Temporosylvian arachnoid cysts in children. Part 2: Postoperative neuropsychological and clinical improvement

Abstract

OBJECTIVE The authors’ objective was to study clinical, imaging, and neuropsychological changes in children who underwent surgery for a temporal arachnoid cyst (TAC). METHODS Thirty-four children were prospectively assessed similarly at diagnosis and postoperatively (mean 14 months) with clinic visits, images, cognitive tests, and parental questionnaires on mood/behavior and executive functions. The scores were compared pre- and postoperatively for the entire cohort and individually. The scores of 25 children were also compared with a control group of 23 healthy age-matched children. Parents were administered an outcome questionnaire on average 4 years postoperatively. RESULTS The 34 children selected for surgery had signs of raised intracranial pressure (74%) and/or selective neuropsychological disorders presumably linked to cyst location (learning difficulties in 65%, cognitive difficulties in 56%, and mood/behavior difficulties in 47%). The majority of patients had a convex cyst (85%) and underwent microsurgical fenestration (85%). The TAC volume decreased ≥ 50% for 59% of children. On the Wechsler Intelligence Scale, the entire cohort significantly improved on Full Scale IQ and verbal and perceptual nonverbal indexes. Individually, nearly half of the children (47%) highly increased their scores (≥ 15 points) on at least one IQ index and 26% on at least two indexes. Language, working memory, episodic memory, and executive functions were also significantly improved. Improvements were more pronounced in patients with a preoperative heterogeneous profile with isolated lower scores and a left-sided cyst. Parental questionnaires showed reduction in anxiety, aggressiveness, social problems, and daily life executive disorders. Preschool-aged children improved significantly in language and verbal IQ, as did middle/high school–aged children in many domains. Individual analyses revealed improvement in 76% of cases. Cognitive scores were lower for patients preoperatively than for controls and were no longer significantly different postoperatively in verbal fluency, visual memory, and working memory. Four years later, 97% of parents described an improvement in their child, correlated with cognitive improvements. CONCLUSIONS Among children with a TAC, some have no clinical signs or neuropsychological difficulties, and others may show signs of raised intracranial pressure and/or specific neuropsychological disorders that impact daily life and require significant and long-lasting rehabilitation. In these cases, consideration may be given to surgical decompression. It is interesting to note that 76% of this surgically treated cohort improved regardless of the child’s age, particularly in patients with selective disorders and an impact on daily life. However, a larger number of children will need to be investigated before the true benefit of such treatment can be known.

Temporal Sylvian Fissure Arachnoid Cyst In Children: Treatment Outcome Following Microsurgical Cyst Fenestration With Special Emphasis on Cyst Reduction and Subdural Collection

“…Controversy remains regarding the management and treatment of SFACs, speci cally regarding the role of surgical intervention for patients with relatively minor presentation. Although it remains controversial, several authors recommend cyst fenestration for asymptomatic SFAC because of improved cyst size reduction and low risk of complications [7,32] and improved neuropsychological disorders [10]. The complication rates presented in this report were low and cranial nerve de cits (3rd and 4th nerve) were transient and resolved spontaneously.…”

“…However, others reported less seizure control [7]. Cuny et al reported neuropsychychological testing before and after cyst fenestration showed improvement in 76% of 34 children [10]. They observed the rounded, convex shape of the cyst being more compressive and deleterious.…”

“…The microsurgery group also showed a tendency for longer cystocisternostomy permeability than the endoscopy group [8]. Cuny et al, analyzing 34 children of SFAC treated with microsurgical fenestration (85%), endoscopic cyst fenestration (9%), or cystoperitoneal shunting (6%), described microsurgical fenestration is a safe and effective procedure [10]. On the other hand, others recommend the endoscopic approach as the best initial option, reserving microsurgical procedure as secondary options [7,38].…”

“…[9]. Of 34 of these 100 children, who underwent cyst fenestration, postoperative assessments showed improvement in 76% of surgically treated cohort regardless of the child's age [10].…”

Ruptured Sylvian arachnoid cysts: an update on a real problem

“…The presentation of ruptured SACs is mainly characterized by worsening raised ICP symptoms in a previously asymptomatic patient, often with apparently normal neuropsychological development [60,139]. Typically, raised ICP occurs some hours/days or even weeks after the injury (time necessary for the subdural collection formation) [11,13].…”