Percutaneous Treatment of Meckel Cave Arachnoid Cyst: Case Report, Surgical Strategy and Literature Review

Abstract

Arachnoid cysts are benign intracranial lesions. They are usually located in the middle fossa, but can be found in other locations. We present a case of symptomatic Meckel cave (MC) arachnoid cyst - a very rare location - and a treatment strategy not elsewhere described before for this condition. A 54-year-old female with trigeminal neuralgia with previous history of radiofrequency rhizotomy treatment 6 years before admission had been experiencing pain recurrence with progression, which required successive increases in carbamazepine dosage. Magnetic Resonance Imaging (MRI) showed dilatation of the right MC with extension to the petrous apex. The lesion was compatible with arachnoid cyst, and due to the worsening of the clinical condition, surgical treatment was chosen. Percutaneous puncture of the cyst through the foramen ovale with injection of intracystic fibrin sealant was performed. The patient woke up from anesthesia with pain improvement and was discharged asymptomatic the next day. After 12 months of follow-up, she remained pain-free. In the literature review, we found only eight cases reported as MC arachnoid cyst. These are likely to progress and become symptomatic owing to their communication with the subarachnoid space and a unidirectional valve mechanism. Pain improvement with this technique is probably secondary to the interruption of these mechanisms.

Resumo

Os cistos aracnoides são lesões intracranianas benignas. Geralmente estão localizados na fossa média, mas podem ser encontrados em outros locais. Apresentamos um caso de cisto aracnoide sintomático no cavum de Meckel (CM) – localização muito rara – e uma estratégia de tratamento nunca antes descrita para esta condição. Uma mulher de 54 anos com neuralgia do trigêmeo e histórico de tratamento com rizotomia por radiofrequência 6 anos antes da admissão apresentava recorrência da dor com progressão, exigindo aumentos sucessivos na dosagem de carbamazepina. Ressonância magnética mostrou dilatação do CM à direita com extensão ao ápice petroso. A lesão era compatível com cisto aracnoide e, devido ao agravamento do quadro clínico, optou-se por tratamento cirúrgico. Foi realizada punção percutânea do cisto através do forame oval com injeção de selante de fibrina intracístico. A paciente acordou da anestesia com melhora da dor e recebeu alta assintomática no dia seguinte. Após 12 meses de acompanhamento, a paciente permaneceu sem dor. Na revisão da literatura, encontramos apenas oito casos relatados como cisto aracnoide do CM. É provável que estes progridam e se tornem sintomáticos devido à sua comunicação com o espaço subaracnóideo e a um mecanismo de válvula unidirecional. A melhora da dor com essa técnica é provavelmente secundária à interrupção desse mecanismo.

Keywords

Meckel cave - arachnoid cyst - petrous apex cephaloceles - trigeminal neuralgia - percutaneous treatment

Palavras-chave

cavum de Meckel - cisto aracnoide - cefalocele do ápice petroso - neuralgia do trigêmeo - tratamento percutâneo

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