Can arachnoid cysts present with vertigo?

Arachnoid Cysts Can Present with Vertigo

Yes, arachnoid cysts can present with vertigo, particularly when located in the posterior fossa region affecting the vestibular system. Multiple studies have documented this association, with patients experiencing significant improvement in vertigo symptoms following surgical decompression of these cysts 1, 2.

Clinical Presentation of Vertigo in Arachnoid Cysts

Location Matters

• Posterior fossa cysts (especially cerebellopontine angle and retrocerebellar) are most commonly associated with vertigo 1, 3
• Temporal fossa cysts can also cause dizziness and imbalance 4

Symptom Characteristics

• Patients with posterior fossa arachnoid cysts score significantly higher on subjective dizziness measures compared to controls 1
• Vertigo may present alongside other neurological symptoms:
  • Progressive or acute sensorineural hearing loss 3, 2
  • Postural instability 1, 4
  • Benign positional vertigo-like symptoms 5

Diagnostic Approach

Imaging

• MRI is the gold standard for initial workup, particularly with dedicated internal auditory canal (IAC) protocol 6

  • Should include standard T1 and T2-weighted sequences
  • T1-weighted sequences before and after gadolinium administration
  • Thin slice spin echo or turbo spin echo T1-weighted sequences
  • Axial submillimetric heavily T2-weighted sequences
  • Diffusion-weighted imaging (DWI) to differentiate from other lesions

• CT cisternography may be useful to determine whether the arachnoid cyst communicates with the cerebrospinal fluid space, which is important for surgical planning 2

Differential Diagnosis

When evaluating vertigo, it's important to distinguish arachnoid cysts from other causes:

• Ménière's disease: Characterized by episodic vertigo with fluctuating hearing loss, tinnitus, and aural fullness 7
• Benign paroxysmal positional vertigo: Short-duration vertigo (seconds) without hearing symptoms 7
• Vestibular schwannoma: More likely to present with chronic imbalance than episodic vertigo 7
• Vestibular migraine: Attacks lasting hours with possible photophobia 7

Management Implications

Treatment Outcomes

• Surgical decompression of arachnoid cysts can lead to significant improvement in subjective dizziness symptoms 1, 2, 4
• In a study of patients with posterior fossa cysts, symptom scores on standardized measures (DHI, VSS-SF) decreased significantly after surgery 1
• For temporal arachnoid cysts, patients showed post-operative improvement in subjective dizziness but not necessarily in objective measures of postural sway 4

Surgical Considerations

• Fenestration of the arachnoid cyst has been reported to improve vertigo while preserving hearing 2
• The decision for surgical intervention should consider the severity of symptoms and their impact on quality of life

Clinical Pitfalls to Avoid

1. Misattribution: Not all vertigo in patients with arachnoid cysts is caused by the cyst. In some cases, the cyst may be an incidental finding while the vertigo has a peripheral cause 5

2. Incomplete evaluation: Patients with vertigo and arachnoid cysts should still undergo comprehensive vestibular evaluation to rule out other common causes

3. Overlooking small cysts: Even small arachnoid cysts in critical locations (like the cerebellopontine angle) can cause significant vestibular symptoms by compressing or displacing cranial nerves 3

4. Delayed diagnosis: Vertigo symptoms may be attributed to more common conditions, delaying identification of an underlying arachnoid cyst

The relationship between arachnoid cysts and vertigo is particularly strong when the cysts are located in areas that can affect vestibular function, such as the posterior fossa. Careful imaging and clinical correlation are essential for proper diagnosis and management.