Arachnoid cysts are relatively common benign and asymptomatic lesions occurring in association with the central nervous system, both within the intracranial compartment (most common) as well as within the spinal canal. They are usually located within the subarachnoid space and contain CSF.
On imaging, they are characterised as well circumscribed cysts, with an imperceptible wall, displacing adjacent structures, and following the CSF pattern (hypodense on CT and hyperintense on T2 with FLAIR suppression on MRI). They can also have a remodelling effect on the adjacent bone.
The majority of arachnoid cysts are small and asymptomatic. When symptoms occur, they are usually the result of gradual enlargement resulting in mass effect. This results in either direct neurological dysfunction or distortion of normal CSF pathways resulting in obstructive hydrocephalus 3.
Arachnoid cysts are thought to arise due to the congenital splitting of the arachnoid layer with accumulation of CSF within this potential space. The cyst wall is comprised of flattened arachnoid cells forming a thin translucent membrane. There is no solid component and no epithelial lining.
Most frequently (50-60%) arachnoid cysts are located in the middle cranial fossa, where they invaginate into and widen the sylvian fissure. There is even a classification system for middle cranial fossa arachnoid cysts, although I doubt it is of much use if a good description is provided (see Galassi classification).
They can occur anywhere, including:
- interhemispheric fissure
- cerebral convexity
- posterior fossa
- quadrigeminal cistern
- spinal canal (see spinal arachnoid cysts)
- ventricles (see intraventricular arachnoid cyst)
- suprasellar cistern (see suprasellar arachnoid cyst)
Arachnoid cysts are extremely well circumscribed, with an imperceptible wall, and displace adjacent structures. When large, and over time, they can exert a remodelling effect on the bone.
CT cisternography (introduction of contrast into the subarachnoid space) demonstrates communication of the cyst with the subarachnoid space. As this communication is slow, the cyst often fills later, and contrast may be seen to pool with it, outlining its dependent portion.
As they are filled with CSF it is not surprising that they follow CSF on all sequences, including FLAIR and DWI. This enables them to be distinguished from epidermoid cysts for example. As their wall is very thin it only occasionally can be seen, and displacement of surrounding structures implies their presence. As there is no solid component, no enhancement can be identified.
Phase contrast imaging can also be employed not only to determine if the cyst communicates with the subarachnoid space, but also to identify the location of this communication.
Magnetic resonance cisternography: high resolution sequences such as CISS & FIESTA help to delineate cyst wall and adjacent anatomic structures.
Treatment and prognosis
Arachnoid cysts are benign, and the vast majority remain asymptomatic throughout life. If they are deemed to be causing symptoms, then surgery can be contemplated. This can either take the form of a craniotomy (fenestration or excision) or placement of a cystoperitoneal shunt.
General imaging differential considerations include:
- enlarged CSF space (e.g. mega cisterna magna)
- often shows a heterogeneous/dirty signal on FLAIR
- restricted diffusion
- more lobulated
- tend to engulf adjacent arteries and cranial nerves
subdural hygroma/chronic subdural haemorrhage
- do not typically show CSF signal intensity on MRI
- can have an enhancing membrane
- cystic tumours: often will have a solid/enhancing component and be intra-axial
- non-neoplastic cysts
- small cyst
- usually multiple when in the subarachnoid space
- 1. Osborn AG, Preece MT. Intracranial cysts: radiologic-pathologic correlation and imaging approach. Radiology. 2006;239 (3): 650-64. doi:10.1148/radiol.2393050823 - Pubmed citation
- 2. Yildiz H, Erdogan C, Yalcin R et-al. evaluation of communication between intracranial arachnoid cysts and cisterns with phase-contrast cine MR imaging. AJNR Am J Neuroradiol. 2005;26 (1): 145-51. AJNR Am J Neuroradiol (full text) - Pubmed citation
- 3. Kornienko VN, Pronin IN. Diagnostic Neuroradiology. Springer Verlag. (2008) ISBN:3540756523. Read it at Google Books - Find it at Amazon