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| ORIGINAL ARTICLE |
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| Year : 2013 | Volume
: 61
| Issue : 4 | Page : 400-405 |
Individual surgical treatment of intracranial arachnoid cyst in pediatric patients
Chao Wang, Guoqiang Han, Chao You, Chuangxi Liu, Jun Wang, Yunbiao Xiong
Department of Neurosurgery of GuiZhou, Provincial People's Hospital, GuiZhou - 550 002, People's Republic of China
| Date of Submission | 02-May-2013 |
| Date of Decision | 14-Jun-2013 |
| Date of Acceptance | 24-Jul-2013 |
| Date of Web Publication | 4-Sep-2013 |
Correspondence Address:
Yunbiao Xiong
Department of Neurosurgery of GuiZhou, Provincial People's Hospital, GuiZhou - 550 002
People's Republic of China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.117618
Background and Aim: Intracranial arachnoid cysts (IAC) are benign congenital cystic lesions filled with cerebrospinal fluid (CSF). This study evaluated microsurgical craniotomy and endoscopy in the surgical treatment of IAC. Materials and Methods: Eight-one consecutive pediatric patients with IAC were surgically treated between January 2004 and January 2011. The surgical procedures included microsurgical craniotomy and endoscopy. Symptoms at presentation, location of IAC, surgical treatment options, and effectiveness were evaluated. Results: There were 43 males and 38 females and the mean age was 8.7 years (range between 1 month and 14 years) at the time of surgery. The cyst location was supratentorial in 72 patients and infratentorial in 9 patients, arachnoid cyst were identified. Follow-up period ranged between 2 and 8 years. Of the 49 patients with headache 83.67% of patients had cure and 10.2% had significant improvement. Of the eight patients with hydrocephalus and gait disturbances, six (75%) had complete total relief of symptoms and two (25%) patients had significant improvement. Four of the six patients with cognitive decline and weakness showed improvement. Of the 18 patients with epilepsy seizure freedom was: Engle class I grade I in 14 (77.78%) patients; class II in 2 (11.11%) patients; and class III in 2 (11.11%) patients. Follow-up studies from 2 to 8 years showed that headache was cured in 41 of the 49 cases (83.67%), significantly improved in 5 cases (10.20%), and showed no variation in 3 cases (6.12%). Hydrocephalus and gait disturbances were controlled in six of the eight cases (75.00%) and significantly improved in two cases (25.00%). Cognitive decline and weakness were obviously improved in four of the six cases (66.67%) and exhibited no variation in two cases (33.33%). According to the Engle standard, the following results were obtained from 18 patients with epilepsy: Grade I in 14 cases (77.78%); grade II in 2 cases (11.11%); and grade III in 2 cases (11.11%). Eleven cases with local or general enlarged skull exhibited no further progression. On follow-up computed tomography (CT) scan, there was variable alleviation of mass effect in all the 81 patients. Cystic size was significantly reduced in 65 patients with supratentorial arachnoid cysts and in 9 patients with infratentorial archnoid cysts. Twenty-one patients who had decreased skull thickness, had no further progression. Four patients who had cranioplasty had good outcome. Conclusion: The endoscopic approach was highly effective for most cases of IAC, particularly for cysts in the suprasellar and quadrigeminal regions as well as in the posterior fossa. Microsurgical craniotomy was recommended for IAC in the extracerebral convexity and intracerebrum. Local skull cranioplasty is needed for patients, or patients with preoperative diagnosis showed signs of cystic tumor and cyst-related epilepsy.
Keywords: Arachnoid cyst, cystoventriculostomy, cystocisternostomy, endoscopy
How to cite this article:
Wang C, Han G, You C, Liu C, Wang J, Xiong Y. Individual surgical treatment of intracranial arachnoid cyst in pediatric patients. Neurol India 2013;61:400-5 |
| » Introduction | |  |
Intracranial arachnoid cysts (IAC) are benign cystic lesions filled with cerebrospinal fluid (CSF) and the presenting features include: Headache, epilepsy, gait disturbances, cognitive disturbances, focal deficits, weakness, and local or general enlargement of head. The clinical manifestations depend on the location and mass effect of IAC. In symptomatic patients, the treatment options include microsurgical resection of the cyst wall, microsurgical fenestration, combined craniotomy for microsurgical fenestration and cystoventriculostomy or cystocisternostomy, endoscopic fenestration, combined endoscopic fenestration and cystoventriculostomy or cystocisternostomy, cystoperitoneal shunt, and stereotactic aspiration. This study reports retrospective analysis of 81 consecutive pediatric patients with IAC treated surgically.
| » Material and Methods | | |
Medical records and outpatient charts of all pediatric patients with symptomatic IAC who underwent surgical treatment at our institution between January 2004 and January 2011 were retrospectively analyzed. The data collected included age, gender, neurologic symptoms and signs, associated abnormalities, psychomotor status, treatment modalities, complications, electroencephalography (EEG) findings, and follow-up. In all the patients the diagnosis was confirmed by neuroimaging, during surgery and histopathological examination.
| » Results | | |
Clinical characteristics
During the study period, 81 pediatric patients with IAC underwent surgery: 43 males and 38 females, mean age at the time of surgery 8.7 years (range between 1 month and 14 years). Of the 81 IACs, 68 were in the supratentorial location and 13 were in the infratentorial location. The presenting symptoms included: Headache in 49 (60.49%); epilepsy in 18 (22.22%), hydrocephalus and gait disturbances in 8 (9.88%); and cognitive impairment and weakness in 6 (7.41%). Eleven patients had either local or general head enlargement.
Imaging findings
On imaging, mass effect of IAC was observed in all the patients in the form of sulcal effacement or obliteration, shifting of neighboring vascular structures, neighboring cortex depression, ventricle effacement or enlargement, and midline shift. Of the 68 supratentorial arachnoid cysts, the location was sylvian fissure in 45 (55.56%); middle carnial fossa in 14 (17.28%); intraventricular region in 4 (4.94%); pineal area in 2 (2.47%); extracerebral convexity in 2 (2.47%); and intracerebrum in 1 (1.23%). Local or general enlargement of skull was observed in 11 patients and decreased skull vault either local or generalized was seen in 21 patients.
EEG findings
Of the 81 patients, 74 patients had scalp EEG, mild abnormality in 36, moderate abnormality in 11, severe abnormality in 13 cases, and no abnormality in 14 cases. Video-EEG monitoring was performed for the patients with epilepsy, and the presence of the epileptic foci strongly correlated to location of the cyst [Figure 1]. | Figure 1: Neuroimaging of the location of the cyst. Cyst located in the (a) extracerebral convexity; (b) sylvian fissure; (c) infratentorial; (d) pineal area; (e) intraventricular; (f) middle fossa; and (g) intracerebrum
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Surgical treatment
The surgical treatments were grouped into (1) microsurgical craniotomy and (2) endoscopy. The selection of an individual surgical technique depended on the symptoms, location, volume, and the requirements of skull cranioplasty [Table 1].
Group I: There were 39 (48.15%) patients in the microsurgical craniotomy. Two patients with extracerebral convexity cyst and one patient with intracerebrum underwent total cyst wall excision. Twenty-four patients in sylvian fissure location, six patients in middle cranial fossa location, and four patients in infratentorial location underwent the combined modification of the partial cyst wall excision, microsurgical fenestration, and cystocisternostomy. One patient in the intraventricular location and one patient in pineal area underwent combined modification of the partial cyst wall excision, microsurgical fenestration, and cystoventriculostomy. Local skull cranioplasty was performed in four patients with local enlarged skull. The epileptic foci and the anterior temporal lobe were resected; neighboring cortical thermocoagulation was performed in 14 of the 18 patients with epilepsy. These operations were performed depending on the intraoperative electrocorticography (ECoG) findings of epileptic waveform discharges [Figure 2]. | Figure 2: A 11‑year‑old male child presented with left intraparietal cystic lesion and secondary generalized epilepsy for 2 years. AEDs did not satisfactorily control epilepsy. ECoG‑guided resection of epileptic foci and neighboring cortical thermocoagulation were performed with good outcome. This patient was seizure free for the 6‑year follow‑up period. (a) T2‑weighted MRI showed cystic lesion located in the left intraparietal lobe. (b) ECoG monitoring was performed before the cystic lesion was resected. (c) Epileptiform discharges were recorded before the cystic lesion was resected. (d) The apparent cystic wall was observed after the incision of the cortex. (e) Epileptiform discharges were recorded after the cystic lesion was totally resected; the location of the epileptic focus was reconfirmed by intraoperative ECoG monitoring. (f) Resection of epileptic focus guided by ECoG monitoring. (g) Epileptiform discharges were recorded again, but the frequency was significantly decreased. (h) Cortical thermocoagulation of residual epileptic foci was performed according to the ECoG monitoring findings, which indicated the presence of epileptic waveform discharges in the functional cortex. (i) No epileptic waveform discharges were detected by ECoG monitoring immediately after cortical thermocoagulation was performed. (j) The image after cystic lesion and epileptic foci were resected, and cortical thermocoagulation was performed. (k) Cystic lesion was arachnoid cyst and confirmed by pathological examination. (l) Glial proliferation and neuron degradation were found in the resected cerebral tissue, which was considered as the epileptic focus. (m) CT scan after 1‑year follow‑up
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Group II: There were 42 (51.85%) patients in endoscopic group: 21 patients with sylvian fissure location; 8 patients with middle cranial fossa location; 3 patients with intraventricular location; 1 patient with pineal location; and 9 patients with infratentorial location. After 2008, all the patients underwent endoscopic fenestration and cystoventriculostomy or cystocisternostomy [Figure 3]. | Figure 3: A 7‑year‑old female child presented with cognitive decline and weakness for 3 years. The preoperative symptoms were completely relieved after she underwent cystoventriculostomy by endoscopy. (a) T2‑weighted MRI showed that a large cystic lesion located in the intraventricle and the homolateral ventricle was enlarged and that the mid‑line shifted to the left side. (b) The area of the shin wall without the blood vessels was clearly observed by endoscopy. (c) Fistula surgery was performed by single‑pole coagulation. (d) The choroid plexus of the third ventricle was observed after cystoventriculostomy. (e) The enlarged lateral ventricle decreased in size, the shifted mid‑line retreated to the normal site, and the small subdural hygroma was observed in the CT scan during the 2‑year follow‑up period. (f) The pathological result of the arachnoid cyst was confirmed
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Complications
There were no deaths in this series. In the microsurgical craniotomy group (Group I), seven patients developed subdural hematoma; hematoma evacuation was performed on one patient and the remaining six patients were treated conservatively. Subdural hygroma occurred in four patients and were managed conservatively. Follow-up computed tomography (CT) revealed a significant reduction in volume without mass effect. One patient had postoperative meningitis and was treated with appropriate antibiotics. In the endoscopic group (Group II), one patient developed acute intraoperative subdural hematoma, which was evacuated by an emergent craniotomy. Subdural hematoma, subdural hygroma, and subcutaneous hygroma were observed in four, two, and one patient, respectively. These patients received conservative therapy.
Follow-up- outcome
The follow-up period ranged from 2 to 8 years. Of the 49 patients with headache, 83.67% of patients had cure and 10.2% had significant improvement. Of the eight patients with hydrocephalus and gait disturbances, six (75%) had complete total relief of symptoms and two (25%) patients had significant improvement. Four of the six patients with cognitive decline and weakness showed improvement. Of the 18 patients with epilepsy seizure freedom was: Engle class I grade I in 14 (77.78%) patients; class II in 2 (11.11%) patients; and class III in 2 (11.11%) patients [Table 2]. | Table 2: Distribution of the treatment methods according to the symptoms and therapeutic effects
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Follow-up CT scan: On follow-up CT scan, there was variable alleviation of mass effect in all the 81 patients. Cystic size was significantly reduced in 65 patients with supratentorial arachnoid cysts and in 9 patients with infratentorial archnoid cysts. Twenty-one patients who had decreased skull thickness had no further progression. Four patients who had cranioplasty had good outcome [Figure 4]. | Figure 4: A 6‑month‑old female child presented with generalized epilepsy and the local left temporal bulged for 3 months. She was seizure free and exhibited good appearance after the arachnoid cyst was microsurgically resected and the bulging bone flap was subjected to cranioplasty. (a) Preoperative CT scan showed that the local skull thickness of the left temporal became thin and bulged. (b) Cranioplasty was performed after the arachnoid cyst was resected. Postoperative CT image indicated that the bulging location had a better appearance. (c) Three‑dimensional reconstruction CT image showed that a reduced bone flap was steadily fixed
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| » Discussion | | |
The reported prevalence of IAC is 2.6% and with wide spread use of modern imaging, IAC is a frequent incidental finding. [1],[2] There is a fair consensus among neurosurgeons that patients with symptomatic IAC require surgical management. [3],[4],[5] However, what should be the most effective surgical management remains controversial. [6],[7] In this study, we focused on the selection of appropriate surgical management in symptomatic patient with IAC. The selection criteria for surgical management mainly depended on the clinical characteristics at presentation, neurologic findings, location and volume of the cyst, age, and the location of the cyst in relation to ventricular system and cisterns. In this study, the surgical procedures included microsurgical craniotomy and endoscopy.
We selected microsurgical craniotomy for patients with arachnoid cysts located in the cerebral convexity and intracerebrum. Local skull cranioplasty was the procedure for patients whose preoperative diagnosis showed features of cystic tumor or cyst-related epilepsy, and for patients who were not subjected to endoscopy. Total resection of the small arachnoid cyst or partial resection of the cyst wall could be performed as much as possible for full fenestration. The combined use of microsurgical fenestration and cystoventriculostomy or cystocisternostomy was performed simultaneously. Microsurgical craniotomy provides a full space for the total resection of the arachniod cyst and ECoG monitoring to record epileptic form discharges and thus localizing epileptogenic zone. [8] This approach also allows the surgeon to perform other procedures like focus excision, cortical thermocoagulation, or local skull cranioplasty. No significant difference in the therapeutic effect and reoperation rate between microsurgical craniotomy and endoscopy was observed in this study. Microsurgical craniotomy was more invasive than endoscopy, but the microsurgical technique can obtain greater control of hemostasis because of the ability to use bipolar forceps. [9] In our study, endoscopy was replaced with craniotomy because of acute intraoperative subdural hematoma for the bleeding of the remote bridge vein in one patient. A full space ensures the ability to perform another operation for cyst-related diseases, particularly in cyst-related epilepsy. Extensive and mature application of endoscopy is expected to replace microsurgical craniotomy gradually; however, the latter technique is more efficient for cortical arachnoid cysts, cyst-related epilepsy, or cysts with preoperative diagnosis for the possibility of a cystic tumor [6],[8] [Figure 5]. | Figure 5: A 5‑year‑old male child presented with hydrocephalus and gait disturbances for 1 year. Endoscopy was performed to obtain the biopsy specimen. Diagnosis of ependymoma was confirmed by a rapid pathological examination. Enlarged microsurgical craniotomy was then performed and the lesion was totally resected. The preoperative symptoms were completely relieved and the lesion did not recur in the follow‑up CT scan for 3 years. (a) T1‑weighted MRI showed that the lateral ventricle was enlarged irregularly and the mid‑line shifted to the left side. (b) The enlarged lateral ventricle decreased in size, the shifted mid‑line retreated to the normal site, and the homolateral subdural hematoma was observed in the CT scan during the hospital stay. (c) Subdural hematoma disappeared and the lesion was not recurred in the follow‑up CT scan for 3 years. (d) Pathological result of ependymoma
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Endoscopy is the newest method for surgical treatment of arachnoid cysts. This treatment involves the use of a high-definition and stereo-vision system to visualize the arachnoid cyst and its neighboring structures. In addition, the technique provides an easy and minimally invasive method for cystoventriculostomy or cystocisternostomy. In this study, a retractable film was used to form an inner channel to stop the rapid shifting of the cerebral tissue or vessels, prevent the bleeding from the bridge veins, ensure that the flushing liquid flows continuously and remains unobstructed, and lessen the possibility of injury between the cerebral tissue and the hard passage. Our results showed that endoscopy exhibited therapeutic effects similar to microsurgical craniotomy for IAC. Therefore, endoscopy is a safe and effective therapeutic modality for IAC, particularly for the cysts located in the suprasellar and quadrigeminal regions as well as the posterior fossa. [10],[11],[12]
| » References | | |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]
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