Post-traumatic complications of arachnoid cysts and temporal lobe agenesis.

Abstract

S U M MARY Six patients with arachnoidal cysts of the middle cranial fossa who presented with raised intracranial pressure are described. All of them had a history of trauma though in two of them it was a remote incident. They all showed radiological changes of an expanded middle cranial fossa and temporal lobe agenesis. The relationship of trauma to these congenital lesions is discussed.Cysts overlying the temporal lobes have been well described in the literature. These are often associated with agenesis of the temporal lobe and their association with epilepsy and asymmetry of the skull is well known. We report our experience with six such cases, all of whom sustained minor trauma and suffered haemorrhagic complications.Case I A 24 year old male nurse was admitted to a medical ward with a three day history of severe headaches and vomiting. He had marked nuchal rigidity with Kernig's sign. There were no lateralising signs or papilloedema. A provisional diagnosis of subarachnoid haemorrhage was confirmed when the CSF obtained at lumbar puncture was found to be xanthochromic. On later questioning he recalled a blow to the right temporal region sustained during a game of football a year previously. He had not lost consciousness or been otherwise disturbed. Skull radiographs showed thinning and outward bulging of the right temporal bone with expansion of the middle cranial fossa. Right carotid angiogram showed medial shift of the middle cerebral artery with appearances suggestive of a right temporal extracerebral collection. Operation A right temporal burr hole was made and on incising the dura xanthochromic fluid gushed out under pressure. A right temporal craniotomy was then performed and a cystic cavity exposed. The superficial part of the cyst wall was adherent to the dura and the deep layer to arachnoid from which it was easily stripped. There appeared to be a direct communication between the cyst and the chiasmatic Address for reprint requests: Mr TRK Varma, Department of Neurosurgery, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF. Accepted 30 July 1980 cistern. The temporal lobe was hypoplastic and the internal carotid artery, the optic nerve and the third nerve were easily visible without retraction. The patient recovered completely and ten years later was symptom free.Case 2 A 7 year old boy was admitted with a six weeks history of headaches and vomiting. Two days prior to the onset of symptoms he had fallen from a fence and bumped his head. He had not lost consciousness and was not taken to hospital. There was no significant past illness and his development had been normal. He was fully conscious but had bilateral papilloedema though no lateralising signs. Skull radiographs showed expansion of the right middle cranial fossa with outward bulging of the squamous temporal bone.Bilateral carotid angiogram showed the midline vessels to be shifted to the left with evidence of an extracerebral collection in the right front temporal region. Operation A right temporal burr hole was made and on open...

Arachnoidplasty for Traumatic Subdural Hygroma Associated With Arachnoid Cyst in the Middle Fossa -Case Report-

“…1,7,[11][12][13] Several mechanisms for acute increase in intracranial pressure have been postulated. 12,13) Acute and chronic hygroma may develop after rupture of the cyst and fluid evasion into the subdural spaces, occasionally observed in children.…”

“…The outer wall of the cyst was torn by the minor head injury, which caused a one-way valvular arrangement facilitating the inflow but blocking the outflow of CSF. 12) Fluid transduction from the cyst cavity to subdural space might gradually increase the size of the subdural hygroma and the persistence of intracranial hypertension after head injury for long periods. Establishment of communication between cyst cavity and basal cistern should be considered an essential step in the treatment.…”

“…2,3,8,9) However, these treatments are sometimes associated with postoperative complications such as subdural effusion, shunt dysfunction, and shunt infection. 5,7,8,11,12) We report a pediatric case of arachnoid cyst in the left middle cranial fossa without subdural hematoma, which later showed subdural effusion with slight midline shift. We closed the outer wall of the arachnoid cyst by arachnoidplasty using Dexon mesh and fibrin glue to maintain the physiological pathway of cerebrospinal fluid (CSF) without shunting, resulting in resolution of the subdural hygroma.…”

“…3,4) Subdural effusion is a known complication of arachnoid cysts, especially of posttraumatic origin. 1,7,[11][12][13] Surgical treatment of intracranial arachnoid cysts with mass effect remains controversial. Treatment options include burr-hole drainage, 1) cyst shunting, 2) craniotomy for fenestration (cystectomy), 3,5) and endoscopic fenestration.…”

“…Communicating arachnoid cysts especially in asymptomatic cases do not require any surgical treatment, but clinical follow up by serial computed tomography (CT) is sufficient. 6,8,12) Each of these techniques has its proponents and debate continues regarding which surgical treatment is the most effective. 2,3,8,9) However, these treatments are sometimes associated with postoperative complications such as subdural effusion, shunt dysfunction, and shunt infection.…”