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Year : 2010  |  Volume : 58  |  Issue : 6  |  Page : 964--966

Thoracic intramedullary arachnoid cyst

Batuk Diyora, Hanmant Kamble, Naren Nayak, Praful Dugad, Alok Sharma 
 Department of Neurosurgery, L.T.M.G. Hospital, Mumbai, India

Correspondence Address:
Batuk Diyora
Department of Neurosurgery, L.T.M.G. Hospital, Mumbai
India




How to cite this article:
Diyora B, Kamble H, Nayak N, Dugad P, Sharma A. Thoracic intramedullary arachnoid cyst.Neurol India 2010;58:964-966


How to cite this URL:
Diyora B, Kamble H, Nayak N, Dugad P, Sharma A. Thoracic intramedullary arachnoid cyst. Neurol India [serial online] 2010 [cited 2022 Jan 26 ];58:964-966
Available from: https://www.neurologyindia.com/text.asp?2010/58/6/964/73774


Full Text

Sir,

Arachnoid cysts are benign developmental cysts that occur in the cerebrospinal axis in relation to the arachnoid membrane. A spinal arachnoid cyst is often encountered as an incidental finding and rarely causes spinal cord compression. [1] Spinal arachnoid cyst usually occurs in the pediatric population and is located in the thoracic or cervical cord. Intramedullary location of the arachnoid cyst is rare, with only a few cases reported in the literature. [2],[3],[4],[5]

A 45-year-old man presented with a history of midline thoracic back pain of 2 years' duration. Ten days prior to his presentation, he had noticed increased severity of pain and weakness in both the lower limbs, which progressed to paraplegia with urinary and fecal incontinence. Neurological examination revealed a flaccid paraplegia with absence of superficial and deep tendon reflexes. There was no muscle wasting. Below T6 level, all modalities of sensation were lost. Hematological and biochemical examinations revealed no abnormality. Lumbar cerebrospinal fluid (CSF) examination was unremarkable. Magnetic resonance imaging (MRI) of dorsal spine revealed a non-enhancing cystic intramedullary lesion at T4 to T5 level measuring 3.1×1.4 cm, which was hypointense on T1-weighted images and hyperintense on T2-weighted images [Figure 1]. Screening of the cervical and lumbar regions of the spine showed no abnormality.

He underwent a T3 to T5 laminectomy. The cyst was identified just below the cord surface after a midline myelotomy. The cyst was bluish, thin walled; and clear fluid drained out under pressure. Cyst wall was partially excised as it was adherent at places to the spinal parenchyma. No communication with the subarachnoid space or an extramedullary component was present. Microscopic examination of the cyst wall showed fibrous connective tissue lined by arachnoid cells, consistent with the diagnosis of arachnoid cyst [Figure 2]. Postoperatively, he had complete relief of pain, while his motor power improved to normal over a period of 6 weeks [Figure 3].{Figure 1}{Figure 2}{Figure 3}

Unlike intracranial arachnoid cysts, spinal arachnoid cysts are uncommon and may be located either intradurally or extradurally. Extradural cysts result from an extradural out-pouching of the arachnoid that is contiguous with the spinal subarachnoid space via a small dural defect. Intradural cysts are out-pouchings of arachnoid that, regardless of size, lie entirely within the dural space; these are more common than extradural cysts. Both these types may or may not communicate with the subarachnoid space. [6],[7]

Intramedullary arachnoid cysts are rare, and so far only 9 such cases have been reported. Aithala et al. reported the first case of intramedullary arachnoid cyst in a 7-year-old boy who presented with diffuse abdominal pain and progressive weakness of the lower extremities. [2] Literature review of reported cases shows that these lesions are commonly seen in the pediatric population in the first and second decades of life, more common in females as compared to males, and are located more commonly in the thoracic region than in the cervical region.

Regarding the etiology of these lesions, several theories exist, suggesting that the occurrence of these lesions is attributed to congenital defect, or to arachnoid adhesion due to inflammation because of various causes. [6],[7],[8] The hypothesis proposed by Hyndman and Gerber is that the cyst arises from misplaced cellular remnants as a result of the embryonic malformation. [9] Ball valve mechanism and fluid shifts as a result of pathological distribution of the arachnoid trabaculae have been postulated for increase in the size of extramedullary cyst. However, the cause for increase in the size of the intramedullary cyst needs to be established.

MRI plays a vital role in diagnosis and treatment planning of these lesions. The differential diagnoses of intramedullary cystic lesions include primary and secondary syrinx, tumor (astrocytoma, ependymoma, teratoma, ganglioglioma)-associated syrinx, epidermoid cyst and synovial cyst. With the widespread availability of MRI, more cases of asymptomatic intramedullary cyst are likely to be reported. However, a wait-and-watch policy appears to be justified for these cases.

Although percutaneous drainage of the cyst and shunting procedure have been reported in the management of spinal extramedullary arachnoid cysts, surgical excision is the treatment of choice for intramedullary cysts.

References

1Gimeno A. Arachnoid neurenteric and other cyst. In: Vinkeri PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Vol. 32. Congenital malformation of the spine and spinal cord. Amsterdam: North Holland; 1978. p. 393-448.
2Aithala GR, Sztriha L, Amirlak I, Devadas K, Ohlsson I. Spinal arachnoid cyst with weakness in the limbs and abdominal pain. Pediatr Neurol 1999;20:155-6.
3Sharma A, Sayal P, Badhe P, Pandey A, Diyora B, Ingale H. Spinal intramedullary arachnoid cyst. Indian J Pediatr 2004;71:65-7.
4Guzel A, Tatli M, Yilmaz F, Bavbek M. Unusual presentation of cervical spinal intramedullary arachnoid cyst in childhood: Case report and review of the literature. Pediatr Neurosurg 2007;43:50-3.
5Medved F, Seiz M, Baur M, Neumaier-Probst E, Tuettenberg J. Thoracic intramedullary arachnoid cyst in an infant. J Neurosurg Pediatrics 2009;3:132-6.
6Choi JY, Kim SH, Lee WS, Sung KH. Spinal extradural arachnoid cyst. Acta Neurochir (Wien) 2006;148:579-85.
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8Holly LT, Batzdorf U. Syringomyelia associated with intradural arachnoid cysts. J Neurosurg Spine 2006;5:111-6.
9Hyndman OR, Gerber WF. Spinal extradural cysts, congenital and acquired. Report of cases. J Neurosurgery 1946;3:474-86.