• History & Physical: This 32-year-old male presented with a progressive 6 year history of double vision, more pronounced on rightward gaze. Neurological examination demonstrated nystagmus on left gaze and a skew deviation. Normal gait was unimpaired but tandem gait and one-legged stance were difficult. He denied headache, dizziness, and other neurological deficits. In the past few weeks the patient complained of morning vomiting.

    Imaging: MRI of the brain and cervical spine revealed a cystic process at the level of the foramen magnum and proceeding down to the level of C2. The cyst wall showed minimal contrast enhancement and appeared more on the right than the left side.

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    1. The treatment option of choice in this patient is:

    2. The optimal surgical option offered to this patient would be:

    3. Adjunctive treatment options would include:

    4. The follow-up of this patient would include:

    5. Please provide any comments or suggestions regarding management of this case:

    "Along with this forsaid plan I would like to discuss the complexity of problem with patient ,make him realise his case is not a straightforward case and surgery may not help him,but with progressive worsening of his symptoms and no benifit with conservati."

    "I really don't think a syringo-subaracnoid shunt would be necessary but it made me choose one. A box labeled "none" would be useful."

    "I think cyst fenestration and biopsy of wall are important."

    "Patient is symptomatic enough to warrant treatment and thia anatomic problem needs surgical treatment in the form of cyst excision and if warranted cystoarachnoid shunt."

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