Arachnoid Cyst Associated Chronic Subdural Hematoma
Pathophysiology
The proposed mechanisms include:
Rupture Theory: Small vessels in the cyst wall rupture due to trauma or pressure fluctuations, leading to a subdural hemorrhage.
Membrane Tear Hypothesis: The thin cyst membrane can tear, allowing CSF to flow into the subdural space, altering osmotic gradients and leading to chronic hematoma formation.
Microvascular Fragility: ACs may cause adjacent dura to thin over time, increasing vulnerability to bleeding.
Case series
The presence of ACs should be taken into consideration in young and middle-aged patients with CSDH. For those patients were found ACs in conventional medical examination, especially those whose imaging examinations demonstrated thinning or external convex of the calvarium, it was crucial to remind them to avoid the occurrence of traumatic brain injury (TBI). Burr hole irrigation is still the preferred treatment for ruptured ACs with CSDH. Ruptured ACs with CSDH were diagnosed in 32 patients in 1231 CSDH cases, which account for 2.60%. Headache was the commonest presenting symptom. According to the Takizawa' classification, there were 22 cases for Type A, 9 for Type B and 1 for Type C. Thinning or external convex of the calvarium was demonstrated in 17/32 cases (53.1%). Thirty-one patients were treated with burr hole irrigation. Favorable outcomes were achieved in all patients 1).
A total of 182 patients (148 males; 81.3%) were evaluated, including 14 cases in our present series. The patients ranged in age from 1 to 80 years (mean age, 24.41 ± 13.69 years). Among the 175 patients with adequate prehospital history information, 119 (68%) had a history of recent head trauma or sport-related injury. AC locations included the middle fossa and sylvian fissure in 162 cases (89.0%), cerebral convexity in 17 cases (9.3%), posterior fossa in 2 cases (1.1%), and interhemispheric fissure in 1 case (0.5%). Among the 161 patients with specific data on outcomes, 159 (98.8%) had favorable recovery, 1 patient had an evident neurologic deficit, and 1 patient died from cardiac arrest.
CSDH is a rare complication in patients with intracranial AC. Male children, juveniles, and young adults with recent head trauma or sport-related injury are most commonly inflicted. Burr hole drainage is the first-choice surgical procedure in symptomatic patients and is still effective in some recurrent cases. Fenestration or resection of the AC membrane is not a requisite in patients with previous asymptomatic AC 2).
Between August 2004 and August 2012, 453 patients were treated with diagnosis of CSDH in our clinic. Of those, 15 patients had ipsilateral arachnoid cyst in the middle fossa. A single burr hole craniostomy was performed to drain the hematoma and the AC left intact at first in 14 patients, one patient had no surgical intervention. Follow-up period ranged from 13 months to 88 months (mean 43.07 ± 23.23 months). RESULTS:
The patients having CSDH with AC were found to be younger than the patients with CSDH alone, the mean age was 13.93 ±12.37 years Eleven patients had head trauma 21 to 50 days before admission. Hematoma evacuation through a single burr hole and closed system subdural drainage 2 to 4 days after surgery improved the symptoms in all patients. Two patients developed subdural fluid collection which is treated by subduroperitoneal shunt placement.
Greater prevalence of ACs in patients with CSDHs has been reported in the literature. We recommend the drainage of the hematoma via a single craniostomy and to leave the AC intact as the first choice of treatment if the associated AC is a Galassi type I or II. Additional subduroperitoneal shunting may be performed in patients with Galassi type III cyst 3).
Ten patients of chronic subdural hematoma associated with AC were retrospectively enrolled from the Neurosurgery Department of Tianjin Medical University General Hospital from January 2012 to September 2015, with a mean age of 27.5±5.6 years (range, 18-37 years). All patients simply performed a burr hole drainage of hematoma and left the AC intact, then followed up for 12 to 18 months after discharge respectively. Results: In this study, the AC in 8 of 10 cases occurs in the middle cranial fossa, and the other 2 cases root in the cerebral hemisphere.The AC of 10 patients all locate near the hematoma cavity.Nine patients had a full recovery, and only one patient had a recurrent subdural hematoma with a secondary operation, then recovery in 3 months postoperation.All patients lived completely free of neurological symptom and showed no recurrence in the follow-up period with a Barthel index more than 90. Conclusion: Simply burr hole drainage of hematoma and leave intact AC achieves satisfied outcome and provides a reliable therapy strategy for chronic subdural hematoma associated with arachnoid cyst 4).
Case reports
A 24-year-old male who presented mild cranial trauma secondary to a fall from his own height due to tonic-clonic seizures. Initially, he exhibited a transient loss of consciousness, followed by neurological improvement, with a Glasgow Coma Scale score of 15. Radiological imaging revealed extensive bilateral complicated arachnoid cysts (AC) in the frontal region, leading to craniotomy and drainage. Despite surgical intervention, follow-up imaging demonstrated rebleeding, necessitating further surgical reintervention. Surgical findings included bilateral CSDH secondary to hemorrhagic AC, as well as absence of the frontal lobes. This case represents an unprecedented source of insight into the diagnostic challenge posed by CSDH in the presence of significant developmental alterations of the frontal lobes, adding complexity to management due to potential cognitive and neurological implications 5).
Arachnoid cyst (AC) is a neurological complication of autosomal dominant polycystic kidney disease (ADPKD). Although an AC can increase the risk of a subdural hematoma, the clinical presentation of bleeding into an AC associated with ADPKD is not well known. We herein report the case of a 59-year-old woman in whom the initiation of hemodialysis for renal failure led to AC bleeding. A change of anticoagulant from heparin to nafamostat mesilate allowed dialysis to continue without rebleeding. These findings suggest that hemodialysis in patients with an AC associated with ADPKD may increase the risk of bleeding. Nafamostat mesilate may be useful in such cases 6).