The use of an adjustable valve to treat over-drainage of a cyst-peritoneal shunt in a child with a large sylvian fissure arachnoid cyst

Effectiveness of multiple endoscopic fenestrations for the treatment of Sylvian fissure arachnoid cysts: a multicenter study

PURPOSE

Arachnoid cysts are usually asymptomatic lesions. However, they can sometimes cause intracranial hypertension, headache, seizures, focal neurological deficits, and bleeding. The most commonly used surgical techniques are microsurgical cyst fenestration/excision/drainage, cyst shunting, and endoscopic procedures. We aimed to investigate the success of different surgical techniques.

METHODS

Between 2000 and 2021, patients with Sylvan fissure arachnoid cysts who received treatment via an endoscopic approach chosen as the first-line treatment in three centers were enrolled. All case notes and radiological studies were evaluated retrospectively.

RESULTS

The study included 131 (female, n = 28; male, n = 103) patients with a mean age of 87.04 ± 66.76 (range, 0-216) months. Of the patients, 25 had Galassi type II left-sided arachnoid cysts, 33 had Galassi type II right-sided arachnoid cysts, 40 had Galassi type III left-sided arachnoid cysts, and 32 had Galassi type III right-sided arachnoid cysts. No difference was found between patients who underwent single and multiple fenestrations in terms of Galassi type, side, clinical outcome, and cyst size (p > 0.05). On the contrary, the rate of additional surgical intervention was lower in patients with multiple fenestrations than in those with single fenestration (36.10% vs. 5.30%; p < 0.001).

CONCLUSION

Endoscopic fenestration of Sylvian fissure arachnoid cysts is a good alternative to open surgery or cystoperitoneal shunting, and the number of fenestrations made during this surgery decreases the need for a second surgical procedure.

Cyst-ventricle stent as primary or salvage treatment for posterior fossa arachnoid cysts

OBJECT

The optimal treatment of symptomatic posterior fossa arachnoid cysts is controversial. Current options include open or endoscopic resection, fenestration, or cyst-peritoneal shunt placement. There are potential drawbacks with all options. Previous authors have described stenting a cyst into the ventricular system for supratentorial lesions. The current authors have used a similar strategy for posterior fossa cysts.

METHODS

The authors performed a retrospective review of 79 consecutive patients (1993-2010) with surgically treated intracranial arachnoid cysts.

RESULTS

The authors identified 3 patients who underwent placement of a stent from a posterior fossa arachnoid cyst to a supratentorial ventricle. In 2 patients the stent construct consisted of a catheter placed into a posterior fossa arachnoid cyst and connecting to a lateral ventricle catheter. Both patients underwent stent placement as a salvage procedure after failure of open surgical fenestration. In the third patient a single-catheter cyst-ventricle stent was stereotactically placed. All 3 patients improved clinically. Two patients remained asymptomatic, with radiographic stability in a follow-up period of 1 and 5 years, respectively. The third patient experienced initial symptom resolution with a demonstrable reduction of intracystic pressure. However, he developed recurrent headaches after 2 years.

CONCLUSIONS

Posterior fossa cyst-ventricle stenting offers the benefits of ease of surgical technique and a low morbidity rate. It may also potentially reduce the incidence of shunt-related headaches by equalizing the pressure between the posterior fossa and the supratentorial compartments. While fenestration is considered the first-line therapy for most symptomatic arachnoid cysts, the authors consider cyst-ventricle stenting to be a valuable additional strategy in treating these rare and often difficult lesions.

Intracranial Cysts Containing Cerebrospinal Fluid-Like Fluid: Results of Endoscopic Neurosurgery in a Series of 64 Consecutive Cases

BACKGROUND:

Intracranial cysts containing cerebrospinal fluid (CSF) may be developmental or acquired.

OBJECTIVE:

To analyze the results of endoscopic neurosurgery in the management of intracranial CSF cysts.

METHODS:

In a 7-year period, 64 consecutive patients underwent endoscopic neurosurgery for CSF cysts. Group 1 consisted of 13 patients with acquired cysts; group 2 included 51 patients with developmental cysts. In all cases, the cyst walls were fenestrated through small burr holes with frameless guided operative endoscopes. Follow-up ranged from 1 to 6 years (mean, 3.4 years).

RESULTS:

There were no mortality and no permanent morbidity, apart from a patient (1.6%) who remained neurologically intact but required ventriculoperitoneal shunting because of intraoperative hemorrhage. The planned fenestrations could be performed in all patients except 2, owing to thick, opaque cyst walls. In group 1, 6 patients fully recovered and remained intact throughout the follow-up, whereas 7 improved but had various degrees of neurological disabilities that were related to their initial diseases. Radiological results were excellent in all cases. In group 2, there were 7 asymptomatic patients who remained unchanged and 44 “symptomatic” patients: 40 (91%) clinically improved, 4 (9%) remained unchanged, and none worsened. Cyst size decreased in 37 patients (74%) and remained unchanged in 13 (26%).

CONCLUSION:

In this series, patients of different ages, harboring cysts of various sizes and locations, could be satisfactorily treated with endoscopic neurosurgery.

Endoscopic treatment of middle fossa arachnoid cysts: a series of 40 patients treated endoscopically in two centres

PURPOSE

Middle fossa arachnoid cysts (MFAC) are a relatively common, benign pathology that pose a therapeutic challenge for both symptomatic and asymptomatic patients. The optimal surgical strategy and indication to treat are still debated by neurosurgeons. We reviewed our experience and results in a group of patients treated with endoscopic fenestration with the aim to assess indications to treat and clinical and neuroradiological results.

METHODS

The data on 40 patients operated with endoscopic fenestration for MFAC in two centres, "Anna Meyer" Children's Hospital, Florence, Italy, and Royal Liverpool Children's Hospital "Alder Hey", Liverpool, UK, between 2001 and 2007 were retrospectively reviewed with prospective follow-up. We analysed clinical and neuroradiological presentation, indications to treat, surgical technique, complications, and clinical and neuroradiological follow-up.

RESULTS

There were 30 males and ten females: mean age, 7.8 years; mean follow-up, 21 months. The neuronavigation system was used in 12 patients in the English cohort. Thirty-seven patients (92.5%) had a satisfactory clinical outcome. The cyst was reduced in size or completely disappeared in 29 patients (72.5%). There was no death or significant morbidity associated with the procedure. Four patients required further surgical treatment. Four patients experienced a post-traumatic intracystic bleeding after surgery.

CONCLUSION

Compared to microsurgical fenestration and cyst shunting, our experience with endoscopic fenestration was as effective and safe but less invasive. Each case must be assessed with its individual characteristics to define the optimal surgical strategy. Successful treatment may not reduce the risk of post-traumatic head injury haemorrhage.

CSF overdrainage in shunted intracranial arachnoid cysts: a series and review

BACKGROUND

Cerebrospinal fluid (CSF) overdrainage in hydrocephalus is well recognized. Overshunting following cysto-peritoneal (CP) drainage in patients with arachnoid cysts (AC) is rarely documented.

AIM

We report five patients with acquired Chiari malformation I and three with posterior fossa overcrowding due to excessive CSF drainage in shunted intracranial ACs. We review our observations and discuss the current knowledge on the pathogenesis and management of this complication.

PATIENTS AND METHODS

The medical records of the eight patients were analyzed in regard to clinical manifestation, cyst and shunt characteristics, management, and outcomes.

RESULTS

Mean age of the patients was 5.5 years. After an average interval of 5 years, five patients developed symptoms related to hindbrain herniation and three to severe shunt overdrainage following CP shunting. Several management modalities were utilized that achieved a good result in seven instances.

DISCUSSION

Some shunted ACs may evolve with overdrainage syndromes. Posterior fossa overcrowding and tonsillar herniation constitute their most severe forms. CSF hypotension, bone changes, venous engorgement, and probably cerebral chronic edema at the posterior fossa constitute the main factors involved in the pathogenesis of this entity. We also review previous instances of acquired Chiari malformation originating after AC shunting.

CONCLUSIONS

Posterior fossa overcrowding and acquired Chiari I malformation can develop after excessive CSF drainage of intracranial ACs. Overshunting manifestations require prompt recognition and management. Preventive measures consist of making a stringent selection of cases being considered for surgery, avoiding CP drainage, and placing of a programmable valve as initial treatment of intracranial ACs if shunting is considered.

Sylvian fissure arachnoid cysts: a survey on their diagnostic workout and practical management

BACKGROUND

The management of Sylvian arachnoid cysts in children is still a matter of debate. Diagnosis is often incidental, and symptoms are frequently aspecific in symptomatic cases. Suggested diagnostic investigation results have been often unclear. Surgical treatment is also controversial, pure, and assisted endoscopic cyst marsupialization having entered in the traditional debate between craniotomic and shunting approach

PURPOSE

The objective of the present study was to survey if (and, eventually, which) agreement points do actually exist between internationally recognized pediatric neurosurgery centers in the management of children with a controversial type of Sylvian arachnoid cyst (Type II cyst).

METHODS

Contributors were asked to answer to a six-separate-part multiple choice questionnaire related to the case of a 2.7-year-old boy with a Type II left Sylvian arachnoid cyst presented in different clinical situations. If surgery was indicated, it was asked which surgical procedure the authors would have suggested as first option.

RESULTS AND CONCLUSIONS

The option of the mere clinical observation was chosen by the majority of surgeons in case of asymptomatic clinical discovery. On the other hand, a constantly high percentage of participants suggested direct surgical treatment based on clinical manifestations or as a preventive measure justified by the risk of spontaneous or traumatic intracranial bleeding. The only diagnostic investigation result which significantly influenced the surgical indication was a localizing electroencephalography, if the child presented with seizures. The result is that in most cases the surgical indication was based on aspecific clinical manifestations and laboratory data. Craniotomy and arachnoid cyst marsupialization represented the preferred surgical option (66.6%), 28.8% of the participants suggesting pure or assisted endoscopic cyst marsupialization as primary surgical procedure. Cyst shunting was suggested by only three centers.

Management of neonatal hydrocephalus: feasibility of use and safety of two programmable (Sophy and Polaris) valves

BACKGROUND

Neonates represent a unique group of pediatric patients with special peculiarities. Hydrocephalus valves have not always been designed to meet the requirements of these small children. Few series have addressed the problem of cerebrospinal fluid shunting in newborn babies.

OBJECTIVES

We aimed (1) to evaluate the feasibility of the use of two programmable valves (Sophy and Polaris) in hydrocephalic neonates and (2) to ascertain complications and safety issues arising from their use.

MATERIALS AND METHODS

We performed a prospective study of 100 consecutive preterm and term babies (<2 months of age) given a programmable valve. Valves' settings were readjusted at different pressure levels as required. Outcomes were obtained from the records of our Outpatient Clinic.

RESULTS

The study group was formed by 60 term and 40 preterm infants (average weight 2,440 g, mean age of 25 days). Mean follow-up was 55 months. Only one fifth deaths was shunt-related. In 70 babies, no complications occurred, and hydrocephalus was successfully controlled. Proximal catheter obstruction presented in 20% and infection in 5% of cases. Several external adjustments of the valves apparently avoided several surgical shunt revisions.

CONCLUSIONS

(1) Both programmable valves (Sophy and Polaris) can be safely used for treatment of neonatal hydrocephalus, introducing some technical modifications. (2) Both valves are comparable to other shunts with regard to indications, performance, and safety. (3) The possibility of modifying their working pressure seems to constitute their main advantage. Prevention of late overdrainage syndromes with these valves needs a longer follow-up.

Experience with the Strata valve in the management of shunt overdrainage

OBJECT

The overdrainage of cerebrospinal fluid (CSF) in children with shunt-treated hydrocephalus may cause chronic disabling symptoms and require repeated surgery. Externally adjustable valves offer a noninvasive way of altering the valve opening pressure. The authors report on their experience with using the Strata valve in the management of symptomatic CSF overdrainage.

METHODS

The authors treated 24 patients with symptomatic CSF overdrainage by inserting a Strata valve. The severity of symptoms was graded, and the frequency of hospital visits and shunt operations was recorded before and after insertion of the valve. Additionally, results of brain imaging and intracranial pressure monitoring were reviewed. Nineteen patients (79.2%) had severe symptoms at the time of the insertion; 1 year after Strata valve insertion only one patient (4.17%) still suffered severe symptoms. The number of hospital admissions was 3.38/patient/year before placement and 1.21 for the 1st year, 1 for the 2nd, and 0.4 for the 3rd postoperative year. The number of operations was 3.42/patient/year during the year before placement of the valve, and then 0.71 for the 1st, 0.56 for the 2nd, and 0.25 for the 3rd postoperative years. During the 1st year after placement of the Strata valve, the settings were changed 2.79 times/patient/year, 1.29 for the 2nd, and 1.33 times/patient/year for the 3rd year.

CONCLUSIONS

The Strata valve was effective in improving the symptoms of overdrainage in the majority of patients in this series. The number of hospital admissions and operations for valve malfunction was reduced.