Progress and Prospects in Parkinson's Research/Causes/Trauma/Cysts

" This page raises the intriguing question - Are there PD patients who are currently condemned to a lifetime of dopamine replacement therapy, who could be cured by a neurosurgical procedure?'"

Background
Cysts are abnormal accumulations of Cerebrospinal fluid (CSF) which can appear within the brain. They may be symptom free or they can result in traumatic symptoms. They can be congenital or appear post natally. They are treatable by drainage through cranial surgery or endoscopically.

Research
1972

Bhandari reported a number of cases of symptomatic cysts.

One case was of a 37 year old male who for 6 months had difficulty in writing and had transient episodes of speech difficulties and at other times felt vaguely drunk. After a convulsive seizure he was admitted to a hospital abroad. An angiogram revealed a cyst in the Sylvian area and 60 millilitres of  clear, colourless fluid was aspirated. Following the procedure the patient made a complete recovery and was leading a normal life 14 year later.

A second case was of a woman who at the age of 46 had a large arachnoid cyst removed from the Sylvian region of her brain. Thereafter she lived a normal life until the age of 62 when she became depressed and developed a mild headache. She then fell down stairs. 4 days after the fall she became drowsy and 14 days later she was admitted to hospital in an unconscious state where she died of pneumonia and oedema. A post mortem examination revealed a large cyst in the left Sylvian fissure.

A third case involved a woman of 57 who, over a period of two and a half years experienced a gradual worsening of stiffness of the left hand and arm. She also experienced two episodes of twitching and shaking of the left arm. An exploratory operation revealed the presence of a thin-walled cyst from which 80 millilitres of clear, colourless fluid was removed. The patient made a good recovery, although slight stiffness of the upper left limb persisted. At a follow-up examination 7 year later she was leading a normal life.

A fourth case was of a 52 year old woman who experienced motor seizures for 18 months, and was prescribed anti-convulsive drugs. 9 months later she was admitted to hospital with seizures, confusion, speech difficulties and weakness of the right arm and leg. A brain operation revealed a large cyst 7 cm. In diameter from which 100 ml. of clear, colourless fluid was removed. At a follow up examination 12 months later the patient was symptom free, but 14 months after this the symptoms returned and an angiogram showed that the cyst had reformed. This time she was aspirated through a burr hole and four months later was re-examined and found to be symptom free once more and leading normal life.

A fifth case was of a female patient of 49 years who presented following gradual stiffening of the left arm and leg over two and a half years. Upon examination a marked cogwheel rigidity was noted in the left upper and lower limbs and there was a slight tremor in the left hand. Her gait was spastic and she did not swing her left arm. She was placed on anti-Parkinsonism drugs for two and a half years and then referred for neurosurgical evaluation. An angiogram revealed signs of a cyst and this was confirmed by a procedure which drained a 5 cm. diameter cyst of 70ml. of clear fluid. At a two year follow up examination she was symptom free and leading a normal life.

1995

Fénelon et al described two PD cases.

"Two men, 89 and 83 years of age, presented with predominantly axial parkinsonian signs. In both cases, magnetic resonance imaging of the brain showed numerous small foci, delineating the striatum. The lesions had the same signal as cerebral spinal fluid in both T1 and T2 sequences. Postmortem examination of the brain showed numerous lacunes due to dilatation of the perivascular spaces, frequently associated with alterations of the surrounding brain parenchyma. Typical changes of Parkinson's disease were associated in one case. Such vascular changes may produce, or modify, a parkinsonian syndrome, "

1996

Schroeder et al reported the case of a 32-year-old woman who presented with headache, mild hemiparesis and clumsiness of the right hand.

" CT and MRI revealed a multicystic formation of the brainstem involving the thalamus and midbrain. We inspected the formation endoscopically and fenestrated some of the cysts. In one of the cysts we found an anomalous vascular nidus. Postoperative MRI revealed reduction of the fenestrated cysts. The patient is doing well 13 months after endoscopy and has no neurological deficit."

2003

Longatti et al reported the case of a 43 year old woman who presented with progressive resting tremor and weakness in the left arm and motor problems in the left leg. In the following year she was referred for neurosurgical observation following an MRI scan which revealed the presence of a cyst in the right mesencephalic region of her brain. This noted left hemiparesis (leg worse than arm) hemirigidity, reduced automatic movements, left bradykinesia, brisk tendon jerks on the left, diplopia on the rightward gaze and Parinaud syndrome. The cyst was drained through a burr hole in the cranium.

Three months later she was found to be neurologically normal apart from a mild resting tremor of the left hand. She had resumed all her regular activities including dancing.

2007

Kim et al describe the case of a 67-year-old man with progressive memory impairment, a masked face, bilateral rigidity with bradykinesia, and shuffling gait. The score on section III of the Unified Parkinson's Disease Rating Scale (UPDRS) was 28. "Brain MRI showed widespread multiple cystic dilated Perivascular Spaces (PVSs) in the periventricular white matter and subcortical areas of both frontoparietal, left temporal, and left occipital lobes. Hyperintense signals were evident in white matter adjacent to the dilated PVSs on T2-weighted images and fast fluid-attenuated inversion-recovery image. Magnetic resonance angiography produced normal results " He was treated with 300mg.per day of levodopa, 6mg.per day of ropinirole and 400 mg. per day of entacapone. After 6 months, bradykinesia and gait disturbance were moderately improved, and his score on section III of the UPDRS had improved to 22. ''Multiple small dilated PVSs have been found previously in Parkinsonism patients, but their contribution to parkinsonian symptoms is still controversial. Some reports have suggested that multiple small dilated PVSs are responsible for Parkinsonism or modify the expression of coincidental Parkinsonism...''

''Therefore, Parkinsonism in our patient may have developed from basal ganglia pathology or interruption of corticostriatal fibers, with dementia resulting from diffuse interruption of the subcortical-cortical connection. The structural damage resulted in a poor response to medication.''

In cases of dilated PVSs with progressive symptoms and signs, especially those of huge size combined with hydrocephalus, surgical treatment is recommended.

2012

Dux et al reported on the outcome of surgical treatment of 75 patients with symptomatic arachnoid cysts. Hydrocephalus, cognitive decline weakness and  gait disturbances  were controlled 100% after overall treatment methods. Their conclusion:-

" Patients with symptomatic arachnoid cysts regardless of age and cyst location should be treated. "

 Further Research