Theco-thecal bypass technique elucidating a novel procedure and perspective on treatment of post-arachnoiditis syringomyelia:A case report

BACKGROUND Post-arachnoiditis syringomyelia is a condition in which there is an intraspinal cerebrospinal fluid(CSF)blockade due to arachnoidal adhesions and bands.Although many of the techniques currently in use,namely,the theco-peritoneal,syringo-pleural,syringo-peritoneal,and syringo-subarachnoid shunts,are effective,the results are often variable.CASE SUMMARY A 36-year-old man with a past history of pulmonary tuberculosis,presented with progressive paraesthesia in the feet and progressive paraparesis along with constipation,difficulty in micturition,and decreased libido.He was bedridden a month before presentation.Magnetic resonance imaging revealed a dorsal multiloculated syrinx from D3-D10 vertebral levels.He underwent a D1-2 to D11 theco-thecal shunt bilaterally to abolish the CSF gradient across the level of the syrinx.There was no direct surgical handling of the spinal cord involved.At the 15-mo follow up,the patient had significant improvement in his symptoms and function.CONCLUSION We present a novel technique aimed at correcting the primary cause of a postarachnoiditis syrinx,the subarachnoid cerebrospinal flow obstruction or block,which we believe is simple and effective,involves minimal handling of the normal neural structures,and attempts to restore the physiology of CSF flow across the obstruction,with favorable clinical results.

Arachnoiditis Ossificans Mimicking Spinal Intradural Extramedullary Tumor: A Case Report and Review of the Literature

Arachnoiditis ossificans is an intradural extramedullary lesion resulting from an unusual chronic meningeal inflammatory process and it is thought to be the sequela of end-stage adhesive arachnoiditis secondary to surgery, trauma, arachnoid hemorrhage, meningeal irritation, myelography (particularly oil-based contrast agents), and spinal anesthesia. The spinal arachnoiditis ossificans may be silent or cause a variety of symptoms depending on its location and uncommonly happen to cause spinal cord compression. Very little attention has been paid to the management and outcome of this rare condition in the neurosurgical reem. We report the case of a 45 years old man admitted with L1 - L2 arachnoiditis ossificans revealed by polyradiculopathy on incomplete cauda equina syndrome mimicking spinal canal tumors. The patient underwent surgery and we performed the laminectomy of L1 - L2, total resection of the lesion, followed by a complete remission of the hemiparesis after three months of kinesitherapy nursing.

A Comparative Study between Landmark Based and Real Time Ultrasound Guided Sub Arachnoid Block

Background: Sub arachnoid block (SAB) performed by traditional landmark palpation technique can be inaccurate. This problem is exacerbated by altered patient anatomy due to obesity and age-related changes. A pre-procedural ultrasound scan of the lumbar spine has been shown to be of benefit in guiding lumbar epidural insertion in obstetric patients. Information on the use of real-time ultrasound (RUS) guided SAB, to date, been limited. This study compared RUS guided SAB to traditional landmark guided technique in patients undergoing spinal anesthesia for different surgical procedures. Methods: This was a prospective, single center, comparative observational study conducted in the department of anesthesiology at our center. 560 patients who underwent spinal anesthesia either by landmark based technique or real-time ultrasound-guided methods. The primary outcome was the first attempt success rate of dural puncture when employing the two methods. Results: Baseline characteristics were similar in the two study groups. The first attempt success rate of dural puncture in landmark guided group was 64.3% compared to 72.6% in the ultrasound guided group. This difference was not statistically significant. The procedure performance time was significantly shorter with landmark palpation compared to use of real-time ultrasound guided method. Conclusion: Use of RUS-guided technique does not significantly improve the first attempt success rate of SAB dural puncture during spinal anesthesia compared to the traditional landmark-guided technique.

Chronic Subdural Hematoma Associated with an Arachnoid Cyst in Elderly, an Intraoperative Finding after Re-Bleeding: Case Report

Intracranial arachnoid cysts (AC) are believed to be congenital and chronic subdural hematomas tend to occur in elderly patients with a history of mild head injury. The association between these two entities sporadically occur in relatively young patients but rare in elderly patients. We report a 65-year-old man who presented with headache and dizziness of 2 months’ duration with a history of head injury. Brain computed tomography (CT) a CSDH in right side and a hygroma in left side. After first operation with burr holes in both sides, the patient underwent an early recurrence of acute subdural hematoma in the right side. The evacuation of this hematoma by a craniotomy allowed seeing an AC that we resected partially with complete recovery of the patient. The association CSDH/AC is rare and possible in elderly patients and there is no consensus on treatment.

Intraparenchymal hemorrhage after surgical decompression of an epencephalon arachnoid cyst: A case report

BACKGROUND This study reports the clinical presentation of intraparenchymal hemorrhage as a rare complication after surgical decompression of an intracranial epencephalon arachnoid cyst(IEAC)at the posterior cranial fossa.CASE SUMMARY The clinical information of a patient with an IEAC was reported,and the related literature was reviewed.A female patient with nausea presented to our hospital.Computed tomography demonstrated an IEAC located at the posterior cranial fossa,which was large and required surgical intervention.After operation,postoperative intraparenchymal hemorrhage was detected.She had a good recovery with conservative treatment 1 mo later.CONCLUSION Though postoperative intraparenchymal hemorrhage is rare after surgical decompression of an IEAC,more attention should be paid to such a complication.

Y-shaped shunt for the treatment of Dandy-Walker malformation combined with giant arachnoid cysts:A case report

BACKGROUND Dandy-Walker malformation(DWM)was first reported in 1914.In this case report,a pediatric case was complicated with giant and isolated arachnoid cysts in the right cerebellar hemisphere along with the typical DWM.CASE SUMMARY The patient was at 20 mo old boy,with the complaint of staggering for more than 2 mo.He was admitted to the hospital due to high intracranial pressure and staggering.At admission,the patient had typical manifestations of high intracranial pressure,including vomiting,poor appetite and feeding difficulty.Physical examination revealed increased head circumference,closed anterior fontanelle,unstable standing,staggering,leaning right while walking and ataxia.After admission,he was diagnosed with DWM accompanied by giant isolated arachnoid cysts in the posterior fossa.He underwent Y-shaped three-way valve repair for treating differential pressure between the supratentorial hydrocephalus and the subtentorial arachnoid cysts at once.The child recovered well after the surgery.CONCLUSION In this case,supratentorial and subtentorial shunts were placed,which solved the problem of differential pressure between the supratentorial and subtentorial parts simultaneously.This provides useful information regarding treatment exploration in this rare disease.

多重枕骨的缺点由蛛网状的使成粒状引起了: 印射的 T2 上的强调

A 56-year-old man presented with a 6-mo history of headache. Although neurological and laboratory examinations were normal, computed tomography (CT) scan was performed which revealed multiple occipital osteolytic lesions, which were suspected to be multiple myeloma. Subsequently nuclear magnetic resonance imaging (MRI) showed that these lesions presented with a cerebrospinal fluid (CSF)-like signal intensity, no diffusional restriction and intrinsic mass-like enhancement on conventional sequences were seen. T2 relaxation time was similar to that of CSF in the ventricles and adjacent subarachnoid space on T2-mapping. Single photon emission CT with 99m Tc-Methyl diphosphonate was performed which revealed no increased radiotracing accumulation. Finally, these lesions were diagnosed as mutiple arachnoid granulations (AGs). The headache was treated symptomatically with medical therapy. On follow up examination after 6 mo no evidence of tumor was detected. This report aimed to illustrate the appearance and differentiation of occipital defects caused by multiple AGs on CT and MRI, with emphasis on the findings from T2 mapping.

Transforaminal endoscopic excision of bi-segmental noncommunicating spinal extradural arachnoid cysts:A case report and literature review

BACKGROUND Spinal extradural arachnoid cysts(SEACs)are a rare cause of spinal cord compression.Typically,these cysts communicate with the intradural subarachnoid space through a small defect in the dural sac.For symptomatic SEACs,the standard treatment is to remove the cyst in total with a(hemi)laminectomy or laminoplasty.We present a rare case of bi-segmental non-communicating SEACs and describe our experience of using an endoscopic minimal access technique to remove bi-segmental non-communicating SEACs.CASE SUMMARY A 79-year-old female presented with pain related to bi-segmental SEACs at the T11-L1 segments.She underwent sequential transforaminal percutaneous endoscopic thoracic cystectomy of the SEACs.Following her first procedure,spinal magnetic resonance imaging demonstrated complete excision of the cyst at the T12-L1 segment.However,the cyst at the T11-T12 segment was still present.Thus,a second procedure was performed to remove this lesion.The patient’s right-sided lumbar and abdominal pain improved significantly postoperatively.Her Japanese Orthopaedic Association score increased from 11 to 25,her visual analogue scale score was reduced from 8 to 1.The physical and mental component summary of the 36-item short-form health survey(SF-36)were 15.5 and 34.375 preoperatively,and had increased to 79.75 and 77.275 at the last follow-up visit,respectively.CONCLUSION Bi-segmental non-communicating SEACs are extremely rare.Endoscopic surgery is a safe,effective,and reliable method for treating these cysts.In the event of bisegmental SEACs,it is important to identify whether both cysts are communicating before surgery,and if not,to remove both cysts separately during the index surgery to avoid re-operation.

Analysis of cases of self-displaced and healed shunt of arachnoid cyst and review of literature

Objective:To investigate the causes,pathogenesis and prognosis of shunt displacement in arachnoid cyst.Methods:Retrospective analysis was made on the case of the left frontal top arachnoid cyst peritoneal shunt self-extraneous and cured in our hospital in November 2019.Combined with literature review,the treatment and prognosis of shunt displacement after arachnoid cyst peritoneal shunt were discussed.Results:Arachnoid cyst disappeared children heal,clinical symptoms improved,wipe out the shift shunt,literature review arachnoid cyst peritoneal shunt tube shift and recover rare,mainly for the shunt tube distal displacement,falling in the scrotum,emergence anus,and shift to the chest,or even a heart,required reoperation processing,timely deal with good prognosis.Conclusion:Arachnoid cyst peritoneal shunt may be an effective method for the treatment of cerebral convex arachnoid cyst in children,and it also suggests that the shunt tube can be removed after the disappearance of cerebral convex arachnoid cyst.Shunt tube displacement is rare in clinic and needs timely surgical treatment.

Symptomatic Extra-Dural Arachnoid Cyst

Objective: The aim of this study is to report a case of arachnoid cyst due to mass effect on the thoracic marrow. Observation: A 15-year-old patient was admitted to our institution and complaining of high back pain. Three months before he developed progressive and occasional back pain with thoracic irradiation in hemi-belt, increased by the dorsal decubitus. Neurological examination revealed a spasmodic paraplegia. The muscular strength was quoted as 2 to the left and 3 to the right on a scale of 5. Magnetic resonance imaging (MRI) revealed and extradural cyst located to the dorsal spinal cord. The ablation of a voluminous translucent cyst was achieved after a vast decompressive laminectomy from the sixth to the eighth thoracic vertebra. The dural communication with the cyst was stitched. After surgery, the pain has disappeared and the neurological recovery was progressive over a period of 21 days. The diagnosis of arachnoid cyst was confirmed by histological examination. Conclusion: The extradural thoracic arachnoid cyst is a rare affection of good forecast. In the symptomatic form, the surgery as soon as possible remains the solution. The MRI keeps all its interest for the diagnostic orientation and the therapeutic strategy.

Intracranial Pressure and the Role of the Vagus Nerve: A Hypothesis

There is reason to believe that the vagus nerve carries sensory afferent messages from the intracranial cavity as it does from the other body cavities. Considering the arachnoid granulations as a secretory apparatus instead of an organ transporting cerebrospinal fluid, a simple model can be built. Assuming that the arachnoid granulations produce nitric oxide in accordance with changes in the intracranial pressure, the jugular foramen with the vagus nerve lying just subendothelially is where this message would be received. Other chemical substances from the granulations or other intracranial tissues could of course also act as messengers. This would mean that the brain stem could adjust to changes in intracranial pressure with small changes in cerebral venous resistance. The general idea is that intracranial pressure is a passive function of the intracranial pressure-volume relationship. But the hypothesis suggests that the vagus nerve constantly mediates changes in intracranial pressure to the brain stem that can rapidly adjust cerebral venous resistance. This control is totally intracranial and easily overridden by considerable changes in absorption of spinal fluid or intracranial calamities. This article looks for clues in support of the idea that the vagus nerve mediates intracranial pressure changes to the brain stem.

Giant Intracranial Arachnoid Cyst Causing Acute Neurologic Symptoms

Intracranial arachnoid cysts (IAC) are benign lesions containing cerebrospinal fluid (CSF). Most of them are clinically silent and remain static in size. However some may present with mild and slow progressive symptoms caused by the cyst. The authors present the case of 54-year-old woman who presented with acute symptoms of severe headache, vomiting, and gait disturbance of 2 day’s duration. She had no history of head trauma. On admission, neurological examination revealed that the patient had a Glasgow Coma Scale score of 15, and a left side hemiplegia. A CT scan revealed a hypodense fluid collection in the right frontoparietal region that mimicked an arachnoid cyst. The symptoms were improved after an emergency marsupialisation via craniotomy.

Hematoma within the Outer Membrane of the Arachnoid Cyst Located in the Middle Fossa: A Mechanism of Development of Chronic Subdural Hematoma Associated with Arachnoid Cysts

It is well known that chronic subdural hematoma (CSDH) occasionally arises in patients harboring an arachnoid cyst (AC) located in the middle fossa. Although the pathogenesis of CSDH associated with ACs remains unknown, several possible mechanisms have been proposed. In many reported cases, the patients with ACs in the middle fossa would be symptomatic according to development of CSDH. A 9-year-old girl presenting with a headache, nausea, and diplopia was referred to our department. Magnetic resonance imaging showed an AC in the left-side middle fossa and ipsilateral CSDH with a remarkable mass effect. Irrigation of the CSDH, partial removal of the outer membrane of the AC and CSDH, and endoscopic cystocisternostomy were performed to relieve her symptoms. Postoperative clinical course was excellent. Histopathological examination of the outer membrane of the CSDH demonstrated an arachnoid cell layer and hemorrhage from the granulation inside the membrane, and collagen fibers outside the membrane. These findings strongly suggested that the membrane and the content of the CSDH were derived from the outer membrane of the AC, and the CSF including the hemorrhage within the membrane, respectively. Laceration and hemorrhage from granulation tissue within the outer membrane of the AC are considered as one of the developmental mechanisms of the CSDH associated with AC in the middle fossa.

Normal Pressure Hydrocephalus: A Simple Hypothesis

Normal pressure hydrocephalus is a devious phenomenon. It is a disease that is difficult to diagnose and difficult to treat, the only treatment being a ventriculo-peritoneal shunt, though good shunting results rarely pass a 70% level of effectiveness. We need to understand its pathophysiology better before things will improve. Although some colleagues know it as a possible “reversible dementia” others hardly know about its existence. Solutions would also have value for the general understanding of hydrocephalus of other types. Many theories have been published recently in the search for the missing pieces in this puzzle and I feel that my own postulations could turn out to be useful. After years of diagnosing and operating on hydrocephalus patients I propose that: 1) There is reason to believe that patients with the Apoprotein E3/3 genotype and a high head size percentile are particularly vulnerable to developing idiopathic normal pressure hydrocephalus (iNPH). 2) The classical theory that the arachnoid granulations (AG) transport cerebrospinal fluid (CSF) into the venous circulation is wrong. I postulate, that the AG essentially are sensors, registering the pressure differences between the CSF in the subarachnoidal space at the top of the skull and the venous pressure in the sagittal sinus. The AG’s endothelium produces nitric oxide (NO) as a messenger that is received by the vagus nerve at the jugular foramen. 3) The disease has its fundamental pathology in the subpial space in the large cisternas and along the large vessels under the brain. Here the intravenous absorption of cerebrospinal fluid (CSF) takes place. Cerebrospinal fluid is transported into the subpial venules and veins, driven by the pulse pressure of the subpial arteries. Morphological changes in the pial/subpial anatomy explain the existence of acquired normal pressure hydrocephalus (aNPH).

Adult Posterior Cranial Fossa Arachnoid Cyst: A Case Report

Adult posterior fossa arachnoid cysts are rare lesions that are considered to be mostly congenital in origin. We present 49-year-old man admitted with a chief complaint of tremor and balance problems for the past 2 months. He had ataxia on examination. Magnetic resonance imaging revealed a well circumscribed midline cystic lesion of the posterior fossa sharing the same signal characteristics as cerebrospinal fluid and non-communicating to the fourth ventricle. He underwent surgical treatment for his symptomatic posterior fossa arachnoid cyst with a good outcome at 2 years follow up.

Two months old with arachnoid cyst and unusual clinical presentation

Arachnoid cysts are relatively uncommon in infancy and are incidental findings in intracranial imaging in pediatric patients. Presentation at a younger age is usually associated with cyst enlargement. Arachnoid cysts are considered to be congenital in origin but the natural history and prevalence is not well defined. Here we report a case of a 2 months old male infant with non-specific illness who was diagnosed with arachnoid cyst.

Intra-Sellary Arachniodocele: About a Case at the Medical Clinic “The Stars” of Bamako

Intrasellar arachnoidocele is a herniation of the optochiasmatic cistern through a dehiscence of the sellar diaphragm producing an empty sella turcica, hence its name empty sella turcica syndrome. It is an extremely rare benign malformative pathology. We report a case of intra-sellar arachnoidocele in a 34-year-old woman revealed during an annual control of a sellar mass under dossinex by cerebral magnetic resonance imaging (MRI) which found the cystic formation of liquid signal identical to that of the LCS in hypo signal T1 and hyper signal T2 without enhancement after injection of Gadolinium. The epidemiological, clinical and radiological aspects of arachnoidocele were analyzed. The purpose of this work is to bring the interest of MRI in the management of this pathology.

Left Temporal Lobe Arachnoid Cyst Presenting with Symptoms of Psychosis

Arachnoid cysts are uncommon benign neurological tumors,and having presentation like schizophrenia,which has been reported in association with this cyst.The presence of psychiatric disturbances of arachnoid cyst has not been clearly mentioned in the literature.Even though,the appearance of some of the references that focuses on a possible link between arachnoid cysts and psychotic symptoms.Here we present a case report of a 35-year-old man,characterized by the insidious onset of psychotic symptoms of varying intensity such as multiple physical assaults on people with stone.Due to organic suspicion one cannot exclude the possibility that the lesion played a significant role in this psychiatric presentation.

Treatment strategy of intracranial arachnoid cysts

Objective To investigate treatment strategy of intracranial arachnoid cysts. Methods 47 cases of Intracranial arachnoid cysts from Sep 1,2010 to Des 1,2010 were analyzed. 25 cases received no intervention but follow . 22 cases received operation,13 of 22 cases neuroendoscopic partial cystectomy and communication between cystic cavity and brain cistern; 7 of 22 cases cysts peritoneal shunt, 2 of 22

Virus etiology research of trigeminal neuralgia combining arachnoids' adhesion

Objective To assess the relationship that trigeminal neuralgia combining arachnoids’adhesions and herpes simplex virus type 1. Methods There are fifty-nine patients with trigeminal neuralgia their trigeminal nerve root area combined with arachnoids’adhesion,