Arachnoid cysts in adults: long-term follow-up of patients treated with internal shunts to the subdural compartment

BACKGROUND: We have previously presented an alternative method for surgical decompression of intracranial arachnoid cysts. This minimally invasive method, with insertion of an internal shunt from the cyst to the subdural compartment, seemed to be an efficient and simple, and hence promising technique. The aim of the present study was to investigate the long-term results of this procedure. METHODS: This study is a questionnaire-based retrospective study that includes 31 adult patients (>18 years) who were operated on in our department for an arachnoid cyst in the temporal fossa or overlying the frontal convexity with the internal shunt technique between April 1990 and October 2003. Follow-up ranged from 15 months to 14.8 years (mean = 8.2 years). RESULTS: Of the patients, 83% were asymptomatic or had insignificant complaints at follow-up. A total of 17% reported no reduction of the preoperative complaints. No patient experienced worsening of the symptoms. The cyst was no longer visible on postoperative radiologic examinations in 37% of the patients. In 37%, the postoperative fluid volume was less than 50% of the original volume. In 13%, the cyst volume was reduced but the postoperative volume was greater than 50% of the original cyst volume. Thus, the cyst was unchanged in only 13% of the patients. There was no correlation between volume reduction and clinical improvement. A complication (subdural hygroma or hematoma) occurred in 7 patients, all with temporal cysts, leading to reoperation in 4. None of the complications caused permanent neurologic deficits or invalidity. Seven patients were reoperated on because of suspected or established treatment failure. CONCLUSIONS: The internal shunt technique is a relatively simple, safe, and efficient alternative method for treatment of arachnoid cysts. It should be considered a valuable alternative in the treatment of arachnoid cysts.     

Arachnoid cysts of the middle fossa and associated subdural hematoma. Three case reports and review of the literature

BACKGROUND AND PURPOSE: We report 3 cases of subdural hematoma associated with arachnoid cyst of the middle fossa, and discuss the treatment. METHODS: Three males aged 33, 63 and 68 were treated in our institution. Before this event the cyst was asymptomatic and unknown. Magnetic resonance imaging was the most contributive radiologic exam. Surgical procedure was limited to subdural hematoma evacuation. The internal wall of subdural hematoma was opened in all cases. RESULTS: The clinical outcome was good for all patients. The CT or MRI scan follow-up 3 months later revealed nearly total disappearance of subdural hematoma for 2 out of 3 cases. For one patient the volume of arachnoid cyst decreased. CONCLUSIONS: We propose subdural hematoma drainage without any specific treatment (shunt or fenestration) of the arachnoid cyst, for this category of patient.     

Arachnoid cyst is a risk factor for chronic subdural hematoma in juveniles: twelve cases of chronic subdural hematoma associated with arachnoid cyst

Chronic subdural hematoma (CSDH) tends to occur in elderly patients with a history of mild head injury at a few months prior to the onset of symptoms. Intracranial arachnoid cyst is believed to be congenital and sometimes becomes symptomatic in pediatric patients. These two distinct clinical entities sporadically occur in the same young patient. Twelve of 541 cases of CSDH surgically treated in our institution had associated arachnoid cyst. The clinical and radiological characteristics of the cases of CSDH associated with arachnoid cyst were retrospectively analyzed and compared with those of CSDH without arachnoid cyst. Arachnoid cysts were located in the middle fossa (eight cases), convexity (two cases), and posterior fossa (two cases). Three cysts were less than 20 mm in diameter. The 12 patients with CSDH and arachnoid cyst (mean age 27.8 +/- 19.7 years) were significantly younger (p < 0.001) than the patients with CSDH without arachnoid cyst (69.5 +/- 13.7 years). Five of the 12 patients were pediatric cases (< 15 years old). The clinical symptoms were also significantly different. The most frequent symptom was headache followed by vomiting in the patients with arachnoid cyst, while gait disturbance and hemiparesis predominated in patients without arachnoid cyst. Hematoma evacuation through burr holes improved the symptoms in all patients with arachnoid cyst. We conclude that even a small arachnoid cyst can be a risk factor for CSDH after mild head injury in young patients and symptoms of increased intracranial pressure are common. Hematoma evacuation is adequate at first operation. If the preoperative symptoms persist, additional arachnoid cyst surgery should be considered. The present results also suggest that CSDH formation may be preceded by subdural hygroma caused by the rupture of arachnoid cyst.     

Subdural fluid collection following craniotomy

The occurrence of subdural fluid collection following craniotomy for intracranial aneurysms was studied with regard to the patient's age, preoperative grade, external decompression, incidence of the craniotomy, external drainage, and ventriculoperitoneal shunt. The following results and conclusions were obtained: Enlargement of the subdural space was observed in 76 of 147 patients (51.7%). The patient's age was the most likely causative factor in producing the lesion. Six patients required surgical management for the collection: three were for subdural hygroma and three were for chronic subdural hematoma. It is estimated that two factors, multiple craniotomy and younger age, accelerated the formation of symptomatic subdural hygromas. When the patient complains of headache or motor weakness 1 or 2 months after undergoing a craniotomy, one should suspect chronic subdural hematoma, especially in an elderly patient with ruptured aneurysm.     

Post-shunt subdural hematoma in infants and children--analysis of eleven cases (author's transl)

Out of 122 hydrocephalic infants and children treated by cerebrospinal fluid shunt, post-shunt subdural hematoma was found in 11 patients in total, 8 cases with non-tumorous hydrocephalus and 3 cases with brain tumors obstructing the cerebrospinal fluid pathway. In most cases the diagnosis of subdural hematoma was delayed since signs of increased intracranial pressure were absent initially. The signs of increased intracranial pressure appeared later, when the shunted venricle collapsed and could not give any more space to the growing subdural hematoma. At this stage those cases were easily misdiagnosed as shunt dysfunction. Post-shunt subdural hematoma was apparently induced by the tear of the bridging vein or leakage of the cerebrospinal fluid into the subdural space through the torn arachnoid membrane due to over-drainage of the cerebrospinal fluid, especially when the patients took the erect position. Since such a complication is not rare and difficult to be diagnosed, intensive follow-up is necessary in the post-shunt period. The precautionary measures as well as the treatment for these subdural hematoma were also discussed.     

Middle fossa arachnoid cyst presenting an interesting clinical course: a case report

The mechanism of the disappearance of arachnoid cysts is not fully understood. We report a case of arachnoid cyst which disappeared after head injury. A 28-year-old male was found to have an arachnoid cyst in the left middle fossa following head injury. We followed him up, because he had no symptoms. Two weeks later, he suffered from severe headache. CT image showed a dilatation of the subdural space, and his symptom deteriorated. We performed subdural-perifocal shunt, but one month after, he developed a subdural hematoma. The subdural hematoma was irrigated through a burr hole. His symptom disappeared post operatively. Two months later, CT image showed the disappearance of subdural hematoma and the arachnoid cyst. This case suggested one of the mechanisms involved in the disappearance of arachnoid cyst after head injury.     

Clinical study on intracranial arachnoid cyst: with reference to the middle cranial fossa

Thirty-two cases of congenital arachnoid cyst (AC), 26 cases of supratentorial, and 6 cases of infratentorial cyst are reported. They were encountered over a period of 9 years. The 26 supratentorial cysts consisted of 21 cases located in the middle fossa, 2 in the frontal, and 3 in the suprasellar. Patients' ages ranged from 7 months to 67 years (mean: 19.3 years), with a male to female ratio of 23:9. The most common symptoms were headache, epileptic seizure, and cranial enlargement. Based on observations between neuroradiological examinations including analysis of the cyst content, and operation, typical AC might be defined as "duplicated arachnoid and its splitting", and it may be said that "there is continuous existence of cerebral structure such as cortex and white matter lying adjacent to AC on MRI". Out of 32 cases, 15 received surgical treatment because of mass effect of AC itself, abnormal dynamics of the AC fluid, and/or increasing sign of ICP. 13 cases had resection of AC outer membrane with craniotomy, and the remaining two had cystoperitoneal shunt. One of the shunting cases complicated subdural hematoma. Surgical treatment was discussed and radical craniotomy rather than a shunt procedure was preferred. Prognosis of all cases was favorable and uneventful.     

Spinal arachnoid cysts in the pediatric age group: an association with neural tube defects.

Between 1979 and 1991, spinal arachnoid cysts were found in 11 patients aged 19 months to 18 years (mean age 5 1/2 years). Of the 11 patients, six had a myelomeningocele and one diastematomyelia. The presenting symptoms included radicular pain (one patient), progressive weakness (three), increasing scoliosis (one), worsening spasticity (three), and recurrent urinary tract infections and progressive constipation (one). Two patients showed no symptoms from the spinal arachnoid cyst. The distribution of lesions was as follows: cervicomedullary (one patient), cervical (one), cervicothoracic (two), thoracic (four), lumbar (two), and sacral (one). Four of the 11 arachnoid cysts (all intradural) were located anterior to the spinal cord, three of which were in children with a myelomeningocele. Only two of the cysts were extradural; both were found in the lumbosacral region, and one was associated with diastematomyelia. Eight patients were treated with fenestration and/or resection of the cyst wall. Three patients with anterior cysts were treated with shunts, a cyst-to-pleural space shunt in two and a cyst-to-subarachnoid space shunt in one. All of the patients either improved or exhibited an arrest in the progression of their symptoms. Spinal arachnoid cysts are a treatable cause of progressive neurological deficits and, in this series, were frequently found in patients with neural tube defects.     

To shunt or to fenestrate: which is the best surgical treatment for arachnoid cysts in pediatric patients?

The treatment options for intracranial arachnoid cysts are either craniotomy and fenestration of the cyst into the cerebrospinal fluid spaces or shunting of the cyst contents extracranially. Fenestration may eliminate the need to shunt, but it is a major operative procedure and is not always successful. To determine which treatment provides the greatest benefit with the fewest complications, the records of 31 patients with 34 arachnoid cysts treated at the Children's Hospital of Los Angeles between 1976 and 1986 were reviewed. The mean age of the patients was 4.4 years, with a range of 0 to 15.5 years. The most common location was the middle fossa (14 cases), followed by the posterior fossa (7 cases), the suprasellar region (5 cases), and hemispheric (5 cases) and other locations (3 cases). Signs and symptoms were related to abnormally rapid head growth in infants and to increased intracranial pressure and seizures in older children. The initial treatment of 29 cysts was fenestration. Twenty-two (76%) procedures were successful, with no additional treatment needed for the cyst. The other 7 cysts required the subsequent placement of a cystoperitoneal shunt. In 5 cases, the cysts were treated initially with cystoperitoneal shunts. Of the total 12 cystoperitoneal shunts, 5 have required revisions on one or more occasions. No significant difference in morbidity was noted between the two treatment options. Because we consider shunt independence to be a major goal of therapy, we suggest that patients with arachnoid cysts be divided into two categories, those presenting with associated hydrocephalus and those without hydrocephalus.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prolonged ICP monitoring in Sylvian arachnoid cysts

BACKGROUND: The decision making process for patients with Sylvian fissure arachnoid cysts still represents a challenge for the neurosurgeon. A high percentage of patients are indeed asymptomatic, despite neuroimaging signs of apparently increased intracranial pressure (ICP). The present study was conducted to evaluate the usefulness of prolonged ICP recording in the preoperative work-up. METHODS: Eleven children (10 M/1 F) harboring temporal arachnoid cysts were investigated (mean age: 5.9 years). According to Galassi classification they were subdivided in three groups. Group I was made up of three patients with Type I cysts; Group II comprised six children with Type II cysts; Group III consisted of two children with Type III cysts. An extensible silicone microprocessor (Codman), developed for continuous ICP recording, was implanted intraparenchymally, adjacent to the major extension of the cyst. The collected information was cable unloaded to a PC and stored. All the patients underwent a minimum of 48 hours to a maximum of 72 hours of ICP continuous check. In resting conditions, 10 mm Hg was arbitrarily chosen as the upper normal limit of ICP, and the patients were classified according to the percentile distribution of their ICP daily and nightly pressure values. RESULTS: ICP recordings were in the normal range in all the three children with Type I cysts (49-86%< 10 mm Hg during the entire recording), despite the fact that two of them were apparently symptomatic. Three of the six children with a Type II temporal cyst had elevated ICP values (69-99%> 10 mm Hg), even though they had an incidental (1 case) or prenatal (2 cases) diagnosis. The remaining three patients had normal ICP values for more than 70% of the recording time period. The two patients with type III temporal arachnoid cysts had almost constantly abnormal ICP values (95-99%> 10 mm Hg). Five patients were operated; in four of them the surgical indication was based on ICP recordings (two of the three children with a Type II cyst and increased ICP and the two patients with a Type III cyst). The last child, harboring a Type I cyst, was operated upon parents' request, as a preventive measure. At a mean follow-up of 9.3 months all the patients operated on are in excellent clinical condition; one of them (Type II cyst) initially undergoing a craniotomy and cystic membrane excision required a subduro-peritoneal shunt implant 3 months after surgery for a symptomatic subdural hygroma on the side of the cyst. Postoperative computed tomography showed signs of brain expansion in the two patients operated on for a Type III cyst, and in the patient operated on for a Type I cyst. CONCLUSIONS: With the limit of the relatively small series presented here, prolonged ICP recording appeared to be an important preoperative tool to rule out the necessity of operating on children with Type I cysts. Furthermore, the study confirmed that an increase of the ICP is almost constantly present in children with Type III cysts. In cases of Type II lesions, the study results were less discriminating, though the ICP monitoring contributed in identifying those patients in whom surgery was indicated despite the absence of symptoms.     

Subdural hygroma as a complication of endoscopic neurosurgery--two case reports

Two cases of subdural hygroma occurred in a series of 77 neuroendoscopic procedures. An 8-year-old boy underwent neuroendoscopic cysto-cisternostomy of a left temporal arachnoid cyst. Routine postoperative magnetic resonance imaging 7 days later showed a large left-sided subdural hygroma without clinical symptoms. During the following 3 months, the subdural hygroma did not resolve spontaneously, so it was drained through a burr hole. A 3-month-old boy with aqueductal stenosis developed bilateral subdural hygromas after third ventriculostomy. Several punctures through the open anterior fontanelle relieved the hygromas but increasing head circumference required ventriculoperitoneal shunting 12 months later. Complications of neuroendoscopic procedures are increasingly reported, including various kinds of bleeding, infections, or damage of neuronal tissue. Only three previous cases of subdural hygroma or hematoma after neuroendoscopic interventions have been reported. The possible etiologies and clinical consequences of this rare complication have to be considered before selecting neuroendoscopy treatment.     

Intracranial hypovolemic syndrome with subdural hygroma developed massive hematoma: timing of treatment and histology of dural hypertrophy

We report a case of a 43-year-old man treated by craniotomy for chronical subdural hematoma (CSH) due to spontaneous intracranial hypovolemia. The patient complained of sudden onset severe headache. Initial CT scan showed normal brain structure, and his headache improved with bed rest in a few days. However, MR images obtained for vertigo one month later demonstrated bilateral subdural hygroma extending to the supracerebellar space and diffuse dural enhancement after gadolinium infusion. We diagnosed bilateral subdural hygroma due to spontaneous intracranial hypovolemia, and observed him conservatively. Four months after onset, he complained of severe headache again and MR images revealed enlargement of bilateral CSH with mass effect, which had heterogenous intensity on the right convexity. We evacuated hematoma on the right by craniotomy and aspirated the left side hematoma using a burr hole. His headache improved 2 weeks after the operation with strict bed rest. The follow-up MR images showed disappearance of abnormal meningeal enhancement and improvement of brain sagging.     

Roller coaster headaches revisited

BACKGROUND: Roller coasters are probably one of the more popular rides at amusement parks around the world. Despite their relative safety, nontraumatic intracranial injuries have been reported following roller coaster rides. The presence of an intracranial arachnoid cyst may increase the risk of nontraumatic injury in this setting. CASE DESCRIPTION: We describe a 33-year-old female with a left middle fossa arachnoid cyst who presented with increasing headaches from bilateral subdural hygromas after a roller coaster ride. The patient underwent bilateral burr hole drainage of her subdural hygromas with resolution of her symptoms. CONCLUSION: This case demonstrates the potential risks of intracranial injury in patients with an underlying arachnoid cyst who engage in certain types of recreational activity.     

颅内蛛网膜囊肿术后并发症分析

目的研究颅内蛛网膜囊肿手术治疗后并发症及防治。方法对47例患者施行手术治疗,术式包括蛛网膜囊肿部分切除、囊肿开放脑池穿通术、蛛网膜囊肿部分切除术、内镜下囊肿脑池穿通术及蛛网膜囊肿-腹腔分流术。结果所有手术后患者均获得良好疗效,与囊肿手术有关的并发症主要有剧烈头痛和高热,裂隙脑室综合征和硬膜下血肿。结论对引起临床症状的颅内蛛网膜囊肿应积极手术治疗,与囊肿有关的并发症有其特殊性,做到术中操作细致,术后严密观察,对此类并发症是可以预防和治愈的。     

Lumboperitoneal shunt: clinical applications, complications, and comparison with ventriculoperitoneal shunt

Lumboperitoneal (LP) shunting has the advantage of completely extracranial surgical management, minimizing intracranial complications. An LP shunt has been intentionally adopted for patients who require cerebrospinal fluid diversion. A retrospective study was designed to examine the indications for and complications associated with LP shunts in 207 patients (including 28 pediatric patients) treated during the past 11 years. Follow-up averaging 5.1 years revealed no deaths related directly to LP shunt placement. Twenty-nine patients (14%) underwent revision of the shunt because of obstruction. Shunt-related infections were observed in only 2 patients (1%). Radicular pain occurred in 10 patients (5%), 2 of whom required shunt replacement. Postoperative occurrence of dyspnea and disturbance of consciousness necessitated conversion to a ventriculoperitoneal (VP) shunt in 2 patients (1%), who subsequently were noted to have Chiari malformations. In 4 patients (2%), an acute subdural hematoma developed after mild head trauma. Symptomatic chronic subdural hematomas were observed in 2 patients (1%). One patient had a mild myelopathy that rapidly resolved after shunt replacement. The comparison to 120 patients treated with a VP shunt during the identical period (an average follow-up of 5.2 years) suggests the following conclusions. After subarachnoid hemorrhage caused by a ruptured aneurysm, hydrocephalus is usually of the communicating type and is an indication for an LP shunt. The incidence of infection and malfunction with an LP shunt is significantly lower than that with a VP shunt. An LP shunt is also indicated for pediatric patients, although a relatively higher incidence of malfunction is noted compared to adults.(ABSTRACT TRUNCATED AT 250 WORDS)     

Arachnoid cyst with traumatic intracystic hemorrhage unassociated with subdural hematoma

Arachnoid cysts of the middle cranial fossa may manifest themselves in several different ways. Most often they remain asymptomatic and are only diagnosed incidentally on computed tomography or at autopsy. When they are symptomatic, headache, nausea, vomiting and seizures are most common in the patients with increased intracranial pressure. Increased intracranial pressure is caused by the ball-valve mechanism of the cyst's membrane which is in communication with the general subarachnoid space or arachnoid cells which contain specialized membranes and enzymes which have secretory activity. A significant number of middle cranial fossa arachnoid cysts are associated with subdural hematoma which may, in turn, be associated with intracystic hemorrhage. We report an unusual case with posttraumatic, isolated intracystic hemorrhage of the arachnoid cyst in the sylvian area without subdural hematoma.     

Transcutaneous pressure adjustable valve for the treatment of hydrocephalus and arachnoid cysts in adults

Summary The authors report a series of 75 adults treated over the last four years for hydrocephalus (69 cases) or arachnoid cysts (6 cases) by using a transcutaneous pressure adjustable valve (Sophy SU 8), the mechanism of which is recalled.The shunt was ventriculo-atrial 46 times, ventriculo-peritoneal 23 times and cysto-peritoneal 6 times. The opening pressure of the valve was initially adjusted 56 times to the medium, 9 times to the high, and 10 times to the low position, according to each particular patient's needs. Following the evolution of the neurological status and/or the CT findings, the opening pressure was secundarily modified in 27 patients (i.e., in 36%), and in some of them several times.It was raised 16 times: 10 times because of subdural hygroma(s) (complicated by a subdural haematoma which required surgical removal, in one case), and 6 times because of clinical symptoms of intracranial hypotension associated with hyperdrainage signs on CT.It was diminished 20 times because of the absence of clinical improvement and persistence of dilated ventricles on CT.In these 27 patients the Sophy SU 8 valve allowed modification of its opening pressure according to the clinical and CT evolution, without need for re-operation.It is concluded that the patients who can benefit most from this valve system are patients with normal pressure hydrocephalus or with arachnoid cysts.     

Two cases of symptomatic arachnoid cysts in elderly patients--a comparison and analysis with child cases

A symptomatic arachnoid cyst in an elderly patient is rare. We report two cases of symptomatic arachnoid cysts in elderly patients. The first case is that of a 73-year-old woman complaining of headache and speech disturbance. She had an arachnoid cyst in the left interhemispheric fissure. This is rare. Only two interhemispheric arachnoid cysts in the elderly have ever been reported. The other case is that of a 64-year-old woman, having right hemiparesis and dementia and a cyst is shown in her left temporal lobe. Both patients underwent a cystectomy which resulted in the disappearance of their symptoms. Only 56 cases of symptomatic arachnoid cyst over the age of 60 years have ever been reported. We made an analysis of 58 cases, including our two cases, and compared it with child cases. In cases of the elderly, the symptoms are usually headache, hemiparesis, gait disturbance and dementia, which are similar to symptoms of chronic subdural hematoma and normal pressure hydrocephalus. On the other hand, child cases usually reveal signs of intracranial hypertension. Several authors have reported their therapeutic method for child symptomatic arachnoid cysts. However, it is difficult to determine the best method for treating child cases at this time. We think a cystectomy is the first choice of operative procedure for symptomatic arachnoid cyst in the elderly.