Spinal intramedullary arachnoid cyst: case report and literature review

doi:10.1016/j.spinee.2013.10.051

The Spine Journal

Volume 14, Issue 6, 1 June 2014, Pages e9-e15

https://doi.org/10.1016/j.spinee.2013.10.051 Get rights and content

Abstract

Background context

Intramedullary arachnoid cysts are extremely rare; only 14 cases have been reported in the literature so far.

Purpose

We report on the case of a 31-year-old woman who presented with back pain and progressive paraparesis secondary to a dorsal intramedullary arachnoid cyst detected on magnetic resonance imaging (MRI): the surgical planning and clinico-radiological outcome are discussed along with a review of the relevant literature.

Study design

Case report and literature review.

Patient sample

One patient affected by intramedullary arachnoid cyst.

Outcome measures

Magnetic resonance imaging and pathological findings from operative specimens were used to confirm the diagnosis.

Methods

A 31-year-old woman presented with a 7-year history of back pain that had worsened 3 months before admission to our department; for this reason, the patient had undergone a spinal MRI revealing the presence of a 1-cm cystic intramedullary lesion at the level T11–T12, with no contrast enhancement. After 2 months, the patient presented with a worsening of clinical symptoms complaining of severe back pain radiating to the lower extremities associated with a progressive paraparesis, urinary incontinence, and abdominal pain. Referred to our department, at the time of admission the patient was bedridden because of the impossibility of maintaining a standing position. The patient underwent a T11–T12 laminectomy with fenestration of the cyst.

Results

She experienced an immediate relief of pain symptoms, and by the seventh postoperative day she was able to stand without help and walk a few meters with assistance. By the sixth postoperative month, the patient had significantly improved, having gained the ability to walk alone without assistance with complete resolution of the bladder dysfunctions, with no cyst recurrence after approximately 2 years of follow-up.

Conclusions

Intramedullary arachnoid cysts should be considered in the differential diagnosis for intramedullary cystic lesions. A particular consideration deserves their occurrence in asymptomatic patients, who should be adequately informed on the possible natural evolution: when symptomatic, surgical therapy should be promptly offered, considering that a postoperative complete recovery is usually observed, regardless of the surgical technique.

Introduction

Spinal arachnoid cysts are uncommon benign lesions and are often diagnosed as incidental asymptomatic findings; however, symptomatic cases also have been reported, requiring surgical intervention [1], [2], [3]. They may be found either in the extradural compartment or, less frequently, in the intradural space [1], [4]. The extradural cysts originate from an arachnoid herniation through dural tearings, whereas the less frequent intradural cysts seem to form mainly due to arachnoidal trabeculae alterations [3]. Intramedullary cysts are extremely rare and only 14 cases have been reported in the literature so far [2], [3], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]. Both their pathogenetic mechanisms and natural history remain unclear; as well, the choice of the most effective surgical approach in cases of symptomatic intramedullary cysts is still matter of debate.

Section snippets

Case report

A 31-year-old woman presented with a 7-years history of back pain that had worsened 3 months before admission to our department; for this reason, the patient had undergone a spinal MRI revealing the presence of a 1-cm cystic intramedullary lesion at the level T11–T12 characterized by hypointensity on T1-weighted images and hyperintensity on T2-weighted images, with no contrast enhancement. The patient had a previous history of occipital cerebral cavernoma for which she had undergone surgical

Discussion

Intramedullary arachnoid cysts represent an uncommon neurosurgical issue; since the first description by Aithala et al. in 1999 [5], only 14 cases have been reported in the literature (Table) [2], [3], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14].

Because of their rarity, many questions remain unresolved, in particular those concerning the etio-pathogenetic mechanisms, the natural history, and the appropriate surgical procedure.

The development of intradural arachnoid cysts have been

Conclusion

Intramedullary arachnoid cysts have been rarely described in the literature; however, with an increasing frequency during the past decade, probably because of the wide availability of MRI, this should be kept in mind when considering the differential diagnosis for intramedullary cystic lesions. A particular consideration deserves its occurrence in asymptomatic patients, who should be adequately informed on the possible natural evolution. When symptomatic, surgical therapy should be promptly

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Symptomatic intramedullary arachnoid cyst. Report of two cases and literature review
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Symptomatic spinal intradural arachnoid cysts in the pediatric age group: description of three new cases and review of the literature
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Spinal intramedullary arachnoid cyst in children
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Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature
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Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature
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Follow-up MRI showed no cyst regrowth, and there was no evidence of symptom recurrence at 4-month follow-up after the second surgery (see Figure 2E). Intramedullary arachnoid cysts are rare, with only 17 cases reported including adult cases2-15 (Table 1). Marsupialization has been performed in 10 cases and excision of the cyst wall in 7 cases.
Symptomatic intramedullary arachnoid cysts are rarely observed lesions, particularly in the pediatric age group. Treatment includes cyst fenestration or resection of the cyst wall, and recurrence after surgery has never been reported. We report a rare case of a spinal intramedullary arachnoid cyst, which recurred after cyst fenestration and required reoperation after a certain period.
A 4-year-old boy presented to our hospital with tetraparesis and bladder and rectum disorder. A cystic intramedullary lesion in the cervical spinal cord was detected in preoperative imaging. An emergency fenestration of cyst was performed, and his symptoms were resolved immediately. One month after the operation, the symptoms and cyst recurred. The symptoms improved in the natural course without reoperation. However, the cyst increased in size and the symptoms recurred after 27 months from the first relapse and the cyst was removed urgently. The diagnosis was an arachnoid cyst. After the reoperation, the cyst has disappeared and not recurred.
To the best of our knowledge, this is the first report of recurrence of an intramedullary arachnoid cyst. This case indicates the importance of considering the resection of cyst wall as possible because of the probability of cyst recurrence after fenestration, while careful observation is the option in the short term, especially for children or high-risk cases.
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We diagnosed case 5 as an intramedullary cyst with a communicating tract between the cyst and subarachnoid space. Only 15 cases of intramedullary arachnoid cysts have been reported previously,18 with no visualized communicating tracts or holes. We applied T-SLIP MRI to this unusual case, assuming that the cause was inflowing CSF from the subarachnoid space, and this was revealed by T-SLIP MRI and intraoperative ultrasonography.
Cystic lesions of the spinal cord such as spinal intradural arachnoid cysts (SIACs) and spinal extradural arachnoid cysts (SEACs) contain cerebrospinal fluid (CSF). The pathology of these lesions is often difficult to understand because it is difficult to detect abnormal CSF flow by conventional magnetic resonance imaging (MRI) or myelography. We preliminarily evaluated the usefulness of time-spatial labeling inversion pulse magnetic resonance imaging (T-SLIP MRI) of cystic lesions of the spinal cord.
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Exclusive information was obtained in all 6 cases. In SEACs and the intramedullary cyst, pathologic CSF flow into the cyst was directly visualized, enabling us to narrow the therapeutic intervention targets. In SIAC, exclusive information involved detection of the cystic cranial wall and the absence of the caudal wall, enabling us to omit the exploration of the caudal wall. The examination required as long as 80 minutes for SIAC and <30 minutes for the other cases.
T-SLIP MRI is useful for obtaining pathologic information about cystic lesions of the spinal cord.
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Arachnoid cysts are malformed lesions that contain a fluid similar to the cerebrospinal fluid, and are usually located within the arachnoidal membrane. They represent 1% of all intracranial lesions, and in recent years, with the development of radiological techniques, the clinical detectability of arachnoid cysts seems to have increased.
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Case ReportSpinal intramedullary arachnoid cyst: case report and literature review

Abstract

Background context

Purpose

Study design

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Case report

Discussion

Conclusion

Pediatr Neurol

Neurochirurgie

Symptomatic spinal intradural arachnoid cysts in the pediatric age group: description of three new cases and review of the literature

Pediatr Neurosurg

Spinal intramedullary arachnoid cyst in children

Pediatr Neurosurg

Thoracic intramedullary arachnoid cyst in an infant

J Neurosurg Pediatr

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature

Spine

Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature

J Neurosurg Pediatr

Case Report
Spinal intramedullary arachnoid cyst: case report and literature review