Spontaneous Subdural Haematoma Developing Secondary to Arachnoid Cyst Rupture

Temporal sylvian fissure arachnoid cyst in children: treatment outcome following microsurgical cyst fenestration with special emphasis on cyst reduction and subdural collection

OBJECTIVES

Controversy remains regarding surgical managements of sylvian fissure arachnoid cyst (SFAC). This review presents our experience in the microsurgical fenestration of pediatric patients with SFAC to define surgical indication, and risks and benefits with special emphasis on postoperative subdural fluid collection (SDFC) and cyst size reduction.

METHODS

Thirty-four children with SFAC who underwent microsurgical cyst fenestration at a single institution over a 10-year period were retrospectively reviewed for their clinical presentation, neuroimaging findings, and postsurgical course. The SFACs were classified by a novel grading system based on the degree of arachnoid cyst extension from the sylvian fissure to the insular cistern shown on MR images: grade 0 - little or no prominence of sylvian fissure, grade I - SFAC confined to the sylvian fissure, grade II - SFAC partially extending to the insular cistern, grade III - SFAC extending to the entire insular cistern.

RESULTS

There were 26 males and 8 females. SFAC was present in the left side in 24. Twelve patients presented with cyst rupturing to the subdural space. Cyst grading did not show significant difference compared with rupture status (p > 0.9). All patients underwent microsurgical cyst fenestration. Postoperative SDFC is common but often resolved overtime in two-thirds of the cases with the mean average of 6 months. However, 3 patients had symptomatic postoperative SDFC and needed reoperation shortly after the first operation. Microsurgical cyst fenestrations for SFAC effectively resolved the presenting symptoms and often showed restorations of intracranial structures on follow-up imaging. Cyst resolution or reduction greater than 75% was noted in 61.8% of the patients postoperatively which was noted in a half of the SFAC of children even with age of 11 years or older. During the follow-up, no cyst recurrence or SDFC was noted. Patients with greater surgical reduction of cyst size tended to occur in younger children, and those with lower MR grade.

CONCLUSION

Our results showed a high reduction rate of SFAC and brain re-expansion after microsurgical fenestration together with symptomatic improvements regardless the patient's age. Considering the developing CNS during childhood, reductions of a large space-occupying lesion followed by restorations of the structural integrity of the developing brain are very desirable. However, a multi-center cooperative prospective longitudinal study on long-term comparative data of those treated and untreated of neuro-psychological outcome and cyst rupture incidence is needed.

Controversies in the Treatment of Arachnoid Cysts with Special Emphasis on Temporal Arachnoid Cysts

Intracranial arachnoid cysts (ACs) are benign lesions. The incidence in children is 2.6%. ACs are often diagnosed incidentally. Because of the broad use of CT and MR imaging, the frequency of AC diagnosis has increased. In addition, prenatal diagnosis of ACs is becoming more common. This places clinicians in a difficult situation with regard to the optimal treatment, since the presenting symptoms are often vague and operative management includes not negligible risks. It is generally accepted that conservative management is indicated in cases with small and asymptomatic cysts. In contrast, patients with definite signs of raised intracranial pressure should be treated. There are however clinical situations in whom the decision about the preferred treatment is difficult to make. Unspecific symptoms such as headaches and neurocognitive or attention deficits can be challenging to evaluate, whether they are related to the presence of the AC or not. The treatment techniques intent to establish a communication between the cyst and the normal cerebrospinal spaces or consist of a diversion of the cyst fluid by a shunt system. Which surgical method (open craniotomy for cyst fenestration, endoscopic fenestration, or shunting) is preferred differs between neurosurgical centers or the pediatric neurosurgeon in charge. Each treatment option has a unique profile of advantages and disadvantages which should be considered when discussing treatment with the patients or their caregivers.

Ruptured Sylvian arachnoid cysts: an update on a real problem

PURPOSE

Sylvian arachnoid cysts (SACs) are the most common type of arachnoid cysts and the most prone to undergo a rupture. This event is considered rare but potentially severe. No definite information is available on its occurrence or management. The goal of the present article is to provide an update on the epidemiological, etiological, and clinical aspects and the management of this peculiar clinical condition.

METHODS

A comprehensive review of the English literature of the last 40 years on this topic has been realized. Moreover, a personal series of children investigated and treated in the last 20 years is presented. These patients were managed as follows: (1) treatment of the subdural collection; (2) identification of candidates for surgical treatment of the residual cyst (brain MRI, perfusion brain MRI, prolonged invasive ICP monitoring (selected cases), EEG, neuropsychological tests); (3) surgical treatment of the cyst in the patients with pathological perfusion MRI and/or ICP measurement and/or clear neurophysiological and neuropsychological correlations.

RESULTS

A total of 446 patients (430 from the literature and 16 from the personal series), mainly children, adolescents, and young adults, have been analyzed leading to the following results: (1) SAC rupture is rare but not negligible (yearly risk of rupture: 0.04%; overall risk up to 10% in children affected by SCAs). Prophylactic surgery in asymptomatic cases is not advisable. (2) The mechanism of rupture is not known but an impact of SAC against the sphenoid wing and/or a direct injury on SAC through a thinned temporal bone, with possible laceration of the cyst wall vessels and/or tear of the bridging veins, can be hypothesized. A head injury is often not reported (may be misdiagnosed). (3) Subdural collection (hygroma > chronic hematoma) is the most common finding followed by intracystic bleeding, extradural hematoma, and other types of bleeding. Signs or symptoms of raised intracranial pressure are the most frequent ones. (4) The complication of the rupture is usually treated in emergency or in the acute period by burr hole or craniotomic evacuation of the subdural collection, although a conservative management is possible in some cases. Following the rupture, the majority of SACs are treated (70%), often at the same time of the complication, but no specific investigations are routinely performed to select candidates. According to our protocol, only 43.7% of SACs needed to be treated.

CONCLUSIONS

The "spontaneous" or posttraumatic rupture of SACs is a rare but potentially significant complication followed by a generally good outcome. The course of the cyst is independent from the outcome of the complication, consequently requiring specific investigations for individuating those lesions interfering with CSF dynamics and/or cerebral blood flow.

Spontaneous rupture of middle fossa arachnoid cysts: surgical series from a single center pediatric hospital and literature review

PURPOSE

Arachnoid cysts may present with symptoms deriving from cyst rupture, usually causing intracystic hemorrhage and subdural hematoma or hygroma. Rupture is usually caused by minor trauma, spontaneous rupture is an exceptional event, and 57 cases have been described in literature. We here present and discuss the largest series of spontaneously ruptured middle fossa arachnoid cysts in order to investigate clinical presentation and best treatment available.

METHODS

We report a retrospective series of 17 pediatric patients surgically treated for middle fossa arachnoid cyst with signs of cyst rupture without a history of trauma in the previous 90 days. We describe clinical presentation, treatment, and outcome at follow-up discussing our results with a literature review including all reported cases of spontaneous rupture of middle fossa arachnoid cysts.

RESULTS

In our experience patients most frequently presented with subdural hygroma, in literature, a chronic hematoma was most frequently reported. Headache is the most reported symptom at presentation. Neurological deficits and consciousness alterations are rare. Surgical treatment may resolve brain compression only or reduce rupture recurrence risk. Conservative treatment has also been proposed. Different treatments are reported and discussed focusing on indications, contraindications, risks, and expected benefits.

CONCLUSION

We propose, when safely possible, microsurgical cyst fenestration in skull base cisterns as the treatment of choice for these patients as long as it addresses both immediate decompression and risk of rupture recurrence. We report good outcomes and low incidence of complications from our series with a mean postoperative follow-up of 30 months.

Cerebral vasospasm after endoscopic fenestration of a temporal arachnoid cyst in a child-a case report and review of the literature

INTRODUCTION

Intracranial arachnoid cysts (ACs) represent rare extra-axial CSF-containing lesions. Surgical management mainly depends on the cyst location and its size. Nevertheless, pure endoscopic fenestration represents a relatively straightforward and safe technique, and-in most cases-the treatment of choice for symptomatic intracranial ACs. The postoperative complication rate of the procedure is low including subdural hematomas, hygromas, and intraparenchymal hemorrhages. Symptomatic cerebral vasospasm after endoscopic treatment of ACs is a very uncommon event.

CASE REPORT/RESULTS

To the authors' knowledge, this adverse event in children has not yet been reported in the literature yet. The authors present a case of a 9-year-old child developing an early symptomatic cerebral vasospasm with an insignificant secondary ischemia following endoscopic fenestration of a large temporal arachnoid cyst.

DISCUSSION

The clinical approach, possible pathogenesis, and the therapeutic strategy is discussed particularly with regard to the literature.

Is arachnoid cyst a static disease? A case report and literature review

INTRODUCTION

The increasing use of intracranial imaging has led to more frequent diagnoses of arachnoid cysts (ACs). Although ACs are a frequent finding on neuroimaging in children, the prevalence and natural history of these cysts are not well defined. Most ACs may persist and remain asymptomatic throughout life and not require treatment. However, there have been some case reports of ACs that have become larger or smaller over time and, in rare cases, have even spontaneously resolved. It is the authors' practice to recommend serial neuroimaging in patients with asymptomatic sylvian ACs and not offer surgery to patients without symptoms, even in those with a relatively large cyst.

CASE REPORT

The present article describes a case involving a 6-year-old boy with a large, asymptomatic AC in the left Sylvian fissure involving the temporo-frontal region, which resolved spontaneously during the 2-year follow-up period after initial diagnosis without any surgical intervention. Currently, at the 7-year follow-up, the patient has remained neurologically intact, attends school, and is symptom-free.

CONCLUSION

Clinicians should be mindful of the possibility of spontaneous regression when encountering patients with asymptomatic and/or incidentally diagnosed sylvian ACs.

Spontaneous Acute Subdural Hematoma Associated with Arachnoid Cyst and Intra-cystic Hemorrhage

Arachnoid cysts (ACs) are congenital, extra-axial lesions containing fluid similar to the composition of cerebrospinal fluid. Usually found incidentally, these lesions are observed with serial imaging to document their growth patterns and stability, and are then followed conservatively until clinical symptoms develop. Surgical options for symptomatic arachnoid cysts include cyst aspiration, cyst evacuation with fenestration into the subarachnoid space, and shunt procedures including cysto-peritoneal and cysto-ventricular shunts. Intra-cystic hemorrhage and subdural hematoma are rare and more emergent sequelae of ACs that may require an emergent craniotomy. This case report further documents a rare cause of spontaneous subdural hematoma, as well as serves as a pivot point for further discussion into whether continued neuroimaging surveillance in patients with ACs would prove to be beneficial.