Headache and Arachnoid Cysts in Children and Adolescents—Clinical Features and Treatment Recommendations


Nearly half of children with arachnoid cysts experience headache, while seizures, trauma, dizziness, and developmental delay are also common.

WASHINGTON, DC—Arachnoid cysts in children are typically found incidentally, and are unrelated to the patients’ initial presenting problem, according to research presented at the 53rd Annual Scientific Meeting of the American Headache Society. The cysts are often accompanied by headache and seizures in pediatric patients, but without the presence of increased intracranial pressure or hydrocephalus, surgery is not imperative.

Shalaka Indulkar, MD, and A. David Rothner, MD, from the Department of Pediatric Neurology at the Cleveland Clinic, examined neuroimaging results and medical information from a population of children and adolescents with arachnoid cysts. The investigators found that 45% of their study population experienced headache, and 15% underwent surgery for the cysts or to relieve increased intracranial pressure.

“Arachnoid cysts are extracerebral CSF collections and are considered incidental developmental findings,” the researchers stated. “They are a common cause of referral to neurologists and neurosurgeons, especially when associated with headaches, head trauma, or seizures. They often result in multiple investigations and are a cause of significant parental anxiety.

“We decided to study arachnoid cysts in children and adolescents and the relationship of headache to arachnoid cysts,” the investigators noted. “We also wanted to review the frequency of arachnoid cysts in the literature and their clinical features.”

Characterizing Arachnoid Cysts in Children
The study population included 200 patients younger than 18 (mean age, 8.7) with arachnoid cysts who underwent CT, MRI, or both. Patient demographics, clinical features, and details of medical intervention, surgical intervention, and outcome were also collected.

“Most common symptoms were headache (n = 90, 45%), seizures (n = 35, 17.5%), trauma (n = 31, 15.5%), dizziness (n = 21, 10.5%), developmental delay (n = 18, 9%), and macrocephaly (n = 17, 8.5%),” the investigators reported. Bony remodeling occurred in 15.5% of the population, followed by hydrocephalus in 4.5%, progressive increase in the size of the cyst in 3.5%, and rupture in 2.5%.

Of the 90 patients with headache in the study population, 25.5% had migraine and 74.5% had chronic daily headaches, tension-type headache, or unclassified headache. “Significant neurologic abnormalities were rare and included papilledema (n = 2), abducens nerve palsy (n = 1), and ataxia (n = 1),” Drs. Indulkar and Rothner stated. Fourteen patients also had increased intracranial pressure with headache, nausea, vomiting, cranial nerve palsy, and papilledema; all of these patients underwent surgery.

Treatment Options
Surgeries were performed on 30 children; 63% underwent endoscopic fenestration, 37% had craniotomy with cyst fenestration, and 10% had cysto-peritoneal shunt placement. “Preoperative headache was reduced in 23 patients, five had unchanged headache, and one had worse headache,” the investigators noted. In patients who had headache but no evidence of increased intracranial pressure or hydrocephalus, Drs. Indulkar and Rothner found that a trial of conservative headache treatment had similar outcomes.

“In the presence of hydrocephalus, symptoms and signs of increased intracranial pressure, or neurologic dysfunction, neurosurgical referral should be made,” Dr. Rothner told Neurology Reviews. “In the absence of neurologic symptoms, conservative therapy or observation is suggested.”

—Ariel Jones

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