Delayed Recurrent Arachnoid Cyst of the Occipital Convexity in an Elderly Woman —Case Report—

Neurol Med Chir (Tokyo) 49, 134¿137, 2009

Masanori SUZUKI, Tomonori TAMAKI, Shigeki TODA*, Masato TSUCHIYA, Kazunari KOGURE, Masaru HOSONE**, Yoji NODE,andAkiraTERAMOTO*

Departments of Neurosurgery and **Pathology, Nippon Medical School Tama Nagayama Hospital, Tama, Tokyo; *Department of Neurosurgery, Nippon Medical School, Tokyo

Abstract

A 62-year-old woman presented with a symptomatic arachnoid cyst of the right occipital convexity manifesting as visual disturbances and headache. She underwent craniotomy with membranectomy and fenestration to the subarachnoid space. Postoperatively, her complaints disappeared and brain magnetic resonance (MR) imaging showed cyst shrinkage. During the first 1 year after surgery, she made a good recovery without clinical symptoms or cyst enlargement. However, she complained of visual disturbances after 6 years. Brain MR imaging revealed cyst enlargement and Goldmann perimetry detected left lower quadrantanopia. The diagnosis was recurrent arachnoid cyst. A second surgical procedure was performed including membranectomy for histological examination of the cyst membrane, and an Ommaya reservoir was inserted into the cyst cavity to prevent further cyst enlargement. The histological findings were compatible with arachnoid cyst, similar to the results seen at the first surgery. She was discharged 3 weeks after the second operation with no complications, and follow up continues as an outpatient. Patients with symptomatic arachnoid cysts typically have good progress after surgery, but the present case shows that follow up should continue for at least 6 years after surgery, even if cyst volume reduction was initially favorable.

Key words: arachnoid cyst, recurrence, occipital convexity, long-term follow up, elderly

Introduction course. Surgical revision after the initial procedure is uncommon, and is usually required after late Arachnoid cysts account for approximately 1% of all shunt failure, overdrainage after shunting, or in intracranial space-occupying lesions.9) Arachnoid patients with intracranial bleeding or abscess after cyst typically occurs in the middle cranial fossa, fenestration. Delayed recurrence of an arachnoid cerebellopontine angle, supracollicular area, sellar cyst requiring surgery is uncommon. and suprasellar areas, and the vermis.14) Sympto- Here we describe a case of delayed recurrent matic convexity cysts account for up to 4% of all arachnoid cyst of the occipital convexity in an elder- cases,7) and are detected more often in adults than ly patient. in children, possibly because of the obvious clinical symptoms, and the cysts may be treated by sur- Case Report gery. However, fewer than 60 cases of symptomatic arachnoid cyst have been reported in the elderly A 62-year-old woman presented in 2000 with (aged À65 years).2,3,6,13,16) Patients with symptomatic headache and visual field defect. Brain magnetic arachnoid cysts generally have a good postoperative resonance (MR) imaging at another institution estab-

Received January 30, 2008; Accepted October 15, 2008 Author's present address: M. Suzuki, M.D., Division of Endovascular Neurosurgery, Stroke Center, Saitama Medical Uni- versity International Medical Center, Hidaka, Saitama, Japan.

134 Recurrent Arachnoid Cyst in the Occipital Convexity 135

Fig. 1 Preoperative T1-weighted (left)andT2- weighted (right) magnetic resonance images showing an arachnoid cyst in the right occipital convexity. Fig. 2 Postoperative computed tomography scan showing significant shrinkage of the arachnoid cyst and decreased compression lished a diagnosis of intracranial cyst, and she was of the brain cortex. admitted to our hospital for surgery. She had no past history of infection or trauma, except for a diagnosis of cervical spondylosis in 2000. MR imaging showed a 48 × 74 × 45 mm cystic lesion in the right occipital convexity (Fig. 1). Computed tomography (CT) cisternography performed at the previous hospital had revealed no direct communication between the cystic lesion and subarachnoid space. Visual field examination showed left lower quadrantanopia. The preoperative diagnosis was symptomatic arachnoid cyst. Parieto- occipital craniotomy was performed, with removal of the outer cyst membrane and fenestration into the subarachnoid space. Postoperatively, her headache Fig. 3 Axial (left) and sagittal (right)T-weighted and visual field defect were improved. CT and MR 2 magnetic resonance images showing a imaging showed significant shrinkage of the recurrent arachnoid cyst. arachnoid cyst and decreased compression of the cerebral cortex (Fig. 2). Postoperative visual field examination (Goldmann perimetry) showed im- dure was performed including membranectomy to provement of the left lower quadrantanopia. During obtain tissue to determine the histology of the cyst the 1-year postoperative follow-up period, the membrane, with insertion of an Ommaya reservoir patient reported no clinical symptoms and MR im- into the cyst cavity. The cyst membrane was physi- aging revealed no evidence of cyst recurrence. No cally similar to that seen at the first surgery, except further MR imaging or CT evaluations were per- for adhesion between the dura and arachnoid mem- formed, as the patient was unwilling to continue out- brane. No long bridging vein passed across the cyst. patient follow-up examinations. After the second surgery, the patient's subjective Six years after surgery, she returned to our symptoms improved. Postoperative MR imaging hospital, complaining of headache and visual distur- showed reduction of the size of the arachnoid cyst in bance persisting for 1 month. MR imaging and the occipital convexity (Fig. 4). The histological di- visual field examinations showed an arachnoid cyst agnosis was arachnoid cyst with no malignancy in the right occipital convexity (48 × 80 × 61 mm) (Fig. 5). and left lower quadrantanopia (Fig. 3). The cystic She was discharged 3 weeks after the second sur- lesion appeared as hypointense on the T1-weighted gical procedure with no complications and has been image, hyperintense on the T2-weighted image, and attending our hospital as an outpatient for 1 year. almost completely homogeneous. Our diagnosis was Long-term observation will continue. recurrent arachnoid cyst. A second surgical proce-

Neurol Med Chir (Tokyo) 49,March,2009 136 M. Suzuki et al.

ed in elderly patients.10) We suggest that arachnoid cysts in the elderly may tend to enlarge more progressively and more slowly than in children. We consider that careful postoperative observation of arachnoid cysts in the elderly over the long term is necessary, even if cyst volume reduction results are favorable. The elderly tend to have decreased ability to absorb cerebrospinal fluid (CSF) or reduce CSF stroke volume, even if CSF dynamic disturbance is absent, for example, as in normal pressure hydrocephalus.5,11) Recurrent symptomatic arachnoid cyst (excluding shunt failure) may occur more frequently in the elderly than in children, but no cases of symptomatic arachnoid cysts

Fig. 4 Postoperative T2-weighted magnetic reso- in the elderly have been treated surgically and fol- nance image at 2 weeks after the second lowedupforlongperiods.Symptomaticarachnoid surgical procedure showing reduction of cyst of the convexity cannot communicate with the the size of the arachnoid cyst. basal cistern if treated by outer membranectomy and fenestration to the subarachnoid space, so dynamic changes in CSF circulation are unlikely to occur. This may cause delayed recurrence with obvious symptoms, as in our present case, and may be one pitfall of the surgical procedures used to treat arachnoid cysts of the convexity in the elderly. In our case, the cyst was located close to the posterior horn of the lateral ventricle, which was ap- parently related to the cyst growth. The previously described one-way valve mechanism1,3) involved with arachnoid cysts may have been located between the right lateral ventricle and cyst wall, allow- ing the cyst volume to enlarge progressively. Our Fig. 5 Photomicrograph of the cyst membrane after the second procedure, indicating non- surgical procedure to treat the cyst recurrence and malignant arachnoid cyst. Hematoxylin possible enlargement used an Ommaya reservoir for and eosin stain, original magnification percutaneous fluid aspiration (as reported previous- ×100. ly8)). This is a simple, non-invasive procedure in the elderly. Our hypothesis is that cyst enlargement in the elderly is an extremely slow process, so per- Discussion cutaneous fluid aspiration under careful follow up with MR imaging or CT may be useful in preventing Most cases of arachnoid cyst in adults were only ob- the fluid build-up that may lead to neurological served during a short follow-up period, so no guide- defects. We recommend that this method be used for lines have been proposed for the follow-up period af- slow-growing recurrent arachnoid cysts in the elder- ter arachnoid cyst surgery in the elderly. Recently, ly. two cases of arachnoid cysts located in the occipital convexity were observed with short follow-up References periods.12,15) A series of 33 children with symptomatic supratentorial arachnoid cyst found no recur- 1) AuerLM,GallhoferB,LadurnerG,SagerWD,Hep- rence of symptoms or progressive enlargement of pner F, Lechner H: Diagnosis and treatment of mid- the arachnoid cyst during long-term follow up of dle cranial fossa arachnoid cysts and subdural hema- 70.0 ± 9.3 months.4) Three of four cases of sympto- tomas. J Neurosurg 54: 366–369, 1981 matic interhemispheric arachnoid cyst in the elderly 2) Caruso R, Salvati M, Cervoni L: Primary intracranial arachnoid cyst in the elderly. Neurosurg Rev 17: (aged À60 years) progressively enlarged during 195–198, 1994 long-term follow up of 8–12 years and caused 3) Dyck P, Gruskin P: Supratentorial arachnoid cyst in 17) headache or hemiparesis. No cases of spontaneous adults. Arch Neurol 34: 276–279, 1977 disappearance of arachnoid cysts have been report-

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