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Children With Intracranial Arachnoid Cysts
Classification and Treatment
Zhen Tan, MD, PhD, Yongxin Li, PhD, Fengjun Zhu, MD, Dongdong Zang, MD, Cailei Zhao, MD,
Cong Li, MD, Dan Tong, MD, Heye Zhang, PhD, and Qian Chen, MD
Abstract: We performed a dynamic study of arachnoid cysts (ACs)
using magnetic resonance cisternography (MRC) and proposed a classi-
fication of ACs.
Twenty-three suitable patients in our hospital entered into this study
according to our inclusion criteria. MRC images were collected in all the
subjects at 1 and 24 hours after the administration of intrathecal
gadolinium-diethylenetriamine penta-acetic acid (Gd-DTPA). We allo-
cate the enrolled patients into 2 groups, MRC group and surgery group.
The MRC results were considered before treatment in 1 group (MRC
group, 13 patients), whereas another group was surgically treated
without considering the MRC results (surgery group, 10 patients).
We calculated the enhanced area of cyst using modified MacDonald
Criteria from the images and measured the surrounding subarachnoid
area as the reference.
We found that it was practically useful to quantify 3 types of ACs,
complete communicating, incomplete communicating, and noncommu-
nicating, according to MRC results in this study. All the subjects in both
groups are closely observed before the treatment and the follow-up
using the MRI examination. In the surgery group, 5 patients were found
that the area of cysts shrank in the follow-up stage. However, there was
no significant difference in the percentage shrinkage area between the
2 groups.
We concluded that MRC with Gd-DTPA as a contrast agent is of
significant clinical value for the diagnosis and treatment of children with
intracranial ACs. This classification based on dynamic MRC is useful
for making surgical recommendations.
(Medicine 94(44):e1749)
Abbreviations: AC = arachnoid cyst, CSF = cerebral spinal fluid,
CTC = computed tomography cisternography, ECG =
electrocardiogram, Gd-DTPA = gadolinium-diethylenetriamine
penta-acetic acid, MRC = magnetic resonance cisternography,
MRI = magnetic resonance imaging.
INTRODUCTION
Arachnoid cysts (ACs) are the benign malformations of the
arachnoid, which can gradually destroy the primitive ara-
chnoid membrane. The continuous development of ACs always
leads to intraarachnoid fluid collection inside the brain.
1,2
Surgical treatment for ACs is a controversial issue. In the most
of previous studies, symptomatic ACs associated with hydro-
cephalus, seizure, increased intracranial pressure, and focal
neurologic deficits were recommended to take surgically treat-
ment.
3,4
However, in daily clinical practice, a number of
symptomatic patients with ACs were found to have unrelieved
symptoms after the removal of ACs. One study reported that
only about 60% of surgical cases have significant clinical
improvement.
5,6
More recent studies have shown that it is
necessary to accurately assess the characteristics of intraarach-
noid fluid, which is the analysis of the communication between
the cyst and surrounding subarachnoid space, would help
clinicians make surgical decisions for different patients.
7
There-
fore, it is necessary to prove that dynamic characteristics of the
fluid flow within ACs may be more meaningful than clinical
symptoms when a surgical decision is made.
Magnetic resonance cisternography (MRC), which uses
low-osmolality paramagnetic gadolinium as an intrathecal con-
trast agent in the setting of enhanced magnetic resonance
myelography/cisternography, is a safer, less invasive, and more
radioactive technique compared with other cisternographic
(radionuclide or computed tomography cisternography
[CTC]) tests. It provides all the advantages of magnetic reson-
ance imaging (MRI),
8
and it can yield both morphologic and
dynamic information.
9,10
MRC has shown that cisternography
and ventriculography gadolinium-diethylenetriamine penta-
acetic acid (Gd-DTPA)-enhanced MRI is a feasible and useful
technique for the evaluation of obstructions and communi-
cations of the subarachnoid space, spontaneous or traumatic/
postsurgical craniospinal cerebrospinal fluid (CSF) leaks, or
postsurgical adhesions/arachnoiditis in the pediatric popu-
lation.
11
In the current study, MRC with Gd-DTPA was used to
assess the dynamic characteristics of symptomatic ACs and to
classify these ACs into 3 groups. On the basis of the classifi-
cation, different patients were treated with different methods.
By comparing the percentage shrinkage of different groups
during follow-up, we sought to prove that the use of MRC
Editor: Kai Wu.
Received: May 22, 2015; revised: September 11, 2015; accepted:
September 15, 2015.
From the Department of Pediatric Neurosurgery, ShenZhen Children
Hospital, ShenZhen (ZT, FZ, DZ, CL, DT, QC); Institute of Anatomy,
Southern Medical University, GuangZhou (YL); Department of Pediatric
Radiology, ShenZhen Children Hospital (CZ); and Shenzhen Institutes of
Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
(HZ).
Correspondence: Heye Zhang, Shenzhen Institutes of Advanced Technol-
ogy, Chinese Academy of Sciences, Shenzhen 518055, China (e-mail:
hy.zhang@siat.ac.cn). Qian Chen, Department of Pediatric Neurosur-
gery, ShenZhen Children Hospital, ShenZhen, China (chenqian68@
126.com).
ZT and YL contributed equally to this manuscript.
This study was supported by Shenzhen Health Development Planning
Commission Research Project (No. 201401052), Natural Science
Foundation of China (No. 8140041337), Guangdong Image-guided
Therapy Innovation Team (2011S013), Shenzhen Innovation Funding
(JCYJ20140901003939025, JCYJ20150529164154046) as well as
China Postdoctoral Science Foundation (2015M572337).
The authors have no conflicts of interest to disclose.
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
This is an open access article distributed under the Creative Commons
Attribution-ShareAlike License 4.0, which allows others to remix, tweak,
and build upon the work, even for commercial purposes, as long as the
author is credited and the new creations are licensed under the identical
terms.
ISSN: 0025-7974
DOI: 10.1097/MD.0000000000001749
Medicine®
DIAGNOSTIC ACCURACY STUDY
Medicine Volume 94, Number 44, November 2015 www.md-journal.com |1
with Gd-DTPA as a contrast agent is of significant clinical value
for the diagnosis and treatment of children with intracranial
ACs, and that this classification based on dynamic MRC is
useful for surgical decision-making.
MATERIALS AND METHODS
Patients
Between December 2013 and February 2015, 23 patients
were diagnosed with ACs by radiology imaging in our hospital,
and all of them were symptomatic. After obtaining signed
informed consent forms, which were approved by the Shenzhen
Children Hospital Ethical Review Board, all 23 patients were
enrolled in this prospective study.
We used sealed envelopes to perform randomization.
Twenty-three symptomatic ACs were distributed into 2 groups
at random, the MRC group and the surgical group. MRC results
were considered before treating 13 patients (MRC group), and a
surgical plan was formulated according to the MRC classifi-
cation. Another 10 patients (surgical group) who composed the
control group were surgically treated without any consideration
of the MRC results. The grouping was described, and the
clinical characteristics, such as age, sex, size, cyst location,
and symptoms, were compared between the 2 groups (Table 1).
The cyst volume was measured pre- and postoperation with the
methods described below.
Cisternography/Ventriculography
All children under 5 years of age took or received an enema
of 10% chloral hydrate (0.5 mL/kg) for sedation before the
cisternography or ventriculography. Patients with an unclosed
anterior fontanelle underwent lateral ventricle puncture through
the anterior fontanelle. Patients with a closed anterior fontanelle
underwent lumbar puncture.
Lumbar Puncture
All the subjects were required to keep in the lateral
decubitus position. One lumbar puncture using a No. 6 needle
was implemented at the L3– L4 level to collect 5 mL of cere-
brospinal fluid. Under sterile conditions, the cerebrospinal fluid
was mixed with 0.5 mL of Gd-DTPA (Magnevist, Bayer Faerie,
Germany). Then, the mixed liquid was injected into the lumbar
cistern through the puncture needle at a rate of 1 mL/min. The
patients were advised to lie supine with their feet higher than
their head for 10 to 20 minutes. After cisternography or ven-
triculography (except for MRI examination), the patients
received continuous electrocardiogram (ECG) monitoring for
24 hours. The children’s vital signs and other incident symptoms
and signs were also observed.
Lateral Ventricular Puncture Through the
Anterior Fontanelle
The patients lay supine. After skin preparation and disin-
fection, the lateral ventricle was punctured at the right angle of
the anterior fontanelle angle with a needle (No. 6), perpendicu-
lar to the imaginary line between the bilateral external auditory
canals. When the clinician had a breakthrough sensation, the
needle core was withdrawn. The outflow of cerebrospinal fluid
indicated successful puncture. Five milliliters of cerebrospinal
fluid was extracted during this process. Under sterile conditions,
the cerebrospinal fluid was mixed with 0.5 mL of Gd-DTPA
(Magnevist, Bayer Faerie, Germany). Then, the mixed liquid
was injected into the lateral ventricle through the puncture
needle at the rate of 1 mL/min. The patients were advised to
lie supine with their feet higher than their head for 10 to
20 minutes. After cisternography or ventriculography (except
for MRI examination), the patients received continuous ECG
monitoring for 24 hours. The children’s vital signs and other
incident signs and symptoms were observed.
MRI Examination
Before the cisternography or ventriculography, the patients
had routine MRI scans including T1-weighted images (TR/TE/
NEX ¼380–460/8–17/3) and T2-weighted images (2000/30 –
90/1) on 3 orthogonal planes with a 1.5T MRI machine (Signa,
HiSpeed, GE, Milwaukee, WI). One hour after successful
puncture and injection, MRI was carried out again. The scan
parameters were the same as those before contrast infusion.
Twenty-four hours after the cisternography or ventriculography,
MRI was carried out again. All MRI data were observed and
diagnosed by 2 neuroimaging physicians.
TABLE 1. Comparison of Baseline Demographic Characteristics Between the 2 Study Groups
Characteristics MRC Group (13 Patients) Surgical Group (10 Patients) PValue
No. of males, % 11 (84.6) 9 (90.0) >0.05
No. of females, % 2 (15.4) 1 (10.0) >0.05
Mean age in years (range) 2.25 1.97 (0.42– 8.0) 2.085 2.64 (0.25– 9.67) 0.998
Symptoms, %
Headache 6 (46.1) 4 (40.0) >0.05
Seizure 3 (23.1) 3 (30.0)
Skull eminence 1 (7.7) 1 (10.0)
Retardation 3 (23.1) 2 (20.0)
Location of cysts, %
Middle cranial fossa 8 (61.5) 6 (60.0) >0.05
Cisterna magna 3 (23.1) 2 (20.0)
Cerebral convexity 2 (15.4) 1 (10.0)
Sellar region 0 (0) 1 (10.0)
Mean cyst volume in cm
3
(range) 88.48 93.91 (6.52 –315.4) 91.27 113.7 (16.99– 408.2) 0.949
Follow-up (range) 5 3 (2– 8) 4.6 3.1 (1– 10) 0.815
Tan et al Medicine Volume 94, Number 44, November 2015
2|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
Cyst Volume Measurement
The modified MacDonald Criteria are applied for volume
measurement in this study.
12
According to the modified Mac-
Donald Criteria, we measure the volume through the following
steps: the number of image slices in which the cyst is visible and
the maximum cross-sectional and orthogonal diameters of the
cyst. We selected the slice with the largest area of cyst, and
measured 2 longest orthogonal diameters of the cyst area
(Fig. 1). These 2 diameters, the number of slices in which
the cyst was present, and the slice thickness plus the gap were
used to compute the volume by using the following formula:
Cyst volume ¼pd1d2(s t)/6
where d1 and d2 are the orthogonal diameters, s the number of
cyst slices, and t is the slice thickness.
Angiographic Diagnostic Criteria
Neuroimaging physicians compared and analyzed the T1-
weighted MRI data from 1 and 24 hour after the cisternography
or ventriculography. By comparing the signals of the cyst and
cistern at 1 and 24 hour, the cysts were classified.
TREATMENT
Surgical treatment was performed in the patients with
incomplete communicating and noncommunicating cysts in
the MRI group and all patients in the surgical group. Endoscopic
fenestration or microscopic fenestration was performed under
general anesthesia. Microscopic fenestration was performed
through a minimal skin incision and a small minicraniotomy.
After opening the dura, the outer cyst wall was partially incised
to penetrate the inner cyst wall and enter the basal cisterns.
Several windows between the cyst and the cisterns were made to
enable a smooth flow of cystic fluid or CSF. The dura was
closed by primary repair or duraplasty with an artificial dura
mater. The bone flap was repositioned with an absorbable strut.
A drain catheter was not inserted in the majority of cases.
Endoscopic fenestration was conducted after 1 burr hole was
made. A rigid neuroendoscope was used for the fenestration
procedure. After the insertion of the endoscope into the cyst
cavity, several fenestrations between the cyst and the basal
cistern (or ventricle) were made. At the end of the procedure, the
dura was closed. The burr hole site was typically not repaired.
Follow-Up
During the follow-up stage, all the patients were required
to take MRI examination. Then, the volume of cyst in each
patient was measured and recorded accordingly.
RESULTS
Patients and Comparability Between the
2 Groups
Age, sex, size and location of cyst, symptoms, and follow-
up time were shown in Table 1.
AC Classification Based on MRC
One 5-month-old boy received lateral ventricle puncture
through the anterior fontanelle, whereas the remaining 12
patients received lumbar puncture. After MRC, the character-
istics of cyst imaging at different time points were summarized
(Figs. 2–4 and Table 2). Based on MRC diagnostic criteria, ACs
were classified into 3 types: complete communicating cyst,
FIGURE 1. Modified MacDonald method to measure cyst volumes.
Medicine Volume 94, Number 44, November 2015 Children with Intracranial Arachnoid Cysts
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |3
incomplete communicating cyst, and noncommunicating cyst
(Table 3).
During the cisternography, no patients developed severe
complications. The only side effect was transient mild headache
in an 8-year-old patient. The symptom was relieved after bed
rest and oral administration of analgesics. After the cisterno-
graphy, no abnormalities in ECG monitoring or clinical mani-
festations were observed in the remaining patients.
Treatment
Five patients with incomplete communicating or noncom-
municating cysts in the MRC group were recommended to take
surgical treatment. Another 8 patients with complete commu-
nicating cysts were not recommended to take surgical inter-
vention. In the surgical group, all 10 patients underwent surgery
without consideration of this MRC classification. Table 2 shows
the surgical information from the 2 groups.
Follow-Up
All patients were continuously followed up. MRI was
regularly checked, whether or not they underwent surgery.
No patients presented with the symptoms of contrast agent
residue, allergic reactions, or neurological impairment. All of
the patients who received surgery did not develop complications
such as intracranial infection or intracranial hemorrhage. We
also evaluated cyst size. We calculated the percentage shrinkage
of cysts pre- and postoperation. The dates from 2 groups were
compared with statistical software. Although significant differ-
ences were not found between them, the percentage shrinkage in
the MRC group was larger than in the surgery group. The results
are shown in Tables 4 and 5.
DISCUSSION
In the current study, 13 symptomatic ACs accepted MRC
and were classified into 3 subgroups based on MRC results. We
applied surgical treatment in the 3 subjects with incomplete
communicating cysts and 2 subjects with noncommunicating
cyst in the MRC group. In the 5 patients who underwent
operations, the cysts had shrunk by the time of the follow-up
investigation. By comparing the percentage shrinkage of the 5
patients and surgical group without MRC, there was no sig-
nificant difference between them. However, we did not perform
FIGURE 2. AC in the cistern magna of an 11-year-old male. An arachnoid cyst located in the cistern magna was unexpectedly found
during CT after a head injury. The cyst did not cause any symptoms. One hour after cisternography, the cyst was enhanced in the sagittal
T1 sequence (B). Sagittal T1 at 24 hours showed the signal inside the cyst was equal to the surrounding cistern, indicating a complete
communicating AC (C). AC ¼arachnoid cyst, CT ¼computed tomography.
FIGURE 3. Arachnoid cyst (AC) in the left middle fossa of a 1.5-year-old male. The patient presented with a left temporal bone eminence
without other symptoms. One hour after contrast injection, sagittal T1 demonstrated enhancement of the surrounding cistern instead of
the cyst (B). Axial T1 at 24 hours showed a higher signal inside the cyst than that in the lateral ventricle, suggestive of incomplete
communicating AC (C).
Tan et al Medicine Volume 94, Number 44, November 2015
4|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
surgery in 8 patients in the MRC group. We concluded that the
use of MRC with Gd-DTPA as a contrast agent is of significant
clinical value for the diagnosis and treatment of children with
intracranial ACs. The results of our study showed that the
classification using dynamic MRC might have potential in
decision of surgical treatment.
Safety of the Gd-DTPA Contrast Agent for MRC
Gd-DTPA, a paramagnetic contrast agent, has been widely
used in angiography.
13
If Gd-DTPA is intrathecally injected, the
relaxation time of T1 and T2 imaging of cerebrospinal fluid can
be shortened. At a low concentration, Gd-DTPA mainly affects
T1 images. At a high concentration, it mainly affects the T2
relaxation time.
14
Intrathecal injection of Gd-DTPA during
MRC was first performed on laboratory animals by Di Chiro
in 1985.
15
In subsequent years, researchers carried out a series
of studies on other animals and on humans.
10,16
These studies
have suggested that the intrathecal injection of Gd-DTPA is a
relatively safe procedure. At a diagnostic dose, it has no
significant effect on the nervous tissue and does not cause
significant side effects. In the published studies, very low
concentrations (eg, 0.17 mmol/g of brain tissue) of Gd-DTPA
are sufficient to clearly show the structure of the spinal cord and
intracranial subarachnoid space.
11
According to these published
data from clinical studies, we controlled the dosage of Gd-
DTPA from each patient, administering doses equivalent to
0.17 mmol of gadolinium element per gram of brain tissue.
11
Until now, only limited information has been available
concerning these procedures in children. To further avoid or
reduce the side effects of drugs, we emphasized strict control of
the injection velocity at 1 mL/min. The vital signs, rashes,
convulsions, and other acute adverse reactions were closely
monitored for 24 hours after successful cisternography. Accord-
ing to the observations, no patients had serious side effects or
complications correlated with MRC. Slight transient headache
was the only symptom, which was observed in only 1 patient.
The symptom was relieved within 24 hours after bed rest and the
oral administration of analgesics. During the follow-up after
cisternography, the patients did not complain of any adverse
reactions. Their parents did not find any adverse reactions,
either. This is consistent with previous reports.
17– 19
In this
regard, we have begun to continue the follow-up to investigate
the long-term impact of Gd-DTPA on children.
The Advantages of MRC Over Other Tests
In the past few decades, intrathecal iodide-enhanced CTC
and radionuclide cisternography have been the most commonly
used methods to evaluate the flow pathways of cerebrospinal
fluid in the cistern or ventricles. However, a growing number of
issues, such as ionizing radiation, the interference of skull
artifacts, the limitations of axial plane imaging (multiplanar
imaging is impossible), and allergies to the contrast agent, have
been raised. Therefore, many centers tend to replace the former
2 methods with noninvasive special MRI sequences, such as 3D
heavily T2-weighted sequences and phase-contrast (PC)-MRI
of cerebrospinal fluid. Although 3D heavy T2-weighted
sequences, represented by 3D constructive interference in
steady state, can clearly show the surrounding anatomical
structures of the cyst, they cannot provide information regarding
cerebrospinal fluid flow. Compared with 3D heavily T2-
weighted sequences, PC-MRI can provide important infor-
mation regarding cerebrospinal fluid flow. When it is used
for the diagnosis of cysts in the suprasellar cistern or the
intraventricular area, where the change of cerebrospinal fluid
flow is complex, the false-positive rate is greatly increased.
9,20
Compared with the above-imaging methods, cisternography
with Gd-DTPA as a contrast agent can make up any
FIGURE 4. Arachnoid cyst (AC) in the cistern magna of a male 1 year and 3 months of age. The patient presented with retardation of
motor development. Physical examination revealed that the muscle force of the lower limbs was grade IV. One hour after contrast
injection, sagittal T1 showed imaging of the 4th ventricle and the spinal subarachnoid space and no immediate imaging of the cyst (B).
Sagittal T1 at 24 hours showed imaging of the 4th ventricle and the subarachnoid space surrounding the cyst. As the signal of the cyst was
lower than the cistern and ventricle, he was diagnosed with noncommunicating AC (C).
TABLE 2. ACs Classification Based on MRC
Type
Complete
Communicating
Incomplete
Communicating Noncommunicating
No. of patient
in MRC group
82 3
AC ¼arachnoid cyst, MRC ¼magnetic resonance cisternography.
Medicine Volume 94, Number 44, November 2015 Children with Intracranial Arachnoid Cysts
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |5
deficiencies. MRC can clearly show the anatomical structures
on different planes and provide accurate information concern-
ing the flow of cerebrospinal fluid.
The Clinical Significance of Different MRC
Results
During the examination of intrathecal Gd-DTPA MRC,
ACs in different patients exhibited different enhancement fea-
tures or commuting modes. We found that the contrast agent
filled more slowly in incomplete communicating ACs. One
possible explanation is that the entrance from the subarachnoid
space to the cysts is small. Therefore, the contrast material
enters the cysts slowly, and this slow process has also been
reported in other study.
21
Another possible explanation is that
CSF can flow into the cyst quickly, but cannot flow out quickly
because of one-way valve. We have not found that cysts with
instant imaging and suspended regression of the contrast
agent.
22
We speculate that it can be the problem of the small
number of subjects in this study. We also speculate that the
incomplete communicating ACs with light terminal filling in
the cysts are caused by the secretive function of the cyst wall
because the cells of the cyst wall can move contrast materials
from the outside into the cyst cavity. The secretive function of
the ultrastructures and immunohistochemistry of the cyst lining
cells in the cyst wall has been observed in many studies.
23– 25
We defined 3 types of ACs (complete, incomplete, and non-
communicating types) in our study according to the result of
consecutive CTC. In our study, the definition of ACs has been
used to the indication of surgery on the patients with ACs, and
its value has been proven in the follow-up.
The Influence of MRC on Surgical Decision-
Making
Although the treatment of intracranial ACs is controver-
sial, a growing number of studies have suggested that accurately
understanding the communicating characteristics between the
cysts and the subarachnoid space are very important in the
choice of surgery.
4,7,26
For example, surgery is necessary for
patients with symptomatic ACs that do not communicate with
subarachnoid space.
4,7
If cisternography shows complete com-
munication, which suggests favorable communication between
the cysts and the subarachnoid space, regular follow-up is
enough for the patients. If the cisternography shows incomplete
communicating or noncommunicating ACs, as was the case in
this study, patients would undergo surgery. In a patient with left
temporal bone uplift, MRC showed delayed imaging,
suggesting the slow communication between the cyst and the
surrounding cerebrospinal fluid. Therefore, we made a surgical
plan for that patient. On the basis of the results in this group, we
believe that it is necessary to carry out rigorous and compre-
hensive analysis of the medical history, physical examination,
and imaging tests, especially MRC, before performing surgery
for AC cases. All 8 patients who did not undergo surgery
exhibited symptoms. When also taking the results of MRC into
account, we concluded that these patients’ symptoms were not
necessarily caused by the cysts. Therefore, we chose to observe
them further. During the follow-up, their symptoms were
relieved. Repeated MRI did not show changes in the cysts.
This also indicates that MRC is of significant value for the
determination of surgical indications. The combination of
clinical symptoms, signs, and MRC can reduce unnecessary
surgery, decrease the risk caused by surgery, and alleviate the
suffering of patients.
27,28
We did not find a significant difference in the percentage
shrinkage between these 2 groups. However, we found that the
MRC group showed more shrinkage than the surgery group. The
reason for this may be that some complete communicating ACs
were included in the surgery group. Liquid inside and outside
the cystic cavity can communicate freely in the patients with
complete communicating ACs. There was no compression of
the adjacent brain tissue by the cysts, and it is difficult for the
brain tissue to return to a normal location after the surgery. In
the MRC group, the patients with complete communicating ACs
were excluded through the MRC before the surgery. We found
the differences of volume between MRC and surgical groups.
TABLE 3. Angiographic Diagnostic Criteria Based on Signal in Cyst and Cistern
Signal of Cyst and Cistern in T1-Weighted Imaging
Time Point 1 hour Cyst ¼cistern Cyst ¼cistern Cyst no enhanced Cyst no enhanced Cyst enhanced but <cistern Cyst enhanced but <cistern
24 hours Cyst ¼cistern Cyst >cistern Cyst >cistern Cyst >cistern Cyst >cistern Cyst ¼cistern
Type CC ICC NC ICC ICC ICC
CC ¼complete communicating, ICC ¼incomplete communicating, NC ¼noncommunicating.
TABLE 4. Treatment and Follow-Up Information of MRC and Surgery Group
Surgery
Program
Group
Treatment
Number EF MF
Cyst Volume
Preoperation, cm
3
Cyst Volume
Postoperation, cm
3
Percent
Shrinkage, % P
MRC group 5 5 0 170.2 97.8 84.56 52.27 48.91 25.4 0.146
Surgery group 10 7 3 91.27 113.7 69.15 101.2 30.57 19.75
EF ¼endoscopic fenestration, MF ¼microscopic fenestration, MRC ¼magnetic resonance cisternography.
Tan et al Medicine Volume 94, Number 44, November 2015
6|www.md-journal.com Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved.
The sample size in this study was small because only children
with intracranial ACs were recruited. The ACs were found in
the middle cranial fossa, cisterna magna, cerebral convexity,
sellar region, cerebellopontine angle, intraventricular region,
and quadrigeminal region. In our data collecting process, the
ACs were most commonly found in the middle cranial fossa and
cisterna magna. Therefore, we chose these 2 types of ACs as our
representative research focus. Furthermore, previous studies
showed that the cysts shrank and the symptoms improved
significantly after surgery.
4,7
Future research with large num-
bers of patients and patients who received lumbar puncture or
lateral ventricular puncture are required. However, this study
might suggest that Gd-DPTA MRC is one safe and tolerable tool
to make the decision of treatment for these patients with ACs.
CONCLUSIONS
MRC should be applied to evaluate the status of ACs. The
classification of ACs using dynamic MRC can benefit the
surgical decision-making. For example, not all the symptomatic
patients with complete communicating ACs were required to
take surgical treatment.
ACKNOWLEDGMENTS
The authors sincerely thank all members who took part in
this study, for their meticulous work in this study.
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TABLE 5. Clinical Characteristics With Follow-Up Result
Case No. Sex/Age Group Symptom Location of Cysts Surgery Follow-Up Time, month Clinical Outcome
1 M/3Y MRC Headache Lt MF No 6 Improved
2 F/1Y6M MRC Sizure Lt MF No 7 No change
3 F/10Y MRC Headache Lt MF No 3 No change
4 M/1Y8M MRC Skull eminence Lt MF Yes 5 No change
5 M/11Y MRC Headache CM No 3 Improved
6 M/3Y MRC Headache Rt MF No 4 Improved
7 M/1Y3M MRC Retardation CM Yes 8 Improved
8 M/5M MRC Retardation Rt CC Yes 8 Improved
9 M/2Y3M MRC Retardation Lt MF No 5 No change
10 M/8Y MRC Headache Rt CC No 4 No change
11 M/1Y8M MRC Sizure Rt MF Yes 2 Improved
12 M/5Y MRC Sizure Lt MF Yes 2
13 M/4Y MRC Headache CM No 6 Improved
14 M/3M Surgery Retardation Lt CC Yes 10 No change
15 M/3Y3M Surgery Headache Lt MF Yes 3 Improved
16 M/4Y Surgery Headache CM Yes 2 Improved
17 M/1Y6M Surgery Skull eminence Rt MF Yes 5 No change
18 M/2Y9M Surgery Seizure Rt MF Yes 3 Improved
19 M/1Y11M Surgery Seizure SR Yes 4 Improved
20 M/1Y9M Surgery Seizure Rt MF Yes 2 No change
21 M/9Y8M Surgery Retardation CM Yes 7 No change
22 M/11M Surgery Headache Lt MF Yes 1 No change
23 M/2Y3M Surgery Headache Lt MF Yes 9 Improved
CC ¼cerebral convexity, CM ¼cisterna magna, Lt ¼left, MF ¼middle cranial fossa, MRC ¼magnetic resonance cisternography, Rt ¼right,
SR ¼sellar region.
Medicine Volume 94, Number 44, November 2015 Children with Intracranial Arachnoid Cysts
Copyright #2015 Wolters Kluwer Health, Inc. All rights reserved. www.md-journal.com |7
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Tan et al Medicine Volume 94, Number 44, November 2015
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