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CASE REPORT
Year : 2017  |  Volume : 6  |  Issue : 3  |  Page : 194-196

Arachnoid cyst with bilateral subdural hygroma: Rare case report


1 Department of Neurosurgery, Citizens Hospital, Hyderabad, Telangana, India
2 Osmania General Hospital, Hyderabad, Telangana, India

Date of Web Publication25-Sep-2017

Correspondence Address:
Maddala Sundeep
Department of Neurosurgery, Citizens Hospital, Nallagandla, Serilingampally, Hyderabad - 500 019, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2277-8632.215524

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  Abstract 

Arachnoid cysts are benign, congenital, nonneoplastic, extra-axial, intra-arachnoid lesions filled with similar to or exactly like cerebrospinal fluid. These cysts are reported to account for at least 1% of all intracranial mass lesions. Most patients present during the first two decades of life; however, presentation during adulthood is not uncommon. Arachnoid cysts are often discovered as incidental findings on cranial imaging. Surgical treatment of arachnoid cysts with bilateral subdural hygroma is controversial. We report a rare presentation of an arachnoid cyst with bilateral subdural hygroma.

Keywords: Arachnoid cyst, craniotomy, subdural hygroma


How to cite this article:
Sundeep M, Faisal MG, Kirmani SA, Ray MP. Arachnoid cyst with bilateral subdural hygroma: Rare case report. J NTR Univ Health Sci 2017;6:194-6

How to cite this URL:
Sundeep M, Faisal MG, Kirmani SA, Ray MP. Arachnoid cyst with bilateral subdural hygroma: Rare case report. J NTR Univ Health Sci [serial online] 2017 [cited 2020 Apr 6];6:194-6. Available from: http://www.jdrntruhs.org/text.asp?2017/6/3/194/215524


  Introduction Top


Arachnoid cysts are benign, congenital, nonneoplastic, extra-axial, intra-arachnoid lesions filled with similar to or exactly like cerebrospinal fluid (CSF).[1] Although they may present at any age, 60-80% of arachnoid cysts are discovered in children,[2] with overall male-to-female ratio of 2:1 to 3:1. Arachnoid cysts may be completely asymptomatic or present with a myriad of symptoms. We report a rare presentation of an arachnoid cyst with bilateral subdural hygroma with papilledema.


  Case Report Top


A 4-year-old male child presented with complaints of headache, visual blurring, and projectile vomiting of 6 days duration. The child had a history of trivial fall while playing at school about 6 days prior to onset of headache, with no loss of consciousness. On examination, child was conscious, coherent with normal higher mental functions. His visual acuity was 6/6 in both eyes, no visual field defects. Fundoscopy showed bilateral papilledema. Other cranial nerves examinations were normal. There were no motor and sensory deficits. Deep tendon reflexes were 2+, with bilateral plantars down going. All routine biochemical investigations were within normal limits. Computed tomography (CT) scan of the brain showed a hypo-dense region in the right Sylvain fissure compressing the temporal horn with bilateral subdural hygroma, bilateral diffuse cerebral edema, and mass effect causing compression of both frontal horns. Magnetic resonance imaging (MRI) of the brain showed a bilateral collection in the subdural space, hypo-intense on T1-weighted and hyper-intense on T2-weighted images in the right Sylvain fissure, matching with the intensities of CSF [Figure 1].
Figure 1: Computed tomography scan of the brain showing hypo-dense region expanding the right Sylvain fissure with bilateral subdural hygroma/hematoma (chronic), bilateral diffuse cerebral edema, and mass effect causing compression of both frontal horns

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Right pterional craniotomy, evacuation of hygroma, fenestration of the cyst into basal cisterns, and marsupialization of the cyst was performed. Postoperatively child developed pseudomeningocele, which was managed by tapping and compression dressings for 1 week and was discharged without any deficits. Postoperative imaging demonstrated a reduction in cyst size and subdural hygroma, with no ventricular compression and mass effect [Figure 2].
Figure 2: The postoperative computed tomography scan showed resolution of the subdural hygroma and significant decrease in mass effect with small extradural and subgaleal collection of the cerebrospinal fluid

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  Discussion Top


Arachnoid cysts constitute about 1% of all nontraumatic intracranial space-occupying lesions. The formation of arachnoid cysts is hypothesized to result from abnormal embryonic development. A slit-valve or ball-valve communication may exist between the subarachnoid space and the cyst. CT cisternography or cine-phase contrast-enhanced MRI sequences often demonstrate slow filling or emptying of the arachnoid cyst.[3]

Majority of the arachnoid cysts are discovered incidentally and remain stable over many years while some disappear spontaneously. Subdural rupture of the arachnoid cyst per se, either traumatic or spontaneous, is sparingly reported.[4],[5],[6],[7] Clinical presentation varies primarily by age and location. The most common presenting symptom is headache, which may be due to local mass effect, raised intracranial pressure, or hydrocephalus, or may be unrelated to the co-existing cyst.

Arachnoid cysts are most commonly located in the middle cranial fossa. Galassi et al. classified middle fossa and Sylvain fissure cysts into three types on the basis of their CT appearance and apparent communication with adjacent normal CSF spaces.[8] The present case is type II cyst, quadrangular-appearing involving up to mid aspect of the Sylvain fissure.

Symptomatic arachnoid cysts may be surgically treated by various modalities such as craniotomy and fenestration, cystoperitoneal shunt or endoscopic marsupialization.[9],[10],[11] We performed craniotomy and cyst excision with microsurgical fenestration in this patient as there was bilateral subdural hygroma with symptoms of raised intracranial pressure, which needed emergency decompression.[12]


  Conclusion Top


Arachnoid cyst rupture causing subdural hygroma is rare. Spontaneous rupture with bilateral subdural hygroma is very rare. Management of arachnoid cyst with bilateral subdural hygroma is controversial. Symptomatic patients are surgical candidates. Microsurgical fenestration by means of a craniotomy is a safe and effective method for the treatment of middle fossa arachnoid cysts.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Wetjen NM, Walker ML. Arachnoid cysts. In: Winn HR, editor. Youmans Neurological Surgery. 6th ed., Vol. 2. Philadelphia, PA: Elsevier Saunders; 2011. p. 1911-7.  Back to cited text no. 1
    
2.
Galassi E, Piazza G, Gaist G, Frank F. Arachnoid cysts of the middle cranial fossa: A clinical and radiological study of 25 cases treated surgically. Surg Neurol 1980;14:211-9.  Back to cited text no. 2
    
3.
Hellwig D, Schulte DM, Tirakotai W. Surgical management of arachnoid, suprasellar, and Rathke's cleft cysts. In: Schmidek HH, Roberts DW, editors. Operative Neurological Techniques. 5th ed. Vol. 1. Philadelphia, PA: Elsevier Saunders; 2006. p. 455-73.  Back to cited text no. 3
    
4.
Cullis PA, Gilroy J. Arachnoid cyst with rupture into the subdural space. J Neurol Neurosurg Psychiatry 1983;46:454-6.  Back to cited text no. 4
    
5.
Goswami P, Medhi N, Sarma PK, Sarmah BJ. Case report: Middle cranial fossa arachnoid cyst in association with subdural hygroma. Indian J Radiol Imaging 2008;18:222-3.  Back to cited text no. 5
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6.
Gupta R, Vaishya S, Mehta VS. Arachnoid cyst presenting as subdural hygroma. J Clin Neurosci 2004;11:317-8.  Back to cited text no. 6
    
7.
Gelabert-González M, Fernández-Villa J, Cutrín-Prieto J, Garcìa Allut A, Martínez-Rumbo R. Arachnoid cyst rupture with subdural hygroma: Report of three cases and literature review. Childs Nerv Syst 2002;18:609-13.  Back to cited text no. 7
    
8.
Galassi E, Tognetti F, Gaist G, Fagioli L, Frank F, Frank G. CT scan and metrizamide CT cisternography in arachnoid cysts of the middle cranial fossa: Classification and pathophysiological aspects. Surg Neurol 1982;17:363-9.  Back to cited text no. 8
    
9.
Holst AV, Danielsen PL, Juhler M. Treatment options for intracranial arachnoid cysts: A retrospective study of 69 patients. Acta Neurochir Suppl 2012;114:267-70.  Back to cited text no. 9
    
10.
Pradilla G, Jallo G. Arachnoid cysts: Case series and review of the literature. Neurosurg Focus 2007;22:E7.  Back to cited text no. 10
    
11.
Maher CO, Garton HJ, Al-Holou WN, Trobe JD, Muraszko KM, Jackson EM. Management of subdural hygromas associated with arachnoid cysts. J Neurosurg Pediatr 2013;12:434-43.  Back to cited text no. 11
    
12.
Levy ML, Wang M, Aryan HE, Yoo K, Meltzer H. Microsurgical keyhole approach for middle fossa arachnoid cyst fenestration. Neurosurgery 2003;53:1138-44.  Back to cited text no. 12
    


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