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  : My  23year old son has been disabled for last 5 years and has right medial
  : temporal arachnoid cyst.  He has been extensively investigated and reviewed.
  : His episodic headaches which have progessively increased are of complex
  : nature, involving one half of the right head, occuring two to three times a
  : day.  The attacks lasts for variable period of half an hour to four hours.
  : The headaches are localised over the left frontotemporal region and involve
  : left orbit as well. Some of these episodes are associated with left sided
  : weakness which last for variable period.  The headache is throbbing in
  : nature and is associated with photophobia and phonophobia. Other features
  : of some of  his attacks are dizziness, left side face numbness, sharp pain
  : originating behind left eye and working down to the back of his neck, balancing
  : problem , talking problem and pain. Most time left side face & body is affected.
  : However when really bad, an attack switches to right on rare occasion .  
  : Over the years his diagnosis included hemiperatic migraine and eplilepsy.
  : Hemiperatic migraine was treated with various antimigraine drugs but has
  : been of little relief to him.  He has been tried on numerous anti-epileptic
  : medications without success. EEG's and video monitored EEG's have not been
  : able to confirm 100% that there is any epileplsy.  Some EEG's have detected
  : epileptiform discharges, most of them on the left side and once on the right side.      
  : His MRI indicates an arachnoid cyst approx 2.2 x 1.7 x 1.4 in the right choroid
  : fissure, which has enlarged to occupy the cistern ambiens. The hippocampus
  : is elevated & displaced latterly by the cyst. Though the majority of the neurological
  : opinion had suggested that there was no direct relationship between the cyst and his
  : condition, in view of  refractoriness  of the headaches, it was decided to aspirate
  : the cyst. He underwent a CT guided stereotactic aspiration of the cyst and around 13ml
  : of clear CSF was aspirated from the cyst.  The aspiration of the fluid was discontinued
  : at this point as it was thought that the cyst must be in communication with subarchnoid
  : space. A CT scan indicated the cyst half filled with CSF and half air. Postoperatively,
  : he had considerable relief for about five days. A CT scan after a week  revealed that
  : the cyst had filled up again.
  : Also  MRI indicates suspicious cortical dysplasia involving cortex around the right superior
  : temporal gyrus. Though there is no altered signal intensity in the hippocampal formation,
  : there is some asymmetery  in the cortex of the superior and to a lesser extent the middle
  : temporal gyrus, that on the right being somewhat bulkier than on the left.
  : Our neurologist recommends  subdural monitoring to determine whether or not his episodes are
  : indeed epileptic in origin and , if so, whether they are due to compression of the hippocampus
  : by the cyst or to the suspicious cortical dysplasia. The neurosurgeon recommends a resection
  : of the cyst so to enable the CSF to flow into the arachnoid space but is unable to confirm that
  : this would help his condition.
  : My son so incapacitated , chair & bed confined,  that he is on pain killers 24 hours a day  
  : in spite of doing whatever the doctors and medical specialists have asked him to do over the
  : last five years. Our question is what is causing his condition. Any information and experiences
  : would be very much appreciated. Anyone with any ideas  please email me. Thank you.  My name is UPI.      
  Dear Upi,
  Arachnoid cysts are congenital anomalies that may cause symptoms by compressing
  on local structures in the brain.  Most can be managed conservatively with
  observation alone, but occasionally drainage and/or surgery is recommended.
  Your physicians have shown that decompression of the cyst is associated with
  relief of your son's symptoms, which returned when the cyst filled with fluid.
  This is an indication for surgery.  A neurosurgeon can fenestrate the cyst,
  that is, open the cyst to drain internally in to the normal CSF spaces.  This
  is the best option and least invasive surgical option.  The drawback is that
  40% of these procedures fail and the patient then needs a shunt to decompress
  the cyst.
  Speak to your neurosurgeon in this regard.  From what you describe, it sounds
  like your son would benefit from surgery for the arachnoid cyst.
  Good luck.
Dear Upendra Patel:
I fully agree with what my collegue has told you about archnoid cysts.  I wanted to touch base with you about the EEG, subdural electrodes, and epilepsy.  I am unsure why the MRI and the EEG would not correlate enough to warrant subdural electrode placement.  Subdural placement is pretty invasive and if possible we at the Cleveland Clinic try to do our best to avoid them.  Our first approach would be to do a battery of test before subdural placement.  Initial workup would include video/EEG monitoring to evaluate the clinical presentation of seizure with the EEG recording of what the brain is doing at the time of the event.  Then we would do a SPECT scan to identify metabolic
correlation to seizure-like events/EEG/Video-wise.  Neuropsych testing would be done to evaluate what functions are associated with the area in question.  These would all be evaluated to determine whether epilepsy surgery is a possibility to "cure" or better the situation.  I tell you all this to let you know that subdural placement would only be a part of this workup if we thought epilepsy surgery was a possibility.  The EEG with or without video would allow us to initially define if epilepsy is the diagnoses or not.  Dysplasia can be epileptigenic but not always.  It sounds like your neurologist is not convinced that the dysplasia found on the MRI is epileptigenic nor is he or she convinced that the EEG is seizure activity.  I have seen patients with cortical dysplasias and no epilepsy.  I think that you should question the placement of the subdural leads at this point until you resolve the subarchnoid cyst issue and actually see if his probelms are related to the cyst.  If after the cyst problem is resolved and there is still questions dealing with epilepsy, then systematically elucidate what the etilogy of the epilepsy might be, if seizure activity is related to his clinical signs, and if the seizure/epilepsy is present, is it focal and resectible.  I hope that the subarchnoid cyst is the problem and that can be definitively taken care of.  Keep us informed if we can be of any further service or help.
CCF Neuro:pediatrics, MD  RPS

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