Cognitive dysfunction and subjective symptoms in patients with arachnoid cyst before and after surgery

Acta Neurochirurgica (2020) 162: 1041–1050

Arachnoid cysts are congenital, benign lesions in the brain and are often incidental radiological findings. Frequently, the arachnoid cysts are left untreated; however, recent studies have shown that arachnoid cysts can cause cognitive dysfunction that affect quality of life. Moreover, the function can improve after surgical decompression. Hence, there is controversy regarding symptomatology and treatment effects of arachnoid cysts. The aim of the study was to analyse if arachnoid cysts can cause cognitive impairment and subjective symptoms and if these impairments are reversible after surgical treatment.

Material and methods Twenty-one consecutive patients with radiologically confirmed supratentorial arachnoid cysts were cognitively evaluated using a battery of seven neuropsychological tests. Twelve of these patients underwent surgery and were evaluated before and after surgery. The patients were also evaluated with neuropsychological testing after surgery. Further information was extracted from the medical records. The cognitive test results were compared to standard population values using z-test, and the test results from the surgically treated patients were compared before and after surgery using paired t-test.

Results The surgically treated patients had a statistically significant improvement of neurocognitive test results after surgery in six out of the seven tests (p < 0.05). The total patient group showed lower mean values in all tests when compared to standard population. Statistical significance was, however, only detected in two of the seven tests. All surgically treated patients reported diminished symptoms after surgery.

Conclusions The patients with arachnoid cysts presented with cognitive dysfunction compared to the normal population which improved after surgical decompression. Arachnoid cysts should not be considered asymptomatic unless thoroughly evaluated with clinical and neuropsychological work-up.

The tethered effect of the arachnoid in vago-glossopharyngeal neuralgia: a real associated alternative mechanism?

Acta Neurochir (2018) 160:151–155

Vago-glossopharyngeal neuralgia (VGPN) is a rarely seen disease when compared to trigeminal neuralgia. When the pain is resistant to medical therapy, microvascular decompression can be performed if a vascular conflict is suspected on magnetic resonance imaging (MRI). In addition, arachnoid pathology may play a role in VGPN. We report two cases of VGPN caused by tethered arachnoid, associated with a vascular contact in which pain was reduced by freeing rootlets from arachnoid compression.

We report two cases relating to 50-year-old and 30-year-old men with a history of electric shooting pain triggered by swallowing in the right pharyngeal and auricular regions. Preoperative MRI documented a neurovascular conflict in the first case and an arachnoid cyst in the second. Surgery was performed via a retrosigmoid craniotomy. In both cases, the intraoperative findings documented a tethered arachnoid membrane compressive to cranial nerves IX and X. Untethering was performed by liberation of the rootlets from the arachnoid with microvascular decompression. No additional rhizotomy was performed. The postoperative course was uneventful and pain was relieved in the first case and decreased in the second.

In VGPN, a tethered arachnoid may play a role in causing the neuralgia, either alone or associated with a neuro-vascular conflict.

A New Classification for Pathologies of Spinal Meninges—Part 2: Primary and Secondary Intradural Arachnoid Cysts

Neurosurgery 81:217–229, 2017

Spinal intradural arachnoid cysts are rare causes of radiculopathy or myelopathy. Treatment options include resection, fenestration, or cyst drainage.

OBJECTIVE: To classify intradural spinal arachnoid cysts and present results of their treatment.

METHODS: Among 1519 patientswith spinal space occupying lesions, 130 patients demonstrated intradural arachnoid cysts. Neuroradiological and surgical features were reviewed and clinical data analyzed.

RESULTS: Twenty-one patients presented arachnoid cysts as a result of an inflammatory leptomeningeal reaction related to meningitis, subarachnoid hemorrhage, intrathecal injections, intradural surgery, or trauma, ie, secondary cysts. For the remaining 109 patients, no such history could be elucidated, ie, primary cysts. Forty-six percent of primary and 86% of secondary cysts were associated with syringomyelia. Patients presented after an average history of 53±88 months. Therewere 122 thoracic and 7 lumbar cysts plus 1 cervical cyst. Fifty-nine patients with primary and 15 patients with secondary cysts underwent laminotomies with complete or partial cyst resection and duraplasty. Mean follow-up was 57 ± 52 months. In the first postoperative year, profound improvements for primary cysts were noted, in contrast to marginal changes for secondary cysts. Progression-free survival for 10 years following surgery was determined as 83% for primary compared to 15% for secondary cysts. Despite differences in clinical presentation, progression-free survival was almost identical for patients with or without syringomyelia.

CONCLUSIONS: Complete or partial resection leads to favorable short- and long-term results for primary arachnoid cysts. For secondary cysts, surgery can only provide clinical stabilization for a limited time due to the often extensive arachnoiditis.


A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias

Neurosurgery 81:29–44, 2017

The clinical significance of pathologies of the spinal dura is often unclear and their management controversial.

OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results.

METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.

RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgerywas recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.

CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.


Surgical Decompression of Arachnoid Cysts Leads to Improved Quality of Life

Suprasellar Arachnoid Cysts- Toward a New Simple Classification Based on Prognosis and Treatment Modality

Neurosurgery 78:613–625, 2016

There is no previous prospective study on the outcome of surgical decompression of intracranial arachnoid cysts (AC).

OBJECTIVE: To investigate if surgical fenestration for AC leads to change in patients’ health-related quality of life.

METHODS: Prospective study including 76 adult patients operated for AC. Patients responded to Short Form-36 and Glasgow Benefit Inventory quality of life questionnaires, and to visual analogue scales, assessing headache and dizziness pre- and postoperatively. Patient scores were compared with those of a large sample of healthy individuals.

RESULTS: Preoperatively, 84.2% of the patients experienced headache and 70.1% dizziness. Mean pre- versus postoperative Visual Analogue Scale scores for headache and dizziness dropped from 45.6 to 25.7 and from 35.2 to 12.2, respectively. Preoperative Short Form-36 scores were significantly below age norms in all subscales, but improved after surgery into normal range in 7 out of 8 subscales for middle-aged and older patients. Younger patients’ scores remained lower than age norm in 6 out of 8 subscales. A significant postoperative improvement was seen in 3 out of 4 Glasgow Benefit Inventory subscales. Improvement in headache and/or dizziness, but not preoperative cyst size or reduction in cyst volume, correlated with improvement in 6 out of 8 Short Form-36 subscales and 3 out of 4 Glasgow Benefit Inventory subscales. Only 1 patient experienced a severe complication causing permanent invalidity.

CONCLUSION: Surgery for AC can be performed with a fairly low risk of complications and yields significant improvement in quality of life correlated to postoperative improvement in headache and dizziness. These findings may justify a more liberal approach to surgical treatment for AC.

Suprasellar Arachnoid Cysts: Toward a New Simple Classification Based on Prognosis and Treatment Modality

Suprasellar Arachnoid Cysts- Toward a New Simple Classification Based on Prognosis and Treatment Modality

Neurosurgery 78:370–380, 2016

Suprasellar arachnoid cysts (SAC) represent between 9% and 21% of pediatric arachnoid cysts. Recent improvements in magnetic resonance imaging, as well as increasing prenatal diagnosis, have allowed more precise knowledge and follow-up.

OBJECTIVE: To describe a novel classification of SAC.

METHODS: We present 35 cases of SAC treated between 1996 and 2014. Patient records and imaging studies were reviewed retrospectively to assess symptomatology, radiological findings, treatment, and long-term follow-up.

RESULTS: Fourteen SAC were diagnosed prenatally (39%). We observed 15 (43%) cases presenting hydrocephalus (SAC-1) removing Liliequist membrane downward. Lower forms (SAC-2) with free third ventricle were observed in 11 (31%) cases. Asymmetrical forms (SAC-3) with Sylvian or temporal extension were seen in the 9 (26%) remaining patients. Twenty-three (66%) patients were treated by ventriculocisternostomy, 3 (8.5%) by shunt surgery, and 3 (8.5%) by craniotomy. Six (17%) patients had no surgery, including 5 cases (14%) that had prenatal diagnosis. Outcomes were initially favorable in 26 cases (87%). Eight (22%) patients had endocrine abnormalities at the end of the follow-up, 3 (8.5%) had developmental delay, and 6 (17%) had minor neuropsychological disturbances.

CONCLUSION: SAC are heterogeneous entities. SAC-1 may come from an expansion of the diencephalic leaf of the Liliequist membrane. SAC-2 show a dilatation of the interpeduncular cistern and correspond to a defect of the mesencephalic leaf of the Liliequist membrane. SAC-3 correspond to the asymmetrical forms expanding to other subarachnoid spaces. Surgical treatment is not always necessary. The recognition of the different subtypes will allow choosing the best treatment option.

Management of subdural hygromas associated with arachnoid cysts

Subdural hygromas associated with cysts

J Neurosurg Pediatrics 12:434–443, 2013

Arachnoid cysts may occasionally be associated with subdural hygromas. The management of these concurrent findings is controversial.

Methods. The authors reviewed their experience with arachnoid cysts and identified 8 patients with intracranial arachnoid cysts and an associated subdural hygroma. The medical records and images for these patients were also examined.

Results. In total, 8 patients presented with concurrent subdural hygroma and arachnoid cyst. Of these 8 patients, 6 presented with headaches and 4 had nausea and vomiting. Six patients had a history of trauma. One patient was treated surgically at the time of initial presentation, and 7 patients were managed without surgery. All patients experienced complete resolution of their presenting signs and symptoms.

Conclusions. Subdural hygroma may lead to symptomatic presentation for otherwise asymptomatic arachnoid cysts. The natural course of cyst-associated subdural hygromas, even when symptomatic, is generally benign, and symptom resolution can be expected in most cases. The authors suggest that symptomatic hygroma is not an absolute indication for surgical treatment and that expectant management can result in good outcomes in many cases.

Risk Factors for Pediatric Arachnoid Cyst Rupture/Hemorrhage: A Case-Control Study


As the availability of imaging modalities has increased, the finding of arachnoid cysts has become common. Accurate patient counseling regarding physical activity or risk factors for cyst rupture or hemorrhage has been hampered by the lack of definitive association studies.

OBJECTIVE: This case-control study evaluated factors that are associated with arachnoid cyst rupture (intracystic hemorrhage, adjacent subdural hematoma, or adjacent subdural hygroma) in pediatric patients with previously asymptomatic arachnoid cysts.

METHODS: Patients with arachnoid cysts and intracystic hemorrhage, adjacent subdural hygroma, or adjacent subdural hematoma treated at a single institution from 2005 to 2010 were retrospectively identified. Two unruptured/nonhemorrhagic controls were matched to each case based on patient age, sex, anatomical cyst location, and side. Risk factors evaluated included arachnoid cyst size, recent history of head trauma, and altitude at residence.

RESULTS: The proportion of imaged arachnoid cysts that presented either originally or subsequently with a rupture or hemorrhage was 6.0%. Larger cyst size, as defined by maximal cyst diameter, was significantly associated with cyst rupture/hemorrhage (P < .001). When dichotomized with a 5-cm cutoff, 9/13 larger cysts ruptured and/or hemorrhaged, whereas only 5/29 smaller cysts ruptured/hemorrhaged (odds ratio = 16.5 (confidence interval [2.5, N]). A recent history of head trauma was also significantly associated with the outcome (P < .001; odds ratio = 25.1 (confidence interval [4.0, N]). Altitude was not associated with arachnoid cyst rupture or hemorrhage.

CONCLUSION: This case-control study suggests that larger arachnoid cyst size and recent head trauma are risk factors for symptomatic arachnoid cyst rupture/hemorrhage.

Transventricular Endoscopic Fenestration of Intrasellar Arachnoid Cyst


Neurosurgery 72:520–528, 2013

To manage arachnoid cysts, incorporation with the normal circulation is the single most important determinant of success. Although the postoperative cerebrospinal fluid leakage rate is 3.9% for all cases of transsphenoidal surgery, it is 21.4% for intrasellar arachnoid cysts.

OBJECTIVE: To present a safe, relatively easy, and effective treatment option for very rare intrasellar arachnoid cysts.

METHODS: We performed a prospective study of intrasellar cystic lesions without a solid portion. Endoscopic exploration and fenestration were performed for all lesions under neuronavigational guidance. We analyzed presenting symptoms, endocrinological status, and magnetic resonance images.

RESULTS: There were 2 male and 4 female patients with a mean age of 45 years (range, 27-67 years). All patients presented with the visual disturbance of bitemporal hemianopsia. Four patients had endocrinological symptoms including galactorrhea, dysmenorrhea, and diabetes insipidus. Endoscopic fenestration of the cyst was successfully performed in all patients. All patients were confirmed to have a pure cystic lesion, namely an arachnoid cyst. The follow-up period was 10 months on average (range, 6-12 months). Visual disturbance improved in 5 patients. Endocrinological problems persisted in all patients for 3 months and then normalized, with the exception of the patient with diabetes insipidus. There was no evidence of recurrence in any of the 6 patients in the 12-month postoperative imaging studies (median follow-up of 10 months). Two patients showed syndrome of inappropriate antidiuretic hormone at 2 and 4 weeks after the operation, but antidiuretic hormones recovered to normal levels after this time point.

CONCLUSION: Endoscopic fenestration of an intrasellar arachnoid cyst is a safe and simple procedure without serious complications.

Intracranial Cysts Containing Cerebrospinal Fluid- Like Fluid: Results of Endoscopic Neurosurgery in a Series of 64 Consecutive Cases

Neurosurgery 68:788–803, 2011 DOI: 10.1227/NEU.0b013e318207ac91

Intracranial cysts containing cerebrospinal fluid (CSF) may be developmental or acquired.

OBJECTIVE: To analyze the results of endoscopic neurosurgery in the management of intracranial CSF cysts.

METHODS: In a 7-year period, 64 consecutive patients underwent endoscopic neurosurgery for CSF cysts. Group 1 consisted of 13 patients with acquired cysts; group 2 included 51 patients with developmental cysts. In all cases, the cyst walls were fenestrated through small burr holes with frameless guided operative endoscopes. Follow-up ranged from 1 to 6 years (mean, 3.4 years).

RESULTS: There were no mortality and no permanent morbidity, apart from a patient (1.6%) who remained neurologically intact but required ventriculoperitoneal shunting because of intraoperative hemorrhage. The planned fenestrations could be performed in all patients except 2, owing to thick, opaque cyst walls. In group 1, 6 patients fully recovered and remained intact throughout the follow-up, whereas 7 improved but had various degrees of neurological disabilities that were related to their initial diseases. Radiological results were excellent in all cases. In group 2, there were 7 asymptomatic patients who remained unchanged and 44 ‘‘symptomatic’’ patients: 40 (91%) clinically improved, 4 (9%) remained unchanged, and none worsened. Cyst size decreased in 37 patients (74%) and remained unchanged in 13 (26%).

CONCLUSION: In this series, patients of different ages, harboring cysts of various sizes and locations, could be satisfactorily treated with endoscopic neurosurgery.

Shunting for the Treatment of Arachnoid Cysts in Children

Neurosurgery 67:1632–1636, 2010 DOI: 10.1227/NEU.0b013e3181f94476

The optimal treatment of symptomatic arachnoid cysts remains controversial.

OBJECTIVE: We present a single-institution experience on surgical treatment of arachnoid cysts.

METHODS: Between January 1983 and January 2008, 92 patients with symptomatic arachnoid cysts underwent surgery at our institute. All patients were evaluated with CT and/or MRI and were operated upon and had regular follow-up examinations.

RESULTS: There were 60 males and 32 females. The mean age was 3.6 years (range, 2 days to 14 years). Forty-eight cysts (52%) were within the sylvian fissure, 16 (17%) were in the cerebral convexity, 15 (16%) were infratentorial, 10 (11%) were in the interhemispheric fissure, and 3 (4%) were parasellar. Cystoperitoneal shunt was placed in 67 (73%) patients; ventricular drainage alone was performed in 14 (15%) patients; and combined drainage of the ventricular system and cyst, using a 3-way connector, was performed in 8 (9%) patients. Craniotomy and fenestration of the cyst was performed in 2 (2%) patients, whereas total excision of the cyst was performed in 1 patient. Shunt revision for various reasons was performed in 34 patients (39%), whereas 13 (14%) patients required more than one revision. Complete alleviation of symptoms was achieved in all patients after treatment, regardless of cyst reduction. After a mean follow-up of 8.5 years no further enlargement of the arachnoid cysts was noted.

CONCLUSION: Shunt placement is a safe and effective surgical treatment of symptomatic arachnoid cysts in children. Cyst reduction is greater in children younger than 2 years of age.

Endoscopic Treatment of Arachnoid Cysts: A Detailed Account of Surgical Techniques and Results

Neurosurgery 67:824-836, 2010 DOI: 10.1227/01.NEU.0000377852.75544.E4

Surgical treatment of arachnoid cysts remains under debate. Although many authors favor endoscopic techniques, others attribute a higher recurrence rate to the endoscope.

OBJECTIVE: The authors report their experience with endoscopic procedures for arachnoid cyst.

METHODS: All pure endoscopic procedures for arachnoid cysts performed by the authors were analyzed. Particular reference was given to surgical complications and patient outcome in relation to cyst location and endoscopic technique.

RESULTS: Sixty-six endoscopic procedures were performed in 61 patients (mean age, 28 years; range, 23 days to 74 years; 35 males, 26 females). The main presenting symptoms were cephalgia (61%), hemisymptoms (18%), and macrocephalus (18%). Cyst location was temporobasal (34%), suprasellar (21%), at the cisterna quadrigemina (18%), paraxial supratentorial (16%), and various (10%). Thirty cystocisternostomies, 14 ventriculocystostomies, 12 cystoventriculostomies, and 10 ventriculocystocisternostomies were performed. The overall clinical success rate was 90%. The endoscopic technique was abandoned in 4 cases (7%). Postoperative complications were found in 16%; there was only one permanent deficit (2%). Five recurrences (8%) occurred up to 7 years after the first procedure. Of the various locations, the temporobasal cysts were the most difficult to treat with lowest clinical success (81%), highest recurrence (19%), and highest complication rate (24%). Of the various endoscopic techniques, ventriculocystostomy and ventriculocystocisternostomy reached the highest success rates with 100%.

CONCLUSIONS: Endoscopic techniques provide very good results in arachnoid cyst treatment. The most frequent cyst location is the most difficult to treat. A long-term follow-up is recommended since recurrences can occur many years after the procedure