Intracranial arachnoid cysts: Pediatric neurosurgery update

Abstract

Background: With the greater worldwide availability of neuroimaging, more intracranial arachnoid cysts (IACs) are being found in all age groups. A subset of these lesions become symptomatic and requires neurosurgical management. The clinical presentations of IACs vary from asymptomatic to extremely symptomatic. Here, we reviewed the clinical presentation and treatment considerations for pediatric IACs.

Case description: Here, we presented three cases of IAC, focusing on different clinical and treatment considerations.

Conclusion: IACs can be challenging to manage. There is no Class I Evidence to guide how these should be treated. We suggest clinical decision-making framework as to how to treat IACs based on our understanding of the natural history, risks/benefits of treatments, and outcomes in the future, require better patient selection for the surgical management of IACs will be warranted.

Keywords: Arachnoid cyst; neurosurgery; pediatric.

Figure 1

Large arachnoid cyst occupying majority left anterior and middle cranial fossae (Case 1). (a–c) Axial, coronal, and sagittal, respectively; coronal T2-weighted magnetic resonance imaging (MRI) of the brain demonstrating an arachnoid cyst eliciting extensive mass effect and 1 cm rightward midline shift. (d–f) Corresponding T2-weighted MRI 8 months postplacement of cystoperitoneal shunt demonstrating interval reduction of cyst size and corresponding midline shift

Figure 2

Large left middle cranial fossa arachnoid cyst (Case 2). (a and b) Axial and sagittal T1-weighted magnetic resonance imaging (MRI) of the brain demonstrating an arachnoid cyst eliciting extensive mass effect with sphenoid wing remodeling and distal left MCA branch displacement. (c and d) Axial and sagittal T1-weighted MRI of the brain 2 years after arachnoid cyst fenestration into the basal cisterns, displaying interval reduction in cyst size and decreased mass effect

Figure 3

Previously asymptomatic right middle and anterior cranial fossae archnoid cyst with subdural fluid collection (Case 3). (a and b) Coronal and sagittal T1-weighted magnetic resonance imaging (MRI) performed secondary to trauma demonstrated a previously asymptomatic archnoid cyst of the right anterior an middle cranial fossae. (c) Axial T2 MRI revealed small bilateral hemisphere CSF-isointense subdural fluid collections suggestive of cyst rupture. (d–f) Coronal, sagittal, and axial T2-weighted MRI performed on presentation to the emergency department 3 weeks after initial trial of conservative treatment. Interval development of extensive right hemisphere hygroma was seen producing midline shift with compression of the lateral ventricle

Figure 4

Right middle and anterior fossae arachnoid cyst with surgical resolution of traumatic hygroma (Case 3). Despite attempted management of hygroma development with cystoperitoneal shunt, symptoms persisted necessitating surgical fenestration of cyst walls, and regular follow-up was maintained. (a) Coronal T2-weighted magnetic resonance imaging (MRI) of the brain performed at 3 years postoperative follow-up demonstrated reabsorption of right hemisphere hygroma. (b) Sagittal T1-weighted MRI revealed interval reduction in arachnoid cyst-induced mass effect with reexpansion of cerebral sulci. (c) Axial T2-weighted MRI illustrated resolution of midline shift and relief of compression of the lateral ventricle

Figure 5

The incidence of arachnoid cysts in 309 children drawn from a sample of 11,738 consecutive MR imaging studies (Modified from Al-Holou WN, Yew AY, Boomsaad ZE, Garton HJ, et al. Prevalence and natural history of arachnoid cysts in children. J Neurosurg Pediatr 2010;5: 578-85)