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CASE REPORT

Full Recovery of Severe Vertigo in Patient with Bilateral Cerebellopontine


Angle Arachnoid Cyst Following Microsurgical Treatment

Aji Setia Utama1, Asra Al Fauzi2


1
Resident of Department of Neurosurgery, Dr. Soetomo Hospital; Airlangga University Surabaya, Indonesia
2
Staff of Department of Neurosurgery, Dr. Soetomo Hospital; Airlangga University Surabaya, Indonesia

Abstract

Arachnoid cysts are benign, rare. These benign cysts, which contain cerebrospinal fluid, develop in the intra-
arachnoid space. Even the pathogenesis of those cysts is unknown; they are thought to be congenital. Symptoms are
produced by the mass effect of the cyst on surrounding structures. The presenting symptoms are frequently
nonspecific. The management of arachnoid cysts of the cerebellopontine angle is controversial. Asymptomatic
arachnoid cysts do not require treatment, and such patients should be monitored clinically and
radiologically. But serious symptoms need to be performed an operation. We report a 19-year-old man with
an bilateral arachnoid cyst of cerebellopontine angle that led to severe vertigo. One months after Microsurgical
surgery, the patient is symptom free
Key words: Arachnoid Cysts; Bilateral Cerebellopontine Angle; Severe Vertigo; Microsurgical Treatment

Introduction The most common site of occurrence is the


sylvian fissure followed by the cerebellopontine
Arachnoid cysts are benign, rare, intra arachnoid angle (CPA) and supracollicular area. However,
lesion filled with fluid similar to or exactly like arachnoid cysts of the CPA are often diagnosed
cerebrospinal fluid. They are thought to be incidentally as they usually remain
congenital or develop secondary to infection, asymptomatic.4
trauma, splitting abnormalities of the arachnoid
membrane, alteration of the cerebrospinal fluid In this article, we describe a 19-year-old man with
(CSF) flow, and/or change in the CSF pressure.1 a bilateral arachnoid cyst of the cerebellopontine
Arachnoid cysts can occur all along the angle that led to progressive vertigo, and we
craniospinal axis, but a large majority are located discuss the treatment in this case.
intracranially.2

Lesions of the cerebellopontine angle account for Case Report


6% to 10% of all intracranial lesions. Acoustic A 19-year-old man with a progressive vertigo
neurinomas and meningiomas represent approximately 1 years-duration was admitted to
approximately 85% to 90% of all tumors of the
our hospital. There was no significant
cerebellopontine angle, and the remaining lesions
neurological deficit. He come with full
of this location are primary cholesteatomas and
facial nerve schwannomas. Arachnoid cysts of awareness. He feel at the time of vertigo relapse,
the cerebellopontine angle are rare.3 Bilateral others like moving around. There was no
CPA arachnoid case are very rare and after disturbance of balance, no hearing loss, no history
reviewing the available English literature we of drug consumption, no previous illness history.
could find only one case report.1

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The results of the neurological examination were weighted (A) and coronal T2-weighted (B) and sagittal T2-weighted
(C) images show a hyperintense on T2 weighting, resembling an
completely normal. Preoperative magnetic
arachnoid cyst in bilateral CPA.
resonance imaging showed a hyperintense on T2-
weighted imaging, in the bilateral CPA,
resembling an arachnoid cyst. Using a standard rectosigmoid approach, with
microneurosurgical technique, the cyst was
opened and typical cerebrospinal fluid flowed
A under moderate pressure. The wall of the cyst was
excised. The postoperative was uneventful and
vertigo disappeared immediately. Histologically,
the cyst wall was a typical arachnoidal
membrane. One months after Microsurgical
surgery, the patient is symptom free.

Discussion
Arachnoid cysts are benign, rare, intra arachnoid
lesion filled with fluid similar to or exactly like
cerebrospinal fluid.1 Arachnoid cysts can occur
all along the craniospinal axis, but a large
B majority are located intracranially.2 Lesions of the
cerebellopontine angle account for 6% to 10% of all
intracranial lesions. Arachnoid cysts of the
cerebellopontine angle are rare.3

Arachnoid cysts are benign developmental cysts


that occur throughout the cerebrospinal axis in
relation to the arachnoid membrane and
subarachnoid space. The cysts generally contain
clear, colourless fluid resembling normal spinal
fluid. They expand progressively, causing
pressure on contiguous brain and the skull.6
The most common location of the arachnoid cyst
C is in the temporal fossa followed by the frontal
convexity, posterior fossa, CPA and other
locations within the neurocranium.5 There were
significantly more males than females. This
difference was attributed solely to the
preponderance of cysts in the temporal fossa in
males, with ratio male/female 2:1. For the other
main locations (frontal convexity, posterior fossa,
and other locations) there was no significant
difference in sex distribution. However, for the
CPA sublocation there was a significant female
preponderance, with ratio male/female 1:2.5 For
FIGURE 1. Preoperative magnetic resonance imaging. The axial T2-
arachnoid cysts in the temporal fossa, both male

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and female patients demonstrated a significantly cerebellopontine angle, the patient’s presenting
increased number of left-sided cysts. For cysts symptoms are frequently neurotologic, such as
overlying the frontal convexity, no difference in sensorineural hearing loss, vertigo, or tinnitus.
sidedness could be detected for either sex. As Those symptoms are due to the dysfunction of the
noted above, there was a female predominance eighth cranial nerve7 Sometimes, nonspecific
for cysts in the CPA, with a significant tendency symptoms (headache, ataxia, gait disturbances,
for right-sided localization.5 dizziness, generalized unsteadiness) develop.
Compression of cranial nerves VII or V can cause
They are thought to be congenital or develop
facial palsy, hemifacial spasm and/or neuralgic
secondary to infection, trauma, splitting
pain.8,9,10 Arachnoid cyst in the cerebellopontine
abnormalities of the arachnoid membrane,
angle manifesting as spastic hemiplegia11,
alteration of the cerebrospinal fluid (CSF) flow,
neuralgia20, contralateral trigeminal neuralgia12,
and/or change in the CSF pressure.1 Arachnoid
inverted burns’ nystagmus13, diplopia and
cysts can occur all along the craniospinal axis, but
headaches7, congenital peripheral facial palsy14,
a large majority are located intracranially.2
gliosis of the eighth cranial nerve15, auditory
The structure features of the arachnoid cyst wall neuropathy16, hearing loss17,18, tinnitus18,
that distinguish it from the normal arachnoid hemifacial spasm19, Our patient exhibited only
membrane are as follows: (1) splinting of the severe vertigo.
arachnoid membrane at the margin of the cyst, (2)
The differential diagnosis of CPA arachnoid cysts
a very thick layer of collagen in the cyst wall, (3)
includes epidermoid and neurenteric cyst, cystic
the absence of traversing trabecular processes
acoustic schwannomas. MRI is helpful in
within the cyst, and (4) the presence of
differentiating arachnoid cysts from other cystic
hyperplastic arachnoid cells in the cyst wall,
lesions. On MRI, arachnoid cysts appear as
which presumably participate in collagen
smooth-surfaced lesions that exhibit a signal
synthesis.6 Arachnoid cysts represent a
characteristic of CSF in all MR sequences (DWI
congenital anomaly of the developing
and FLAIR).1
subarachnoid cistern in early intrauterine life. It is
postulate that, during the process of the complex The management of arachnoid cysts of the
folding of the primitive neural tube and the cerebellopontine angle remains controversial.
formation of normal subarachnoid cisterns, an Asymptomatic arachnoid cysts do not require
anomalous splitting of the arachnoid membrane treatment, and such patients should be monitored
occurs.6 clinically and radiologically with serial MRIs. If
the patient demonstrates no significant
Usually, arachnoid cysts are asymptomatic.
compromise in local neural or vascular structures,
Symptoms from an arachnoid cyst are caused by
no severe symptoms, and no suspected or proven
an increase in the osmotic gradient of the liquid
rapid cyst growth, a watch-and-wait policy
content of the cyst; the creation of a valve
should be implemented. The risks of surgery are
mechanism between the arachnoid cyst and the
few, but complications (meningitis, hemiparesis,
subarachnoid space, which leads to an increase in
oculomotor palsy, subdural hematoma, grand mal
the size of the cyst; or the secretion of liquid from
epilepsy, and death) have been reported.1
the cyst wall, which enlarges the cyst. The onset
of the symptoms and signs are usually due to The surgical treatment of arachnoid cysts of the
cortical irritation, compression of the cerebral cerebellopontine angle consists of total resection
parenchyma, or the obstruction of CSF and surgical drainage. To reduce the likelihood of
circulation.7 Symptoms are produced by the mass complications, surgical drainage via the
effect of the cyst on surrounding structures. When retrolabyrinthine or retrosigmoid exposure is the
an arachnoid cyst is located in the recommended therapy. Some authors recommend

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the placement of a cystoperitoneal shunt in angle: Diagnosis and surgery. Neurosurgery
patients with hydrocephalus. In recent years, 1997;40:31–7.
5. Christian A. Helland, Morten LJ, Knut
endoscopic cyst decompression, has been shown
wester: Location, sidedness, and sex
to be safe and effective.1,21 distribution of intracranial arachnoid cysts in
a population-based sample: Clinical article, J
Outcome Neurosurg 2010, 113:934–939
Using a standard rectosigmoid approach, with 6. Setti SR, Itaru W: Ultrastructure and
Pathogenesis of Intracranial Arachnoid
microneurosurgical technique, the cyst was Cysts: Journal of Neuropathology and
opened and typical cerebrospinal fluid flowed Experimental Neurology: 1981, vol 40,
under moderate pressure. The wall of the cyst was No.1, pp. 61-83
excised. The postoperative was uneventful and 7. Eslick GD, Chalasani V, Seex K: Diplopia
vertigo disappeared immediately. Histologically, and headaches associated with
cerebellopontine angle arachnoid cyst. ANZ
the cyst wall was a typical arachnoidal J Surg 2002; 72: 915-917.
membrane. One months after Microsurgical 8. Bonneville F, Sarrazin JL, Marsot-Dupuch K,
surgery, the patient is symptom free from severe Iffenecker C, Cordoliani YS, Doyon D,
vertigo. Bonneville JF: Unusual lesions of the
cerebellopontine angle: a segmental
approach. Radiographics 2001; 21: 419-43
9. Alaani A, Hogg R, Siddiq MA, Chavda SV,
Conclusion Irving RM: Cerebellopontine angle arachnoid
cysts in adult patients: what is the appropriate
Bilateral arachnoid cysts of CPA is very rare management? J Laryngol Otol 2005; 119:
clinical entity with poorly defined etiology, 337-341.
pathogenesis and can cause various symptoms in 10. Eslick GD, Chalasani V, Seex K: Diplopia
this case with only severe vertigo or may be and headaches associated with
asymptomatic. It becomes even more challenging cerebellopontine angle arachnoid cyst. ANZ
J Surg 2002; 72: 915-917.
when more uncertainties exist regarding rare 11. Manuel RG, Takehiko Y, Collin SM:
bilateral arachnoid cysts operations. Arachnoid Cyst of the Cerebellopontine
Angle and Infantile spastic hemiplegia, case
report: Sections of Pediatric Neurology and
Neurologic Surgery, Mayo Clinic and Mayo
References Foundation, Rochester, Minnesota
12. Ramesh B, Raj M: Arachnoid cyst of the
1. Ucar T 1. , Akyuz M , Kazan S , Tuncer R . Cerebellopontine Angle Manifesting as
Bilateral Cerebellopontine angle arachnoid Contralateral Trigeminal Neuralgia: Case
cysts: case report . Neurosurgery 2000 ; 47 : Report: Neurosurgery, The Congress
966 – 8 Neurological Surgeon, 1991: vol. 28, No.6
2. Richard KE, Dahl K, Sanker P: Long-term 13. Jun-Ichi Y, Hisamasa I, Osamu O, Kiyoshi S:
follow-up of children and juveniles with Inverted Burns’ Nystagmus in Arachnoid
arachnoid cysts. Childs Nerv Syst 5: 184– Cysts of the Cerebellopontine Angle:
187, 1989 Original paper, Eur Neurol 1993, 33:62-
3. Brackmann DE, Arriaga MA: Extra-axial 64
neoplasms of the posterior fossa. In: 14. Erman T, Demirhindi H, Gocer I, Akgul E,
Cummings CW, Fredrickson JM, Harker LA, Ildan F, Boyar B: Congenital Peripheral
Krause CJ, Richardson MA, Schuller DE Facial Palsy Associated with
(eds) Otolaryngology Head and Neck Cerebellopontine Angle Arachnoid Cyst:
Surgery. 3rd ed. St. Louis, MO: Mosby-Year case report, Pediatr Neurosurg 2004;40:297–
Book: 1998: 3294-3314 300
4. Jallo GI, Woo HH, Meshki C, et al. 15. Gonul E, Izci Y, Onguru O: Arachnoid cyst
Arachnoid cysts of the cerebellopontine of the cerebellopontine angle associated with
gliosis of the eighth cranial nerve: case

Page 4 of 5
report, Journal of Clinical Neuroscience 14
(2007) 700–702
16. Boudewyns A.N, Declau F, Ridder D.D,
Parizel P.M, Van den Ende. J, Van de
Heyning: Auditory neuropathy, in a newborn
caused by a cerebellopontine angle arachnoid
cyst, Case report, International Journal of
Pediatric Otorhinolaryngology (2008) 72,
905—909
17. Messerer M, Nouri M, Diabira S, Morandi,
Halmat A: Hearing Loss Attributable to a
Cerebellopontine-Angle Arachnoid Cyst in a
Child, Case Report, Pediatr Neurosurg
2009;45:214–219
18. Kessler P, Bodmer D: Arachnoid Cyst of the
Cerebellopontine Angle Causing Tinnitus
and Hearing Loss, Otology & Neurotology,
2010, 32:e1-e2
19. Mastronsrdi L, et al: Cerebellopontine angle
arachnoid cyst: A case of hemifacial spasm
caused by an Organic lesion other than
neurovascular Compression: case report,
Congress of Neurological Surgeons, 2009,
Volume 65, Number 6
20. Grande-Martin A, Diaz-Conejo R, Verdu-
Perez A, Hernandez-Moreno JL: Trigeminal
Neuralgia in a Child With a Cerebellopontine
Angle Arachnoid Cyst, journal, Elsevier,
Pediatric Neurology xxx (2015) 1-2
21. Bonneville F, Sarrazin JL, Marsot-Dupuch K,
Iffenecker C, Cordoliani YS, Doyon D,
Bonneville JF: Unusual lesions of the
cerebellopontine angle: a segmental
approach. Radiographics 2001; 21: 419-43.

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