OBJECTIVEOptimal diagnosis and management strategies for intradural spinal arachnoid cysts (SACs) are still unresolved given the rare nature of this entity, with few large case series and virtually no statistical analyses of patient characteristics in the literature. Here, the authors studied a large patient cohort with these lesions to determine whether pre- or postoperative attributes could be used to aid in either diagnosis or prognosis.METHODSA chart review was completed at a single institution for the period from 2002 to 2016 to determine the preoperative characteristics and postoperative outcomes of 21 patients with exclusively intradural SACs. Patients were assessed for symptoms such as weakness, pain, sensory changes, bowel and/or bladder dysfunction, and gait changes. Postoperatively, patients were analyzed for symptom improvement, complication occurrence, and duration of follow-up.RESULTSApproximately two-thirds of the patients in this series had developed SACs idiopathically, and the mean duration of symptoms prior to diagnosis was 15 months among all patients. A slight majority (57%) underwent CT myelography in the course of diagnosis, and a quarter of the patients had a syrinx. There was a statistically significant association between location of the SAC and number of presenting signs and symptoms; that is, patients with cysts in the lumbosacral region had more symptoms than those with cysts at the cervical or thoracic levels (p = 0.031). Overall, outcomes were largely positive, with approximately 60%–70% of patients experiencing postoperative improvement in symptoms, with motor weakness showing the highest response rate (71%) and pain symptoms the least likely to subside (50%). In the cohort with preoperative pain, those who had undergone expansile duraplasty were significantly more likely to experience relief of their pain symptoms (p = 0.028), which may have been a result of the superior restoration of cerebrospinal fluid pathways allowing for more adequate reduction in compression.CONCLUSIONSIn this large case series on intradural SACs, new light has been shed on aspects of both pre- and postoperative care for patients with these rare lesions. Specifically, the authors revealed that lumbosacral intradural SACs may be associated with a higher disease burden and that patients who undergo expansile duraplasty may have an increased likelihood of experiencing postoperative pain relief.

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A middle-aged Caucasian woman presented with an ascending aortic pseudoaneurysm (AAP) located at the suture site of her previous surgical dissection repair. The pseudoaneurysm was located along the anterior aspect of the ascending thoracic aorta, above the right coronary cusp. We demonstrate successful percutaneous repair of the pseudoaneurysm using a ventricular septal occluder (VSO) and discuss the significance of this procedure for future cardiovascular care.

The authors report on a 47-year-old woman with a symptomatic thoracic spinal arachnoid cyst (SAC) who underwent a novel procedure that involves direct puncture of the SAC to visualize, diagnose, and potentially treat these rare spinal lesions. The method described utilizes 3D fluoroscopy to gain access to the SAC, followed by injection of myelographic contrast into the cyst. A characteristic “jellyfish sign” was observed that represents the containment of the contrast within the superior aspect of the cyst and a clear block of cranial flow of contrast, resulting in an undulating pattern of movement of contrast within the cyst. Following balloon fenestration of the cyst, unimpeded flow of contrast was visualized cranially throughout the thoracic subarachnoid space. The patient was discharged the following day in good condition, and subsequently experienced 1 year free from symptoms. This is the first reported case of a successful direct puncture of an SAC with balloon fenestration, and the first noted real-time fluoroscopic “behavior” of CSF within an arachnoid cyst.

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