Direct puncture for diagnosis of intradural spinal arachnoid cyst and fenestration using 3D rotational fluoroscopy: technical note and the “jellyfish sign”

The authors report on a 47-year-old woman with a symptomatic thoracic spinal arachnoid cyst (SAC) who underwent a novel procedure that involves direct puncture of the SAC to visualize, diagnose, and potentially treat these rare spinal lesions. The method described utilizes 3D fluoroscopy to gain access to the SAC, followed by injection of myelographic contrast into the cyst. A characteristic “jellyfish sign” was observed that represents the containment of the contrast within the superior aspect of the cyst and a clear block of cranial flow of contrast, resulting in an undulating pattern of movement of contrast within the cyst. Following balloon fenestration of the cyst, unimpeded flow of contrast was visualized cranially throughout the thoracic subarachnoid space. The patient was discharged the following day in good condition, and subsequently experienced 1 year free from symptoms. This is the first reported case of a successful direct puncture of an SAC with balloon fenestration, and the first noted real-time fluoroscopic “behavior” of CSF within an arachnoid cyst.