Abstract
Arachnoid cysts are developmental anomalies that represent 1% of all intracranial space occupying lesions. Treatment of symptomatic cases may include shunting of the cyst or an open fenestration of it, among other less acceptable surgical procedures. Each procedure has its own pros and cons. We present a case of the development of an acute intracranial hypertension during cysto-peritoneal shunt malfunction in a child. We describe the possible mechanism of these phenomena and, based on this report and by reviewing other case series in the literature, we raise the possibility that acute increase in intracranial pressure and the development of shunt dependency, although rare, are important complications of shunting an arachnoid cyst.
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There is a general belief in the neurosurgical community that shunt dysfunction is mainly related to CSF diversion procedure of the ventricular space, that is to say complications of the treatment of hydrocephalus. Laliv and Michowitz present a new case of shunt dysfunction occurring after the insertion of a cysto-peritoneal shunt (CPS) in a temporo-sylvian AC. Looking at previous report about this complication, they were able to identify less than 20 cases of intracranial AC complicated with acute intracranial pressure at the time of CPS malfunction. This complication probably reflects a sort of decreased intracranial compliance due to the chronic drainage of CSF with a low pressure shunt. These patients behave almost like those who have a slit ventricle syndrome and that are prone to develop acute intracranial hypertension in case of shunt blockage. Although the authors mention in their last sentence the possibility of elective shunt removal in their patient, we would advise to keep the patient for several days in the ward to be sure that he would not develop a delayed raised ICP or to be prepared to restore the intracranial compliance with an expansion craniotomy.
Benedict Rilliet
Geneva, Switzerland
This paper describes the development of shunt dependency and the need for multiple procedures following placement of a cystoperitoneal shunt in the treatment of a temporal arachnoid cyst. This case highlights again the long-standing debate concerning the treatment of arachnoid cysts in childhood. It also touches on some of the other questions raised by this topic, what symptoms or signs constitute an indication for treatment? What is the optimal age for treatment? How should treatment success be determined?
In contrast to the suggestion that this is an exceptional case, I suspect that the scenario presented is one that is all too familiar to a number of pediatric neurosurgeons. The pathophysiology of arachnoid cysts, treated and untreated remains poorly understood though most would agree that managing the complications of the failed shunt or shunt malfunction in the context of arachnoid cysts can be a formidable task typified by repeated interventions, prolonged hospital admissions not to mention significant morbidity.
The statement “placing a shunt is a minor procedure with little risks compared with fenestration” is one that would be questioned by most pediatric neurosurgeons and probably not supported by current literature; whilst there is indeed no universal consensus of treatment the prevailing mood seems to be toward fenestration (either open or endoscopic) at least in the first instance. Whether or not fenestration of this temporal arachnoid cyst into the basal cisterns as an initial treatment in this case would have had a better outcome remains unknown though whenever there is a treatment alternative to placement of a shunt this is surely worthy of consideration.
Certainly, if reduction in cyst size is the end point by which success is to be measured then fenestration is likely to be judged unfavorably. Whilst it is always satisfying to see a reduction in cyst size and re-expansion of adjacent brain on the post-treatment imaging, this is by no means essential for success, the equilibration of pressure between the cyst and the rest of the CSF pathway should perhaps be considered the more appropriate goal, a goal more likely to be achieved via fenestration than drainage
Dominic Thompson
London, UK
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Laviv, Y., Michowitz, S. Acute intracranial hypertension and shunt dependency following treatment of intracranial arachnoid cyst in a child: a case report and review of the literature. Acta Neurochir 152, 1419–1423 (2010). https://doi.org/10.1007/s00701-010-0658-x
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DOI: https://doi.org/10.1007/s00701-010-0658-x