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Table of Contents    
LETTER TO EDITOR
Year : 2011  |  Volume : 59  |  Issue : 3  |  Page : 467-469

Cerebellar distortion after a cystoperitoneal shunt for arachnoid cyst


1 Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
2 Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Korea
3 Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea

Date of Submission01-Feb-2011
Date of Decision01-Apr-2011
Date of Acceptance07-Apr-2011
Date of Web Publication7-Jul-2011

Correspondence Address:
Suk-Won Ahn
Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul
Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.82739

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How to cite this article:
Ahn SW, Kim KT, Shin HW, Youn YC, Park KY, Kwon OS, Park YS. Cerebellar distortion after a cystoperitoneal shunt for arachnoid cyst. Neurol India 2011;59:467-9

How to cite this URL:
Ahn SW, Kim KT, Shin HW, Youn YC, Park KY, Kwon OS, Park YS. Cerebellar distortion after a cystoperitoneal shunt for arachnoid cyst. Neurol India [serial online] 2011 [cited 2019 Dec 12];59:467-9. Available from: http://www.neurologyindia.com/text.asp?2011/59/3/467/82739


Sir,

Arachnoid cysts account for 1% of all the intracranial mass lesions and 10-30% of them are posterior fossa in location. [1],[2] Posterior fossa arachnoid cysts are often asymptomatic and may not grow, when symptomatic the clinical presentations include: ataxia, dizziness, tinnitus, hearing loss, headache, seizures, and tremors.[1],[2],[3] The clinical symptoms result from hydrocephalus and compression of the adjacent structures. Treatment of symptomatic arachnoid cysts includes serial cyst fenestration, stereotactic puncture, endoscopic cyst fenestration, cystoperitoneal shunt, cyst marsupialization into the subarachnoid space, and complete or partial resection of the cyst wall. [3],[4],[5],[6] However, the natural course of arachnoid cysts remains to be elucidated and surgical treatment remains controversial.

A 31-year-old woman presented with intractable dizziness, nausea, and gait disturbance of 1-year duration. Her past medical history indicated chronic headaches since her early twenties and the headache description was bilateral insidious-onset severe hemicranial accompanied by nausea and vomiting without photophobia and phonophobia, lasting for a few days without fully remitting. Two years before she visited our clinic, her headaches had become more intense, and their duration had increased. She had brain magnetic resonance imaging (MRI) at other hospital which revealed a large arachnoid cyst involving the posterior fossa [Figure 1]a. Although no neurological abnormalities besides the headache were noted, she had consented to surgery and undergone a fenestration surgery without relief of the headache. She had subsequently undergone cystoperitoneal shunt operation of the arachnoid cyst at the other hospital. One year after the shunt operation, the patient started complaining of severe dizziness and gait disturbance. For 1 year, she visited several hospitals for treatment, but the symptoms worsened over time. Neurological examination on admission to our hospital revealed ataxia in the right upper and lower extremities and gait ataxia. She could not sit up owing to the severe dizziness and could not help but lying down almost all day. Repeat brain MRI showed severe distortion of the right cerebellum, cerebellar peduncle and herniation of the cerebellar vermis into the cyst with a reduction in the size of the arachnoid cyst in the posterior fossa [Figure 1]b and c. Cerebellar distortion and vermian herniation were suspected to be the cause of the dizziness and gait disturbance. The patient was treated with various medications, but none could cure the dizziness. Subsequently she underwent ligation of the shunt catheter at the level of her neck, and the dizziness and gait disturbance completely disappeared postoperatively.
Figure 1: The axial and coronal T2-weighed brain MRI revealed a large arachnoid cyst of posterior fossa in the patient (a, black arrow). Brain MRI at a follow-up after a cytoperitoneal shunt operation showed severe distortion of the right cerebellum (b, white arrow) and cerebellar peduncle (b, white arrow), and herniation of the cerebellar vermis (b, black arrow head) into the cyst with a reduction in the size of the arachnoid cyst in the posterior fossa. Because of severe dizziness, she underwent ligation of the shunt catheter at the level of her neck, and the distortion of cerebellum and cerebellar peduncle improved postoperatively (c)

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Intracranial arachnoid cysts are intra-arachnoid collections of cerebrospinal fluid. They are regarded as a developmental abnormality of the arachnoid, originating from splitting or duplication of this membrane. [1],[2] The management of arachnoid cysts is somewhat controversial, even though many operative procedures have been recommended. [1],[2],[3] Undoubtedly, surgical treatment is necessary for patients with increased intracranial pressure, compression on the surrounding brain structures, cyst rupture, intracystic or subdural hemorrhage and the corresponding clinical symptoms. However, conservative management can be considered for asymptomatic patients or for those complaining of mild symptoms. In our case, the patient had complained of chronic daily headaches, indicating that the retrocerebellar arachnoid cyst with increased intracranial pressure was a cause of the headache.[3],[5] Thus, the arachnoid cyst in our patient warrants surgical treatment, however unfortunately, surgical procedure resulted in an unexpected complication of the distortion in cerebellum, cerebellar peduncle and vermis. To our knowledge, this is the first reported case of such a complication occurring in association with a cytoperitoneal shunt operation of a retrocerebellar arachnoid cyst. We hypothesize that surgical drainage of the cyst in the posterior fossa led to distortion of the cerebellum and cerebellar peduncle resulting in intractable dizziness and gait dsturbance. The vestibular nervous system in part projects directly to the phylogenetically oldest parts of the cerebellum-namely, the flocculus, nodulus, ventral uvula, and the ventral paraflocculus-on its way directly through the vestibular nucleus. The stretching distortion of cerebellum in our patient might result in functional impairment of vestibular system, which might result in dizziness and gait disturbance. [7] However, unfortunately, the etiology of asymmetrical drainage is not clear, and there has been no previous report on asymmetrical drainage similar to our patient. We could just assume that this phenomenon might result from adhesion between right cerebellum and arachnoid cyst during surgical procedure. However, further studies on causes of asymmetrical drainage are needed. In conclusion, cystoperitoneal shunt operation for arachnoid cysts may result in intractable complications, as in our patient. And, in such case, ligation of the shunt catheter at the level of the neck could recover cerebellar distortion and neurological symptoms.

 
  References Top

1.Erdinçler P, Kaynar MY, Bozkus H, Ciplak N. Posterior fossa arachnoid cysts. Br J Neurosurg 1999;13:10-7.  Back to cited text no. 1
    
2.Samii M, Carvalho GA, Schuhmann MU, Matthies C. Arachnoid cysts of the posterior fossa. Surg Neurol 1999;51:376-82.  Back to cited text no. 2
    
3.Helland CA, Wester K. A population based study of intracranial arachnoid cysts: Clinical and neuroimaging outcomes following surgical cyst decompression in adults. J Neurol Neurosurg Psychiatry 2007;78:1129-35.  Back to cited text no. 3
    
4.Marin SA, Skinner CR, Da Silva VF. Posterior fossa arachnoid cyst associated with Chiari I and syringomyelia. Can J Neurol Sci 2010;37:273-5.  Back to cited text no. 4
    
5.Umredkar AA, Gupta SK, Mohindra S, Singh P. Posterior fossa arachnoid cyst presenting with cerebrospinal fluid rhinorrhea. Neurol India 2010;58:327-8.  Back to cited text no. 5
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6.Jain R, Sawlani V, Phadke R, Kumar R. Retrocerebellar arachnoid cyst with syringomyelia: A case report. Neurol India 2000;48:81-3.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.Lee H. Neuro-otological aspects of cerebellar stroke syndrome. J Clin Neurol 2009;5:65-73.  Back to cited text no. 7
    


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