Middle Cranial Fossa Arachnoid Cyst Research Articles

Shunt placement after cyst fenestration for middle cranial fossa arachnoid cysts in children.

OBJECT Some pediatric patients with middle cranial fossa arachnoid cysts present with symptoms of increased intracranial pressure (ICP) and require shunt placement after a cyst fenestration. However, factors concerning increased ICP after fenestration followed by shunt placement have not been elucidated. This study evaluated factors that are associated with shunt placement following cyst fenestration in pediatric patients with middle cranial fossa arachnoid cysts. METHODS Twenty-six pediatric patients with middle cranial fossa arachnoid cysts who were surgically treated at a single institution between 2004 and 2013 were retrospectively identified. The surgical indications for middle cranial fossa arachnoid cysts were as follows: 1) arachnoid cysts associated with symptoms such as headache and abnormally enlarging head circumference; 2) progressively expanding arachnoid cysts; and 3) large arachnoid cysts such as Galassi Type III. A cyst fenestration was performed as a first-line treatment, and shunt placement was required if symptoms associated with increased ICP were found following fenestration. The risk factors evaluated included age, sex, presenting symptoms, the presence of head enlargement, progressive cyst expansion, and subdural hematoma/hygroma. RESULTS Four patients (15.4%) required shunt placement after cyst fenestration. Younger age, abnormal head enlargement, and progressive cyst expansion before fenestration were significantly associated with the need for shunt placement following fenestration. Arachnoid cysts decreased in size in 22 patients (84.6%) after fenestration and/or shunt placement. The presence of symptoms was not associated with postoperative cyst size in this study. CONCLUSIONS In this study, younger age, abnormal head enlargement, and progressive cyst expansion were risk factors for shunt placement after cyst fenestration in pediatric patients with middle cranial fossa arachnoid cysts. It is important to consider that cyst fenestration may not be effective because of a latent derangement of CSF circulation in patients with these risk factors.

P122 – 2666: Neuropsychological evaluation of children with middle cranial fossa arachnoid cysts, before and after decompression of the cyst through neurosurgical fenestration

Objective To evaluate cognitive outcome in children after surgical decompression of arachnoid cysts of the middle cranial fossa. An additional objective was to assess the children as one part of the decision whether to perform a surgical intervention or not. Arachnoid cysts are often considered asymptomatic incidental findings of MRI or CT. In this project the aim was to assess prevalence of cognitive symptoms correlated to the cyst and possible postsurgical improvement. Methods Neuropsychological assessment at the department of child neurology at Karolinska University Hospital, Stockholm. The assessment of intellectual ability was done using WISC-IV. Assessment of specific cognitive functions was done using NEPSY-II, Rey Oesterrieth Complex Figure test, BNT-II and FAS (test of verbal fluency). A follow-up with the same psychometric tests 4–5 months after surgery. Results To this date 6 children has gone through presurgical assessment. Four of six children showed cognitive symptoms in the assessment. Symptoms that was correlated to the location of the cyst and the neurosurgeon decided on fenestration of the cyst. Two of six children had no cognitive symptoms and the neurosurgeon decided on no surgical intervention. Two of the four children with symptoms have been evaluated 5 months after decompression of the cyst. Both clinical and psychometric results points towards reduction of cognitive symptoms in these two patients. Conclusion Neuropsychological assessment might be used as a help in decisions regarding surgery. Pre- and post-op assessment might be a way of evaluating the possible benefits of decompression of arachnoid cysts of the middle cranial fossa in children.

Progressive post traumatic tearing of an arachnoid cyst membrane resulting in intracystic and subdural haemorrhage

We report the case of a 43-year-old man with a middle cranial fossa arachnoid cyst who presented post trauma with neurological symptoms. The initial CT scan of the brain did not detect acute changes in the arachnoid cyst but subsequent imaging revealed abnormalities which progressed over time. Arachnoid cysts are usually a benign and incidental finding. Rare complications such as intracystic haemorrhage and subdural haemorrhage can occur. It is important to be aware of these complications so that patients with arachnoid cysts are appropriately investigated when presenting with neurological symptoms.

Extensive Middle Cranial Fossa Arachnoid Cysts and Different Clinical Presentation in Two Patients

Arachnoid cysts (ACs), particularly suprasellar cysts, cause a wide spectrum of endocrine disorders. Herein, we report two patients diagnosed with an extensive AC in the middle cranial fossa while being investigated for etiologies of precocious puberty and short stature. One of them required surgery due to his pubertal disorders associated with compression effects of cyst. After surgery, his puberty progression was regressed within one year. On the other hand, surgery was not planned for the second patient considering of his cranial imaging findings and the extremely low incidence of growth hormone (GH) deficiency caused by middle fossa AC (MFAC). We started treatment with recombinant human GH and no complication was found during treatment follow-up. Endocrine disorders associated with MFACs are extremely rare. By presenting with these two cases, we aimed to remain our fellow physcians that ACs can be possibly cause of endocrine disorders. Clinicians should be careful evaluating endocrine disorders because real cause may not be cyst itself but masked by it.

The efficacy of neuroendoscopic treatment for middle cranial fossa arachnoid cysts assessed by MRI 3D segmentation and modeling

The purpose of this study was to present a more precise and objective way to assess the effectiveness of neuroendoscopic application in the treatment of middle cranial fossa arachnoid cysts. Between March 2009 and December 2012, 28 patients affected by middle cranial fossa arachnoid cysts were initially treated with endoscopic fenestration at the three spaces. The volumes of the cysts on MR images at the time of pre-op and 4 months after surgery were reconstructed by 3D Slicer and quantitatively calculated to compare the volumetric changes. The possible predisposing factors of surgical outcomes were analyzed as well. All the models of the cysts were successfully reconstructed, and the mean volume of the cysts was 135.77 ± 90.43 cm(3) before surgery and 93.08 ± 100.31 cm(3) after surgery at 4 months follow-up (t = 2.98, P = 0.006). The volumes of those two cases (7.14 %), presenting intracranial hypertension and ventricular dilation after surgery, were dramatically increased, whereas the others were decreased in 20 cases (71.43 %) or remained unchanged in 6 cases (21.43 %). There was significant difference on the age factor among the three result groups (P = 0.001). The reconstruction of 3D for the assessment of the endoscopic fenestration outcomes is a feasible and precise way for clinical work. The variety of outcomes probably depends on age discrepancy.

Bilateral temporal lobe agenesis with bilateral arachnoid cysts – a rare congenital anomaly

Bilateral temporal lobe agenesis/hypogenesis along with middle cranial fossa arachnoid cysts (ACs) is extremely rare, and very few cases have been reported in the literature. We present the case of 2-year-old female presenting with chief complaints of headache, vomiting, and fever. There was a history of premature delivery in the seventh month and up-rolling of eyes since birth. Magnetic resonance imaging findings revealed bilateral temporal lobe agenesis with bilateral ACs, along with encephalomalacia in both parietal lobes. Ultrasound abdomen findings and biochemical tests revealed renal parenchymal disease. The lipid profile analysis revealed highly elevated triglyceride levels to 457.4 mg% and also enhanced very-low-density lipoprotein levels to 91.5 mg%. Presently, the patient is being treated on conservative lines. To our knowledge, this is the first report of an unusual association between bilateral temporal lobe agenesis associated with renal parenchymal disease and dyslipidaemia.

Rapid spontaneous resolution of acute subdural hematoma associated with a contralateral arachnoid cyst: A case report and review of the literature

Rapid resolution of post-traumatic acute subdural hematoma is infrequently reported. We report a case of rapid spontaneous disappearance of post-traumatic acute subdural hematoma in one patient who was discovered to have a contralateral middle cranial fossa arachnoid cyst. The previously reported mechanisms responsible for the rapid spontaneous disappearance of post-traumatic acute subdural hematoma are reviewed and the contribution of the middle cranial fossa arachnoid cyst to the disappearance of the pos-traumatic acute subdural hematoma that has taken place in our case is discussed. To the best of our knowledge the association between spontaneous disappearance of post-traumatic acute subdural hematoma and arachnoid cysts has not been previously reported.

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

ObjectiveThe 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. MethodsTwenty-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. ResultsNo 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. ConclusionsCystocistern 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.

Endoscopic treatment of middle cranial fossa arachnoid cysts in children

Arachnoid cysts located in the middle cranial fossa are common, comprising about half of all intracranial arachnoid cysts. The management of these cysts is challenging, and the optimal surgical treatment is controversial. This study evaluates the role of endoscopy in the treatment of middle cranial fossa arachnoid cysts (MCFACs) in children, focusing on some factors or technical aspects that might influence the outcome. Thirty-two children with symptomatic MCFACs were the subject of this study. The group included 23 boys and 9 girls, with a mean age of 3.6 years. All patients underwent operations using a purely endoscopic cystocisternostomy procedure through a transtemporal approach. Significant clinical improvement occurred in 28 cases (87.5%). Postoperative MR imaging showed a reduction in cyst size in 23 cases (71.9%), whereas in the remaining 9 cases (28.1%), the cyst size was unchanged. Minor intraoperative bleeding occurred in 3 cases (9.4%), which stopped spontaneously without any postoperative sequelae. Ipsilateral subdural hygroma occurred in 2 cases (6.3%) and resolved within a few weeks without surgery; transient oculomotor palsy occurred in 1 case (3.1%). During follow-up (mean 4.6 years), 3 patients (9.4%) experienced recurrence of symptoms and an increase in cyst size. Interestingly, all 3 patients who had recurrence had also experienced intraoperative bleeding at initial surgery. At a second endoscopic procedure, the fenestration was found to be closed in all 3 patients. Endoscopic cystocisternostomy is recommended in the treatment of MCFACs in children because it is simple, minimally invasive, and effective. It maintains the basic strategy of cyst fenestration into the basal cisterns without the invasiveness of open craniotomy. This procedure reduces operative and recovery times and is associated with low morbidity and mortality rates.

Editorial: Arachnoid cysts

Arachnoid cysts possess several features that make them ideal targets for primary endoscopic fenestration. First, the target membrane is typically avascular. Second, there are generous amounts of CSF for optimal image transmission. Third, the technique of membrane fenestration is amply familiar to surgeons regularly practicing neuroendoscopy, principally through the experience of performing endoscopic third ventriculostomy. Lastly, there is no traditional approach that is universally agreed upon as being optimal. While the rationale for primary endoscopic fenestration has been collectively accepted for some arachnoid cyst variants, notably the prepontine arachnoid cyst, there justifiably remains considerable disagreement about its role for cysts of the middle temporal fossa.5–11 In reading the recent publication by Dr. El-Ghandour,4 one would conclude that much of the ongoing debate regarding optimal management of middle cranial fossa arachnoid cysts (MCFACs) has come to closure. Of 32 children with “symptomatic” arachnoid cysts treated with a purely endoscopic fenestration, reported rates of improvement were 87.5% for clinical assessment and 71.9% for radiographic dimensions. Furthermore, 100% of patients with preoperative headache or skull deformity showed improvement. These admirable results include a low complication rate that was composed of a clinically silent subdural hygroma in 2 children and a transient third cranial nerve paresis in 1 patient. While these results could redefine our expectations regarding this form of treatment for children with MCFACs, a degree of caution is called for because these findings are appreciably incongruous with recently published clinical results as well as our own personal experience.3,5,9 With regard to operative indications, we support the consensus that treatment should be reserved for symptomatic patients.2–7,9,10 The operative indications included in the current paper beg some clarification. While there is no argument about offering treatment to children with raised intracranial pressure, the interpretation of this finding is frequently subjective. The definition of “symptomatic” in this current series included cranial deformity (temporal bulging), a frequent finding in infants and young children who are otherwise without symptoms. Further, 72% of children underwent treatment due either to symptoms of headache or signs of macrocrania. These features frequently are not related to elevated intracranial pressure. The rate and trend of head circumference growth (unknown in the current paper) is more meaningful than a single measurement. Similarly, headache alone without supportive evidence can be tenuous as a sole justification for surgery. While papilledema is unambiguous in documenting raised intracranial pressure, the frequency of that finding (37.5%) in this cohort of 32 children is appreciably higher than in most reported series.5,9 While the author notes that prophylactic surgery may be offered to avoid the potential of subdural hematoma, there exists limited clinical data to discount this notion. Recent evidence is convincingly clear that the potential for symptomatic progression in an otherwise asymptomatic child is exceedingly rare.1 In fact, the association of intracranial hemorrhage with arachnoid cysts has been documented after head injury despite long-term postsurgical neuroradiological confirmation of MCFAC size reduction and symptom resolution.9 In short, the indications for surgical treatment of MCFAC are highly variable and open to interpretation. The outcome in this series of 32 patients is even more impressive given the described technique. The author used an embolectomy catheter to create a single fenestration in 75% of patients without intraoperative computer-assisted neuronavigation. This “simple” technique of endoscopic fenestration warrants some elaboration and 228 23

Scientific Letter: Middle cranial fossa arachnoid cyst presenting with obsessive compulsive behaviour associated with psychosis – two cases

Arachnoid cysts are benign space-occupying lesions of the brain containing cerebrospinal fluid (CSF). From an etiological point of view, the primary or true cysts are congenital in nature and false cysts are secondary to the post-inflammatory accumulation of CSF during cranial traumas, infections or intracranial hemorrhages.

Congenital intradiploic arachnoid cyst presenting as painless proptosis

A 12-year-old girl presented with several years of progressive painless proptosis and orbital fullness. On imaging, she was found to have marked expansion and remodeling centered in the right greater wing of the sphenoid bone with an adjacent middle cranial fossa arachnoid cyst. A clinical diagnosis of intradiploic arachnoid cyst was made. This entity was benign, and other ophthalmic and neurologic signs or symptoms were absent. Our patient was observed without surgical intervention. To our knowledge, this is the first such case reported in a child. Although this cyst has been described in the occipital and frontal bones, this is the first description of occurrence in the sphenoid bone.

Assessment of endoscopic treatment for middle cranial fossa arachnoid cysts

Endoscopic cystocisternotomy is one of three surgical methods used to treat middle cranial fossa arachnoid cysts. There is debate about which method is the best. The aim of this study is to evaluate the effectiveness and safety of endoscopic cystocisternotomy for treatment of arachnoid cysts of the middle cranial fossa. Thirty-two patients with arachnoid cysts of the middle cranial fossa who had undergone endoscopic cystocisternal fenestration between 2004 and 2009 were studied retrospectively. Data were obtained on clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and the results of clinical and neuroradiological follow-up. Among the 27 patients with symptoms before surgery, 8 had disappearance of symptoms and 17 had improvement of symptoms. The cyst was reduced in size or it completely disappeared in 24 (75%) patients. The incidence rate of complications was 18.8%. Endoscopic cystocisternal fenestration is an effective treatment for symptomatic arachnoid cysts of the middle cranial fossa and should be the initial surgical procedure.

An Aneurysm Rupturing into a Middle Cranial Fossa Arachnoid Cyst Presenting as an Intracystic Hemorrhage

We report a case of an aneurysm rupturing into an arachnoid cyst presenting as a confined intracystic hemorrhage. A 37-year-old man with a history of sporadic headaches for several years complained of a headache of several days' duration. Brain computed tomography and magnetic resonance imaging revealed a cystic lesion in the left side of the middle cranial fossa that included a 3-cm-diameter hematoma in the Sylvian fissure without extracystic hemorrhage. Left carotid artery angiography showed an internal carotid artery-posterior communicating artery (IC-PC) aneurysm and an anterior choroidal artery aneurysm. The cyst wall was excised, and the aneurysms were clipped. The bleeding point was the spot at which the IC-PC aneurysm entered the arachnoid cyst. Right oculomotor nerve palsy developed after surgery, but resolved after 3 months. To the best of our knowledge, this is the only fourth report to date in the literature of a confined aneurysm rupturing into an arachnoid cyst.

Ocular Manifestations of Oblique Facial Clefts

In the Tessier classification, craniofacial clefts are numbered from 0 to 14 and extend along constant axes through the eyebrows, eyelids, maxilla, nostrils, and the lips. We studied a patient with bilateral cleft 10 associated with ocular abnormalities. Clinical report with orbital and cranial computed tomography. After pregnancy complicated by oligohydramnios, digoxin, and lisinopril exposure, a boy was born with facial and ocular dysmorphism. Examination at age 26 months showed bilateral epibulbar dermoids, covering half the corneal surface, and unilateral morning glory anomaly of the optic nerve. Ductions of the right eye were normal, but the left eye had severely impaired ductions in all directions, left hypotropia, and esotropia. Under anesthesia, the left eye could not be rotated freely in any direction. Bilateral Tessier cleft number 10 was implicated by the presence of colobomata of the middle third of the upper eyelids and eyebrows. As the cleft continued into the hairline, there was marked anterior scalp alopecia. Computed x-ray tomography showed a left middle cranial fossa arachnoid cyst and calcification of the reflected tendon of the superior oblique muscle, trochlea, and underlying sclera, with downward and lateral globe displacement. Tessier 10 clefts are very rare and usually associated with encephalocele. Bilateral 10 clefts have not been reported previously. In this case, there was coexisting unilateral morning glory anomaly and arachnoid cyst of the left middle cranial fossa but no encephalocele. Bilateral Tessier facial cleft 10 may be associated with alopecia, morning glory anomaly, epibulbar dermoids, arachnoid cyst, and restrictive strabismus.

Middle Cranial Fossa Arachnoid Cyst Presenting With Subdural Effusion and Endoscopic Detection of Tear of the Cyst -Case Report-

A 15-year-old boy presented with a case of middle cranial fossa arachnoid cyst associated with subdural effusion and manifesting as headache and vomiting after minor head injury. Computed tomography disclosed a cystic lesion in the left middle cranial fossa and ipsilateral subdural effusion. Fundoscopic examination revealed papilledema. A small tear of the cyst wall was confirmed endoscopically. Fenestration of the cyst was performed under the operating microscope. Postoperative course was uneventful. The tear in the outer wall of an arachnoid cyst may suggest the mechanism of occurrence of subdural effusion associated with middle cranial fossa arachnoid cyst.

Middle cranial fossa arachnoid cysts complicated with subdural collections

Intracranial arachnoid cysts are congenital collections of fluid that develop within the arachnoid membrane be cause of splitting or duplication of this structure. It corresponds to 1% of all non-traumatic intracranial mass lesions 1 . Arachnoid cysts most frequently occur in the middle cranial fossa, followed by the posterior fossa, convexity, and suprasellar region. Middle cranial fossa cysts are more often associated with subdural hematoma, subdural hygroma, and intracystic hemorrhage. Usually, the patients present with signs and symptoms of intracranial hypertension, mainly headache and vomiting 2 . We report two cases of arachnoid cysts associated with concurrent subdural collections, describing their clinical presentation, radiographic findings and neurosur gical management. CaSeS Case 1 A 15-year-old male patient presented with a 3-day history of headache and vomiting. He reported an episode of mild head trauma without loss of consciousness four days before the admission. There was no history of drugs, alcohol abuse or previous neurological illness. The Glasgow coma score was 14 (confused conversation). Pupil reactions were normal and there was no other abnormality in the neurologic examination. Computed tomography (CT) revealed an arachnoid cyst in the left middle cranial fossa (Fig 1A) and a low-density crescentic collection across the entire left hemispheric convexity, corresponding to a chronic subdural hematoma, with signs of acute hemorrhage (Fig 1B). The patient underwent surgical treatment with evacuation of the subdural hematoma and endoscopic fenestration of the cyst to obtain communication with the chiasmatic cistern. The recovery was uneventful and an eight months follow-up CT showed a residual non-hypertensive cyst. There was no evidence of any subdural collection.

Comparative study on two surgical procedures for middle cranial fossa arachnoid cysts

In this study, we explored the operation options for middle cranial fossa arachnoid cysts (MCFAC). One hundred and forty-nine patients who were operated for a symptomatic MCFAC between 1993 and 2006 in our hosptial were analyzed. Follow-up time ranged from 1 y to 14 y (mean=5.4 y). All these patients were divided into three subgroups according to Galassi classification. Long-term outcome and complications were studied respectively. Fenestration (F) resulted in a more favorable long-term outcome and less complication for cysts of types I and II, whereas a favorable outcome was noted in type III patients who underwent cysto-peritoneal shunting (S). We are led to conclude that Fenestration is suitable for cysts of types I and II (Galassi classification), cysto-peritoneal shunting is better for cysts of type III.

Intracranial Hemorrhagic Arachnoid Cyst: The Role of Diffusion-Weighted Imaging

The majority of hemorrhagic arachnoid cysts are correlated with trauma or aneurysmal rupture. We report on a 35-year-old woman with acute headache and an intracranial mass lesion that was hyperdense in CT and hyperintense in conventional MRI images. The history and imaging were negative for trauma or vascular anomaly. Diffusion-weighted imaging (DWI) clearly demonstrated a large right anterior and middle cranial fossa arachnoid cyst with associated subacute intracystic hemorrhage without subdural hematoma. DWI offers invaluable information for the differential diagnosis of hemorrhagic arachnoid cysts from other extra-axial space-occupying lesions.

Case report: Middle cranial fossa arachnoid cyst in association with subdural hygroma

Arachnoid cysts are congenital, cerebrospinal fluid (CSF)-filled, intra-arachnoidal lesions that are a common incidental finding on routine brain imaging. While this lesion can present as a mass lesion, the vast majority is generally asymptomatic. Rarely, posttraumatic or spontaneous rupture of arachnoid cysts can result in intracystic hemorrhage, subdural hematoma, or subdural hygroma. We describe a rare presentation of an arachnoid cyst, which ruptured after a minor head injury and resulted in a subdural hygroma. Arachnoid cysts are intra-arachnoidal space-occupying lesions containing fluid similar to CSF. They are benign in nature and congenital in origin. Arachnoid cysts represent 1% of all nontraumatic intracranial masses.[1] Most arachnoid cysts are supratentorial in location and 50-65% occur in the middle cranial fossa. Arachnoid cysts can also occur less frequently in the suprasellar and quadrigeminal cisterns, cerebral convexities, cerebellopontine angle, and cisterna magna. Occasionally, arachnoid cysts are complicated by intracystic or subdural hemorrhage, with or without history of preceding trauma.[1–3] A very rare complication of arachnoid cysts is the spontaneous or traumatic development of subdural hygromas.[2,4–7] We report a patient with an intracranial arachnoid cyst that was complicated by a subdural hygroma after a minor head injury.