Large Intracranial Cyst Research Articles

Anaesthetic concerns for large intracranial cyst excision: expect the unexpected!

Neurosurgical procedures in infants poses various challenges such as difficulty in venous cannulation, securing invasive vascular lines, difficult airway, controlling intra-cranial tension, managing large fluid shifts to positioning- related issues and temperature maintenance. We hereby present an case of a large intracranial space occupying lesion, suspected to be a hydatid cyst, which later turned out to be an infected ventricular cyst and intraoperative problems. A thorough preparation prior to operation of infected cystic lesion of the brain is required including anticipation of massive blood loss and its management. A slow decompression of the large cystic lesion should be done.

Anesthetic Concerns for Large Intracranial Cyst Excision: Expect the Unexpected!

The management of neurosurgical procedures for infants is always challenging for the anesthesiologists. We hereby present a case of a large ICSOL (intracranial space occupying lesion), suspected to be a hydatid cyst, which later turned out to be an infected ventricular cyst and intraoperative problems. We faced an unexpected problem of massive blood loss intraoperatively due to disease pathology. We conclude that a thorough preparation prior to operation of infected cystic lesion of the brain is required including anticipation of massive blood loss and its management. A slow decompression of the large cystic lesion should be done. doi:10.4021/jnr20e

Anesthetic Concerns for Large Intracranial Cyst Excision: Expect the Unexpected!

The management of neurosurgical procedures for infants is always challenging for the anesthesiologists. We hereby present a case of a large ICSOL (intracranial space occupying lesion), suspected to be a hydatid cyst, which later turned out to be an infected ventricular cyst and intraoperative problems. We faced an unexpected problem of massive blood loss intraoperatively due to disease pathology. We conclude that a thorough preparation prior to operation of infected cystic lesion of the brain is required including anticipation of massive blood loss and its management. A slow decompression of the large cystic lesion should be done. J Neurol Res. 2011;1(2):78-80 doi: https://doi.org/10.4021/jnr20e

Low bispectral index values in a 2-yr-old with a large bifrontal porencephalic cyst

EDITOR: Bispectral index (BIS) is routinely used as a monitor of depth of anaesthesia. Unusually low BIS values may be seen during cerebral ischaemia [1], in neuroradiology during glue embolization [2], in patients with dementia [3] and in persons with genetically determined low-voltage electroencephalographic (EEG) signals [4]. Recently, we detected persistently low BIS values in a patient diagnosed with large porencephalic cysts in the frontal lobes. A 2-yr-old male child, weighing 12 kg, was admitted to our neurosurgical ward with major complaints of increasing head size since 4 months of age, two episodes of generalized tonic-clonic seizures a week ago and delayed milestones. The child responded to commands, recognized his mother but had difficulty in holding his head with a tendency to fall while walking. Contrast-enhanced computed tomography showed two large cystic intraparenchymal lesions in the frontal lobe, suggestive of porencephalic cysts with paucity of periventricular matter and prominent ventricles. Magnetic resonance imaging showed bilateral communicating frontal lobe porencephalic cysts with secondary aqueductal stenosis and secondary corpus callosal hypoplasia (Fig. 1). He was scheduled for an elective frontal craniotomy and fenestration of frontal porencephalic cyst with right cystoperitoneal shunt. In the operating theatre, routine monitors (electrocardiogram, non-invasive blood pressure and pulse oximetry) were attached. A BIS monitor (A-2000; Aspect Medical Systems, Newton, MA, USA) was also attached. The BIS sensor (paediatric) was applied to the forehead and left temporal area. A low BIS value of 39 was observed. Lower values persisted till induction of anaesthesia. General anaesthesia was induced with thiopental sodium 40 mg after fentanyl 20 μg. Rocuronium 10 mg facilitated tracheal intubation. Anaesthesia was maintained with sevoflurane in an oxygen and nitrous oxide mixture (1 : 2). Intermittent boluses of fentanyl and rocuronium were given to facilitate mechanical ventilation to target an end-tidal carbon dioxide value of 32 ± 1 mmHg. Throughout the surgical procedure, the BIS values remained between 30 and 40 with a signal-quality index (SQI) of more than 90%. Due to the low BIS values, the sevoflurane concentration was reduced from inspired concentration of 1–0.2%. Still, no changes in the BIS values were observed. No burst and suppression pattern was observed and the electromyography value remained below 30. At the end of an uneventful surgery, the anaesthetics were discontinued and neuromuscular block reversed. The trachea was extubated and the child cried actively. The BIS value continued to remain low, even 6 h later in the neurosurgical ICU.Figure 1: Magnetic resonance imaging showing bilateral communicating frontal lobe porencephalic cyst.BIS monitoring has been largely used to monitor the depth of anaesthesia. However, nothing has been published regarding the role of BIS monitoring and its validity in neurosurgical patients with raised intracranial pressure. Since the BIS algorithm analyses the EEG signals of the patient, it should be expected to vary or else alter the values displayed, to some extent, especially in patients with grossly elevated intracranial pressure. Schnider and colleagues [4] reported a case in which, due to the patient's EEG amplitude being genetically very low, the BIS value was 40 during consciousness. This EEG pattern occurs with an incidence of approximately 10% of the population. It has also been suggested that emotional tension may induce low-voltage EEG activity. In our patient, an increase in intracranial pressure as a result of the cyst may have resulted in decreased cerebral perfusion pressure and thereby caused global cerebral ischaemia over a long period. This may have been responsible for the lower BIS values. A large prospective study may be needed to validate the role of the BIS monitor in neurosurgical patients with signs of raised intracranial pressure as in cases of gross hydrocephalus or patients with large intracranial cysts. Lower BIS values in these patients may not reflect the true hypnotic state and could be a result of cerebral ischaemia or even low-voltage EEG signals. To adjust the level of anaesthesia based entirely on BIS could be erroneous and inappropriate.

Endodermal cyst presenting as a prenatally diagnosed large intracranial cyst

Endodermal cysts of the central nervous system are unusual lesions. Most reported cysts develop in the spinal canal, whereas others, which occur intracranially, are usually located in the posterior fossa. Although endodermal cysts are considered congenital, a prenatal diagnosis has not been reported. In this report the authors present an extremely rare case of a large intracranial endodermal cyst detected prenatally and treated successfully after birth.

Isolated Large Third-Trimester Intracranial Cyst on Fetal Ultrasound: Fact or Fiction?

To distinguish the fact from artifact of an isolated, large, intracranial cyst on prenatal sonography (PSG). The use of PSG is rapidly increasing with most obstetric ultrasounds occurring in general community settings like small hospitals and clinics with personnel who have variable training, experience, and interest levels. In contrast, most PSG articles and books are produced in large subspecialty centers with concentrated referral bases plus both highly-trained and experienced personnel. We report a series of 2 normal newborn patients who had a large prenatal unilateral intracranial cyst diagnosed by PSG in the 10 years between July of 1989 and 1999 at a rural community hospital. The newborns had imaging studies at birth and their neurodevelopmental progress was followed for several years. Textbook, bibliography and computerized Medline (1966-present) searches including prenatal ultrasound, observer variation, diagnostic errors, reproducibility of results, sensitivity and specificity, accuracy, central nervous system, false-positive, prenatal diagnosis, and brain were examined starting in August 1996 for reports. There were 4079 obstetric ultrasounds performed in 3.5 years, January 1996 through July 1999 at this rural community facility. This rate extrapolates to a total of 11 654 obstetric ultrasounds over the 10-year study period in which the 2 cases of intracranial cyst artifact occurred. Thus, the incidence of 2 intracranial cyst artifacts was estimated as 2/11 654 PSG, a .0002% false-positive rate. This is the first report of the occurrence of PSG artifacts in a community facility. Artifact is a real problem and needs to be specified in differential diagnoses. There are ways to decrease sonographic artifact-or at least to recognize it-so our estimates at a community hospital for its occurrence are presented with the relevant technical and ethical issues. None of these issues have been previously reported in the pediatric literature. Our false-positive rate for large intracranial cyst compares favorably with other reports. Our estimate may inflate our denominator by reporting scans rather than the number of fetuses scanned, and our numerator may miss cases that moved from the community. Confusion differentiating PSG artifact from reality often occurs when interpreting static or frozen real-time images. The signs that sonogram images may be artifacts include defects that: extend outside the fetal body; change shape, size and echogenecity with different scan planes; are not seen on all examinations; and are isolated in an otherwise normal fetus. Failure to offer quality PSG in clinical settings where it is available restricts access of pregnant women to the diagnosis of fetal anomalies, and therefore restricts access to the options of pregnancy termination, fetal therapy like fetal surgery, and delivery options of timing, setting, and mode. We suggest a multidisciplinary approach to prenatal abnormalities like isolated third trimester unilateral intracranial cyst in both primary and tertiary care settings aids interpretation followed by expectant conservative management without elaborate, risky, or terminal interventions.

Giant glioependymal cyst resembling holoprosencephaly on prenatal ultrasound: case report and review of the literature.

We report the earliest in utero presentation of a 'giant' glioependymal cyst detected on routine prenatal ultrasound at 22 weeks estimated gestational age. The clinicopathologic features of these rare lesions are reviewed as well as previous reports of glioependymal cysts detected in utero. The effects of large intracranial cysts on neurodevelopment are discussed as well as the differential diagnosis of infantile intracranial cysts and therapeutic alternatives.

Adipsic Hypernatremia in Two Sisters

We describe two sisters with chronic hypernatremia, lack of thirst, and inappropriate osmoregulated vasopressin secretion. Only one sister, who presented with microcephaly and developmental delay, showed signs of dysplasia of the midline structures (ie, septum pellucidum and corpus callosum) and a large intracranial cyst. Neither sister showed any signs of thirst, even when osmolality exceeded 337 mmol/kg. In both patients, the vasopressin secretion did not respond to either osmotic or nonosmotic stimuli or was suppressed by a water load. Plasma osmolality values returned to normal after treatment with forced hydration and a vasopressin analogue, desamino-D-arginine vasopressin. These findings indicate a severe defect in the hypothalamic osmoreceptors that control thirst and vasopressin secretion. To our knowledge, this is the first report of such a disorder in two sisters.

Use of Otoscope for Cranial Transillumination of the Infant Skull

To the Editor.— Transillumination of the head is a simple and useful technique for evaluating intracranial content in very young children. For detecting suspected hydrocephalus, subdural effusions, and large intracranial cysts, this procedure remains inexpensive and very easy to perform.1 High intensity transilluminators have been used for this procedure; however, they are not readily available at the bedside in the office. Therefore, in such situations an otoscope can be used for such a purpose. A Welch Allen wall model was used for this purpose with good success.

Kallman's syndrome with associated cardiovascular and intracranial anomalies

A patient with Kallman's syndrome was found to have an atrial septal defect, mitral valve prolapse, and a large intracranial cyst. None of these anomalies has been previously reported in association with Kallman's syndrome, and all have diagnostic and prognostic importance.