<%server.execute "isdev.asp"%> Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature Krishnan P, Kartikueyan R - J Pediatr Neurosci
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LETTER TO THE EDITOR
Year : 2013  |  Volume : 8  |  Issue : 2  |  Page : 177-179
 

Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature


Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, Kolkata, India

Date of Web Publication7-Sep-2013

Correspondence Address:
Prasad Krishnan
Department of Neurosurgery, National Neurosciences Centre, Peerless Hospital Complex, IInd Floor, 360, Panchasayar, Kolkata - 700 094
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1817-1745.117869

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How to cite this article:
Krishnan P, Kartikueyan R. Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature . J Pediatr Neurosci 2013;8:177-9

How to cite this URL:
Krishnan P, Kartikueyan R. Arachnoid cyst with ipsilateral subdural hematoma in an adolescent - causative or coincidental: Case report and review of literature . J Pediatr Neurosci [serial online] 2013 [cited 2019 Apr 20];8:177-9. Available from: http://www.pediatricneurosciences.com/text.asp?2013/8/2/177/117869


Dear Sir,

Arachnoid cysts (AC's) are congenital malformations commonly located in the temporal fossa and sylvian fissure regions. They are usually asymptomatic but may present with seizures, mass effect or with bleeding manifestations. Subdural hematoma (SDH) on the other hand is usually found in the elderly in the setting of cerebral atrophy wherein the potential subdural space [closed in the young due to apposition of brain to the dura] opens up. Numerous studies have stated AC's to be a predisposing factor for SDH in the young. We present one such case and review the available literature.

A 15-year-old boy presented with progressively increasing holocranial headache and multiple episodes of vomiting of 1-week duration. There was a history of trivial trauma to the head 2 weeks previously, not followed by any loss of consciousness, seizures, or ENT bleed. He had no visual complaints.

On examination, he was conscious and oriented with normal higher mental functions. Extra-ocular movements were full. He had bilateral papilledema. Other cranial nerve functions were normal. There were no focal motor deficits. The left plantar was extensor.

CT scan of brain showed a right-sided sub-acute subdural hematoma (SDH) isodense to brain with significant mid-line shift to the left. Cortical sulci were effaced. There was also a right temporal arachnoid cysts (AC) which was isodense to cerebrospinal fluid (CSF). There was no intra-cystic hemorrhage [Figure 1]. The patient underwent a digital subtraction angiogram (DSA) which showed no evidence of any aneurysm or intra-cerebral or dural arteriovenous malformation [Figure 2]. The middle cerebral artery (MCA) branches were pushed medially by the extra-axial SDH [Figure 3]. He underwent burr hole drainage of the SDH. Post-operative period was uneventful. Follow-up CT scan showed resolution of the SDH and restitution of the mid-line. The AC continues to remain the same size [Figure 4]. At 3 years follow-up the SDH has not recurred and the patient is asymptomatic.
Figure 1: CT scan of brain showing a right-sided sub-acute SDH isodense to brain with significant mid-line shift to the left. Cortical sulci are effaced. There is also a right temporal AC which was isodense to CSF with no intra-cystic hemorrhage

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Figure 2: DSA showing no evidence of any aneurysm or intra-cerebral or dural arteriovenous malformation

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Figure 3: The MCA branches are pushed medially by the extraaxial SDH on DSA

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Figure 4: Follow-up CT scan showing resolution of the SDH and restitution of the mid-line with the AC continuing to remain of the same size

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ACs have been stated to be a pre-disposing factor for development of SDH. In 658 patients with SDH reviewed by Parsch et al.,[1] 16 were found to have AC (an incidence of 2.43%). This was five-fold greater than the prevalence of ACs in asymptomatic patients.Wester et al. [2] found SDH in 11 patients of 241 cases of AC referred for treatment (an incidence of 4.6%). Iaconetta et al.[4] have mentioned the annual risk of bleeding in patients with middle fossa ACs to be probably less than 0.1%.

Page et al. [3] first highlighted the relation between AC and SDH speculating two reasons for the association: Firstly magnification of pressure waves, following trauma, within an AC compared to normal sub-arachnoid space with rupture of bridging veins and secondly lower compliance of cyst wall compared to normal brain tissue with tearing of unsupported bridging veins after trauma.

Chan et al. [5] (29-year-old male patient) have also suggested that increased compressibility of the ipsilateral cerebral hemisphere in the presence of AC allows SDH to form more easily following trauma [5] while others emphasize the loose attachment of the AC membrane to the middle fossa dura as being causative. [2]

Kocaeli et al.[6] have described a patient (25-year-old male) with MCA bifurcation aneurysm that bled into an AC and leaked into the subdural space causing SDH.

Conversely, Domenicucci et al.[7] state that ACs, in patients diagnosed with SDH, are only incidental findings since the neurological symptoms are due to mass effect of the SDH alone, the patients can be managed by simple burr hole drainage and post-operative clinical course is same as that of SDH without ACs. They further draw upon histological evidence to show that ACs and SDH are two "separate non-communicating entities."

Takayasu et al.[8] also hold that AC does not contribute to SDH formation and that tackling of the cyst is not necessary if it was previously asymptomatic. Mere drainage of the SDH is sufficient treatment. The same was done in our patient.

Patients in this setting [Table 1] are predominantly younger and male (probably reflecting increased incidence of AC in males and their proclivity for outdoor activities). They usually present with signs of raised intra-cranial pressure (headache, vomiting) rather than incontinence and hemiparesis that is commonly seen in SDH. [5]
Table 1: Profile of patients and treatment offered to them


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Our patient too was an adolescent male with symptoms of raised ICP that regressed after draining of the SDH. While an aneurysm had been ruled out by DSA, the role played by the AC in SDH formation can only be speculative. If he has no further bleeding episodes the AC may well be coincidental.

While the association of ACs with SDH is well documented, the role that ACs has (causative vs. coincidental) in SDH formation is of more than academic interest as it raises the issue if mere drainage of the SDH alone will suffice or whether the cyst must also be tackled to prevent recurrence.

We feel that while AC may be a risk factor for the development of SDH in young, burr hole drainage will probably suffice for the majority in the absence of recurrence or intra-cystic hemorrhage. However, DSA must be done to rule out an aneurysmal rupture before tackling the SDH.

Patients with incidentally detected ACs also need to be counseled regarding the possibility of development of SDH in the future and to avoid contact sports and head trauma.

 
   References Top

1.Parsch CS, Krauss J, Hofmann E, Meixensberger J, Roosen K. Arachnoid cysts associated with subdural hematomas and hygromas: Analysis of 16 cases, long-term follow-up, and review of the literature. Neurosurgery 1997;40:483-90.  Back to cited text no. 1
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2.Wester K, Helland CA. How often do chronic extra-cerebral hematomas occur in patients with intracranial arachnoid cysts? J NeurolNeurosurg Psychiatry 2008;79:72-5.  Back to cited text no. 2
    
3.Page A, Paxton RM, Mohan D. A reappraisal of the relationship between arachnoid cysts of the middle fossa and chronic subdural haematoma. J Neurol Neurosurg Psychiatry 1987;50:1001-7.  Back to cited text no. 3
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4.Iaconetta G, Esposito M, Maiuri F, Cappabianca P. Arachnoid cyst with intracystichaemorrhage and subdural haematoma: Case report and literature review. NeurolSci 2006;26:451-5.  Back to cited text no. 4
    
5.Chan JY, Huang CT, Liu YK, Lin CP, Huang JS. Chronic subdural hematoma associated with arachnoid cyst in young adults: A case report. Kaohsiung J Med Sci 2008;24:41-4.  Back to cited text no. 5
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6.Kocaeli H, Korfali E. Rupture of a small middle cerebral artery aneurysm into middle fossa arachnoid cyst presenting as a chronic subdural haematoma. ActaNeurochir (Wien) 2008;150:407-8.  Back to cited text no. 6
    
7.Domenicucci M, Russo N, Giugni E, Pierallini A. Relationship between supratentorial arachnoid cyst and chronic subdural hematoma: Neuroradiological evidence and surgical treatment. J Neurosurg 2009;110:1250-5.  Back to cited text no. 7
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8.Takayasu T, Harada K, Nishimura S, Onda J, Nishi T, Takagaki H. Chronic subdural hematoma associated with arachnoid cyst. Two case histories with pathological observations. NeurolMed Chir (Tokyo) 2012;52:113-7.  Back to cited text no. 8
    


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