ARACHNOID CYSTS OF THE CENTRAL NERVOUS SYSTEM in Kamenge

University Hospital Center: About a case and literature review

Dr. Herve NIKUZE, D.E.S. Intensive Care Unit /Kamenge University Hospital Center.
Wednesday, 7/10/2020.

I. INTRODUCTION
Arachnoid cysts of the central nervous system are defined as cystic cavities of a benign
nature, containing a clear fluid whose composition is close to that of cerebrospinal fluid and
which are limited by a wall developed at the expense of the arachnoid cells.
Arachnoid cysts of the central nervous system account for about 1% of all non-traumatic
spinal cord compression and expansion processes.
Their etiopathogeny remains controversial to this day. They are in the majority of cases
congenital but can be acquired.
Clinically, they can be asymptomatic. When they are symptomatic, they can be revealed by
any neurological sign depending on their size and location (1, 2)
The overall objective of this work is to "Contribute to the medical and surgical management
of patients suffering from arachnoid cysts".
III. PATIENT AND OBSERVATION
3-year-old male child, transferred to the Kamenge University Hospital for the treatment of
paralysis of the entire left hemi body, due to an intracranial arachnoid cyst.
The symptomatology had started in January 2020 with a limp of the left leg, his mother did
not consult immediately because she thought it was a simple trauma. Afterwards, he
developed a fever which led him to consult at his local Health Center; he was given a thick
drop positive and was put on Artesunate and Amodiaquine. Malaria was successfully treated.
Given the persistence of the limp, the mother began sessions of massage of the left leg with
hot water. The symptomatology did not give way but was aggravated by hypo motricity of the
right arm, progressive loss of sensitivity, ptosis of the right eye, deviation of the mouth and
dysarthria, headaches predominating in the morning and the second half of the night.
The intensification of the symptomatology made the parents who first consulted the Regional
Hospital of Ngozi. According to the mother, the doctor considered physiotherapy but asked
for a brain scan before starting it. The parents did not have the scan immediately but consulted
a center for the disabled in Muyinga the next day. The consulting doctor also prescribed a
brain scan, which was done four days later. The results of the imaging showed a large
arachnoid cyst in the temporal territory with a mass effect on the paramedian structures as
well as hydrocephalus.
He was then referred to a neurologist who in turn referred him to a neurosurgeon after
prescription of Depakine
Background:
- Medical:
Ante-natal: 5th child born through the vaginal route, extended vaccination program well
monitored and closed.
Objective rhythm disturbances in pre-anaesthetic consultation
- Surgical:
Nothing to report
Vital parameters and measurements made at the entrance:
FC: 104/’, Fr: 28/’ T˚: 37˚C, Weight: 12kg.
The physical examination took place in a conscious and cooperative child: Glasgow Score :
15/15, motor score for right limb: 5/5, for left upper limb: 4/5 and left lower limb: 3/5.
Sensitivity was decreased for the whole left hemi body. Facial paralysis and ptosis. The rest of
the physical examination did not note any special features
The tests done in the emergency room were the blood count which showed white blood cells
at 6590/microL, haemoglobin at 12.7g/dl, platelets: 385000/microL. Urea and creatinine were
within norms, while blood glucose was 4.0 mmol/L.
During the pre-anaesthetic consultation, a heart rhythm disorder and a murmur was detected
during auscultation of the mitral focus. A cardiac ultrasound was requested and the operation
was postponed. The cardiac ultrasound showed undilated heart cavities with non-
hypertrophied walls, irregular contractility, more or less calcified valves with grade 2 mitral
murmur. In conclusion the child presented a mitral disease with rhythm disorders.
The intervention scheduled for 25 February was made at 03/03/2020.
The child was hospitalized in the intensive care unit for post-operative follow-up. He was put
on Cefotaxime meningeal dose, 800 mg every 6 hours, gentamycin 30 mg every 24 hours,
paracetamol 15mg/kg/6 hours i.e. 200 mg every 6 hours + Tramadol 20mg/6h, phenobarbital
5mg/kg i.e. 60 mg per day.
On the same day of the operation, at H2 postoperative, the child developed tonic-clonic
convulsions of the left hemi corps which gave way after administration of valium 6mg
intravenously. His first three days of hospitalization in intensive care were marked by
paroxysmal convulsions which regressed from D4 until his transfer to the surgical department
for continued care on D6 postoperatively.
By D8 postoperatively, he had almost completely regressed all the signs which had motivated
the consultation; sensitivity, dysarthria, ptosis, morning headaches and vomiting. Motor skills
were slowly recovering and were not yet complete. Physiotherapy was not prescribed.
Discharge from hospital was authorized on 11 March 2020.
IV. DISCUSSION AND REVIEW OF LITERATURE
1. Epidemiology
Arachnoid cysts are the most common cerebral malformation and are most often a chance
discovery (3). Most arachnoid cysts are small and asymptomatic. The symptoms depend on
the location and size of the cyst.
2. Age distribution:
All authors agreed on the clear predominance of intracranial arachnoid cysts in children.
- For Boutarbouch (1), 53% of the patients were under 15 years old.
- For Zain alabedin (4), 76% of the patients were under 15 years old.
In our study, it was a small child of 3 years old, we have similar results to those of the other
authors.
3. The distribution by sex
In several series the male sex was more affected than the female sex:
- 59% for Boutarbouch(1)
- 60% for Gabriel Zada(5)
These results are similar to those of our case.
4. CLINIC
The clinical signs of calling are variable and non-specific and depend on the location of the
arachnoid cyst.
The most common signs in children are intracranial hypertension, macrocranial and cranial
deformity, whereas they are predominantly headache and epilepsy in adults (6)
The association of hydrocephalus is estimated to be between 30 and 60% (7) and is mainly
associated with non-hemispheric cysts.
In our research setting, symptomatology was dominated by sensory-motor deficit,
convulsions, dysarthria, headache vomiting, ptosis and facial paralysis.

5. PARACLINIC:
Currently, MRI is the technique of choice for the diagnosis of intracranial arachnoid cysts.
It makes it possible to study the communication with the subarachnoid space. It can also be
used to rule out certain lesions that are a differential diagnosis on scan. Thus, it leads to
differentiate between the arachnoid cyst in the dandy Walker malformation and the mega
large cistern based on the study of the 4th ventricle and the vermis, which remain intact but
can be compressed in the case of arachnoid cyst (7)
Finally, it is interesting to note that fetal cerebral MRI confirms the diagnosis of arachnoid
cyst made by prenatal ultrasound, searches for other cerebral abnormalities and optimises
neonatal management by accurately determining the fetal cerebral anatomy (8).
In our study, MRI was not performed due to lack of availability.
V. CONCLUSION
Arachnoid cysts of the central nervous system are benign collections of cerebrospinal fluid,
but which can by their evolutionary potential cause significant neurological damage in the
absence of early diagnosis and adequate treatment.
Most patients are asymptomatic and should not be treated but only monitored. For
symptomatic cysts, the best treatment is surgical, but the modalities are varied and still
controversial.
The evolution is good after surgical treatment.

VI. REFERENCES
1. Boutarbouch M, El Ouahabi A, Rifi L, Arkha Y, Derraz S, El Khamlichi A. Management
of intracranial arachnoid cysts: institutional experience with initial 32 cases and review of
the literature. Clinical neurology and neurosurgery. 2008;110(1):1-7.
2. Gómez CE, García IM, Galán LD, Gimenez-Torres M, Simon-Heras R, Valencia J, et al.
Intracranial arachnoid cysts. A study of a series of 35 cases. Revista de neurologia.
2001;33(4):305-11.
3. Catala M, Poirier J. Arachnoid cysts: histologic, embryologic and physiopathologic review.
Revue neurologique. 1998;154(6-7):489-501.
4. Jamjoom ZAB. Intracranial arachnoid cysts: treatment alternatives and outcome in a series
of 25 patients. Annals of Saudi medicine. 1997;17(3):288-92.
5. Zada G, Krieger MD, McNatt SA, Bowen I, McComb JG. Pathogenesis and treatment of
intracranial arachnoid cysts in pediatric patients younger than 2 years of age.
Neurosurgical focus. 2007;22(2):1-5.
6. Gelabert-Gonzalez M. Intracranial arachnoid cysts. Revista de neurologia.
2004;39(12):1161-6.
7. Cincu R, Agrawal A, Eiras J. Intracranial arachnoid cysts: current concepts and treatment
alternatives. Clinical neurology and neurosurgery. 2007;109(10):837-43.
8. Osborn AG, Preece MT. Intracranial cysts: radiologic-pathologic correlation and imaging
approach. Radiology. 2006;239(3):650-64.