reporting an improvement in the sensitivity component of their pain. Clinical improvements correlated with an average 45% (sd 18%) volume increase in previously compressed cord. CONCLUSION: Intradural arachnoid cysts commonly present with paraesthesia, neuropathic pain and gait disturbance. Marsupialisation of the SAC heralds immediate and long-term improvement in symptoms. Cysts putatively arise within a dissection in the septum posticum and give rise to both dynamic and static compression of cord parenchyma secondary to the complex CSF flow dynamics within the thoracic spine.

Case Report: Severe back pain, epigastric distress and refractory nausea; an unusual presentation of mediastinal bronchogenic cyst.

Background: Bronchogenic cysts are congenital malformations from abnormal budding of embryonic foregut and tracheobronchial tree. We present a case of bronchogenic cyst with severe back pain, epigastric distress and refractory nausea and vomiting.   Case Presentation: A 44-year-old Hispanic female presented with a 3-week history of recurrent sharp interscapular pain radiating to epigastrium with refractory nausea and vomiting. She underwent cholecystectomy 2-years ago. Computed tomography (CT) abdomen at that time showed a subcarinal mass measuring 5.4 X 5.0 cm. Subsequent endoscopic ultrasound diagnosed it as a bronchogenic cyst. Endobronchial ultrasound (EBUS) guided aspiration resulted in incomplete drainage and she was discharged after partial improvement. Current physical examination showed tachycardia and tachypnea with labs showing leukocytosis, elevated inflammatory markers, and hypokalemic metabolic alkalosis. CT chest showed an increased size of the bronchogenic cyst (9.64 X 7.7 cm) suggestive of possible partial cyst rupture or infected cyst. X-ray esophagram ruled out esophageal compression or contrast extravasation. Patient's symptoms were refractory to conservative management. The patient ultimately underwent right thoracotomy with cyst excision that resulted in complete resolution of symptoms. Conclusion: Bronchogenic cysts are the most common primary cysts of mediastinum with the prevalence of 6%. The most common symptoms are chest pain, dyspnea, cough, and stridor. Diagnosis is made by chest X-Ray and CT chest. Magnetic resonance imaging chest and EBUS are more sensitive and specific. Symptomatic cysts should be resected unless surgical risks are high. Asymptomatic cysts in younger patients should be removed due to low surgical risk and potential late complications. Watchful waiting has been recommended for asymptomatic adults or high-risk patients. This case presents mediastinal bronchogenic cyst as a cause of back, nausea and refractory vomiting. Immediate surgical excision in such cases should be attempted, which will lead to resolution of symptoms and avoidance of complications.

Congenital Abnormalities of the Pericardium.

Congenital abnormalities of the pericardium are a rare group of disorders that include congenital absence of the pericardium, pericardial cysts, and diverticula. These congenital defects result from alterations in the embryologic formation and structure of the pericardium. Although many cases are incidentally found, they can present as symptomatic, life-threatening disease. Owing to their rarity, many cases are inappropriately diagnosed. Alterations in the embryologic formation and structure may result in the formation of these congenital abnormalities. We review the presentation, diagnosis, and management of congenital absence of the pericardium, pericardial cysts, and diverticula. A summary of multimodality imaging features is provided.

Hemorrhagic Pericardial Cyst Diagnosis Accelerated by Emergency Physician Echocardiography: A Case Report.

BACKGROUND: The differential diagnosis for chest pain in the emergency department is broad and includes both benign and life-threatening conditions-with pericardial cyst as a rare example. Emergency physician-performed point-of-care focused cardiac ultrasound (FOCUS) is increasingly recognized as a useful modality in the evaluation of patients with chest pain. CASE REPORT: We report a case of hemorrhagic pericardial cyst in a young woman presenting with chest pain in which findings on FOCUS contradicted findings on chest x-ray study and thus, accelerated diagnosis and definitive treatment. We also comment on epidemiology, pathophysiology, clinical presentation, diagnosis, and management of this uncommon, potentially fatal cause of chest pain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report aims to bring an uncommon case to the attention of emergency providers and emphasize the importance of facility with FOCUS. Although definitive diagnosis and management were not accomplished at the bedside in this case, an abnormal finding on FOCUS prompted further investigation and timely treatment.

Pericardial Masses, Cysts and Diverticula: A Comprehensive Review Using Multimodality Imaging.

Pericardial masses/tumors, cysts, and diverticula are quite rare. Presentation is variable and often patients may be asymptomatic with pericardial involvement initially only detected at time of autopsy. When patients do present with symptoms they are often non-specific and often mimic other conditions of the pericardium such as pericarditis, pericardial effusion, constriction or tamponade. Therefore, echocardiography and cross-sectional imaging are essential in identifying and characterizing pericardial disease. Imaging findings vary in specificity depending on the type of tumor. The purpose of this review is to describe the role of multi-modality imaging and characteristic findings in patients with pericardial masses/tumors, cysts, and diverticula.

[Large pericardial cyst in a young woman presenting with fever abdominal pain and diarrhea].

Pericardial cysts are rare mediastinal abnormalities occurring in 1 in 100,000 persons. Most pericardial cysts are congenital but may also be acquired. Their presence poses a diagnostic challenge, distinguishing them from other intracardiac and mediastinal lesions. We describe an unusual presentation of a large pericardial cyst which was diagnosed during the evaluation of prolonged fever, abdominal pain and diarrhea. This case emphasizes that the evaluation and treatment of a pericardial cyst should be based on clinical judgment and should be managed on a case by case basis.

Quiste paratiroideo funcionante gigante de localización mediastínica: una causa insólita de disnea de esfuerzo y disfagia de carácter leve / Giant Functioning Mediastinal Parathyroid Cyst: An Unusual Cause of Exertional Dyspnea and Mild Dysphagia

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Atypically located pericardial cyst compressing the left ventricle during the whole cardiac cycle: a case report.

We report the uncommon case of a pericardial cyst with unremitting compression of the left ventricle during the whole cardiac cycle, but normal ejection fraction. On CT scan, the cyst was found at an atypical location, lateral to the pulmonary artery, the ascending aorta, and the right ventricular outflow tract in the left anterior mediastinum. The radio-density of the cyst was 41 Hounsfield units (HU), higher than other cases reported in the literature. As the cyst was stable, conservative treatment was adopted. The usefulness of echocardiography for the diagnosis and follow-up of pericardial cysts is discussed.

Quiste pericárdico / Pericardial cyst

Los quistes pericárdicos son raros, habitualmente asintomáticos y su descubrimiento suele ser casual. Presentamos el caso de un paciente con un quiste pericárdico que fue encontrado casualmente en una radiografía de tórax como una lesión radiopaca en el ángulo cardiofrénico derecho (AU)

Pericardial cysts are rare, are usually asymptomatic and their discovery is generally incidental. We report the case of a male patient with a pericardial cyst that was found incidentally on a chest X-ray as a radio-opaque lesion in right cardiophrenic angle (AU)

[Cardiac MRI with SENSE technology: study of ventricular and valvular functionality in 30 patients].

PURPOSE: The latest innovation in MR imaging is SENSE (SENSitivity Encoding), a technology providing an important solution for the time necessary for signal encoding. In the SENSitivity Encoding (SENSE) approach, an array of multiple, simultaneously operated receiver coils is used for signal acquisition. In particular, the efficacy of SENSE technology is able to reduce the number of phase encodings by a factor (named R factor or Reduction factor) and to evaluate the same k space with fewer readout lines obtaining higher spatial and temporal resolution. MATERIALS AND METHODS: An heterogeneous group of 30 patients with a variety of clinically proven diagnoses underwent Cardiac MR with SENSE technology to evaluate the technique's diagnostic efficacy. The sequences used were "Balanced" Ultrafast Gradient Echo (B-FFE) characterised by a hyper-intense blood signal with multislice multiphase and single slice multiphase acquisitions. RESULTS: In addition to reducing scan times, SENSE technology improved spatial and temporal resolution (40 frames/cardiac cycle) providing optimal dynamic evaluation of valve structures and wall kinesis. Furthermore, the use of the SENSE technique with B-FFE sequences (sB-FFE) enabled the qualitative evaluation of abnormal blood movements and transvalvular flows. CONCLUSIONS: The considerable time savings allowed by SENSE technology and the clear improvement in image quality constitute a step forward in cardiac MR imaging. The possibility of executing morphologic, dynamic, perfusional and spectroscopic studies in the same MR examination session with short acquisition times and good image quality are becoming more feasible.

Surgical pathology of cystic lesions of the mediastinum.

BACKGROUND: Mediastinal cysts are uncommonly encountered in a pathologist's experience. AIMS: To study the incidence, location, clinical presentation and histologic subtypes of cysts in the mediastinum. MATERIALS AND METHODS: Cystic lesions of the mediastinum, surgically excised over a period of 22 years were studied after retrieval of relevant clinical data and slides. RESULTS: Thirty-nine mediastinal cysts were encountered in the study period. Most of the patients (81.5 %) were symptomatic. Histologically, foregut cysts (19 cases, 50 %) were the most common followed by teratomatous cysts (ten cases, 26.3 %) and thymic cysts (four cases, 10.5 %). Bronchogenic cysts represented 63 % of the fore-gut cysts. Unusual lesions in the form of cystic mediastinal tuberculous lymphadenitis and cystic schwannoma were seen in three patients. CONCLUSIONS: Despite varied location and histology, clinical presentation of mediastinal cysts are similar. Surgical intervention is the preferred line of management.

Presentación atípica de un quiste pericárdico en un paciente pediátrico / Atypical presentation of a pericardial cyst in a pediatric patient

Introducción. Dentro de los quistes primarios del mediastino, el originado en el pericardio es muy raro en pacientes pediátricos, normalmente es un hallazgo en una radiografía de tórax tomada durante una examen de rutina. Caso clínico. Se informa el caso de un adolescente masculino de 14 años de edad, que presentaba evolución de 10 meses con disnea progresiva hasta llegar a ser de pequeños esfuerzos, dificultad respiratoria leve, dolor torácico que se incrementaba con la respiración, cuya primer radiografía de tórax era compatible con un gran derrame pleural; posterior a su punción sólo se observó una pequeña zona de radiopacidad de forma triangular en el ángulo cardiofrénico derecho, que mediante ultrasonido demostró su naturaleza quística, el cual fue retirado quirúrgicamente. El estudio histopatológico reveló que se trataba de un quiste peicárdico. Conclusión. No obstante la baja frecuencia de este tipo de quistes en niños se considera necesaio recordar esta posibilidad cuando se tiene la sospecha de una lesión mediastinal y se observa una radipacidad redonda, pequeña, adherida al borde cardiaco en cualquiera de los ángulos cardiofrénicos

Quistes del timo, una lesion poco comun: informe de 1 caso / Thyme cysts, an uncommon lesion: report of 1 case

Se presenta el caso de una paciente joven, con una masa en el cuello, asintomatica, no dependiende del tiroides, quistica, que recidiva luego de puncionarla. Durante el acto operatorio, se encontro una lesion uniloculada, que contenia un liquido claro, localizada por debajo de polo inferior izquierdo del tiroides, sin hacer contacto con esta glandula, con extension al mediastino anterior, diagnosticada histologicamente como quiste del timo. Se revisa la literatura sobre el tema y se concluye que esta es una entidad poco comun

Functional mediastinal parathyroid cyst. Dynamics of parathyroid hormone secretion during cyst aspirations and surgery.

A patient presented with a large neck mass, hypercalcemia, and elevated serum parathyroid hormone levels. Aspiration of the cystic mass yielded 100 ml of fluid that contained a low concentration of thyroxine, but large amounts of parathyroid hormone, as measured by bioassay or with three different radioimmunoassays. After each of four aspirations, the serum calcium level declined significantly. Serial measurements showed that serum amino-terminal and mid-region parathyroid hormone levels and urinary cyclic adenosine monophosphate values declined after aspiration. Surgical resection of the cervical-mediastinal cyst restored normal serum calcium and parathyroid hormone levels, and these have been maintained for nine months. Calculations suggest that parathyroid hormone traversing the cyst lumen might contribute significantly to the excess circulating parathyroid hormone.