Teflon sponge shunt for recurrent arachnoid cyst.(Case Report)(Case study)(Clinical report)

Byline: Atul. Goel, Abhidha. Shah, Samir. Pareikh

A 50-year-old female presented with complaints of progressive ataxia. Investigations showed a large intradural arachnoid cyst located anterior to the brainstem. Following marsupialization of the cyst she improved remarkably in her symptoms. The symptoms recurred nine months later and investigations revealed recurrence of the cyst. The cyst was evacuated again and two Teflon sponge sheets were placed such that they traversed the length of the cyst cavity and extended into the cisterna magna. At follow-up after 25 months, there has been no recurrence of symptoms or the cyst. The role and advantages of Teflon sponge in such cases is evaluated.

Introduction

Symptomatic recurrence of arachnoid cyst after partial wall resection or marsupialization is a well-known phenomenon. A variety of shunt procedures have been advocated to prevent cyst recurrence. We report a case where the cyst was located anterior to the brainstem and a radical total resection of the cyst wall was not possible. Recurrence of the cyst was treated with a cyst to subarachnoid space Teflon sponge shunt. We believe that such a shunt could be a useful mode of treatment of arachnoid cysts.

Case Report

A 50-year-old- female presented with symptoms of headache and progressive ataxia. Neurological examination revealed mild papilledema and marked truncal ataxia. Magnetic resonance imaging (MRI) showed a large cyst located anterior to the brainstem and resulted in its significant posterior hump [Figure 1]. A posterior midline approach was adopted. The cyst containing clear cerebrospinal fluid (CSF) was drained after exposing it from between the lower cranial nerves. The entire surgical field collapsed as soon as the cyst was evacuated. This made identification of the cyst wall difficult and its safe isolation from the adjoining arachnoid membrane, cranial nerves and blood vessels impossible. The patient had rapid improvement of symptoms following surgery and she returned to her normal lifestyle. She followed up nine months after surgery with complaints of recurrence of symptoms of progressive ataxia. Repeat MRI showed recurrence of the large arachnoid cyst. The lesion was again approached from the same exposure. After evacuation of the cyst, two 4 mm thick, 8 mm wide and 30 mm long Teflon sponge strips were placed that extended from the cyst cavity to the cisterna magna. The Teflon sheaths were anchored with a stitch to the dura and arachnoid in the region of the foramen magnum. The patient improved again after surgery and at follow-up after 25 months there has been no recurrence of symptoms. A track of CSF could be seen along the site of the Teflon sheath, probably suggesting functioning of the shunt [Figure 2],[Figure 3].

Discussion