Intracranial arachnoid cysts are congenital compartments. They are frequently localized in the middle fossa and are intimately bordered by the arachnoid membrane. (1,2) Clinical symptoms appear commonly at an early age. Cases of symptomatic arachnoid cysts are rare in the elderly. (1,3,4) In this case report, we describe clinical and radiological signs of a 66 year old patient presenting with a giant suprasellar arachnoid cyst. Treatment options are discussed

Nicolas Segal

Olfawwlha Chakroun

Patrick Plaisance

Said Laribi

Selma Hamdi

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 43www.signavitae.comIntracranial symptomatic giant arachnoid cystSAID LARIBI (  ) •OLFA WALHA-CHAKROUN •NICOLAS SEGAL •SELMA HAMDI • PATRICK PLAISANCEDepartment of Emergency MedicineGroupe hospitalier Saint-Louis - LariboisicreFernand Widal, APHP2 rue Ambroise Paré75010 Paris, FrancePhone: + 33 1 49 95 82 42Fax: + 33 1 49 95 85 45E-mail: said.laribi@lrb.aphp.frSAID LARIBI • OLFAWWLHA CHAKROUN • NICOLAS SEGAL • SELMA HAMDI • PATRICK PLAISANCECASE REPORT   SIGNA VITAE 2012; 7(1): 43 - 45IntroductionIntracranial arachnoid cysts are congen-ital compartments. They are frequently localized in the middle fossa and are intimately bordered by the arachnoid membrane. (1,2) Clinical symptoms appear commonly at an early age. Cases of symptomatic arachnoid cysts are rare in the elderly. (1,3,4) In this case report, we describe clinical and radiological signs of a 66 year old patient presenting with a giant suprasel-lar arachnoid cyst. Treatment options are discussed.Case reportA 66-year old man presented to our emergency department suffering from vertigo. He had no medical history of infection or cerebral trauma and no previous disease.He described a 3 week history of   ver-tigo, diplopia and behavioural distur-bances, including somnolence and fatigue. He also complained of memory disturbances, which had been present for a year. The patient denied any his-tory of headache, emesis, or impair-ment of consciousness.Except for diplopia, neurological exami-nation in the emergency department was normal, without any focal neuro-logical deficits or clinical evidence of vertigo. The Glasgow Coma Scale was normal, as were the deep tendon reflex-es. Optic fundi were normal.Cranial Computed Tomography (CCT) revealed a right hemispheric low den-sity area with a midline and ventricle shift to the left (figures 1,2).The patient was admitted to the neu-rosurgery department, where it was deemed appropriate to perform a crani-otomy and a cyst wall excision. After the operation, 20 cc of cerebrospinal fluid (CSF) was aspirated every two days to avoid possible complications due to rapid decompression. Neurological Figure 1. Cranial computed tomography (CCT). A. First CT, before any cerebrospinal fluid (CSF) aspiration.B. Second CCT, after the first CSF aspiration through the craniotomy fene-stration. C. CCT, 6 months later and following 12 CSF aspirations.44 www.signavitae.comexam remained unchanged after each aspiration and no changes were found in the CCT images, analyzed after each aspiration.The patient was discharged 8 days after surgery. Memory disturbances disappeared, but he continued to feel lethargic.  The patient was followed-up for one year, with three hospitalisa-tions- at one, six and nine months- for recurrence of vertigo. Three to four CSF aspirations were performed dur-ing each hospitalisation, resulting in marked improvement of the patient’s neurological disturbances.DiscussionArachnoid cysts are compartments filled with fluid almost identical to CSF and bordered by the arachnoid mem-brane. (1,5) Their incidence is close to 1% of all intracranial masses. (6,7) To our knowledge, fewer than 60 cases of symptomatic arachnoid cysts have been reported. (8) Symptoms of arach-noid cysts include headache, motor and neuropsychological disorders, sometimes resulting in seizures. In our case, even though the patient’s cyst was huge, he had no evidence of sei-zure activity. Four mechanisms explain-ing the re-filling of the fluid-filled cyst have been reported: (2) a difference in the osmotic pressure of the cystic cavity and the subarachnoid space; (3) fluid secretion from the wall of the cyst; (2,9) the presence of clefts with a one-way valve mechanism that allows fluid to enter  the cyst and, (10) pul-sation of intracystic fluid of venous or arterial origin. (2) Development of the cyst is probably associated with one of these mechanisms. Arachnoidal cysts probably develop at a very slow rate, explaining the absence of symptoms for many years, as in our case.Treatment options are still controver-sial: some authors believe that the benefits of surgery are not proven and therefore that surgery is not justified when the cyst is asymptomatic or when the symptoms are not severe. In other reports, surgery was judged neces-sary when the cyst was crossed by bridging vessels, to avoid hemorrhagic complications, even in the absence of symptoms were. (2,3) If surgery is indicated, as in our case, the choice of  technique is also controversial. The aim of surgery is to reduce the pres-sure exerted by the arachnoid cyst on adjacent brain structures, and to reduce symptoms. (1) The reported techniques for cyst surgery are stere-otactic aspiration, craniotomy and cyst wall excision or fenestration, shunt-ing of the cyst to the peritoneal cavity, Figure 2. Cranial computed tomo-graphy 3D reconstruction, after the first cerebrospinal fluid aspiration. A front view. B lateral view.and endoscopic fenestration of the cyst to the ventricles or the subarach-noid space. (1,2,6) The technique cho-sen in our case was  craniotomy with fenestration. In view of the size of the cyst in our patient, this technique was chosen to avoid rapid decompression of brain tissue surrounding the cyst, seizures and worsening of symptoms already present. The aim of surgery in our case was to have a fenestra-tion allowing aspiration of CSF fluid each time the patient had recurrent symptoms without risking excessive drainage. The other procedures have their own advantages: direct surgery with excision of the cyst wall is a good technique with a low risk of recurrence, (11,12) a cysto-peritoneal shunt is a simple technique with low morbidity, (2) and the endoscopic shunt seems to be an interesting procedure with good outcomes. (1,2) However, each one of these procedures has potential disad-vantages such as rapid drainage with direct surgery, infection, obstruction or over drainage with a cysto- perito-neal shunt and vessel damages with the endoscopic shunt. (2,12) None of these procedures are  universally suc-cessful. In our case, CSF fluid aspira-tion was tolerated, with no side effects. The absence of long term follow-up has prevented us from defining the optimal surgical technique and indication.ConclusionSymptomatic arachnoid cysts remain rare in the elderly, which is probably due to their very slow development. Symp-toms usually consist of headaches, with or without seizures or neuropsychologi-cal disturbances. Their management is still controversial; if surgical treatment is decided many techniques are possible with no consensual indication, probably because of the absence of long term follow-up. 45www.signavitae.comREFERENCES1.  Kotil K, Balci N, Bilge T. Intracranial Symptomatic Giant Arachnoid Cyst of the Interhemispheric Fissure Presenting With Frontal Lobe Syn-drome. Tur Neurosur 2007;17:147-51.2.  Yamasaki F, Kodama Y, Hotta T, Taniguchi E, Eguchi K, Yoshioka H, et al. Interhemispheric arachnoid cyst in the elderly: case report and rexiew of the literature. Surg Neurol 2003;59:68-74.3.  Dyck P, Gruskin P. Supratentorial arachnoid cysts in adults. 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Intracranial symptomatic giant arachnoid cyst

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