Arachnoid cyst is a risk factor for chronic subdural hematoma in juveniles: twelve cases of chronic subdural hematoma associated with arachnoid cyst

Arachnoid Cysts in Athletes with Sports-Related Concussion: A Case Series and Literature Review

BACKGROUND

Arachnoid cysts (AC) are associated with a risk of rupture or haemorrhage following head impact and pose a potential predisposing factor for significant complications of sport-related concussion. Despite a recognised association between ACs and intracranial haemorrhage/cyst rupture, the risk profile of participating in contact sports with AC is not well defined. We report a retrospective case series of players presenting to the Birmingham Sports Concussion Clinic between 2017 and 2023 and underwent MRI head, with a comprehensive review of the prior literature.

RESULTS

432 athletes underwent MRI of which 11 were identified to have AC (middle fossa n = 8; posterior fossa n = 2, intraventricular n = 1). Average maximal diameter was 4.1 ± 1.2 cm. 64% had a protracted recovery (≥ 3 months). 9% experienced an AC specific complication (cyst rupture, complete neurological recovery, maximal diameter 6.5 cm, Galassi II, 4 previous concussions). 91% of patients (mean maximal diameter 3.9 ± 1.0 cm) experienced no complications despite multiple previous accumulated sports-related concussions (mean 3.3, range 1-9). Case studies from the literature are summarised (n = 63), with 98% reporting complications, none of which resulted in adverse or unfavourable neurological outcomes. Across prospective and retrospective cohort studies, 1.5% had a structural injury, and (where outcome was reported) all had a favourable outcome.

CONCLUSIONS

AC is an incidental finding in athletes, with the majority in our cohort having sustained serial concussions without AC complication. The single complication within this cohort occurred in the largest AC, and AC size is proposed as a tentative factor associated with increased risk of contact sports participation. Complications of AC appear to be a rare occurrence. This case series and review has not identified evidence to suggest that participation in sports with AC is of significant risk, though individualised assessment and discussion of the potential risks of contact sports participation should be offered.

Concomitant spontaneous subdural and intracystic hematoma in arachnoid cyst: a case report and review of the literature

BACKGROUND

Intracystic hematoma in arachnoid cyst are a very rare pathology that commonly occurs after head trauma, while spontaneous intracystic hematomas in arachnoid cyst associated with subdural hematoma is extremely rare. Currently there are 33 patients of spontaneous intracystic hematomas in arachnoid cyst reported in the literature. In this case report we present an adult patient with concomitant chronic subdural hematoma with intracystic hematoma in arachnoid cyst.

CASE PRESENTATION

A 19-year-old Egyptian Arabian female patient presented to the outpatient clinic complaining of severe headache of 1-month duration that was progressive in nature. Provisionally, it was thought that it might be an arachnoid cyst with associated chronic subdural hematoma along with intracystic hematoma. Decision to proceed with craniotomy and cyst evacuation was made.

CONCLUSION

Concomitant intracystic hematoma in arachnoid cyst along with subdural hematoma is a serious condition that might be life-threatening if not well managed.

Middle fossa arachnoid cyst fenestration for ruptured cysts associated with subdural collections: paediatric neurosurgery tertiary unit experience

INTRODUCTION

Arachnoid cysts are commonly encountered benign cystic structures and often come to attention as incidental findings following cranial imaging. Surgical intervention rates vary in different studies; however, rupture of cyst and subdural collection with mass effect are some of the indications for surgical intervention. In this study, we aimed to evaluate our operated cohort of middle fossa arachnoid cysts to determine the rate of traumatic subdural collection in this cohort and further assess outcomes.

METHODS

A retrospective review of all consecutive operated middle cranial fossa arachnoid cysts was carried out for the period 2010 to 2024. Demographics including age, sex, Galassi type, surgical technique for fenestration, preceding history of trauma, presence of papilloedema, and complications following surgery were extracted. Indication for surgery included papilloedema and headaches or increasing head circumference or rupture and subdural collections. Arachnoid cysts managed with CSF diversion as primary surgery were excluded.

RESULTS

Over the study period, 21 fenestrations of the arachnoid cysts were carried out in 19 patients with mean age of 7 years and M:F ratio of 2.2:1 (laterality: 9 right-sided and 10 left-sided). These included seven Galassi 2 and twelve Galassi 3 arachnoid cysts. At presentation, 10 had papilloedema, 5 with no papilloedema, and 4 with no available ophthalmological assessment. Fenestration of cyst included 12 microscopic, 6 endoscopic, and 3 combined approaches. Of the operated cohort, 8 were due to rupture of arachnoid cyst and subdural collections causing mass effect. Of 8 cases of ruptured arachnoid cyst with subdural collections, 75% had clear history of preceding head injury in the context of accidental or sports-related injuries. Two patients required redo-fenestration (10.5%), 1 patient required temporary lumbar drain (5.2%), and 2 patients required cysto-peritoneal shunts (10.5%).

CONCLUSION

Rupture of arachnoid cysts and subdural collections although rare can be associated with head injury in majority of cases. All operated cases belonged to grade 2 and 3 Galassi.

Chronic subdural hematoma: What precisely are we treating?

Subdural hematoma (SDH) refers to the collection of blood between the dura matter and the arachnoid membrane. Advancements in imaging technology have enabled the categorization of SDH based on specific imaging characteristics, causative factors, and the onset of symptoms. Given that the prognosis of SDHs varies significantly and is contingent upon the size and chronicity of the hemorrhage, a comprehensive understanding of its subtypes may carry crucial treatment implications. For example, an acute SDH classically results from severe traumatic brain injury and appears as a homogenous, crescent-shaped hyperdense extra-axial collection. If not treated, over the course of 1-3 weeks, this hematoma will evolve into a sub-acute phenotype as a consequence of subdural effusion and demonstrate mixed-density hemorrhage on imaging. Chronic SDH (cSDH) becomes the end result of an untreated SDH, with neo-membranization and neo-angiogenesis from branches of the middle meningeal artery driving a mass-like growth pattern. This review article aims to elucidate the complex anatomical features of the end-stage cSDH, with a particular focus on reconceptualization of this entity based on its mass-like growth patterns, and how this is driving a shift towards endovascular treatment.

A chronic subdural hematoma complicating an arachnoid cyst in a juvenile boxer: a rare case report with comprehensive literature review

Introduction and importance

Arachnoid cyst (AC) is the most frequently founded lesion reported in adolescent patients suffering from chronic subdural haematoma (CSDH). Association between these two distinct clinical entities is known for a long time. However, in the literature there are numerous clinical cases that reflect this relationship and few large series that analyze them in detail. Paediatric population is more rarely affected with this association.

Case presentation

The authors report the case of AC of incidental discovery complicated with CSDH in 15-year-old male recreational boxer presented with progressive onset of holocranial drug-resistant throbbing headache with favourable clinical course after conservative treatment.

Clinical discussion

ACs are a well-known predisposing cause for CSDH after head trauma. In all cases of CSDH in children, the diagnosis of ruptured AC should be considered. Rupture may be spontaneous or following even mild head trauma with rupture of bridging veins causing subdural bleeding as it was seen in our patient who was practicing a full-contact free-sparring sport like boxing sustaining repeated and direct mild head traumas. MRI is recommended to detect small cysts in adolescents with CSDH. The management of these patients remains controversial.

Conclusion

This is a rare reported case of CSDH complicating an AC in a juvenile recreational male boxer. This association remains extremely rare in children and adolescents, as evidenced by the rare cases reported in the literature.

Neoplasms and tumor-like lesions of the sellar region: imaging findings with correlation to pathology and 2021 WHO classification

The sellar region represents a complex anatomical area, composed of multiple structures of different embryological derivation, including the skull base and the pituitary gland, along with vascular, nervous, and meningeal structures. Masses arising in this region include benign and malignant lesions arising from the pituitary gland itself, but also from vestigial embryological residues or surrounding tissues, that may require different therapeutic approaches. While assessing sellar region masses, the combination of clinical presentation and imaging features is fundamental to define hypotheses about their nature. MR represents the imaging modality of choice, providing information about the site of the lesion, its imaging features, and relation with adjacent structures, while CT is useful to confirm the presence of lesion calcifications or to reveal tumor invasion of bony structures. The aim of this pictorial review is to provide an overview of the common neoplasms and tumor-like conditions of the sellar region, according to the 2021 WHO Classification of Tumors of the Central Nervous System (fifth edition), with an emphasis on the radiologic-pathologic correlation. After a brief introduction on the anatomy of this region and the imaging and pathological techniques currently used, the most relevant MRI characteristics, clinical findings, and pathological data, including histologic and molecular features, will be shown and discussed, with the aim of facilitating an appropriate differential diagnosis among these entities.

Surgical indications in pediatric arachnoid cysts

INTRODUCTION

Arachnoid cysts are developmental lesions consisting of CSF collections within the subarachnoid space. There are many theories and hypotheses about their pathogenesis and histopathology and this may also explain the diversities seen in clinical behaviors of these cysts, their natural history and consequently their management where there is a great controversy about selecting patients for surgical intervention. The most common location in pediatrics is the Sylvian or middle cranial fossa and this made it gain more concern and greater debate about its management where its diagnosis is often accidently or associated with nonspecific symptoms.

AIM

Our aim in this article was to review the main surgical indications for pediatric arachnoid cysts in the literature.

CONCLUSION

We concluded that the decision for surgical intervention for pediatric arachnoid cysts is not a simple one and highly debatable and should be taken cautiously especially with sylvian arachnoid cysts that may reach a large size without symptoms. However, there is a consensus that the occurrence of symptoms definitely correlated to the presence of these cysts or their rupture with consequent subdural hematoma or hygroma are indications for surgical intervention. Large cysts in locations compressing CSF pathways causing hydrocephalus are also candidates for surgical fenestration. The surgical gain from prophylactic surgery is questionable particularly when asymptomatic.

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.

A Rare Triad of Lateral Rectus Palsy, Sylvain Fissure Bleed, and Bilateral SDH Shrouding a Benign Pathology

BACKGROUND

Arachnoid cysts are benign extra-cerebral congenital lesions that are thought to arise from the splitting of the arachnoid membrane. Although most arachnoid cysts remain static with advancing age, occasionally they can become symptomatic due to cyst enlargement or hemorrhage. Hemorrhage into the arachnoid cysts (intra-cystic hemorrhage) with or without associated subdural hematoma is of rare occurrence.

CASE DISCUSSION

A 23-year-old male presented with a history of sudden onset severe headache while sleeping. The patient also noticed double vision, especially when looking towards the left side. Non-contrast computed tomography (NCCT) scan of the head showed left temporal pole hematoma with left Sylvian fissure bleed and bilateral fronto-temporoparietal (FTP) subacute SDH.

CONCLUSION

Every patient with incidentally detected AC, especially in the middle cranial fossa, should be counseled regarding the risk of possible complications including hemorrhage and regular follow-up.

Characteristic and management of pediatric arachnoid cysts: A case series

Background/Aim: Arachnoid cysts (ACs) are the collection of fluid, which is similar in composition to cerebrospinal fluid, within the congenitally duplicated arachnoid membrane. ACs are clinically silent lesions, but sometimes they can manifest themselves with headache, convulsion, focal neurological deficits, cognitive decline, torticollis, and macrocephaly. Although the appropriate surgical approach is less clear, there is a consensus on the need for surgical treatment in symptomatic ACs. This study aims to reveal the advantages and disadvantages of cystoperitoneal shunt and microsurgical fenestration techniques. Methods: One hundred ninety-one consecutive patients from 1 month to 15 years old with AC were evaluated for suitability. Sixteen patients who underwent surgery were included in the study. Medical records of the patients with AC managed at our institutions were retrospectively collected and analyzed. Sixteen of 191 patients underwent surgical treatment via craniotomy for microsurgical cyst fenestration (CF) and cysto-peritoneal shunting (CS). CF was performed with partial cyst wall excision in all patients. Results: Seizure was the most common presentation in the patients, followed by headache and trauma, respectively. In our series the most common indications of the surgery were increased intracranial pressure (IICP). CF was performed in nine patients, and CS was performed in seven as the primary treatment. CS-related complications, such as infection (n = 2), dysfunction (n = 2) and intraabdominal abscess (n = 1) were the most commonly observed complications. No infections were observed after CF, but subdural hematoma was observed in one child. Conclusions: Although the most common symptoms in cases with arachnoid cysts are headache, rare symptoms, such as torticollis, may exist. Due to this, clinicians should reveal the cyst-complaint relationship first. Given the increased complications of CS, in addition to shunt independency and being free from shunt-related complications, the microsurgical CF with wide excision of the membranes seems to be the more preferable surgical option.

Factors Associated with Nontraumatic Spontaneous Subdural Hematomas in Pediatric Patients

OBJECTIVE

 In our study, we aimed to summarize the etiology of subdural hematoma that was not traumatic and required operation in pediatric patients. The subdural hematoma characteristics, possible etiologies, and treatment, as well as the patient outcomes, were analyzed.

METHODS

 A retrospective examination was made of pediatric patients with subdural hematoma who were operated on at Ümraniye Training and Research Hospital. Patients with a history of trauma were excluded. Data on patient sex, age, bleeding location, type of hematoma based on computed tomography imaging, surgical treatment, presenting symptoms, presence of comorbidities, Glasgow Coma Scale, thrombocyte counts, and international normalized ratio values were recorded.

RESULTS

 Of the 19 patients included in the study, 4 were female and 15 were male. Their ages ranged between 0 and 15 (mean = 5.84) years. In 57.8% of the patients, comorbidities, including acute myeloid leukemia, a history of shunt operation, epilepsy, mucopolysaccharidosis, known subdural effusion, autism, coagulopathy, ventricular septal defect/tetralogy of Fallot, cerebrospinal fluid leakage after baclofen pump administration, Marfan's syndrome, and late neonatal sepsis were present, while 21% had arachnoid cysts and 21% had no reported comorbidities.

CONCLUSION

 This study suggests that, in pediatric patients with subdural hematoma with an amount of bleeding requiring surgical management, any underlying comorbidities should be investigated regardless of the presence of a history of trauma. While investigating systemic diseases, special attention should be paid to the presence of arachnoid cysts or disruption in cerebrospinal fluid dynamics along with a history of hematologic diseases.

Multiple etiologies of secondary headaches associated with arachnoid cyst, cerebrospinal fluid hypovolemia, and nontraumatic chronic subdural hematoma in an adolescent: A case report

Background:

Diagnosing the cause of headaches can be challenging. Even if intracranial lesions are found in a patient, careful assessment is essential for diagnosis, and treatment strategies will differ for each etiology.

Case Description:

A 16-year-old boy presented with sudden-onset headache which had lasted for 2 days. His headache was aggravated in the orthostatic position. The patient denied recent head trauma. He had been diagnosed with an arachnoid cyst (AC) in his right middle cranial fossa. Computed tomography (CT) revealed bilateral subdural effusions and slit-like lateral ventricles with no significant changes to the AC. After intravenous hydration followed by 2 days bed rest, his symptoms abated. He was diagnosed as having suffered spontaneous cerebrospinal fluid (CSF) hypovolemia. One month later, the patient experienced recurrent gradual onset headache and vomiting. CT revealed chronic right side subdural hematoma (SDH) with intracystic hemorrhage, which resulted in the elevation of intracranial pressure. An urgent hematoma evacuation was performed. He became symptom-free immediately after surgery. Postoperative follow-up CT showed no change in the AC and no recurrence of SDH. The lateral ventricles and subdural space were normal in size.

Conclusion:

We report a case presenting multiple types of secondary headaches, which were caused by intracranial hypotension or hypertension, with different etiologies. These were spontaneous CSF hypovolemia, nontraumatic intracystic hemorrhage form of AC, and nontraumatic chronic SDH. Although lesions seen at the time of initial diagnosis did not need surgical treatment, careful observation and repetitive imaging assessments might be useful for discovering unsuspected additional etiologies requiring surgical intervention.

Concomitant chronic subdural hematomas and arachnoid cysts in young adults

Objective: This study aimed to evaluate the correlation between arachnoid cysts and chronic subdural hematomas in young adults. Methods: This retrospective study evaluated ten patients having concomitant chronic subdural hematomas and arachnoid cysts. Patients were evaluated with the data of age and gender, location of hematoma and arachnoid cyst, trauma history, symptoms at admission, maximum hematoma diameter, contiguity between arachnoid cyst and hematoma, and treatment  methods. Results: We treated 285 patients who were diagnosed with cSDH between January 2013 and December 2019. 22 patients were under the age of 40 years. Ten of them had both cSDH and arachnoid cysts. The mean age of patients was 24.8±3.9 years. Patients with only chronic subdural hematoma had higher mean age than the patients with arachnoid cyst-related chronic subdural hematoma. In four patients, the onset of chronic subdural hematoma was reported after arachnoid cyst diagnosis. Four of the patients did not have causative trauma history, and two patients suffered minor sports-related traumas. All patients had headache, and only two patients had hemiparesis. The location of arachnoid cysts were in the middle fossa in eight patients. All patients had chronic subdural hematomas on the ipsilateral side of arachnoid cyst. Four patients who had smaller than 10 mm maximal cSDH diameter underwent conservative management. They were followed by serial neuroimaging studies and it was noted that the hematoma disappered and the size of the arachnoid cysts decreased over time without any neurological complication. In six cases, craniotomy was required, and all recovered completely. cSDH did not recur during 5–60 months of follow-up period (median 12 months). Conclusions: It seems that presence of an arachnoid cyst in young adults is a predisposing factor for the formation of chronic subdural hematoma. Coincidentally diagnosed arachnoid cyst patients may be followed up with periodical clinical examinations and neuroimaging studies.

Spontaneous chronic subdural hematoma associated with arachnoid cyst in a child: A case report and critical review of the literature

Background

Arachnoid cysts (ACs) are benign, congenital, fluid-filled collection between two layers of the arachnoid membrane accounting for about 1% of all the intracranial space occupying lesions. These lesions are usually asymptomatic and detected incidentally by magnetic resonance imaging (MRI) or computed tomography scan imaging (CT). However, these lesions can present as spontaneous chronic subdural hematoma (CSDH) causing neurological deficits that require neurosurgical intervention.

Case Description

We report a case of CSDH associated with AC in a 14-year-old Kuwaiti boy who presented with a 2 weeks history of headache, which was worsening over the time. Brain CT scan demonstrated a left frontotemporal large CSDH in contact with an underlying temporal AC that appeared isodense to the CSF. The patient underwent an emergency surgery to evacuate the CSDH through a burr hole, while the AC was left intact. During the postoperative period, the patient showed good recovery in terms of neurological symptoms. Follow-up MRI showed stable size of the AC with no recurrence of the CSDH.

Conclusion

Literature's review was done to determine the best surgical approach in treating spontaneous CSDH associated with AC. Burr hole evacuation of CSDH with irrigation only, leaving the AC intact, is a successful surgical approach for treatment and was associated with good outcome.

Unusual Etiology for a Chronic Subdural Hematoma: Whole-Body Vibration Machine

A chronic subdural hematoma is more common in the elderly, particularly after a minor trauma sustained several weeks before the diagnosis. The use of a whole-body vibration machine had not been reported as an etiology. We report an 80-year-old male patient without a history of head or body trauma who developed a bilateral chronic subdural hematoma and required surgery to drain the hematoma. Four weeks before the diagnosis, he purchased and used a whole-body vibration machine. The first time he used the whole-body vibration machine, he felt his brain vibrating and rotating and could not tolerate more than two minutes. The event was so annoying that he did not use it again. In this patient, using a whole-body vibration machine may have led to the formation of the chronic subdural hematoma.

Paediatric chronic subdural haematoma: what are the predisposing factors and outcomes in management of these cases?

INTRODUCTION

Chronic subdural hematoma (cSDH) is a disease of the elderly population. Incidence in paediatric population is relatively uncommon. Child abuse, birth trauma, coagulopathy and shunt surgeries represent major causes. Major impact of the disease on life of patient due to recurrence and repeat surgical procedure is significant, not to mention the burden on health care system.

MATERIAL AND METHODS

We retrospectively reviewed our institute data for chronic sub-dural cases for the past 10 years (2008-2018) and collected data on the demography, clinical features, metabolic workup, mode of treatment, recurrence rates, predisposing factors, laterality, hematoma characteristics and factors associated with recurrence in all cases with less than or equal to 18 years of age.

RESULTS

A total of 30 such cases were found in a period of 10 years (2008-2018). The mean patient age was 7.3 years (range 2 months-17 years), with 20 males (66.67%) and 10 females (33.33%). Raised intracranial pressure (n = 9) was the commonest presenting symptom in 30% of cases followed by seizures in 26.67% (n = 8). The previous shunt was the commonest predisposing factor seen in 43.33% (n = 13). cSDHs were unilateral in 56.67% cases (n = 17) and bilateral in 43.33% (n = 13). Burr hole craniostomy was done in 27 cases (90%), and conservative management was done in three cases (10%). Follow up was available for 27 cases (90%) with a mean follow up duration of 24 months. Recurrence rate was 30% (n = 9). Shunt surgery contributed to 77% of bilateral disease (p = 0.009). Child abuse was not reported in our series.

CONCLUSION

Presence of paediatric cSDH is alarming, and the physician should be alerted to look for underlying cause and rule out child abuse. Detailed metabolic, skeletal workup is required. Treatment of primary pathology should be the goal as CSF diversion is not the solution to all problems, but can definitely be the cause of all the problems.

Non-Operative Management of a Pediatric Patient With Bilateral Subdural Hematomas in the Setting of Ruptured Arachnoid Cyst

Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.

Ruptured middle cranial fossa arachnoid cysts after minor trauma in adolescent boys presenting with subdural hygroma: two case reports

Background

Intracranial arachnoid cysts are common, cerebrospinal fluid-filled, innocent lesions that are usually detected incidentally on brain imaging. They may rupture and complicate due to subdural hematoma or hygroma after minor trauma.

Case summary

Authors present two cases of ruptured middle cranial fossa arachnoid cysts in adolescent (12-year-old and 15-year-old) Afghan boys presenting with subdural hygroma after minor trauma.

Conclusion

Imaging work-up is necessary for symptomatic patients following minor head trauma as incidentally detected ruptured intracranial arachnoid cysts can be responsible for the symptoms.

PKD1-Associated Arachnoid Cysts in Autosomal Dominant Polycystic Kidney Disease

OBJECTIVES

the prevalence of intracranial aneurysms and arachnoid cysts is higher in patients with autosomal dominant polycystic kidney disease (ADPKD) than in the general population. A genotype correlation was reported for intracranial aneurysms, but it is unclear for arachnoid cysts. Therefore, the genotype correlation with intracranial aneurysms and arachnoid cysts was investigated in ADPKD.

MATERIALS AND METHODS

intracranial aneurysms and arachnoid cysts were screened by magnetic resonance imaging (MRI), and PKD genotypes were examined using next-generation sequencing for 169 patients with ADPKD.

RESULTS

PKD1-, PKD2- and no-mutation were identified in 137, 24 and 8 patients, respectively. Intracranial aneurysms and arachnoid cysts were found in 34 and 25 patients, respectively, with no significant difference in frequency. Genotype, sex, estimated glomerular filtration rate and age at ADPKD diagnosis significantly affected the age at brain MRI. The proportional hazard risk analyzed using the age at brain MRI adjusted by these four variables was 5.0-times higher in the PKD1 group than in the PKD2 group for arachnoid cysts (P = 0.0357), but it was not different for intracranial aneurysms (P = 0.1605). Arachnoid cysts were diagnosed earlier in the PKD1 group than in the PKD2 group (54.8 vs 67.7 years, P = 0.0231), but no difference was found for intracranial aneurysms (P = 0.4738) by Kaplan-Meier analysis.

CONCLUSIONS

this study demonstrated the correlation between arachnoid cysts and PKD1 mutation. The reported association of arachnoid cysts with advanced renal disease may be due to the common correlation of these factors with PKD1 mutation.

Head Injury without Head Blow? A Rare Case of Subdural Hematoma Associated with Minute Arachnoid Cyst in a Teenage Skater

BACKGROUND

 Skateboarding has been reported to cause diverse kinds of injuries, including head trauma. However, the risk of brain injury without direct blow to the head seems to be underestimated. In particular, the impact of the inertial forces related to the vigorous character of skateboarding tricks is not sufficiently recognized.

CASE DESCRIPTION

 In our report, we demonstrate a case of chronic subdural hematoma developing without previous blow to the head in a 17-year-old skater bearing small frontal convexity arachnoid cyst.

CONCLUSION

 Based on the described case, the possibility of acceleration and angular forces related to skate park leisure activities resulting in subdural hematoma needs to be discussed. This risk should be critically appraised in patients carrying arachnoid cyst as a malformation predisposing to develop subdural bleeding.

Paediatric arachnoid cysts: Surgical outcomes from a Singapore children's hospital

Arachnoid cysts (AC) are reported to have a prevalence of up to 2.6% in children. Most AC remain indolent, but others may expand or rupture to cause life-threatening symptoms of raised intracranial pressure. Currently, there are 2 controversial topics with regards to the management of ACs: the indications for surgery and the choice of surgical procedure. We therein report our institution's neurosurgical experience for symptomatic AC over a 22-year period and corroborate our results with published literature. This is a single institution, retrospective study conducted at KK Women's and Children's Hospital from 01 January 1998 to 31 December 2019. A total of 38 patients with ACs that required surgery were recruited. The 3 most common anatomical locations were in the middle cranial fossa (40.5%), posterior fossa (24.3%) and interhemispheric (13.5%). Typical clinical presentations included symptoms of raised intracranial pressure (34.2%), obstructive hydrocephalus (28.9%) and AC rupture (21.1%). Surgical approaches included 17 craniotomy-based procedures, 7 endoscopic fenestrations, 11 cystoperitoneal shunts, 2 burrhole drainage operations and 1 excision of spinal AC. Thirteen patients (34.2%) underwent either another operation due to the lack of resolution of their AC-related symptoms or secondary to complications directly related to their initial surgery. Average length of followup from time of first operation was 84.1 months. Overall, our results demonstrate similarities in epidemiology, clinical presentation and surgical experience, in comparison to larger cohort studies. We advocate collaborative efforts to better understanding of the pathophysiology of paediatric ACs, particularly for deciding between the various surgical treatment modalities.

Experience with Management of Intracranial Arachnoid Cysts

OBJECTIVES

 The aim of this study was to analyze the demographics, clinical presentation, and surgical outcome of intracranial arachnoid cysts and to review the surgical options.

METHODS

 This is a retrospective observational study of 56 cases of symptomatic arachnoid cysts among all age groups treated between 2004 and 2020 at the Bombay Hospital, Mumbai. Endoscopic fenestration, microsurgical cyst excision, and shunt insertion were the interventions performed. Clinical presentation, cyst reduction post-intervention, and complications were studied. The follow-up period varied from 1 month to 16 years. Statistical analysis was done for 43 patients with a minimum of 3 years' follow-up.

RESULTS

 In all, 75% of patients were <18 years of age. Of these, the majority were between the age of 1 and 10 years. There were 14 cases of temporal, 13 cases of retrocerebellar, 10 cases of quadrigeminal cistern, and 7 cases each of interhemispheric and suprasellar arachnoid cysts. The most common clinical presentation was headache and vomiting. Concomitant hydrocephalus was seen on imaging in 24 cases. Endoscopic fenestration of cyst was the most routinely performed procedure (35 cases). Four patients of endoscopic fenestration underwent a redo endoscopic procedure on follow-up. Post-operative reduction in cyst size was found to be significantly better after endoscopic fenestration (p < 0.05).

CONCLUSION

 Though the best available treatment for arachnoid cysts remains controversial, surgery has been found to be beneficial in symptomatic cases. Endoscopic fenestration is considered the first-line surgical option and it may be followed by shunt, if necessary. Shunts may be preferred in very young children where there is associated hydrocephalus/macrocephaly.

A Prospective Randomized Study on the Preventive Effect of Japanese Herbal Kampo Medicine Goreisan for Recurrence of Chronic Subdural Hematoma

Although the recurrence of chronic subdural hematoma (CSDH) after surgical treatment significantly affects the patients' quality of life, the recurrence rate has not improved in decades. Goreisan, a Japanese herbal Kampo medicine, promotes the hydragogue effect and has been empirically used in the treatment of CSDH in Japan. We conducted a prospective randomized study to investigate whether Goreisan treatment decreases the recurrence rate of CSDH. Between March 2013 and December 2018, a total of 224 patients who underwent initial burr hole surgery for CSDH were randomly assigned to receive Goreisan for 3 months (Group G) or no medication (Group N). The primary endpoint was symptomatic recurrence within 3 months postoperatively, and the secondary endpoint was complications, including the adverse effects of Goreisan. Of 224 randomized patients, 208 were included in the final analysis (104 in Group G and 104 in Group N). The overall recurrence rate was 9.1% (19/208). The recurrence rate of Group G was lower than that of Group N (5.8% vs 12.5%, P = 0.09), but the difference was not statistically significant. However, a significant preventive effect of Goreisan was found in 145 patients with high-risk computed tomography (CT) features, namely, homogeneous and separated types (5.6% vs 17.6%, P = 0.04). Although the present study did not prove the beneficial effect of Goreisan treatment, it suggested the importance of selecting patients with an increased risk of recurrence. A subset of patients whose hematoma showed homogeneous and separated patterns on CT image might benefit from Goreisan treatment.

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.

Ruptured intracranial arachnoid cysts in the subdural space: evaluation of subduro-peritoneal shunts in a pediatric population

PURPOSE

Rupture of arachnoid cysts (AC) in the subdural space after trauma may cause a subacute/chronic subdural hematoma or a hygroma. Treatment of this complication still remains controversial, and no consensual strategy is to date clearly proposed. In this study, the authors evaluated the clinical and radiological evolution of patients treated by a subduro-peritoneal shunt for symptomatic subdural collections complicating ruptured AC.

METHODS

Medical records of the 10 patients treated at our institution between January 2005 and December 2018 for a subdural collection associated with an intracranial AC were reviewed. Subduro-peritoneal shunts consisted of low-pressure valves from 2005 to 2012 (6 cases) and medium-pressure valves after 2012 (4 cases).

RESULTS

A benign head trauma was retrospectively found in the history of 8 patients. The mean time to diagnosis ranged from 15 days to 5 months. Symptoms resulted mainly from intracranial hypertension. Six patients had an ipsilateral hygroma to the AC, 2 patients had a bilateral hygroma predominantly to the AC side, and 2 patients presented an ipsilateral chronic subdural hematoma. Arachnoid cysts were classified as Galassi I in 5 cases and Galassi II in 5 cases. Patients with chronic subdural hematoma were given a medium-pressure valve. Patients with subdural hygroma received a low-pressure valve in 6 cases and a medium-pressure valve in 2 cases. There were no complications during surgical procedures. All patients were rapidly free of symptoms after surgery and were discharged from hospital 1 to 4 days postoperatively. The subdural collection completely disappeared in all cases. In the long term, only 2 patients with low-pressure valves underwent shunt removal without any consequences, while a second surgical procedure was necessary to treat recurrence of intracranial hypertension in the 4 remaining cases. All the medium-pressure valves were removed without problems. The size of the AC was reduced in 3 cases, remained stable in 4 cases, and increased in 3 cases. No patients experienced recurrence of subdural collection during follow-up.

CONCLUSIONS

Medium-pressure subduro-peritoneal shunts should be considered as part of the arsenal of surgical strategy in symptomatic ruptured AC in the subdural space. The procedure is simple with a very low morbidity, and it allows rapid improvement of symptoms. Although the shunt is located in the subdural space, we strongly recommend avoiding devices which may create an overdrainage and expose the patient to shunt dependency such as low-pressure shunts.

Arachnoid cyst in young soccer players complicated by chronic subdural hematoma: personal experience and review of the literature

Arachnoid cysts (ACs) are congenital intracranial benign cavities originating from the meninges during embryological development. Several studies have shown the existence of a relationship between AC and a higher risk to develop ipsilateral chronic subdural hematoma (CSH) especially in a young population. In the presence of an AC, the practice of sport activities may expose young patients to minor head trauma and to an increased risk of developing CSH. We describe three cases of young soccer players with AC associated with CSH. Then, we performed a literature review of all the reported cases in the literature of patients younger than 18 years with AC-associated CSH related to sport practice. A total of 33 cases, including the three cases reported by us, are analyzed. Soccer is the most represented sport activity in this association (39% of cases). The treatment of choice is surgical in all patients, with burr hole or craniotomy in similar proportions. In one-third of patients, the AC has been fenestrated. Outcome is good in all the reported cases. We reviewed the main pathogenic theories, the main surgical strategies described in literature, as well as recurrence rate of CSH, the association of AC and cranial deformities, and the clinical outcome. AC might be associated with skull deformities, but their real incidence remains unclear. The clinical detection of such anomalies should suggest performing further radiological investigations. If the presence of AC is confirmed, the practice of sport activities should not be avoided, as the real incidence of AC-associated CSH is not clear yet and the reported outcomes in literature are good. Surgical treatment of AC-associated CSH should be hematoma removal through burr hole, reserving AC fenestration only for cases with intracystic bleeding or recurrences. The surgeon should adequately advise and inform the young patients and their families that they could have an increased risk of developing CSH given by the presence of the AC, and that they should be referred to a neurosurgical center if they become symptomatic.

Spontaneous Regression of Pineal Region Arachnoid Cyst: A Case Report and Review of Literature

Arachnoid cyst is a rare benign cerebrospinal fluid-filled cyst that can develop anywhere in the brain along the arachnoid membrane and usually unaccompanied by the anomalous development of the brain structure. These cysts are usually located in the middle cranial fossa. However, they are also denoted in other regions. Arachnoid cysts are mostly asymptomatic and diagnosed incidentally. Spontaneous regression of arachnoid cysts in different anatomical regions of the brain has been reported in the literature. However, to the best of our knowledge, this is the first case reporting an unusual spontaneous regression of arachnoid cyst in the pineal region in a 3-year-old child presented to our hospital with hydrocephalus without alarming signs and was treated conservatively as the patient was stable, and the cyst showed spontaneous regression. A comprehensive review of the literature regarding spontaneous regression of arachnoid cysts has been collected and discussed in this article.

Spontaneous Disappearance of an Arachnoid Cyst after Burr Hole Drainage of Chronic Subdural Hematoma

It is well known that the presence of arachnoid cysts (ACs) in young patients is a risk factor for developing a chronic subdural hematoma (CSDH) after a minor head injury. Although there have been controversies with the treatment, most authors recommend only draining the CSDH if the AC is asymptomatic. This judgement is based on the facts that this surgical approach has shown good clinical outcomes, and the AC usually remains unchanged after the surgery. Our case demonstrates that the AC of a young patient who developed a CSDH after a minor head injury completely disappeared after a burr hole drainage of the CSDH. Although the chances of an AC disappearing are low, this case shows that an AC might disappear after only draining a CSDH when a rupture of the AC membrane is identified. In such cases, we recommend first draining only the CSDH for the treatment of AC-associated CSDHs.

Microsurgical, endoscopic, and shunt management of pediatric temporosylvian arachnoid cysts: a comparative study

OBJECTIVE

Arachnoid cysts (ACs) are most frequently located in the middle cranial fossa. Some patients are asymptomatic whereas others exhibit signs of increased intracranial pressure, seizures, or cognitive and behavioral symptoms. When ACs do require treatment, the optimal surgical technique remains controversial. This study was conducted to assess the most effective surgical treatment for these cysts.

METHODS

The authors retrospectively reviewed 240 temporal intracranial ACs managed over a 25-year period in their pediatric neurosurgical unit. Pre- and posttreatment results were clinically and radiologically assessed.

RESULTS

A majority of male patients (74.6%) with an overall median age of 6.9 years were included. The mean cyst size was 107 cm3; the Galassi classification showed 99 (41.3%) type I, 77 (32.1%) type II, and 64 (26.7%) type III cysts. Forty-four ACs (18.3%) were diagnosed after rupture. Surgical management was performed by microsurgery (28.3%), endoscopic cyst fenestration (14.6%), cystoperitoneal shunting (CPS; 16.2%), or subdural shunting (10%). Furthermore, 74 children (30.8%) did not undergo operations. After a mean follow-up of 4.1 years, the mean percentage decrease in cyst volume and the overall rate of clinical improvement did not significantly differ. The endoscopy group had earlier complications and a shorter event-free survival (EFS) time (EFS at 3 years = 67.7%, vs 71.5% and 90.5% for CPS and microsurgery, respectively; p < 0.007) and presented with more subdural hematomas compared to the microsurgery group (p < 0.005). The microsurgery group also showed a tendency for longer cystocisternostomy permeability than the endoscopy group.

CONCLUSIONS

Concerning the management of unruptured symptomatic temporal ACs, microsurgery appears to be the most effective treatment, with longer EFS and fewer complications compared to shunting or endoscopy.

Clinical Course in Chronic Subdural Hematoma Patients Aged 18-49 Compared to Patients 50 Years and Above: A Multicenter Study and Meta-Analysis

Objective: Chronic Subdural Hematoma (cSDH) is primarily a disease of elderly, and is rare in patients <50 years, and this may in part be related to the increased brain atrophy from 50 years of age. This fact may also influence clinical presentation and outcome. The aim of this study was to study the clinical course with emphasis on clinical presentation of cSDH patients in the young (<50 years).

Methods: A retrospective review of a population-based cohort of 1,252 patients operated for cSDH from three Scandinavian neurosurgical centers was conducted. The primary end-point was difference in clinical presentation between the patients <50 y/o and the remaining patients (≥50 y/o group). The secondary end-points were differences in perioperative morbidity, recurrence and mortality between the two groups. In addition, a meta-analysis was performed comparing clinical patterns of cSDH in the two age groups.

Results: Fifty-two patients (4.2%) were younger than 50 years. Younger patients were more likely to present with headache (86.5% vs. 37.9%, p < 0.001) and vomiting (25% vs. 5.2%, p < 0.001) than the patients ≥50 y/o, while the ≥50 y/o group more often presented with limb weakness (17.3% vs. 44.8%, p < 0.001), speech impairment (5.8% vs. 26.2%, p = 0.001) and gait disturbance or falls (23.1% vs. 50.7%, p < 0.001). There was no difference between the two groups in recurrence, overall complication rate and mortality within 90 days. Our meta-analysis confirmed that younger patients are more likely to present with headache (p = 0.015) while the hemispheric symptoms are more likely in patients ≥50 y/o (p < 0.001).

Conclusion: Younger patients with cSDH present more often with signs of increased intracranial pressure, while those ≥50 y/o more often present with hemispheric symptoms. No difference exists between the two groups in terms of recurrence, morbidity, and short-term mortality. Knowledge of variations in clinical presentation is important for correct and timely diagnosis in younger cSDH patients.

The Clinical Characteristics, Treatment, and Outcomes of Chronic Subdural Hematoma in Young Patients

OBJECTIVE

To investigate the clinical characteristics, treatment, and outcomes of chronic subdural hematomas (CSDH) in young patients.

METHODS

We retrospectively reviewed young patients under 40 years of age who received diagnoses of and were surgically treated for CSDH between August 2011 and May 2017. Clinical data, computed tomographic findings, surgical outcomes, and recurrence were collected for further analysis.

RESULTS

A total of 101 patients (92 male; 91.1%) were analyzed. Ages ranged from 1 to 40 years (27.3 ± 10.5), and 59 (58.4%) patients had a history of recent head trauma. The most frequent symptoms were headache (86.1%) and dizziness (26.7%). A total of 60 (59.4%) patients had arachnoid cyst (AC), and 8 (7.9%) patients had ventriculoperitoneal (V-P) shunt. After burr hole drainage craniotomy, all patients experienced good outcomes, and 1 patient experienced recurrence requiring reoperation. Sixty-eight patients with AC/V-P shunts had a higher incidence of head trauma (P = 0.014), younger age at onset (P < 0.001), and lower incidence of dizziness (P = 0.013) than did those without AC/V-P shunts. Surgical recurrence rates and outcomes did not differ significantly between patients with and without AC/V-P shunts.

CONCLUSIONS

Headache is the most common symptom, and AC/V-P shunts are risk factors of CSDH in young patients. AC/V-P shunt-associated CSDH is associated with younger morbidity. Head trauma is a risk factor for AC/V-P shunt-associated CSDH, but is not significance in patients without AC/V-P shunts. Catheter drainage through a burr hole may be the first-choice surgical procedure in treatment of CSDH in young patients, including AC/V-P shunt-associated CSDH.

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.

Chronic Subdural Hematoma Associated with Congenital Arachnoid Cysts: Management Dilemmas

Chronic subdural hematoma (CSDH) is one of the commonest diseases encountered by a neurosurgeon in daily practice. It is however rarely seen in young patients. Congenital arachnoid cysts have been implicated in both traumatic and spontaneous CSDH in young individuals. Optimum treatment strategies to address the CSDH and arachnoid cyst are not very well described. We report a young gentleman who was treated for a CSDH with arachnoid cysts, two months after a mild head injury. The patient was operated with a simple burr hole drainage of hematoma with a drain. He was discharged with no further need to address the arachnoid cyst. CSDH associated with arachnoid cysts can be treated with simple burr hole drainage. Craniotomy, fenestration and cerebrospinal fluid (CSF) diversion should be reserved only as secondary procedures.

Arachnoid cysts with spontaneous intracystic hemorrhage and associated subdural hematoma: Report of management and follow-up of 2 cases

Arachnoid cysts are one of the most frequently encountered intracranial space-occupying lesions in daily neurosurgery and neuroradiology practice. Majority of arachnoid cysts, particularly those of smaller sizes, have a benign uneventful lifetime course. Certain symptoms may indicate serious complications related to underlying arachnoid cysts. Hemorrhage is one of the most fearsome complications of arachnoid cysts and almost all reported cases in the literature have undergone surgical correction. In this study, we aimed to present clinical and radiologic follow-up findings in two adult cases of intracranial arachnoid cyst with spontaneous intracystic hemorrhage and associated subdural hematoma, one of which was successfully treated conservatively. In addition, we broadly summarized and discussed pertinent studies in the English literature.

Remote Hemorrhage after Burr Hole Drainage of Chronic Subdural Hematoma

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.

The Neurocritical and Neurosurgical Care of Subdural Hematomas

Subdural hematomas (SDHs), though frequently grouped together, can result from a variety of different etiologies, and therefore many different subtypes exist. Moreover, the high incidence of these lesions in the neurocritical care settings behooves practitioners to have a firm grasp on their diagnosis and management. We present here a review of SDHs, with an emphasis on how different subtypes of SDHs differ from one another and with discussion of their medical and surgical management in the neurocritical care setting. In this paper, we discuss considerations for acute, subacute, and chronic SDHs and how presentation and management may change in both the elderly and pediatric populations. We discuss SDHs that arise in the setting of anticoagulation, those that arise in the setting of active cerebrospinal fluid diversion, and those that are recurrent and recalcitrant to initial surgical evacuation. Management steps reviewed include detailed discussion of initial assessment, anticoagulation reversal, seizure prophylaxis, blood pressure management, and indications for intracranial pressure monitoring. Direct surgical management options are reviewed, including open craniotomy, twist-drill, and burr-hole drainage and the usage of subdural drainage systems. SDHs are a common finding in the neurocritical care setting and have a diverse set of presentations. With a better understanding of the fundamental differences between subtypes of SDHs, critical care practitioners can better tailor their management of both the patient's intracranial and multi-systemic pathologies.

Comparative analysis of bleeding risk by the location and shape of arachnoid cysts: a finite element model analysis

OBJECTIVE

Although arachnoid cysts (ACs) are observed in various locations, only sylvian ACs are mainly regarded to be associated with bleeding. The reason for this selective association of sylvian ACs with bleeding is not understood well. This study is to investigate the effect of the location and shape of ACs on the risk of bleeding.

METHODS

A developed finite element model of the head/brain was modified for models of sylvian, suprasellar, and posterior fossa ACs. A spherical AC was placed at each location to compare the effect of AC location. Bowl-shaped and oval-shaped AC models were developed to compare the effect by shape. The shear force on the spot-weld elements (SFSW) was measured between the dura and the outer wall of the ACs or the comparable arachnoid membrane in the normal model.

RESULTS

All AC models revealed higher SFSW than comparable normal models. By location, sylvian AC displayed the highest SFSW for frontal and lateral impacts. By shape, small outer wall AC models showed higher SFSW than large wall models in sylvian area and lower SFSW than large ones in posterior fossa. In regression analysis, the presence of AC was the only independent risk of bleeding.

CONCLUSION

The bleeding mechanism of ACs is very complex, and the risk quantification failed to show a significant role of location and shape of ACs. The presence of AC increases shear force on impact condition and may be a risk factor of bleeding, and sylvian location of AC may not have additive risks of AC bleeding.

Spontaneous Subdural Haematoma Developing Secondary to Arachnoid Cyst Rupture

Arachnoid cysts are congenital, benign, non-neoplastic, extra-axial intra-arachnoidal lesions. Arachnoid cysts rarely become symptomatic, with bleeding. Intracranial haemorrhage as a complication of arachnoid cyst is a very rare condition. It is well-known that mid-cranial fossa cysts might cause intracerebral haemorrhage or subdural haematoma secondary to traumas. However, the occurrence of spontaneous subdural haematoma secondary to arachnoid cysts, developing without any trauma, is even rarer. A 17-year-old boy presenting with diplopia and headache, with no history of trauma, was diagnosed with left temporal lobe arachnoid cyst and left fronto-parietal subdural haematoma. He was operated on, solely for his haematoma, with no intervention performed for the arachnoid cyst. Authors suggest that it is sufficient to perform an operation for the haematoma only -without arachnoid cyst resection- if there is no clinical presentation specific to the arachnoid cyst itself.

Sport-related structural brain injury associated with arachnoid cysts: a systematic review and quantitative analysis

OBJECTIVE Arachnoid cysts (ACs) are congenital lesions bordered by an arachnoid membrane. Researchers have postulated that individuals with an AC demonstrate a higher rate of structural brain injury after trauma. Given the potential neurological consequences of a structural brain injury requiring neurosurgical intervention, the authors sought to perform a systematic review of sport-related structural-brain injury associated with ACs with a corresponding quantitative analysis. METHODS Titles and abstracts were searched systematically across the following databases: PubMed, Embase, CINAHL, and PsycINFO. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Peer-reviewed case reports, case series, or observational studies that reported a structural brain injury due to a sport or recreational activity (hereafter referred to as sport-related) with an associated AC were included. Patients were excluded if they did not have an AC, suffered a concussion without structural brain injury, or sustained the injury during a non-sport-related activity (e.g., fall, motor vehicle collision). Descriptive statistical analysis and time to presentation data were summarized. Univariate logistic regression models to assess predictors of neurological deficit, open craniotomy, and cystoperitoneal shunt were completed. RESULTS After an initial search of 994 original articles, 52 studies were found that reported 65 cases of sport-related structural brain injury associated with an AC. The median age at presentation was 16 years (range 4-75 years). Headache was the most common presenting symptom (98%), followed by nausea and vomiting in 49%. Thirteen patients (21%) presented with a neurological deficit, most commonly hemiparesis. Open craniotomy was the most common form of treatment (49%). Bur holes and cyst fenestration were performed in 29 (45%) and 31 (48%) patients, respectively. Seven patients (11%) received a cystoperitoneal shunt. Four cases reported medical management only without any surgical intervention. No significant predictors were found for neurological deficit or open craniotomy. In the univariate model predicting the need for a cystoperitoneal shunt, the odds of receiving a shunt decreased as age increased (p = 0.004, OR 0.62 [95% CI 0.45-0.86]) and with male sex (p = 0.036, OR 0.15 [95% CI 0.03-0.88]). CONCLUSIONS This systematic review yielded 65 cases of sport-related structural brain injury associated with ACs. The majority of patients presented with chronic symptoms, and recovery was reported generally to be good. Although the review is subject to publication bias, the authors do not find at present that there is contraindication for patients with an AC to participate in sports, although parents and children should be counseled appropriately. Further studies are necessary to better evaluate AC characteristics that could pose a higher risk of adverse events after trauma.

Sports participation with arachnoid cysts

OBJECT There is currently no consensus on the safety of sports participation for patients with an intracranial arachnoid cyst (AC). The authors' goal was to define the risk of sports participation for children with this imaging finding. METHODS A survey was prospectively administered to 185 patients with ACs during a 46-month period at a single institution. Cyst size and location, treatment, sports participation, and any injuries were recorded. Eighty patients completed at least 1 subsequent survey following their initial entry into the registry, and these patients were included in a prospective registry with a mean prospective follow-up interval of 15.9 ± 8.8 months. RESULTS A total 112 patients with ACs participated in 261 sports for a cumulative duration of 4410 months or 1470 seasons. Of these, 94 patients participated in 190 contact sports for a cumulative duration of 2818 months or 939 seasons. There were no serious or catastrophic neurological injuries. Two patients presented with symptomatic subdural hygromas following minor sports injuries. In the prospective cohort, there were no neurological injuries CONCLUSIONS Permanent or catastrophic neurological injuries are very unusual in AC patients who participate in athletic activities. In most cases, sports participation by these patients is safe.

A case of organized arachnoid cyst with repeated hemorrhage

Hemorrhage sometimes occurs within arachnoid cysts, however, organized arachnoid cysts has not been reported. We speculate the previous invasive stress or some kind of infection may have triggered the formation of the organized membrane, which may have formed via a similar mechanism to that for organized chronic subdural hematomas.

Spontaneous Arachnoid Cyst Rupture with Subdural Hygroma in a Child

Arachnoid cyst of the brain is common in children but its association with spontaneous subdural hygroma is rare. A case of a nine-year-old boy, without any preceding history of trauma, is presented here who came to the emergency department of a tertiary care hospital with complaints of headache, nausea, and vomiting for the last two weeks but more for the last two days. Examination showed a young, fully conscious oriented boy with positive Cushing's reflex and papilledema of left eye. MRI (magnetic resonance imaging) of the brain showed left temporal extra-axial cystic lesion of 5.40 × 4.10 cm in size, representing arachnoid cyst, with bilateral frontoparietal subdural hygromas. Cyst was partially drained through left temporal craniectomy and subdural hygromas were drained through bilateral frontal burr holes. Postoperatively the child recovered uneventfully and was discharged on the seventh postoperative day. Histopathology proves it to be arachnoid cyst of the brain with subdural CSF (cerebrospinal fluid) collection or hygroma.

Middle Meningeal Artery Embolization in Recurrent Chronic Subdural Hematoma Combined with Arachnoid Cyst

Chronic subdural hematoma (CSDH) is a collection of old blood and its breakdown products between the surface of the brain parenchyma and the outermost layer called the dura. The most common treatment option for primary CSDH is burr-hole trephination; however, the treatment method for recurrent CSDH is still widely debated. An arachnoid cyst (AC) is a sac filled with cerebrospinal fluid located between the brain or spinal cord and the arachnoid membrane, which is one of the three meninges covering the brain or spinal cord. Although it is rare, the cyst is associated with CSDH in juveniles, and the recurrence rate of CSDH increases in such cases. Much of the literature has supported the preventive role of middle meningeal artery (MMA) embolization in recurrent CSDH. We report a 13-year-old male patient with recurrent CSDH and AC where the early intervention of MMA embolization was proven effective in preventing the further recurrence of CSDH.

Chronic Subdural Hematomas Associated with Arachnoid Cysts: Significance in Young Patients with Chronic Subdural Hematomas

Although arachnoid cysts (ACs) are associated with chronic subdural hematomas (CSDHs), especially in young patients, the detailed features of CSDHs associated with ACs remain poorly understood. The objective of this study was to clarify the relationship between the location of CSDHs and ACs and the significance of ACs in young patients with CSDHs. We retrospectively assessed 605 consecutive patients 7 years of age and older who were diagnosed with a CSDH between 2002 and 2014. Twelve patients (2%) had ACs, and 10 of the 12 patients were 7–40 years of age. Patients with ACs as a complication of CSDHs were significantly younger than those without ACs (p < 0.05). Three different relationships between the location of CSDHs and ACs were found: a CSDH contacting an AC, an ipsilateral CSDH apart from an AC, and a CSDH contralateral to an AC. In 21 patients with CSDHs who were 7–40 years of age, 10 (47.6%) had ACs (AC group) and 7 (33.3%) had no associated illnesses (non-AC group). All 10 young patients with ACs showed ipsilateral CSDHs including a CSDH apart from an AC. All 17 patients in both the AC and non-AC groups showed headache but no paresis at admission. The pathogenesis of CSDHs associated with ACs may be different among the three types of locations. The clinical characteristics of patients with a combination of a CSDH and an AC including headache as a major symptom may be attributed to young age in the majority of patients with ACs.