Dr.Ghaniya KC, Dr.Praveena Bhaskaran, Dr.C.Jayakumar
Two years ten months , male child
Presented with h/o Not bearing weight on right foot and Pain ? Abdomen ? Lower limbs X 10 days
HISTORY OF PRESENTING ILLNESS
• Child was apparently normal 10 days
• He was travelling in a car and was sleeping
• Hit a gutter and he woke up wincing with pain , later went back to sleep
• Next day noticed right leg limping
• Later days it gradually progressed and last one week he is non- ambulatory
• No h/o fever
• No h/o vomiting/diarrhea
• No h/o joint swelling
• No h/o URI symptoms during / prior to onset of illness
• No h/o upper limb weakness/ history suggestive of cranial nerve involvement /ataxia/nystagmus
• No h/o bladder / bowel retention/ incontinence
PAST HISTORY
• No h/o previous hospital admissions
BIRTH HISTORY
• 3RD child of NCM
• Antenatal : uneventful
• Natal : Term/ LSCS ( Ind : prev LSCS) /
• BW : 3.3 kg / CIAB
• Post natal : uneventful
DEVELOPMENT AND IMMUNIZATION HISTORY
• Achieved age appropriate milestones
• Immunized for age according to NIS schedule
FAMILY HISTORY
• No significant h/o illness/ tumors in the family
ON EXAMINATION
• Child is active, not sick looking
•Temp : 97 F , PR – 80/min , RR – 22/min , SPO2 : 100 % on RA, BP :
90/56 mmHg
•No pallor, icterus, cyanosis, clubbing, lymphadenopathy, edema
• Anthropometry :
• Weight : 15 kg (b/w 0 and 2 SD)
• Length : 104 cm (b/w 2 and 3 SD)
• HC – 53 cm (b/w 2 and 3 SD)
Head to foot examination – no spinal tenderness / swellings
• CNS : Higher mental function : normal
• CN I to CN X11 – intact
• Bulk normal
• Tone – slightly reduced bilateral lower limbs
• Power : Upper limbs – grade 5 , lower limbs Reflexes 2/5 : + ? Brisk lower limbs
• Plantar : upgoing
• Sensory – Normal sensation to touch, pain and temperature.
• Cerebellar – No ataxia / nystagmus
Other systems
• RS : AEBE , NVBS
• P/A : soft, non-tender , BS + • CVS : S1 S2 +
DIFFERENTIAL DIAGNOSIS
• Spinal cord lesion
• Transient synovitis of the hip
• Intrabdominal / pelvic abscess •Septic arthritis hip
INVESTIGATIONS
•CBC – TC – 8 K/uL , N – 25.5 % , L- 57.5 %, Hb- 12 g/dl , Plt – 254 K/ uL • CRP – 0.56 mg/L
• LFT/RFT/S.electrolytes / PT/INR/ aPTT – normal
• Pre-op serology negative
• Ultrasound Hip – no joint effusion in bilateral hips
• Ultrasound abdomen – Non specific mesenteric
lymphadenopathy
• Ortho consult – likely transient synovitis of the hip
• Prescribed Ibuprofen , symptoms did not improve in 3 days , hence MRI Spine and MRI Brain was done
MRI spine with CVJ screening : Indural extramedullary CSF intensity cystic lesion at T1-T2 level , ventral to spinal cord causing marked region cord compression ? Arachnoid cyst /neurenteric cyst
MRI Brain : no intracranial abnormality
COURSE
• Child was referred to Neurosurgery
• Underwent T2,T3 and T4 laminectomy with T1 partial laminectomy and gross total excision of lesion with under GA on 31/8/2024
HISTOPATH – EXCISION BIOPSY
• Section studied showed fragments of cyst wall with fibrohyalinized tissue lined flattened to cuboidal cells.
• Impression – Cyst wall : Cyst with flattened to cuboidal lining, suggestive of arachnoid cyst.
ARACHNOID CYST
• Arachnoid cysts à collections of cerebrospinal fluid arising from the splitting layers of the arachnoid membrane
• The etiology of most arachnoid cysts is unclear à likely formed due to abnormal splitting during the embryogenesis of the arachnoid
• Most commonly à arachnoid cysts are detected incidentally on cross-sectional neuroimaging of the brain.
EPIDEMIOLOGY
• most arachnoid cysts are found in the first decade of life
• Males tend to be affected more than females, an approximately 2 to 1
ratio
• The prevalence is estimated at 2.6% in children
TREATMENT / MANAGEMENT
The vast majority of cases of arachnoid cysts à need no treatment
However, in patients with symptomatic arachnoid cysts, surgery should be considered based on
the clinical factors present, including:
• Cyst location
• Presence of mass effects
• Impaired CSF flow dynamics (eg, hydrocephalus)
• Focal neurological deficits
• Headaches
• Seizures
• Developmental or cognitive deficits
In cases where treatment is indicated, numerous surgical therapies exist
PROGNOSIS
• In most cases à no treatment is necessary
• Surgery is almost always curative when needed, but recurrences have been reported
• There have been reports of spontaneous resolution of arachnoid cysts, especially following a trauma