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| EDITORIAL |
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| Year : 2013 | Volume
: 61
| Issue : 1 | Page : 1-2 |
Intracranial arachnoid cysts
Raja D Reddy
Department of Neurosurgery, Apollo Hospital, Jubilee Hills, Hyderabad, India
| Date of Submission | 28-Jan-2013 |
| Date of Decision | 28-Jan-2013 |
| Date of Acceptance | 28-Jan-2013 |
| Date of Web Publication | 4-Mar-2013 |
Correspondence Address:
Raja D Reddy
Department of Neurosurgery, Apollo Hospital, Jubilee Hills, Hyderabad-500 096
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.107911
How to cite this article:
Reddy RD. Intracranial arachnoid cysts. Neurol India 2013;61:1-2 |
Arachnoid cysts are benign mass lesions of congenital origin containing cerebrospinal fluid (CSF) like material and are enclosed inside a membrane resembling arachnoid. These common lesions are mostly found incidentally because of increased use of neuroimaging. Precise etiology of these lesions and their natural history remain poorly defined and, hence, their optimal treatment guidelines have not yet been established. Majorities of the cases are asymptomatic and are compatible with normal life while some cases grow, and few even resolve spontaneously. Surgery is required in symptomatic cases with expanding cysts, some with bleeds and others with an evolving hydrocephalus of obstructive nature. The results of various surgical interventions in 68 adult patients with intracranial arachnoid cysts have been reviewed in this issue of the journal. [1]
Arachnoid cysts arise during development by splitting or duplication of the arachnoid membrane and account for 1% of all intracranial mass lesions. Different hypotheses have been postulated to explain the development of arachnoid cysts such as agenesis of brain structures, arachnoiditis, active fluid secretion, and pulsatile pump nature of fluid collection. Slit valve mechanism observed by cine-mode magnetic resonance imaging (MRI) preoperatively and confirmed during the endoscopic intervention has been reported for the fluid collection in the cysts. [2] Larger cysts can cause hydrocephalus by mass effect by blocking the aqueduct and in some, there could be intra-ventricular abnormalities such as membrane obstructing the aqueduct, occlusion of the foramen of Munro, and obstruction of aqueduct by quadrigeminal cyst, etc., These intra-ventricular anomalies and the cysts may have a common origin. Arachnoid cysts are a frequent finding on intracranial imaging in children. In one study of 11,738 consecutive series of MRI in children over an 11-year period, the prevalence rate of arachnoid cysts was 2.6%. [3] After a mean follow-up of 3.5 years, out of 111 patients, 11 increased in size, 13 decreased in size, and 87 remained stable. A younger age at presentation was significantly associated with cyst enlargement and no patient older than 4 years of age at the time of initial diagnosis had cyst enlargement nor demonstrated new symptoms. In another study in adults, 48,417 patients underwent MRI over a 12-year period and arachnoid cysts were identified in 661 patients with a prevalence of 1.4%. [4] Thirty-five of these cysts were symptomatic and 24 of them needed surgery. There is strong predilection for intracranial arachnoid cysts in the temporal fossa, followed by frontal convexity, posterior fossa, suprasellar region, quadrigeminal area, and lastly, in the ventricles. Rarely, the cysts could be located in brain parenchyma itself. More cysts are located on the left side and in men, whereas, cerebellopontine cysts are found frequently in women and on the right side. These observations suggest a possible genetic component in the development of some arachnoid cysts. Mirror image arachnoid cysts in a pair of monozygotic twins also support the genetic origin, and these cysts are also known to occur in cases of Aicardi and Panayiotopoulos syndromes [5],[6] Some cysts may rupture spontaneously resulting in life threatening hemorrhagic complications. [7],[8],[9] The proportion of imaged arachnoid cysts that ruptured or hemorrhaged was 6%. Larger cyst size more than 5 cm was significantly associated with cyst rupture/hemorrhage ( P < 0.001) in 9 out of 13 cases, whereas, only 5 out of 29 smaller cysts ruptured. Larger arachnoid cysts and recent head trauma are risk factors for symptomatic arachnoid cysts, which rupture/hemorrhage.
Majority of arachnoid cysts are asymptomatic and not all growing cysts may be symptomatic. [10] Sensory hearing loss and facial nerve palsy has been reported in cases of arachnoid cysts located in the cerebellopontine angle with complete recovery following surgery. [11] Impairment of neurocognitive functions has been reported in cases of arachnoid cysts. Dynamic studies can be performed to find out the communication between cysts and subarachnoid spaces by computed tomography (CT) cisternography or cine mode MRI. Cysts with communication to cerebrospinal fluid (CSF) pathways are less likely to increase in size, and those cysts, which did not fill early, might grow requiring surgery. Surgical options available are open craniotomy for cyst removal or fenestration into adjacent arachnoid spaces, shunting or stenting of cyst contents into ventricle, endoscopic fenestration or cystoperitoneal shunt operation. [12] Obstructive hydrocephalus caused by arachnoid cysts is the optimal indication for resecting the cyst and performing third ventriculostomy. The cystoperitoneal shunt is the best method for achieving obliteration of the cysts, but it has the disadvantage of shunt dependency. Among surgical options, primary endoscopic fenestration appears to be an ideal procedure. As the target membranes are avascular, CSF provides optimal image transmission and the method of fenestration is familiar to those performing neuroendoscopy. [13] However, particularly high rate of relapse (73%) was noted in cases of endoscopic fenestration and by comparison, only 28% of open fenestrations and 36% of the shunted group needed a second surgical procedure. [14] Cyst regresses in size in the majority of cases but in significant proportion of cases, it remains same, especially in the case of posterior fossa cysts as in the cases presented in this issue of the journal. [1] Though the intracranial arachnoid cysts are common lesions, their natural history in an individual site needs further elucidation. The best surgical treatment of arachnoid cysts is yet to be established, and endoscopic approaches are preferred to shunt operations.
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| 1. | Wang C, Liu C, Xiong Y, Han G, Yang H, Yin H, et al. Surgical treatment of intracranial arachnoid cyst in adult patients. Neurol India 2013; 2013;61;60-4. 
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| 2. | Santamarta D, Aquas J, Ferrer E. The natural history of arachnoid cysts: Endoscopic and cine-mode MRI evidence of a slit-valve mechanism. Minim Invasive Neurosurg 1995;38:133-7.
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| 3. | Al-Holou WN, Yew AY, Boomsaad ZE, Garton HJ, Muraszko KM, Maher CO. Prevalence and natural history of arachnoid cysts in children. J Neurosurg Pediatr 2010;5:578-85.
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| 5. | Zhon JY, Pu JL, Chen S, Hong Y, Ling CH, Zhang JM. Mirror image arachnoid cysts in a pair of monozygotic twins: Case report and review of literature. Int J Med Sci 2011;8:402-5.
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| 6. | Yalçin AD, Toydemir HE, Celebi LG, Forta H. Panayiotopoulos syndrome with coincidental brain lesions. Epileptic Disord 2009;11:270-6.
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| 7. | Moon KS, Lee JK, Kim JH, Kim SH. Spontaneous disappearance of a suprasellar arachnoid cyst: Case report and review of the literature. Childs Nerv Syst 2007;23:99-104.
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| 8. | Russo N, Domenicucci M, Beccaglia MR, Santoro A. Spontaneous reduction intracranial arachnoid cysts: A complete review. Br J Neurosurg 2008;22:626-9.
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| 9. | Cress M, Kestle JR, Holubkov R, Riva-Cambrin J. Risk factors for pediatric arachnoid cyst rupture/hemorrhage: A case control study. Neurosurgery 2013, PMID=23313978 [Epub ahead of print].
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| 10. | Lee JY, Kim JW, Phi JH, Kim SK, Cho BK, Wang KC. Enlarging arachnoid cyst: A false alarm in infants. Childs Nerv Syst 2012;28:1203-11.
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| 11. | Olaya JE, Ghostine M, Rowe M, Zouros A. Endoscopic fenestration of a cerebellopontine angle arachnoid cyst resulting in complete recovery from sensorineural hearing loss and facial nerve palsy. J Neurosurg Pediatr 2011;7:157-60.
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| 12. | Oertel JM, Wagner W, Mondorf Y, Baldauf J, Schroeder HW, Gaab MR. Endoscopic treatment of arachnoid cysts: A detailed account of surgical techniques and results. Neurosurgery 2010;67:824-36.
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| 13. | Kandasamy J, Souweidane M. Editorial: Arachnoid cysts. J Neurosurg Pediatr 2012;9:228-30.
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| 14. | Holst AV, Danielsen PL, Juhler M. Treatment options for intracranial arachnoid cysts: A retrospective study of 69 patients. Acta Neurochir Suppl 2012;114:267-70.
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