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Arachnoid cysts (ACs) are developmental anomalies formed by splitting the arachnoid membrane's layers. ACs contribute around 2% of all intracranial space–occupying lesions. ACs are more prevalent in children. Because of varied clinical presentation, there has been a constant need for clinicoradiologic risk stratification with a possible role in outcome prediction. The present study describes the management strategies and outcomes in symptomatic intracranial ACs. All biopsy-proven symptomatic patients who underwent surgical management over last 15 years were included in this study (January 2008–December 2022), while those with non-conclusive biopsies were excluded. Patients presenting with acute deterioration were managed in the emergency department with or without cerebrospinal fluid diversion and decompression of the AC. The microsurgical or endoscopic approach was the preferred surgical modality. Postoperative clinicoradiologic improvement was evaluated at 3 months follow-up visit. A total of 108 patients were analyzed in this retrospective observational study. The median age of the patients was 27.5 years (range, 1 to 76 years). Headache was the most typical clinical presentation. Supratentorial ACs (n = 59, 54.6%) were higher than the infratentorial ACs (n = 49, 45.4%). Forty-seven patients belonged to the pediatric age group (<18 years), and seizure was their presenting complaint. In this observational study, there was no statistical difference in operative duration between microsurgical technique versus endoscopic decompression (P = 0.23). ACs are uncommon brain lesions having a broad spectrum of symptoms. The location and clinical presentation of ACs decide the preferred surgical approach. Individuals in high-risk groups must be treated on priority to achieve long-term relief of symptoms. [ABSTRACT FROM AUTHOR]

Generally, enlargement of arachnoid cysts (ACs) has been found mostly in cases occurring during early childhood. Therefore, progressively enlarged ACs found to be symptomatic in elderly patients are extremely rare, and the mechanisms have remained unexplored. Our first patient was a 72-year-old woman with memory disturbance, who had presented with a large cyst beneath the right temporal convexity 9 years previously. The annual follow-up magnetic resonance imaging (MRI) studies had revealed that the cyst had progressively enlarged. In addition, her memory disturbance had become advanced. Endoscopic cyst fenestration was performed between the cyst and lateral ventricle, resulting in a reduction of her symptoms. Our second patient was a 79-year-old woman with unsteadiness, who had presented with a large cyst under the right parietal convexity 6 years previously. The annual follow-up MRI studies had shown that the cyst had gradually enlarged. She subsequently developed left hemiparesis. Because the pyramidal tract was located between the cyst and ventricle, a cyst–ventricle shunt was placed to allow the cystic fluid into the lateral ventricle, with complete resolution of her symptoms. In both cases, MRI showed obliteration of the subdural spaces around the cysts. Endoscopic observations revealed that the arachnoid membrane was lined under the surrounding brain, leading to the diagnosis of an AC. The establishment of stable communication between a cyst and the normal cerebrospinal fluid space is important to treat symptomatic ACs characterized by progressive enlargement, even in elderly patients. The 1-way entry of the cerebrospinal fluid into the cyst and the closure of the surrounding subdural space might result in AC enlargement internally. [ABSTRACT FROM AUTHOR]

To evaluate the feasibility, success rate, and safety of endovascular revascularization of nonacute symptomatic proximal extracranial vertebral artery occlusion (PEVAO). In a retrospective, single-center study, we analyzed clinical and imaging data from consecutive patients with PEVAO who underwent endovascular revascularization from June 2011 to March 2018. The study enrolled 23 patients (mean age, 59 years; range, 42–77 years; 17 men). The rate of successful technical revascularization was 91.3% (n = 21), and the rate of complications was 4.3% (n = 1). At 3-month follow-up, the patients with successful endovascular revascularization of nonacute symptomatic PEVAO did not present any neurologic symptoms and computed tomography angiography did not show restenosis of the stent. Endovascular revascularization of nonacute symptomatic PEVAO is feasible and associated with a high rate of procedural success and low rate of procedural complications. A large, multicenter, randomized study is warranted to confirm the findings. [ABSTRACT FROM AUTHOR]

Background Surgical intervention in a case of internal carotid artery stenosis with moyamoya vessels has not been well described. We present a case with detailed description of the surgical procedure and perioperative management. Case Description A 58-year-old man with symptomatic internal carotid artery stenosis had concurrent moyamoya vessels intracranially. He had motor weakness and numbness in the left upper extremity. Magnetic resonance imaging showed an ischemic lesion in the right frontal lobe and right chronic subdural hematoma. On day 18 after surgery for subdural hematoma, carotid artery stenting was performed under proximal balloon protection and distal filter protection. After carotid artery stenting, systolic blood pressure was maintained at <120 mm Hg. Hyperperfusion syndrome or hemorrhagic complication did not occur. The patient was discharged without any neurologic deficits. Conclusions In our patient with internal carotid artery stenosis with moyamoya vessels, strict control of blood pressure likely contributed to prevention of hyperperfusion syndrome or hemorrhagic complications. [ABSTRACT FROM AUTHOR]

Background Cerebral cavernous malformations are more common than generally thought, affecting approximately 1 in every 250 adults. Most of these lesions are asymptomatic or have a relatively benign course, but a small minority behave aggressively and present with recurrent episodes of symptomatic hemorrhage. A safe and effective medical treatment option for the management of this latter group would be useful. Propranolol has recently been shown to be effective in the treatment of infantile hemangioma, a close pathologic counterpart of cavernous malformations. These results suggest a potential role for propranolol treatment in the management of patients with symptomatic cavernous malformations. Methods Low-dose propranolol (20 mg, three times daily) was used to treat 2 adult female patients in their mid- to late fifties, both of whom had symptomatic cavernous malformations and a history of repeated hemorrhage. Serial magnetic resonance imaging studies after the initiation of propranolol demonstrated regression of the lesions and no evidence of recurrent hemorrhage. Conclusions Propranolol may offer a safe and effective treatment for patients who have cavernous malformations with symptomatic hemorrhage. Additional studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

Most pineal cysts are not surgical lesions and should be conservatively managed. Select lesions, notably those that present with hydrocephalus and Parinaud syndrome and lesions presenting with symptoms consistent with intermittent blockage of cerebrospinal fluid pathways and/or neurovascular compression, however, can be considered for surgical intervention. Two workhorse surgical approaches to the pineal region include the occipital interhemispheric transtentorial and supracerebellar infratentorial approaches. Each approach provides unique benefits and drawbacks and is associated with morbidities. In this patient, we demonstrate the use of a minimally invasive, supine, lateral supracerebellar infratentorial approach to the pineal region (Video 1). The approach makes use of early access to the foramen magnum to release cerebrospinal fluid for cerebellar relaxation, followed by navigation-guided, minimal dissection of the supracerebellar potential space to arrive at the pineal cyst. Opening of the arachnoid membranes ventrolateral to the confluence of the deep cerebral veins allows for direct access to the cyst with minimal manipulation of the venous complex and risk for injury. The cyst is then fenestrated, and the cyst capsule is removed. It should be noted that surgical fenestration does not guarantee relief of headache symptoms, and patients should be consoled about this preoperatively. [ABSTRACT FROM AUTHOR]

Cardiac myxomas are benign cardiac neoplasms that can send a shower of emboli to cerebral arteries and cause cerebrovascular complications including large, fusiform intracranial aneurysms. These aneurysms result from myxomatous cells invading and weakening the vessel wall and can develop years after myxoma resection. In this clinical image, we illustrate a symptomatic, giant fusiform aneurysm that was discovered and treated 5 years after successful surgical resection of atrial myxoma. [ABSTRACT FROM AUTHOR]

Background The treatment of Tarlov cysts is challenging and difficult. The objective of our study was to describe the security and efficacy of the subcutaneous infusion port for drainage of symptomatic Tarlov cysts. Methods The authors executed a retrospective review of data from 5 symptomatic Tarlov cysts patients who were treated using a subcutaneous infusion port from June 2014 to July 2017. Numerical Rating Scale scores and the Japanese Orthopedic Association scores of back pain were analyzed. Complications and adverse effects on postoperative days 1, 7, 14, and 28 were also analyzed. The mean follow-up was 12.6 months. Results Five adults (3 females and 2 males) who had been symptomatic received a subcutaneous infusion port. After treatment, all patients experienced pain relief and pain alleviation lasted from 1 day to 3 years without complications and adverse effects. Conclusions A subcutaneous infusion port is a useful treatment option for symptomatic Tarlov cysts. When the patients’ symptoms returned and the cysts repressurized, we quickly and simply drained the cysts by using the infusion port. [ABSTRACT FROM AUTHOR]

Background Ecchordosis physaliphora (EP) is a benign notochordal remnant that is usually asymptomatic. We report a case of a symptomatic large EP mimicking an epidermoid cyst. Case Description A 44-year-old woman presented with right facial dysesthesia. Brain magnetic resonance imaging showed a mass with a diameter of 3.2 cm that was hypointense on T1-weighted imaging, hyperintense on T2-weighted imaging, isointense to hyperintense on diffusion-weighted imaging, and hyperintense on apparent diffusion coefficient map (1.2–1.6 × 10 −3 mm 2 /second). There was no apparent contrast enhancement. Differential diagnoses included epidermoid cyst, dermoid cyst, EP, chordoma, chondrosarcoma, neurenteric cyst, and arachnoid cyst. Clinicopathologic examination revealed that the mass was an EP. Conclusions EP in the prepontine cistern should be considered in the differential diagnosis of epidermoid cyst. [ABSTRACT FROM AUTHOR]

Background Instances of ectopic salivary gland tissue within the pituitary gland are rare, they are mostly asymptomatic, and the underlying pathophysiology of symptomatic cases is unclear. We report a case of intrasellar salivary gland rest that presented clinical symptoms and clearly related to inflammatory changes. Case Description In the present case, headache, bitemporal hemianopia, and hormone abnormality led to the detection of ectopic salivary gland tissue within the pituitary gland of a 24-year-old man. Imaging revealed a well-circumscribed intrasellar cystic lesion having a diameter of major axis of 16 mm, for which tumorectomy was performed using the nasal approach. The tumor was cystic with stringy content. Pathologic findings revealed that the lesion was composed principally of secretions lacking cell components, whereas the salivary gland tissue was found in the cyst wall. Dilated ducts due to the leakage of secretions were also observed. Acute and chronic inflammation was present around the salivary gland. Conclusions Not only are instances of symptomatic ectopic salivary glands rare, but this was also the first case detected to be caused by the pathophysiology involving the leakage of secretions from an ectopic salivary gland and associated inflammation. We report this case to help elucidate the pathophysiology of the condition. [ABSTRACT FROM AUTHOR]