Endoscopic Clipping of a Middle Cerebral Artery Aneurysm in a Middle Fossa Arachnoid Cyst and Review of the Literature

Abstract

Background: Arachnoid cysts are often associated with subdural hematoma following head trauma. The incidental finding of an aneurysma and a cyst is rare. We describe for the first time the treatment of such a case using endoscopic techniques.

Case Report: A 44-year-old man was admitted to our hospital with a mild headache and a hemifacial spasm attack at the right side of his face. The radiological examinations demonstrated bilateral slyvian fissure arachnoid cysts and an aneurysm with the dome projecting superolaterally, at the bifurcation of the right middle cerebral artery in the arachnoid cyst. The patient underwent a complete endoscopic surgical clipping of the aneurysm, and partial excision of the right cyst wall and bilateral fenestration to the basal cistern via a single burr-hole craniectomy at the right temporal region. The patient had an uneventful postoperative course without neurological impairment and complication. However, his complaints still persisted postoperatively.

Conclusion: Endoscopic management of arachnoid cysts is an effective and less morbid treatment. This less invasive option might be safe for the clipping of aneurysms within an arachnoid cyst with no additional morbidity for the patient. With smaller operative exposures and yet better visualization offered, neuroendoscopy may reduce operative morbidity.

endoscopy - intracranial aneurysm - vascular NS - arachnoid cyst

References

• 1 Auer LM, Gallhofer B, Ladurner G. et al . Diagnosis and treatment of middle fossa arachnoid cyst and subdural hematoma.  J Neurosurg. 1981;  54 366-369
• 2 Mori T, Fujimoto M, Sakae K. et al . Disappearance of arachnoid cyst after head injury.  Neurosurgery. 1995;  36 938-942
• 3 Ochi M, Morikawa M, Ogino A. et al . Supratentorial arachnoid cyst and associated subdural hematoma: neuroradiologic studies.  Eur Radiol. 1996;  6 640-644
• 4 Barker RA, Phillips RR, Moseley IF. et al . Posterior communicating artery aneurysm presenting with haemorrhage into an arachnoid cyst.  J Neurol Neurosurg Psychiatry. 1998;  64 558-560
• 5 Berhouma M, Jemel H, Khaldi M. Aneurysm ruptures into an arachnoid cyst of the middle cranial fossa.  J Neuroradiol. 2006;  33 206-207 (Fr)
• 6 Hirose S, Shimada S, Yamaguchi N. et al . Ruptured aneurysm associated with arachnoid cyst: intracystic hematoma without subarachnoid hemorrhage.  Surg Neurol. 1995;  43 353-356
• 7 Huang D, Abe T, Kojima K. et al . Intracystic hemorrhage of the middle fossa arachnoid cyst and subdural hematoma caused by ruptured middle cerebral artery aneurysm.  AJNR Am J Neuroradiol. 1999;  20 1284-1286
• 8 Jinkins JR, Siqueira EB, Holoubi A. Ruptured middle cerebral aneurysm with accumulation of subarachnoid blood within convexity arachnoid cyst.  Comput Radiol. 1987;  11 185-187
• 9 Kajýwara I, Tanaka T, Kan I. et al . Intracystic hematoma of middle fossa arachnoid cyst caused by rupture of internal carotid-posterior communicating artery aneurysm: case report.  Neurol Med Chir (Tokyo). 2008;  48 220-222
• 10 Kocaeli H, Korfali E. Rupture of a small middle cerebral artery aneurysm into middle fossa arachnoid cyst presenting as a chronic subdural hematoma: Brief report of special case.  Acta Neurochir (Wien). 2008;  150 407-408
• 11 Marcoux J, Roy D, Bojanowksi MW. Acquired arachnoid cyst after a coil-ruptured aneurysm.  Case illustration. J Neurosurg. 2002;  97 722
• 12 Shimazu M, Homma M, Kaji M. et al . A case of ruptured aneurysm associated with arachnoid cyst.  Nihon Kyukyu Igakkai Zasshi Kantoshi. 1990;  11 684-686 (Jpn)
• 13 Zanini MA, Gabarra RC, Faleiros AT. et al . Cerebral aneurysm and arachnoid cyst: about a case with intracystic hemorrhage.  Arq Neuropsiquiatr. 2000;  58 330-335 (Portuguese)
• 14 Chhabra VS, Zhang J, Olson JJ. Association between an arachnoid cyst and intracranial aneurysms misdiagnosed as a cystic tumor with a mural nodule. Case report and review of the literature.  Neurosurg Focus. 2007;  22 E3
• 15 Ge PL, Chen QX, Chen ZB. et al . Arachnoid cyst complicated with an inner aneurysm: case report.  Chin Med J. 2007;  120 2344-2345
• 16 Hirota N, Ueno J, Naitoh H. et al . Giant aneurysm associated with a large cyst. Case illustration.  J Neurosurg. 1999;  91 160
• 17 Leo JS, Pinto RS, Hulvat GF. et al . Computed tomography of arachnoid cysts.  Radiology. 1979;  130 675-680
• 18 de Oliveira JG, Giudicissi-Filho M, Rassi-Neto A. et al . Intracranial aneurysm and arachnoid cyst: a rare association between two cerebral malformations.  Br J Neurosurg. 2007;  21 406-410
• 19 Sato N, Sze G, Awad IA. et al . Parenchymal perianeurysmal cystic changes in the brain: report of five cases.  Radiology. 2000;  215 229-233
• 20 Schumacher M, Baust W, Terwey B. Unusual combination of cerebral dysplasias. Report of two cases.  Neurochirurgia (Stuttg). 1986;  29 210-214
• 21 Takai K, Nishihara T, Nemoto S. et al . Multilocular cystic lesion associated with a giant aneurysm.  J Neurosurg. 2001;  95 1081
• 22 Galassi E, Piazza G. Arachnoid cysts of the middle cranial fossa: a clinical and radiological study of 25 cases treated surgically.  Surg Neurol. 1980;  14 211-219
• 23 Galassi E, Gaist G, Giulani G. et al . Arachnoid cysts of the middle fossa: experience with 77 cases treated surgically.  Acta Neurochir Suppl (Wien). 1988;  42 201-207
• 24 Becker T, Wagner M, Hofmann E. et al . Do arachnoid cysts grow? A retrospective CT volumetric study.  Neuroradiology. 1991;  33 341-345
• 25 Levy ML, Wang M, Aryan HE. et al . Microsurgical keyhole approach for middle fossa arachnoid cyst fenestration.  Neurosurgery. 2003;  53 1138-1145
• 26 Albuquerque F, Giannotta S. Arachnoid cyst rupture producing subdural hygroma and intracranial hypertension: case reports.  Neurosurgery. 1997;  41 951-954
• 27 Arai H, Sato K, Wachi A. et al . Arachnoid cysts of the middle cranial fossa: experience with 77 patients who were treated with cystoperitoneal shunting.  Neurosurgery. 1996;  39 1108-1113
• 28 Boutarbouch M, El Ouahabi A, Rifi L. et al . Management of intracranial arachnoid cysts: institutional experience with initial 32 cases and review of the literature.  Clin Neurol Neurosurg. 2008;  110 1-7
• 29 Daneyemez M, Gezen F, Akboru M. et al . Presentation and management of supratentorial and infratentorial arachnoid cysts: review of 25 cases.  J Neurosurg Sci. 1999;  43 115-121
• 30 Erdincler P, Kaynar MY, Bozkus H. et al . Posterior fossa arachnoid cysts.  Br J Neurosurg. 1999;  13 10-17
• 31 Huang Q, Wang D, Guo Y. et al . The diagnosis and neuroendoscopic treatment of noncommunicating intracranial arachnoid cysts.  Surg Neurol. 2007;  68 149-154
• 32 Schroeder HW, Gaab MR, Niendorf WR. Neuroendoscopic approach to arachnoid cysts.  J Neurosurg. 1996;  85 293-298
• 33 Eloy JA, Carai A, Patel AB. et al . Combined endoscope-assisted transclival clipping and endovascular stenting of a basilar trunk aneurysm: case report.  Neurosurgery. 2008;  62 (3 Suppl 1) 142-143
• 34 Kassam AB, Mintz AH, Gardner PA. et al . The expanded endonasal approach for an endoscopic transnasal clipping and aneurysmorrhaphy of a large vertebral artery aneurysm: technical case report.  Neurosurgery. 2006;  59 (1 Suppl 1) ONSE162-ONSE165
• 35 Dix GA, Gordon W, Kaufmann AM. et al . Ruptured and unruptured intracranial aneurysms − surgical outcome.  Can J Neurol Sci. 1995;  22 187-191
• 36 Fogelholm R, Hernesniemi J, Vapalahti M. Impact of early surgery on outcome after aneurysmal subarachnoid hemorrhage. A population-based study.  Stroke. 1993;  24 1649-1654
• 37 Samson D, Batjer HH, Kopitnik Jr TA. Current results of the surgical management of aneurysms of the basilar apex.  Neurosurgery. 1999;  44 697-702
• 38 Wang E, Yong NP, Ng I. Endoscopic assisted microneurosurgery for cerebral aneurysms.  J Clin Neurosci. 2003;  10 174-176
• 39 Gumprecht H, Trost HA, Lumenta CB. Neuroendoscopy combined with frameless neuronavigation.  Br J Neurosurg. 2000;  14 129-131
• 40 Mangano FT, Limbrick Jr DD, Leonard JR. et al . Simultaneous image-guided and endoscopic navigation without rigid cranial fixation: application in infants: technical case report.  Neurosurgery. 2006;  58 (4 Suppl) ONSE377
• 41 Rohde V, Reinges MH, Krombach GA. et al . The combined use of image-guided frameless stereotaxy and neuroendoscopy for the surgical management of occlusive hydrocephalus and intracranial cysts.  Br J Neurosurg. 1998;  12 531-538

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