Exploring predictors of surgery and comparing operative treatment approaches for pediatric intracranial arachnoid cysts: a case series of 83 patients

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Although intracranial arachnoid cysts are a common incidental finding on pediatric brain imaging, only a subset of patients require surgery for them. For the minority who undergo surgery, the comparative effectiveness of various surgical approaches is debated. The authors explored predictors of surgery and compared operative techniques for pediatric patients with an intracranial arachnoid cyst seen at a tertiary care center.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors reviewed records of pediatric patients with an intracranial arachnoid cyst. For each patient, data on baseline characteristics, the method of intervention, and surgical outcomes for the initial surgery were extracted, and cyst size at diagnosis was calculated (anteroposterior × craniocaudal × mediolateral). Baseline variables were analyzed as predictors of surgery by using logistic regression modeling, excluding patients whose surgery was not related to cyst size (i.e., those with obstructive hydrocephalus secondary to the cyst compressing a narrow CSF flow pathway or cyst rupture/hemorrhage). Data collected regarding surgical outcomes were analyzed descriptively.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Among 83 pediatric patients with an intracranial arachnoid cyst seen over a 25-year period (1989–2013), 27 (33%) underwent surgery; all had at least 1 cyst-attributed symptom/finding. In the multivariate model, age at presentation and cyst size at diagnosis were independent predictors of surgery. Cyst size had greater predictive value; specifically, the area under the curve for the receiver-operating-characteristic curve was 0.89 (95% CI 0.82–0.97), with an ideal cutoff point of ≥ 68 cm<jats:sup>3</jats:sup>. This cutoff point had 100% sensitivity (95% CI 79%–100%), 75% specificity (95% CI 61%–85%), a 53% positive predictive value (95% CI 36%–70%), and a 100% negative predictive value (95% CI 91%–100%); the positive likelihood ratio was 4.0 (95% CI 2.5–6.3), and the negative likelihood ratio was 0 (95% CI 0–0.3). Although the multivariate model excluded 7 patients who underwent surgery (based on prespecified criteria), excluding these 7 cases did not change the overall findings, as shown in a sensitivity analysis that included all the cases. Descriptive results regarding surgical outcomes did not indicate any salient differences among the surgical techniques (endoscopic fenestration, cystoperitoneal shunting, or craniotomy-based procedures) in terms of symptom resolution within 6 months, need for reoperation to date, cyst-size change from before the operation, morbidity, or mortality.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The results of these exploratory analyses suggest that pediatric patients with an intracranial arachnoid cyst are more likely to undergo surgery if the cyst is large, compresses a narrow CSF flow pathway to cause hydrocephalus, or has ruptured/hemorrhaged. There were no salient differences among the 3 surgical techniques for several clinically important outcomes. A prospective multicenter study is required to enable more robust analyses, which could ultimately provide a decision-making framework for surgical indications and clarify any differences in the comparative effectiveness of surgical approaches to treating pediatric intracranial arachnoid cysts.</jats:p></jats:sec>

Does subjective improvement in adults with intracranial arachnoid cysts justify surgical treatment?

“…22,26,28,29 In fact, although most neurosurgeons agree that surgery should be reserved for symptomatic patients, arachnoid cyst size has been shown to be the most important predictor of surgical treatment. 3 Headache, the most common symptom in arachnoid cyst, is also one of the most common and disabling conditions of humankind. 8,15 In our study, headache was the most frequently reported symptom in the group of patients who underwent surgery, whereas it was less prevalent among those who declined surgery.…”

Cognitive Impairment in Children with Arachnoid Cyst of Sylvian Fissure: Does it Justify the Neurosurgical Treatment?

“…Physicians often ask whether to qualify a patient with AC for surgery, and if so, on the basis of what criteria. 8,9,18,28,31,34,36 There is no doubt that symptomatic ACs should be treated surgically. However, should a reduced intellectual potential, problems at school, or a diminished psychomotor drive be criteria for indicating surgery?…”

“…An estimated 50 to 80% of all ACs are diagnosed before patients reach 16 years of age. 1,3,6,[8][9][10] The ACs are often located in the middle cranial fossa ($ 60%) and on the left side (almost four times more frequently). ACs occur three times more frequently in male than in female patients.…”

“…However, ACs also can lead to various symptoms of chronic intracranial hypertension such as headaches, vomiting, disturbances of vision, cranial nerve palsies, and pareses. 1,2,5,8,[12][13][14][15][16] For many years, developmental disturbances and cognitive impairments were considered not being related to ACs. However, more recent publications suggest an association between an AC and psychopathologic symptoms: Patients with ACs may experience cognitive deficits such as memory and attention functioning disorders, visuospatial disorders, and language impairments.…”

A retrospective case cohort study of managements and outcomes of pediatric patients with intracranial arachnoid cysts

“…IACs are congenital and benign lesions with CSF-like fluid collection inside.There is no consensus in treatment approaches for an effective management. Manifestations such as neurological deficits, intracranial hypertension, seizures due to expansion or mass effect of the cyst are suggested as indications for neurosurgical interventions [1][2][3][4][5][6]. A survey of neurosurgeons has suggested that surgical managements were also preferred for asymptomatic huge cysts or growing cysts without any symptoms in order to improve brain development or avoid skull malformation [4,5,7].…”