British Journal of Neurosurgery, 2014; Early Online: 1–5 © 2014 The Neurosurgical Foundation ISSN: 0268-8697 print / ISSN 1360-046X online DOI: 10.3109/02688697.2014.976175

REVIEW ARTICLE

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Spinal arachnoid cyst associated with arachnoiditis following subarachnoid haemorrhage in adult patients: A case report and literature review Recep Basaran1, Mustafa Kaksi2, Mustafa Efendioglu3, Mustafa Onoz3, Ece Balkuv4 & Tuncay Kaner3 1Department of Neurosurgery, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Istanbul, Turkey, 2Department of

Neurosurgery, Yalova Hospital, Yalova, Turkey, 3Department of Neurosurgery, Istanbul Medeniyet University Goztepe Education and Research Hospital, Istanbul, Turkey, and 4Department of Neurology, Istanbul Medeniyet University Goztepe Education and Research Hospital, Istanbul, Turkey

Abstract Objective. Arachnoiditis is an inflammatory process resulting with the fibrosis of arachnoid mater. It can vary in severity from mild thickenings to catastrophic adhesions that ruins subarachnoid space. As a result, arachnoid cysts can be formed. Arachnoid cyst induced by symptomatic spinal arachnoiditis is a rare complication of subarachnoid haemorrhages. In this article, we aimed to present a case of spinal arachnoid cyst formation following subarachnoid haemorrhage and examine similar cases in the literature. Case Report. Forty-six years old, previously healthy female patient has been treated medically for headaches due to perimesencephalic subarachnoid bleeding. Approximately two and a half months later, she started to have severe headaches and diplopia. We detected hydrocephalus and performed ventriculoperitoneal shunt surgery. Two months later, she started to have complaints of weakness in her lower extremities. On neurological examination, she had paraparesis and on spinal magnetic resonance imaging she had an arachnoid cyst lengthening from C7 to T2 and compressing the spinal cord posteriorly. We performed partial laminectomy, drainage of arachnoid cyst and replacement of cystopleural T tube shunt. On follow-up, her lower extremity strength has ameliorated. She was taken into a physical therapy and rehabilitation programme. Three months later she was able to walk with a crutch. Conclusion. Subarachnoiditis and associated arachnoid cyst can cause severe morbidity. This rare situation (which especially occurs following subarachnoid haemorrhage of posterior fossa) should be known and physicians should keep in mind that it requires urgent surgical procedure.

Introduction Arachnoiditis is an inflammatory process that causes fibrosis of arachnoid. It can vary in severity from mild thickenings to catastrophic adhesions of subarachnoid space. As a result, arachnoid cysts can be formed.1 Spinal arachnoiditis (SA) can develop due to trauma, spinal surgery, spinal anaesthesia, tumour and various infections.2 Nevertheless, arachnoid cyst formation due to symptomatic SA caused by subarachnoid haemorrhage (SAH) is a rare situation. Spinal arachnoid cyst is a rare cause of nerve root compression.3 In this article, we aimed to present a case of spinal arachnoid cyst formation following subarachnoid bleeding and we aimed to examine similar cases in the literature.

Case report Forty-six years old, previously healthy female patient’s brain computerised tomography (CT) revealed perimesencephalic SAH (Fig. 1). Any vascular pathology was not detected. Approximately two and a half months later, she started to have severe headaches and diplopia. We detected hydrocephalus and performed ventriculoperitoneal shunt surgery (Fig. 2). Two months later, she started to have complaints of weakness in her lower extremities. On neurological examination she had paraparesis (3/5) and any intracranial pathology was not detected on cranial magnetic resonance imaging (MRI). On spinal MRI, she had an arachnoid cyst image that extends from C7 to T2. The arachnoid cyst was severely pressing the spinal cord posteriorly (Fig. 3). We performed a right T1 and T2 partial laminectomy, dissected the dura vertically and drained the arachnoid cyst. Then we dissected the septas of the bilobulated cyst (Fig. 4). We placed a T tube shunt into the cyst and the distal portion of tube was sent into

Keywords: arachnoid cyst; arachnoiditis; hydrocephalus; paraparesis; subarachnoid haemorrhage

Correspondence: Recep Basaran, MD, Department of Neurosurgery, Dr. Lutfi Kirdar Kartal Education and Research Hospital, Kartal, Istanbul, Turkey. Tel: ⫹ 90 506 659 72 21. Fax: ⫹ 90 216 372 99 63. E-mail: [email protected] Received for publication 10 April 2014; accepted 8 October 2014

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Fig. 3. Spinal MRI shows an arachnoid cyst image lengthening from C7 to T2 and severely pressing the spinal cord posteriorly.

Fig. 1. CT scanning reveals perimesencephalic subarachnoid haemorrhage.

pleura. On her post-operative follow-up, her lower extremity strength was improved to 4/5. She was taken into a physical therapy and rehabilitation programme. Three months later, she was able to walk with a crutch.

Discussion

cases but there have not been many studies with regard to the prevalence of SA. All of the studies realised until today are summarised in Table I. Along with our report, there are a total of 25 case presentations in the literature as we know. It is not possible to obtain any information on three cases reported by Lombardi et al.5 When we examine the age distribution of SA, we see that 21 cases are between 22 and 69 years old and the mean age is calculated as 54.14. Eighteen of these patients are females 86%) and three of them are males.

Epidemiology

Clinical presentation

SA was defined for the first time in 1943 by Nelson after examination of a patient who presented with progressive muscle weakness in lower extremities and who had a history of spinal haemorrhage 4 years ago.4 Until today, SA has been reported via case presentations that comprise one or more

SA is rare cause of spinal cord and nerve root compression. Signs and symptoms of patients depend on the size and location of compression. Leg pain, progressive paraparesis, sphincter dysfunction and sometimes the co-existence of these signs along with deficiencies in feeling sensation can be the first signs of the disease. Clinical features of 25 patients were evaluated in 22 (along with ours); one patient had sciatic nerve pain,11 one patient had cauda equina

Fig. 2. CT scanning after ventriculoperitoneal shunt surgery shows ventricular part in right lateral ventricle.

Fig. 4. Spinal MRI after arachnoid cyst surgery shows right T1 and T2 partial laminectomy, collapsing of arachnoid cyst.

Whetstone and Crane 201319 Present case

Ishizaka et al. 201217 Van Heerden and McAuliffe 201318

Tumialan et al. 200512 Thines et al. 200513 Marshman et al. 200714 Abhinav et al. 201215 Eneling et al. 201216

Augustijn et al. 19898 Jourdan et al. 19909 Taguchi et al. 199610 Lorenzana-Honrado et al. 199611 Kok et al. 20001

Weiss et al. 19626 Tjandra et al. 19897

Nelson 19434 Lombardi et al. 19625 50/M ND ND ND 69/F 47/M 33/M 54/F 56/F 59/M 22/F 63/F 68/F 53/F 64/F 57/F 58/F 57/F 65/F 65/F 35/F 65/F 51/F ND 46/F

Thrombo-cytopenic purpura ND ND ND ND ND PICA aneurysm PICA aneurysm PICA aneurysm PICA aneurysm PICA aneurysm PcoA aneurysm PICA aneurysm PICA Aneurysm Angionegative perimesencephalic Aneurysm PICA aneurysm AcoA aneurysm PICA aneurysm PICA aneurysm PICA aneurysm PcoA aneurysm PICA aneurysm PICA aneurysm Angionegative perimesencephalic

No ND ND ND ND ND ND Yes Yes No No Yes Yes Yes No Yes No Yes No No No No No No Yes

Hydrocephalus

Progressive paraparesis, urinary incontinence ND ND ND Progressive paraparesis, urine incontinence Progressive paraparesis and sensory loss Progressive paraparesis and sensory loss Progressive paraparesis Progressive paraparesis Spastic paraparesis Sciatic pain, urinary urgency Mild paraparesis and urinary incontinence Paraparesis Paraparesis Progressive paraparesis Progressive paraparesis Paraparesis Progressive paraparesis Progressive paraparesis Progressive paraparesis and sensory loss Progressive paraparesis and sensory loss Progressive paraparesis and sensory loss Progressive paraparesis Cauda equina syndrome Progressive paraparesis

Symptoms

4 yrs ND ND ND 4 wks 4 wks 9 mos 32 days 30 days 4 mos ND 5 wks 10 wks 1 yr 10 mos 2 yrs ND 18 mos 6 yrs 4 mos 12 yrs 9 mos 4 yrs ND 3 mos

Interval after SAH

Th6-L1 ND ND ND Th4 Th 3 C2 Th 1–3 Th 5 Th 3–8 Th6-L4 Th 1–3 C7-Th1 Th1–2 Thoracic Thoracic ND Th3–5 Th6–8 Th2–7 Th7-L1 Th8–10, L1–2 Th1–8 L1–5 C7-Th2

Location of SA

Yrs: years, F: female, M: male, SAH: subarachnoid hemorrhage, PICA: posterior inferior cerebellar artery, PcoA: posterior comminican artery, AcoA: anterior comminican artery, SA: subarachnoiditis, ND: not defined, Mos: months, Wks: weeks, Th : thoracic, L: lumbar, C: cervical.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Table I. Summary of reported cases of arachnoid cysts following subarachnoid haemorrhage. Age No Authors (year) (yrs)/ Sex Etiology of SAH

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syndrome19 and the rest had progressive paraparesis. When we examined previous cases, we concluded that SA following SAH is mostly seen on thoracic area (19/22 cases). In one patient SA has been detected on cervical area7 and in three patients it has been detected in lumbar area11,18,19 Multiple localisations have been detected in one patient (thoracic and lumbar)18 and one patient had thoracolumbar lengthening of SA.11 Because the most common site of SA is thoracic area, the most common neurological sign is paraparesis. The duration between symptom revelation and the subarachnoid haemorrhage varies. When we examine the literature, we see that there are 19 case reports in which the duration between SAH and SA has been determined. According to the information obtained from these reports, we conclude that the duration between SAH and SA differ between 30 days and 12 years and the mean duration is 4.2 years. When we exclude two cases that have 12 and 6 years of duration between SAH and the development of SA, we calculate the mean duration between SAH and SA as one year. In 20 cases of the literature (along with our case) the causes of SAH formation are determined. One patient had thrombocytopenic purpura,4 two patients (including present case) had angionegative perimesencephalic SAH13 and 17 patients had aneurysm. One of the patients with aneurysm has been detected with an anterior communicating artery aneurysm16 and the origin has not been determined in one patient.14 All the other 15 patients had aneurysms of posterior circulation; 13 of these are posterior inferior cerebellar artery and two are posterior communicating artery aneurysms. We conclude that majority of SA patients have haemorrhage in areas concerning the fourth ventricle of posterior fossa, perimesencephalic area and cerebellopontine cisterna magna. The blood that accumulates here passes to subarachnoid space via foramina of Magendie and Luschka.20 This accumulation provide basis for formation of arachnoiditis and arachnoid cyst. Hydrocephalus is an expected situation secondary to SAH due to deteriorated and blocked cerebrospinal fluid (CSF) circulation. There are 19 cases in the literature (including ours) from which we could obtain information about hydrocephalus; 8 of these patients had hydrocephalus and CSF diversion have been maintained by external ventricular drain or permanent ventriculoperitoneal shunt.

Pathophysiology It is widely believed that the presence of blood in subarachnoid space causes chronic inflammation in pia–arachnoid formation and thus causes accumulation of procollagen propeptides, fibrosis and scar formation, and therefore causes arachnoiditis and later arachnoid cyst.21–23 Following SAH, collagen synthesis markers increase and induce fibroproliferative reactions or fibrosis.24 Also, there are some hypotheses which claim that the use of fibrin glue,10 repetitive SAH and meningitis play a role in the pathogenesis of arachnoiditis.17 Further evidence is needed in order to define the exact mechanisms of the underlying pathology.

Diagnosis Today, thanks to advanced neuroimaging techniques, the diagnosis of arachnoid cysts is much easier than before.

Usually, myelography reveals partial or complete blockage and several narrowings in subarachnoid space by the irregular distribution of contrast material. CT and MRI reveal the structure of arachnoid cysts, the compression effect on spinal cord, displacement, atrophy and intramedullary cavitations. As the formation of SA and arachnoid cyst can take years, patients with SAH history and neurological signs of spinal cord compression should be evaluated for SA and it should be known that this situation is diagnosed by myelography, CT or MRI.

Treatment The treatment of SA is controversial. Use of steroids does not work and the benefits of surgery are not certain.1 Surgical decompression is effective for treatment of paraparesis due to arachnoid cyst compression. But the paraesthesia due to syringomyelia becomes permanent despite decrease in the size of syrinx cavity. Even though the placement of shunt is widely used, this operation has poor outcomes because of high syrinx recurrence ratio and infections.25 Decompression and use of cystoperitoneal shunt are most common surgical procedures.11,12,14,16 In our case, we performed a decompression surgery, then dissected arachnoid adhesions and placed a cystoperitoneal shunt.

Prognosis The prognosis of disease depends on adhesions, the size of arachnoid cyst, localisation, neurological status and certainly early diagnosis and treatment. As indicated before, in cases with syrinx cavity surgical procedures cannot improve paraesthesia.25

Conclusion Subarachnoiditis and related arachnoid cyst can cause morbidity. This rare situation that especially develops after SAH of posterior circulation should be kept in mind and it should be remembered that urgent surgical intervention is essential. Declaration of interest: The authors report no declarations of interest. The authors alone are responsible for the content and writing of the paper.

References 1. Kok AJ, Verhagen WI, Bartels RH, van Dijk R, Prick MJ. Spinal arachnoiditis following subarachnoid haemorrhage: report of two cases and review of the literature. Acta Neurochir 2000;142:795–9. 2. Quiles M, Marchisello PJ, Tsairis P. Lumbar adhesive arachnoiditis. Etiologic and pathologic aspects. Spine 1978;3:45–50. 3. Campagna MJ, Dodge HW Jr, Keith HM. Intraspinal tumors in infants and children. J Int Coll Surg 1956;26:199–215. 4. Nelson J. Intramedullary cavitation resulting from adhesive spinal arachnoiditis. Arch Neurol Psychiatry) 1943;50:1–7 5. Lombardi G, Passerini A , Migliavacca F. Spinal arachnoiditis. Brit J Radiol 1962;35:314–20. 6. Weiss RM, Sweeney L, Dreyfuss M. Circumscribed adhesive spinal arachnoiditis. J Neurosurg 1962;19:435–8 7. Tjandra JJ, Varma TRK, Weeks RDW. Spinal arachnoiditis following subarachnoid haemorrhage. Aust NZJ Surg 1989;59:84–7

Br J Neurosurg Downloaded from informahealthcare.com by SUNY State University of New York at Stony Brook on 12/21/14 For personal use only.

Spinal arachnoiditis after subarachnoid haemorrhage 8. Augustijn P, Vanneste J, Davies G. Chronic spinal arachnoiditis following intracranial subarachnoid haemorrhage. Clin Neurol Neurosurg 1989;91:347–50 9. Jourdan C, Artru F, Convert J, et al. Complication rare et grave de l’he Âmorragie me Âninge Âe: arachnoidite dorsale avec paraple Âgie. Agressologie 1990;31:413–4. 10. Taguchi Y, Suzuki R, Okada M, Sekino H. Spinal arachnoid cyst developing after surgical treatment of a ruptured vertebral artery aneurysm: a possible complication of topical use of fibrin glue. J Neurosurg 1996;84:526–9. 11. Lorenzana-Honrado L, Cabezudo-Artero JM, Gozez-Perals L. Arachnoid cyst. (Letter). J Neurosurg 1996;85:734–5 12. Tumialan LM, Cawley CM, Barrow DL. Arachnoid cyst with associated arachnoiditis developing after subarachnoid haemorrhage: Case report. J Neurosur 2005;103:1088–91. 13. Thines L, Khalil C, Fichten A , Lejeune JP. Spinal arachnoid cyst related to a nonaneurysmal perimesencephalic subarachnoid haemorrhage: case report. Neurosurgery 2005;57: E817. 14. Marshman LA , David KM, King A , Chawda SJ. Delayed fibrotic obliteration of the spinal subarachnoid space after cerebral aneurysmal subarachnoid haemorrhage. Case report. Neurosurgery 2007;61: E659–60; discussion E660. 15. Abhinav K, Bradley M, Aquilina K , Patel NK . Spinal arachnoiditis and cyst formation with subarachnoid haemorrhage. Br J Neurosurg 2012;26:574–5. 16. Eneling J, Boström S, Rossitti S. Subarachnoid haemorrhageassociated arachnoiditis and syringomyelia. Clin Neuroradiol 2012;22:169–73.

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17. Ishizaka S, Hayashi K, Otsuka M, et al. Syringomyelia and arachnoid cysts associated with spinal arachnoiditis following subarachnoid hemorrhage. Neurol MedChir(Tokyo) 2012;52:686–90. 18. van Heerden J, McAuliffe W. Spinal arachnoiditis as a consequence of aneurysm-related subarachnoid haemorrhage. J Med Imaging Radiat Oncol 2013;57:61–4 19. Whetstone KE, Crane DA . Cauda equina syndrome resulting from lumbar arachnoiditis after intracranial subarachnoid haemorrhage: a case report. PMR 2013;5:539–41. 20. Gupta S, Soellinger M, Boesiger P, Poulikakos D, Kurtcuoglu V. Three-dimensional computational modeling of subject-specific cerebrospinal fluid flow in the subarachnoid space. J Biomech Eng 2009;131:021010. 21. Koyanagi I, Iwasaki Y, Hida K, Houkin K. Clinical features and pathomechanisms of syringomyelia associated with spinal arachnoiditis. Surg Neurol 2005;63:350–5. 22. Sercombe R, Tran Dinh YR, Gomis P. Cerebrovascular inflammation following subarachnoid haemorrhage. Jpn J Pharmacol 2002;88:227–49. 23. Sajanti J, Heikkinen E, Majamaa K . Transient increase in procollagen propeptides in the CSF after subarachnoid haemorrhage. Neurology 2000;55:359–63. 24. Sajanti J, Majamaa K. Detection of meningeal fibrosis after subarachnoid haemorrhage by assaying procollagen propeptides in cerebrospinal fluid. J Neurol Neurosurg Psychiatry 1999;67:185–8 25. Chang HS, Nakagawa H. Theoretical analysis of the pathophysiology of syringomyelia associated with adhesive arachnoiditis. J Neurol Neurosurg Psychiatry 2004;75:754–7.

Spinal arachnoid cyst associated with arachnoiditis following subarachnoid haemorrhage in adult patients: A case report and literature review.

Arachnoiditis is an inflammatory process resulting with the fibrosis of arachnoid mater. It can vary in severity from mild thickenings to catastrophic...
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