Originalarbeiten - Ar ticles
177
Arachnoid cysts of the middle cra nial fossa
K. von Wild
Neurochirurgische Abte ilung Clemenshos pttal. Akadem isches Lehrkr anke nhaus
der westr. wühefms-unrversüät Münster
Sum m ary
In 18 cas es of temporal arachnoid cysts the
etiology. clinical a nd radiographie ündtngs. surgical
treat ment. and outcome are reviewed . Cysts of the
middle erentel fossa are susceptible to trauma, which
may cause bleeding either Into the cyst or lnto the sub-
dural space. er or MRI sean s are dta gnosdc in arach-
noid cysts . In cases ofintracranial mas s lesion with dis -
placem ent of th e midline str uctures end increas ing [e p,
osteoplastic craniotomy ts performed and the medial
wa ll of tbe cyst is resected down to the tentorial notch .
with opening tnto the basal ciste rns . Ther e were 00
operative or postoperative complicat ions in 18 consecu-
tive cas es. However, one boy required a cysto peritoneal
shunt 3 months la ter as a result of hydrocephalus fol-
lowing subdural hematoma a nd two other pati ents were
also subsequently shunted. Asymptomatic a raeh noid
cysts are disoussed with the respect to brain function
and potential risks.
Key-words
Arac hnoid cyst s - Subdura l hematoma -
Hydr ocephalus - Peritoneal shunt - Microsurgica l tech -
nique - Congemtal Jestons
Introdu cnon
Although recent studies ha ve evaluated new
concepts of the pathogenesis. anatomieal ultrastructure,
clinioal an d radiclogical manifestations of intr aarachnoid
cysts, as the y are called today, the re ts an ongotng debate
a s to the cho iee of their proper surgi cal treatment in re -
spect to the final outcome of patients in the pedtatric and
ad ult age group (5, 8, 10, 12,1 5, 16. 21, 23). Since the ad -
vent of cranial com puterized tomography (CT). num erou s
case reports have been presented. We are in a greement
with most of the se a uthors that these lesion s are much
more common the n previously rea lized when they are dt-
agnosed by chance being asym pto mati c before. According
to Robinson (19, 20) arachnoid cysts account for ahout 1 %
of all atra umatic intracranial mass lestons. Most of the
cysts become symptomatic in ea rly ch ildhood in so far as
Neurochirurgia 35 (1992) t 77- 182
© Georg Thleme Verla g. Stuugart - Npw York
Arac hnoidalzyste n de r mittl e ren
Schädelgru be
Die derzeitigen diagnostisc hen und neu -
roch irurgischen Beha ndlungsmögliehkeiten von temp o-
ralen Arac hnoidalzysten werden vor dem Hintergrund
gesicherter pathologisch-anatomis cher Kenntnisse an
typischen Beispiele n von 3 Kind ern und 15 Erwa ch -
senen a ufgezeigt. Hierbei verd ient Beachtung, daß diese
Zysten, die etw a die Hä lfte aller intrak ra niellen Arac h-
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noidalzysten ausmachen, durch lan gsame Größenzu-
nahme Ursa che lokaler Hirndruckzeichen und von Li-
quorzt rkulationsstörungen sein könn en. Besonders bei
Kind ern besteht die Gefahr subduraler Blutungskompli-
kationen nach leichten Schädelhirn verletz ungen und die
Möglichkeit von zerebralen Kr ampfanfällen. Schließ lich
bewirken die Zyste n eine Entwicklungshemmung der
verlagert en und komprimiert en Hirnlap penstru ktu ren.
die sieh nach erfolgreicher Entlastun g wieder a usdeh-
nen. Die Vorteile der mikrochirurgischen Zyst enwand-
resektion mit Wiederherstellung einer freien basale n
Uquorzirkulation sowie die Möglichkeite n eines ven-
triku lo- oder zysto-peritoneale n Shunts wer den auf-
grund eigener Erfahrungen und unte r Berücksi chtigung
der Literatur diskuti er t.
60 % to 90 % of pe uents in mixed sories have been shown
to be in the pediatric age group (I , 2, 8, 9, 14- 17). The dis -
tribution of arachnoid cysts in two hundred and eight col-
lected cases of Rengachary et al. (17) was as follows . Syl-
vian fissure, 49 %; cerebellopo ntine angle, 11 %; supra-col-
licula r a rea , 10 %; the vermts. 9 %; sella r and suprasellar
area. 9 %; interhemispheric fissure , 5 %; cerebral convex-
ity, 4 %; the d ival and interpeduncular a rea. 3 % . This
paper will deal exclusively with cysts ofthe mlddle cranial
fossa since they consütute abo ut one ha lf of all cases and
a re of major neurosur gtcal interest on account of malfor-
matio n of the base of the skull and fronto-tempora l bone,
progressive hydrocephalus syndrome , epilepsy, and are an
im porta nt cause of associated hemorrhagic comp lications
after minor head trauma (1, 4, 5 - 9, 11-13, 17, 18,27).
Pathology
Morpho logical studies during the last two
decades have elucidated the pa thogenesis as weil as the
anato mieal ultra structure of intraarachno id cysts , which
were described for the first tim e by Bright (3) in 183 1.
178 Neurochirurgia 35 (1992)
llowever, the cause of the a rachnoid eysts in generar re-
mains still controverstal. They are classlfled today Into two
groups:
- first: ccngenita l ma lform ations tptgs. 1- 8) (4.8. 11, 17 -
20 .2 2,25) .
- second . resulting from lnfla mmatlon , herncrrhage. tra u-
ma , tumor (1 . 12, 24).
Distin ct from these intra ar a chnoid eysts the
middle -fossa pitholes and the tnt radiploic a raehnoid cysts
are different pa thogenetic enuues (26) . arid are not dis-
cussed he re . The historieal rovlew shows tha t ara chnold
cysts ha ve been given a vartety of designa tions, reflecting
differe nt pathogenetie fac tors, for insta nce: ehronie cystic
arachnoiditis. meningitis serosa ctrc umsc rtpta. eh re nie
a rac hnciditis. cere bral pseudotumur, leptomemngaal cyst,
or simply pnmary oth erwise idio pathic arachno id cyst (24).
There is clear cvlden ce that som e arachnoid
cysts do commun icate with the suba raehnoid space. This is
bea utifully demonstrated by isotope cistern ogra phy end
still better today wit h cont rast me dium CT ctsternog ra ph y
(9) (Figs. 2 - 4). Aeeor din g to these functional studie s we call
the m communicating or noncommunieating arachnoid
cysts. These cysts have to be dist ingu ished from morpho-
logica l findings like arachnotd diverüculum, ara chnoid
hernia, aru chnold pouch . internalmeningoeele, and arach-
noidoceie (18).
Starkman et al. (24) have demonstrated for
the first tim e, by evalua ting histologica l deta ils. dtfferences
in the a natomieal relationships of the idiopathic eysts from
those following inflamma tory or irritative eon ditions .
Therefore th ey sug gested that these pr imary eysts originate
from anomalous developmental splitt ing of the araehn oid
me mbrane as they are enveloped by the leptom eni nges and
related to the ctste rns and the subarae hnoid spaee (Figs. 3.
K. VOll Wild
61. 'IoRengachary and Watanabe (17, 18) the eredit is prin-
cipally du e that they were a ble to demonstrate wit h light
and eleetron mtcroscopic Iindings the splitting ofthe araeh-
nold membrane to enclose the cyst, wh ile the pia ma ter re-
ma ins as aseparate Inta ct membra ne (Fig. 7). Moreover
the cyst wa ll was rein forced with a den se collage nous layer
in respo nse to high intraeystie prcssure. whic h may be suf-
fieient 10 ca use erosion a nd expa nsion of the ealvarium.
Th us. intr aarachnoid cysts are a develo pme ntal a noma ly of
the subarachnoid ciste rns in the developing embryo caus-
ing a minor aberratio n in the CSF flow with in the suba-
rac hnoid space , and resulting in an increasing divertic u-
lum wit hin the araehnoid me mbrane. This is why these
cysts oceur nearly always in relation to an su baraehnoid
ctstern . approximately half of them Involvi ng the Sylvian
fissure (Figs. 1,4.6.7). Like lnte rhernispherlc cysts the Syl-
via n fissu re arachnoid eysts ten d to become very large
(Figs. 5. 6 ). The inte rmittently communieating type of cyst
(Figs. 2. 3) may expand by progressive accumulation ofCS F
secreted through cells of the cyst wall rather than by osmo-
tically induced filtratio n or uni -direetional CSF Ilow - the
latter was called "ball-valve tr a pping " by Smuh an d Smith
(1976) . This mechanismus has to be ta ken into aecount
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wh en shunti ng procedere and resection of the cyst wa Uare
discussed.
The contained fluid is usua lly clear and eo-
lorless. If the protei n content is higher than CSF. this ma y
be the residue of an intracystic bemor rhage. The latter h as
bee n reported by us and others even a fte r min or head tra u-
ma , when acute or ehronie su bdural hemorrhage oecur in
combination with intraarachnoid eysts mostly of the Syl-
vtan region (1, 5, 27).
As already menuoned arachnoi d eyst of th e
middle fossa themselves re present compressive elements
ca using both loeal bulging and thinning of the temporal
Fig. 1 Cl scans 01 bilateral intraarachnoid
cvsts 01 the middle cranarrossa {l a, b1 in a 24
years oId man (HD 051 1641who was admitted
because 01 beadaches arid ecaectc fits with
tocar spike eno wave electrical octivity over the
left !rontotemporal region. EpidurallCP measure-
ment was in normal renge. Microsurgical ooeo
ing 01 theleft cyst with cecorcresscn Uarge
black errowl 01 the temporal lobe tsmeu black
arrow, I cd). Chronic subdural hematoma fron-
tal light due to oeccrcresson 6 weeks post-
operalively (l d).
Fig. 2 Cl scans alter lumbar injection 01 suae-
rochnoid contrast medium lor cislemography to
ovest aete CSf and cyst flu id communicalions
in a 29 ys old man (HGl 200656) with healf.
ache. Bulging and thinning 01 the right lemporal
bOlle over the exparidl1garachnoid cyst 01 the
middle lossa. Changes in mean density values
(ME) 01 the cyst Iluid demonstrate patent but
delayed communication 01 the cyst, although
signs and symptoms of Iocal compression were
present: a)and b) ME alter 12 hs 13.7 HE arid
10.2 HE; c} alter 24 hs 17.8 HE; d)alter 72 hs
10.4HE.
Ara chnoid cys ts of the middle cranialfossa {I,!elUochirurgia 35 (1992) 179

bone (Fig. 21. eleveno n of the lesse r a nd a forward projec-

tion of the gr eater sphenoid wing. so that the middle rosse
on the side of the cyst becom es wider than that on the nor -
ma l side (91. For eshortening er the tempora l lobe. as the
cyst occupies the a nterior or the posterior temporal area, ts
demonstrated by er and magneue resonace imaging (MRI)
(Fig. 21. 111e tip of the temporal lobe may be abse nt al-
though the gyrt on the adja cent part of the bra in are ncr-
mal while th e insula is exposed and its opercu la absent in
the sense of a dysgeneti c temporal lobe (Figs. 5.61. 111e cysr
may be small or terge . mostly rectan gular in horizontal Cr-
cuts. a nd sometimes on bcth sides (Figs. 1,21. Displa ce-
ment of the frontal lobe (9) may be also present (H gs. 2, 6).
Reexpansion of the brain can be observed after success ful
opera tive treatme nt with decompression (Fig. 8). It is likely Fig. 3 Cl scens demonstrating a noocomnuücating iltraarachnoid
tha t the case in whlc h the cyst disappeared sup ports the cyst 01 the left middle crarsa tcssa 1 h after contrasl medium cisterro-
theory of abnorma l development af the subar achnoid space graphy fl a 54 yeers old female !WB 190238) admrtled beceuse of hee-
as opposed to the cyst remaini ng as a conse quence of ab - daches.
normal development of the temporal lohe during fetal life
(Fig. 81. ücclustcn of the tento rial stn ue. tnto which the
telencephaltc vein flows , has been descr ibed when the Syl-
vian vein is not visualize d on cerebral angiography (8. 9);
the combina tion with an arue rto -ven ous rnallorm ation of

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the sa me regten may confirm thls thoory (Hg . 5).

Clinical aspects

Most of the intraaraehnotd cysts 300m 10re -

main asymptomatic throughout the life . How ever; the
physical a nd neurological signs a nd symptoms. if they oc-
eure. reflect their mass effect on compressed adjacent te m-
poral br a in structures an d on 3rd an d 6th erentel nerves Ag.4 Cl scens demonstrating a COOVTUlCamg Iltraaractnoid cyst
01tre left mIlkIe t rarwal fossa 2 h aftercontrast medUni cstero-
be sides their elTect on CSF flow causi ng hydrocephalus. In gra~ 13 e. bl with cooseaerce 01~Il:oneal s/'IlI'll: ooce-
our series, 18 patients with middle cranial rosse CYSIS (3 dlSe13 cl 111 a 35 years oIdman (K-HH 1102S4J aaritted teceee 01
childre n. 15 adults i came 10 medical atte ntion an d were reeeecres.
ope rared because of hea daches la sting for years without
accompa nying ne urological deficits in all but two. Follow
up er scans demonstrated increasing hydro cephalus that
caused intracranial hypertension an d vomiting only in two
adults. Convulsive seizures hav e bee n obs erved a s leading
symptoms in three cases. l\vo boys were admltted as
emergency ca ses suffertng from subdural hematoma after
mild hoa d tra uma . in whom the aracbnold cysts ha d been
asymp tomatic before (Fig. 8). vessels in the wall ofthe cyst
(Fig. 7) pa rticularly susceptible to trau ma may be respon-
sib le for the hem orrhage. as in patients (5.8.27).

er scans ma de the definitive diagn ose of

the mass lesion in aU our cases (2.9). MRI sca ns (Fig. 5)
olTer superior diagnostic infor ma tion compared with er
scan s by d iscriminati ng bet\licc n the CSF of true arachnoid
cysts . residua l hemorrhage into or around the cyst. and the
fluid of neoplastic cysts (6.81. Howe\'er in res pect to the
bony structures we stiDprefer er as the diagnostic method
of choice an d include contrast medium cistemography for
the follow-up examinations (Figs . Z. 5. and 6).
Intraventri cula r and ep idural Ic r monitor-
ing did not correspond in our series with clinical signs and
symptoms of increased intra crania l pressure that was
ca used by CSF disturban ces or by the mass elTect itself. es -
pecially in case of imp ressive hydroceph alic dilatation of
the ventricular system.
Fig.5 MRI scans CTR 2.10. TE 28. Ll8.0. SP 48.6 Dr. tneoe. MJn.
sterl tl traaanial evst cf the left rridde cranial fossa with speec h disturb-
ances and diso/acement of ee lerl'l)Ol"a1 lobe as consequence of
matlormation because 01 thecontinabon with a eleeO seated Ieft fron.
tomedIobasai a-v-malfonnabonof Ihe i'lsula and caputn. caudattm 111 a
47 years 0Id mal pabeft [tti 08 03#40) oMlo was adrntted because of
epilepsy arid Ieftlroolotemporal headaches.
Surgicalrreatmenl. rists. and outcome
The two main questions a re the indications
for sur~cal treatment an d the therapeutic elTect which can
be expccled . Genera lly speaki ng. it depen ds on the com-
plaints of the patient corresponding to objective c1inical
findings. whether or not surgery is indicated after the diag·
nosis has been confirmed. Time an d type of appro priate
180 Neurochirurgia 35 (1992) K. von Wild

Fig. 6 MRI scans

20.03.90 lTR 0.52,
TE 20, SL 5, SP 5.5
01'. Thiede, Münster)
demonstrating a large
Ief! fronlotemporal
arachnoid cyst in a
23 veers old male
patent (SR 240267)
who was admitted be-
cause of headacne,
frontobasal psycho-
syndrome and
speech dislurbances.
Congential meucrrne
tion wilh dysplasia of
frontal and temporal
obes. lndication tor
cysto-pentoneal shunt Fig.7 Arac oooid cyst cf Ihe Ief! middle cranial fossa. Microsurgical
in resoect of CSF vew ot Ihesurtace with arachnoid membrane, reinforced wilh a cense
communicalion end collagenous layer and vesseis in Ihe wall crossing the cyst
expansion of lhe cyst.

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operative procedure have 10 be designed in the ind ividual
case of the pediatri c as we il as of the adult age group (1,4,
5,8, 10 - 12. 15, 16,2 1,23,25): Ta ppin g or shunting tho
Fig. 8 Follow-up Cl scan of a 7 yeers-old boyccerateo uoon for a
cyst. fenestrati on through a burr hole or tre ph ine operring. posl-traumatic subdural hydroma. al betete operaton (19 october
additional peri toneal shunting or exctston ofthe cyst (partly 1984), b)after ooeration (24 april 1986), demonslrating reorecemeot
or completely) arn reco mmende d. of Ihe rightlemporal lobe.

In dication for su rgical Intervention is ob-

viou s in cases of acute intracranial he morrhage an d evi-
dence of elevered ICP with hydrocephalus. In cases. how -
eve r; where the cyst seems asymptomatic, we have to take
into account the significant risk of surgical treatment in th is
vulnerable anato mical regten. even postoperative fatalJties
have becn re ported in prcvious papers (4, 20). This ts why
so me authors sti ll emphasize conse rvative management in
patients with cysts drscovered fort ultously or those causing
only mild cosmetic defects. We are in agree ment with
Har sh et al. (8) who stressed the potential for hindcring the
de velopment and function of adjacent brain. particu larly in
chü drc n. and for cyst ruptu re with int racystic he morrhage,
or s ubdural hemo rrhage leading to sudden severe neuro-
logical deterioration . This has happened in two boys of our
sertes. Therefore Jfar sh et al. (8) recommended cyst-perito-
nea l shunting procedures in all arachnoid cysts th at exert
a m ass effect. as weil as cyst-ventriculo pe ritoneal sh unting
in all cases if there ts an associated ventriculomegaly.
Contrary to this opinion from our experi-
ence we wish to suess that CT and microsurgica l tec h-
niques make cys t wall resccu on without shunting a safe
surgical procedure. The practice in our d inic is as folIows :
In case of Sylvian cyst with intracra nial
rnass effect. e. g. displacement of tem poral and frontal
lobes and ofmidline structures. with CSF disturbances, os-
teoplastic craniotomy is indicated as it is in case of compli-
cated middle cranlal fossa cyst with su bd ural hygroma or
hematoma. The cyst ts exposed th rough a free frontote m-
poral bone flap (Hg. 7). After tap ping of the cys t 10 gai n ad -
ditional expcsure. the anterior and medial pa rt of th e wall
is resected atong its attachment to the normal arachn oid
and pia meter; down to the tentorial no tch, where the
thickened wall of the intraarachnoid cyst and adjacent
arachnoid membranes are cut. w üh opening of the supra-
setlar and prepontine cisterns tF ig. 7 ). Cranial nerves are
Arachnoid cysts ofthe middle cranial f ossa
deccmpressed and vase ular structures within the waUa nd
sometimes erossing the cyst are preserved. The waU at -
tached to the dura of the middle eranial fossa and to the
tempora l lobe are not detaehed to avoid subaraehnoid
bleeding after the compressed brain strucrures have been
released from the eyst waU and membranes. Watertight
closure of the dura follows, without drainage or associat ed
cyst- or ventric ulc-peritcneal shuntlng. and replaeeme nt of
the bone Ilap.
There wer e no operative or severe pos-
toperative eomplications in our 18 consecuuve cases using
this teehnique. However 6 weeks alter decompression of a
left temporal araeh noid eyst one male patient was read-
mitted beca use of a ehronic subdural hema tom at the eon-
tralateral side where there was another temporal arae h-
noid cyst. Beeause of the development of hydrocephalus
three patients needed a shu nting proeedure during the fol-
low up: one a eystoperiton eal 3 months after the evacu-
ation of traumatte subdura l hem atoma and partial resec-
tion of the araehnoid eyst and two other patients required
ventriculoperitoneal drainage. The shunü ng proeedures
resulte d in the immediate improveme nt of foeal neurologt-
eal defieits and reexpansion ofthe temporal lobe as demon-
strated by CT postoperatively. We saw one translent 3rd
nerve palsy lasting 3 weeks in ease of a very large eyst.
Tempora l seizures disappeared in th ree patients, although
the re were still foeal dysrhythm ie abno rma ltnes showing
loealized slow waves or a n asymmetrie depression of the
electr fcal aetivity but no further spikes and waves in the
EEG.
In aseries of 36 eases of supratentorial
cysts in children Cnoux et al. (4) reported epileptie fits in 18
eases as weil as mental and motor retardation in 19 child-
ren when seteur es have persisted in spite of surgery in
a bout 50 %! Moreover, one of these 16 ehildren developed
new gran d mal selzures with worsening of her neurologieal
deficit even after ventrtculo-perttoneal shunt.
Although final outeome for epilepsy re-
mains, from these and other reports. still open we do be·
lieve that in patients, especially in children, open microsur -
l{ical reseetion ofthe medial wall ofthe araehnoid eyst is in-
dieated in eases of focal epileptie pattern in the EEG rec-
ords related to the frontotemporal cortex, even if there is
no inereased intraera nial pressure. CSF-disturbanees, and
no loeal brain eompression or displacement.
Conclu sion
Comparing our res ults with those in the lit-
erature , partial mierosurgieal exeision of the arae hnoid
cyst wall and opening of the basal cisters at the tentorial
nooch has proved to be an efTective and safe procedure. Re-
expans ion ofthe compressed temporal lobe has been dem-
onstrated by CT. Can surgieal eure, however. be aehieved?
Loeal neurological deficits usually improve immediately
after the operation. Headaehe and seizures may be dim-
inished and can disappear, but the y may persist or increase
in frequeney after deeompression . We therefore ean not
predict the outeome in arachnoid cyst<;, which have been
show n to be eongential, eompressing the brain and hinde-
r ing the development and funetion of adjacent brain . We
Neurochirurgia 35 ( 1992) 11'11
agree wlth Ha rsh et al. (1986), who proposed opera tive
tre atment in all araehnoid cysts that exert a mass effuct,
partieularly those in children. oven if they are clinically
asymptomatlc. We did not observe a ny eorre lation between
size and sha pe ofthe eyst and increased ICP. The lanor was
shown to be in a normal range preoperat ively in all cases
although the cyst was demonsu-ated to be "ball-valve tra p-
ping " and patients eomplained of headac he. In centrast to
cu rselves. some a uthors still prefer cystopcritoneal shunt-
ing as the first a nd the prooedure of chotce. Shunttng pro -
cedure ean be the first step in the management of middle
cranial fossa cysts. beeause thts method is simple. safe. a nd
effective . However. these patients will rcmain shunt-du-
pendent, as we have seen in scme patien ns operated upon
elsewhere. We ther efore recommend exposure of the cyst
by means of frontotemporal era niotomy, as in expanding
mass lesions. So far as we know, larger series ha ve not
been report ed that have dealt with the final outcome after
operative management für asymptomat ic arachnoid eysts.
in respect of brain runenon and secta t beha vior. This will be
our tas k in the future.
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Neuroeh ir. Abt. Clemenshospital
Akade misches Lehrkran kenhaus
der Westf. Wilhelms-Uni v.
Düesbergweg 124
4400 Münster
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