[Chronic Subdural Hematoma with Middle Cranial Fossa Arachnoid Cyst Concomitant with Bilateral Papilledema:A Case Report].

Arachnoid cysts(AC)are benign cystic lesions often diagnosed in childhood. Although usually asymptomatic, AC can become symptomatic when the lesion size increases or coexists with a subdural hygroma or hematoma. AC patients with signs of increasing intracranial pressure(IICP)or neurological deficits may need surgical intervention; this usually results in a good prognosis. However, whether asymptomatic AC patients should undergo surgical treatment is controversial. Although trivial head trauma, such as that from contact sports, can cause subdural hematoma in AC patients, there are currently no definite criteria regarding sports participation for children with AC. CASE: A 12-year-old boy who belonged to a soccer club visited an ophthalmologist with the chief complaint of having had diplopia for two weeks. He was identified as having bilateral papilledema. Since he had been diagnosed with a right middle cranial fossa AC five years earlier, he was referred to our outpatient clinic. Cranial CT scans showed right chronic subdural hematoma alongside the AC. The patient subsequently underwent burr hole surgery and was discharged after one week. In this case, the patient did not present with the typical signs of IICP, such as headache or vomiting. This experience indicates that care must be taken when encountering patients with atypical symptoms, particularly children. In addition, it is important to carefully consider sports participation for children with AC.

Retroclival Arachnoid Cysts: Case Series, Literature Review, and New Classification Proposal.

BACKGROUND: The retroclival region is among the rarest locations for an arachnoid cyst (AC), with only a few reported cases. No accepted classification system is available for these rare cysts. Such a classification system would solve the nomenclature problem and could result in easier and more systematic management. We reviewed and analyzed data from databases and reported studies of retroclival ACs (RACs) and have proposed a classification system. METHODS: A retrospective review of RACs was conducted in Marmara and Adiyaman University Hospitals, Turkey. Cysts in the prepontine and/or premedullary cisterns that spared the chiasmatic cistern were included. Additionally, the reported data were searched for relevant studies on cysts. The findings were analyzed to establish a clear nomenclature and classification system, and the clinical presentations, treatment strategies, and surgical approaches were reviewed. RESULTS: We identified 1 adult and 1 pediatric patient, and only the adult had undergone surgery. Additional data searches yielded 14 patients with RACs. The cysts were classified as type 1 if they had extended superiorly beyond the borders of the diencephalic leaf of the Liliequist membrane. If they had not extended, they were classified as type 2. Finally, type 2 cysts that had extended to the anterior spinal cistern were classified as type 3. CONCLUSIONS: RACs can be more easily and systematically managed using a simple clinical classification system. Together with the previously proposed suprasellar AC classification, our proposed RAC classification should be adequate to classify all ACs in the ventral midline cistern, which could solve the nomenclature problem.

Suprasellar Arachnoid Cysts: Toward a New Simple Classification Based on Prognosis and Treatment Modality.

BACKGROUND: Suprasellar arachnoid cysts (SAC) represent between 9% and 21% of pediatric arachnoid cysts. Recent improvements in magnetic resonance imaging, as well as increasing prenatal diagnosis, have allowed more precise knowledge and follow-up. OBJECTIVE: To describe a novel classification of SAC. METHODS: We present 35 cases of SAC treated between 1996 and 2014. Patient records and imaging studies were reviewed retrospectively to assess symptomatology, radiological findings, treatment, and long-term follow-up. RESULTS: Fourteen SAC were diagnosed prenatally (39%). We observed 15 (43%) cases presenting hydrocephalus (SAC-1) removing Liliequist membrane downward. Lower forms (SAC-2) with free third ventricle were observed in 11 (31%) cases. Asymmetrical forms (SAC-3) with Sylvian or temporal extension were seen in the 9 (26%) remaining patients. Twenty-three (66%) patients were treated by ventriculocisternostomy, 3 (8.5%) by shunt surgery, and 3 (8.5%) by craniotomy. Six (17%) patients had no surgery, including 5 cases (14%) that had prenatal diagnosis. Outcomes were initially favorable in 26 cases (87%). Eight (22%) patients had endocrine abnormalities at the end of the follow-up, 3 (8.5%) had developmental delay, and 6 (17%) had minor neuropsychological disturbances. CONCLUSION: SAC are heterogeneous entities. SAC-1 may come from an expansion of the diencephalic leaf of the Liliequist membrane. SAC-2 show a dilatation of the interpeduncular cistern and correspond to a defect of the mesencephalic leaf of the Liliequist membrane. SAC-3 correspond to the asymmetrical forms expanding to other subarachnoid spaces. Surgical treatment is not always necessary. The recognition of the different subtypes will allow choosing the best treatment option.

[Clinical presentation of a dorsal epidural arachnoid cyst after an epidural anesthesia]. / Presentación clínica de quiste aracnoideo epidural dorsal posterior a anestesia epidural.

BACKGROUND: Arachnoid cysts are dural diverticula with liquid content similar to cerebrospinal fluid, with 1% occurring in the spinal cord. They locate mainly in the dorsal region of the thoracic spine, and are unusual causes of spinal cord compression. CLINICAL CASE: The case is presented of a previously healthy 15-year-old boy, with a 20-month history of spastic paraparesis that started apparently after epidural block for ankle osteosynthesis. There was decreased sensitivity and strength of the pelvic limbs and gradually presented with anaesthesia from T12 to L4 dermatomes, L5 and S1 bilateral hypoaesthesia and 4+/5 bilateral strength, in the L2 root and 2+/5 in L3, L4, L5, S1, hyperreflexia, Babinski and clonus, but with no alteration in the sacral reflexes. In the magnetic resonance it was diagnosed as an extradural arachnoid cyst from T6 to T9. The patient underwent a T6 to T10 laminotomy, cyst resection, dural defect suture, and laminoplasty. One year after surgery, the patient had recovered sensitivity, improvement of muscle strength up to 4+/5 in L2 to S1, and normal reflexes. CONCLUSIONS: After the anaesthetic procedure, increased pressure and volume changes within the cyst could cause compression of the spinal cord, leading to symptoms. Despite being a long-term compression, the patient showed noticeable improvement.

Children With Intracranial Arachnoid Cysts: Classification and Treatment.

We performed a dynamic study of arachnoid cysts (ACs) using magnetic resonance cisternography (MRC) and proposed a classification of ACs.Twenty-three suitable patients in our hospital entered into this study according to our inclusion criteria. MRC images were collected in all the subjects at 1 and 24 hours after the administration of intrathecal gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA). We allocate the enrolled patients into 2 groups, MRC group and surgery group. The MRC results were considered before treatment in 1 group (MRC group, 13 patients), whereas another group was surgically treated without considering the MRC results (surgery group, 10 patients). We calculated the enhanced area of cyst using modified MacDonald Criteria from the images and measured the surrounding subarachnoid area as the reference.We found that it was practically useful to quantify 3 types of ACs, complete communicating, incomplete communicating, and noncommunicating, according to MRC results in this study. All the subjects in both groups are closely observed before the treatment and the follow-up using the MRI examination. In the surgery group, 5 patients were found that the area of cysts shrank in the follow-up stage. However, there was no significant difference in the percentage shrinkage area between the 2 groups.We concluded that MRC with Gd-DTPA as a contrast agent is of significant clinical value for the diagnosis and treatment of children with intracranial ACs. This classification based on dynamic MRC is useful for making surgical recommendations.

Epidemiología y clasificación de los quistes aracnoideos en niños / Epidemiology and classification of arachnoid cysts in children

La prevalencia de los quistes aracnoideos en niños es del 1-3%. Son más frecuentes en el sexo masculino. Pueden localizarse tanto en el espacio intracraneal como a nivel espinal. Los intracraneales se clasifican en supratentoriales, infratentoriales y supra-infratentoriales. Los supratentoriales se subclasifican en de fosa media, hemisféricos de la convexidad, interhemisféricos, de la región selar e intraventriculares. Los infratentoriales se subdividen a su vez en supracerebelosos, infracerebelosos, hemisféricos, clivales y de ángulo pontocerebeloso. Por último, los espinales se clasifican según su localización extra o intradural y su afectación de raíces nerviosas

The prevalence of arachnoid cysts in children is 1-3%. They are more frequent in boys. They can be located intracranially or in the spine. Intracranial cysts are classified as supratentorial, infratentorial, and supra-infratentorial (tentorial notch). Supratentorial are divided into middle cranial fossa, convexity, inter-hemisferic, sellar region, and intraventricular. Infratentorial are classified into supracerebellar, infracerebellar, hemispheric, clivus, and cerebellopontine angle. Finally spinal arachnoid cysts are classified taking into account whether they are extra- or intradural, and nerve root involvement

[Epidemiology and classification of arachnoid cysts in children]. / Epidemiología y clasificación de los quistes aracnoideos en niños.

The prevalence of arachnoid cysts in children is 1-3%. They are more frequent in boys. They can be located intracranially or in the spine. Intracranial cysts are classified as supratentorial, infratentorial, and supra-infratentorial (tentorial notch). Supratentorial are divided into middle cranial fossa, convexity, inter-hemisferic, sellar region, and intraventricular. Infratentorial are classified into supracerebellar, infracerebellar, hemispheric, clivus, and cerebellopontine angle. Finally spinal arachnoid cysts are classified taking into account whether they are extra- or intradural, and nerve root involvement.

Neuroendoscopic management of suprasellar arachnoid cysts.

BACKGROUND: The first case of an intracranial arachnoid cyst was described by Bright in 1831. In 1935, Barlow published the first case of a suprasellar arachnoid cyst. Fewer than 200 cases of suprasellar-prepontine arachnoid cysts have been reported in the literature as of January 2011. METHODS: Between 1994 and 2010, the senior author operated on 34 cases of suprasellar-prepontine arachnoid cysts. Eighteen female and 16 male patients ranged in age from 6 days to 16 years (mean 5.2 years). Follow-up of the patients ranged from 1 year to 16 years. RESULTS: Outcome may be evaluated according to radiological and clinical follow-up data. Postoperative radiological examinations must reveal: 1) the adequacy of fenestrations and flow through fenestration sites, 2) reduction of the cyst and ventricle size, and 3) reorientation of the chiasma and mammillary bodies to an acceptable anatomical position. In our series, no mortality occurred. Postoperative complication occurred in 3 cases. CONCLUSIONS: Suprasellar arachnoid cysts can be treated with favorable clinical and radiological results with endoscopic interventions when feasible. Results with ventriculocystocisternostomy are believed superior to those of ventriculocystostomy.

The clinical classification and treatment of middle cranial fossa arachnoid cysts in children.

OBJECTIVE: The optimal management for middle fossa arachnoid cysts (MFAC) remains controversial, but cystocistern fenestration is effective. MFACs are divided into non-communicating arachnoid cysts (NCIAC) and communicating arachnoid cysts (CIAC). This retrospective observational study evaluated the role of phase-contrast cine magnetic resonance imaging (PC-MRI) in the diagnosis and postoperative evaluation of MFACs and assessed surgical outcomes. METHODS: Twenty-eight children with MFAC that were diagnosed by conventional neuroradiology were enrolled. PC-MRI was performed preoperatively. The clinical manifestations, cyst volumes and PC-MRI data were analyzed, and the flow of cerebrospinal fluid (CSF) at the fistula was qualitatively evaluated. RESULTS: No communication with the adjacent subarachnoid space was found on preoperative PC-MRI in 20 patients, and they were diagnosed with NCIAC. A statistically significant decrease in cyst volume was observed in all 20 patients postoperatively. Symptoms resolved or improved in the 14 patients who were symptomatic preoperatively, and a positive CSF flow was found in all 20 patients postoperatively. PC-MRI diagnosed eight patients with CIAC, and the cyst sizes did not increase during follow-up. CONCLUSIONS: Cystocistern fenestration is an effective treatment for children with lateral fissure IAC. PC-MRI can be used to determine the IAC type and to evaluate the effectiveness of cystocistern fenestration.

Haga su diagnóstico / Make your diagnosis

El diagnóstico es Quiste aracnoideo de la fosa media con extensión a la fosa anterior Galassi III

CT cisternography in intracranial symptomatic arachnoid cysts: classification and treatment.

OBJECTIVES: The symptom and neuroimaging as indications for treating arachnoid cysts (ACs) are not adequate. Understanding the communication between cyst and subarachnoid space is helpful for decision-making. We took a dynamic study of ACs using CT cisternography (CTC) and proposed a classification of arachnoid cysts. MATERIALS AND METHODS: Total 52 symptomatic patients with ACs were enrolled in this prospective study. CTC images were ordered, in all enrolled patients, at the 1, 3, 6, 12, 24 and 48 h after the intrathecal Omnipaque administration. Enhancement in cysts was measured quantitatively and was compared with neighboring subarachnoid spaces. All enrolled patients were allocated randomly in 2 groups. The CTC result was considered before treatment in one group (CTC group), while another group was surgically treated without considering CTC results (surgical group). RESULTS: ACs in our study were classified into 3 types: complete (cyst filling time at 1 h), incomplete (filling time began at 3 h) and noncommunicating cysts (no or slight filling after 24 h). Twenty-two patients in CTC group with incomplete communicating, or noncommunicating cysts underwent surgeries. And other 6 patients with complete communicating cysts were closely observed. In CTC group, the symptom of all surgical patients was relieved, and 5 out of 6 observational patients showed clinical improvement or no deterioration during the follow-up. In surgical group, only 18 out of 24 patients showed clinical improvement after surgeries, and there were 6 patients showing no difference before and after surgeries in symptom and in imaging. CONCLUSIONS: This classification based on dynamic CT cisternography is useful for the decision of surgical indication. Some symptomatic patients with complete communicating ACs may not need surgical intervention.

[Neuroendoscopic treatment of different types of quadrigeminal cistern arachnoid cysts].

OBJECTIVE: To evaluate the method, strategy and efficacy of treating different types of quadrigeminal cistern arachnoid cysts (QCAC) with neuroendoscope. METHODS: A retrospective analysis was conducted for 12 QCAC patients with obstructive hydrocephalus. They were classified into 3 types and underwent neuroendoscopic operation at our hospital between November 2005 and November 2009. Their surgical approaches, complications and efficacy were analyzed. The mean age of first diagnosis was 3.7 years old. There were 7 type II cases and 5 type III cases with a varying level of symptoms. The follow-up period was 6 - 24 months. Cine-MRI (magnetic resonance imaging) examination was performed both preoperatively and post-operatively. RESULTS: Among them, 12 patients recovered well without any occurrence of hemorrhage, paralysis, lower cranial nerve injury, cerebrospinal fluid leakage, infection or death. Subdural effusion occurred in 3 cases, but disappeared within 6 months. Seven feverish cases recovered after a symptomatic treatment. The shapes of cysts and ventricles almost returned to a normal level in 8 cases. Three cases of arachnoid cyst had a slight change. CONCLUSION: In accordance with the QCAC patient types, different neuroendoscopic approaches can fully reconstruct the cerebrospinal fluid circulation. And the use of frameless navigation makes it more precise and safe.

[Therapeutic strategy for intrasellar cystic lesions].

OBJECTIVE: To make a clear distinction of intrasellar cystic lesions: craniopharyngioma (CR), Rathke's cleft cyst (RCC), cystic pituitary adenoma (PA) and intrasellar arachnoid cyst (AC). METHODS: A total of 72 adult patients underwent transsphenoidal approach for the removal of intrasellar cystic lesions. The authors conducted a study to (1) investigate preoperative clinical, biochemical and radiographic features of patients with CR, RCC, PA and AC; (2) identify clinicopathological features of independently predicting recurrence in CR, PA and RCC in adults. These adult patients included CR (n = 10), RCC (n = 27), cystic PA (n = 32) and 1 patient with AC (n = 1). RESULTS: The CR patients presented with hypopituitarism in 80% of cases. According to the biochemical criteria, the percentage of patients with a slight prolactin increase happened in PA (55.6%) and RCC (44.4%). Cystic PA had post-contrasting enhancement in cyst wall because of tumor tissue. Calcification detectable on computed tomographic scanning was present in 70% of CR patients. It was a significantly greater proportion compared to other diseases. Typical RCC was located between anterior and posterior pituitary and the contents in RCC were variable. Mass effects vanished post-operatively in all kinds of lesions. Long-term hormone replacement therapy was administered more in CR patients (60%) and diabetes insipidus than other lesions. One PA patient and 2 CR patients had recurrence during a follow-up of 12 - 52 months (mean: 34). RCC and AC had no recurrence. CONCLUSION: Craniopharyngioma, Rathke's cleft cyst, cystic pituitary adenoma and intrasellar arachnoid cyst are a spectrum of diseases with different therapeutic strategies. An accurate diagnosis of these lesions is essential so as to determine the type of treatment to improve outcome.

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.

Midline cystic malformations of the brain: imaging diagnosis and classification based on embryologic analysis.

This article describes a classification and imaging diagnosis of intracranial midline cystic malformations based on neuroembryologic analysis. Midline cystic malformations are classified into two categories from an embryologic point of view. In one category, the cyst represents expansion of the roof plate of the brain vesicle, and in the other the cyst consists of extraaxial structures such as an arachnoid membrane or migrating ependymal cells. Infratentorial cysts, such as the Dandy-Walker cyst or Blake's pouch cyst, and supratentorial cysts, such as a communicating interhemispheric cyst with callosal agenesis or a dorsal cyst with holoprosencephaly, are included in the first category. Infratentorial arachnoid cavities, such as the arachnoid cyst, arachnoid pouch, and mega cisterna magna, are in the second category. Noncommunicating interhemispheric cysts, such as interhemispheric arachnoid cyst or ependymal cyst, with callosal agenesis are also in the second category. A careful review of embryologic development is essential for understanding these midline cysts and for making a more accurate radiologic diagnosis.

Chronic subdural hemorrhage into a giant arachnoidal cyst (Galassi classification type III).

The authors present CT and MRI of a patient with an extremely large arachnoidal cyst (Galassi classification type III). The cyst extended from the base of the skull, posterior to the brain stem, on the base of the temporal lobe over the complete convexity of the left hemisphere. The cyst consisted of multiple compartments with intracystic septa and was accompanied by a chronic subdural hemorrhage in the compartments. After contrast agent application, the typical characteristics of chronic subdural membranes were found. Besides bony deformities, a thinning of the inner table was found. The patient underwent craniotomy for evacuation of the hemorrhage and fenestration of the septa while he was free of symptoms. This is a remarkable case proving that chronic local intracranial pressure does not inevitably lead to neurologic symptoms or intellectual disabilities.

Cisto aracnóideo / Arachnoid cyst

O cisto aracnóideo é um importante processo expansivo que atinge o sistema nervoso. Os autores reuniram, nesta revisäo, aspectos relevantes para a compreensäo e o manejo desta patologia

[Coccygodynia disclosing Tarlov's cysts]. / Coccygodynies révélant des kystes de Tarlov.

In a 63-year old male patient coccygodynia, initially isolated then complicated by incomplete cauda equina syndrome, could be attributed to large perineurel meningeal cysts on the sacral nerve roots. The diagnosis was suspected at computerized tomography and nuclear magnetic resonance and confirmed by sacculoradiculography. Intradural injections of corticosteroids provided lasting pain relief. Arachnoid cysts are often asymptomatic, by they may be responsible for coccygodynia and/or incomplete cauda equina syndrome. Their presence is suggested by the characteristics of the symptoms which are paroxysmal, exacerbated in standing position, relieved in dorsal position and revived by percussing the sacrum. Treatment is medical in most cases. The decision to operate depends on the persistence and intensity of pain and on whether signs of neurological defecit are present.