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

Li, Boyi; Ng, Christina; Feldstein, Eric; Muh, Carrie R.; Mohan, Avinash; Tobias, Michael

doi:10.7759/cureus.20099

Cited by 4 publications

(3 citation statements)

References 20 publications

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“…cSDH from ruptured arachnoid cysts often resolves spontaneously with conservative management, and there are many standard or minimally invasive surgical strategies as well. 17 , 18 In these cases, we would argue that MMA embolization is a riskier treatment option for pediatric cSDH. In contrast, recurrence is a known risk when treating cSDH after NAT, and, in that setting, there is considerable variability in success rates of drainage with or without temporary drains or subdural shunts.…”

Section: Discussionmentioning

confidence: 99%

Middle meningeal artery embolization for refractory chronic subdural hematoma in a pediatric victim of nonaccidental trauma: illustrative case

Gal,

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2023

Journal of Neurosurgery: Case Lessons

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BACKGROUND Chronic subdural hematoma (cSDH) in children is associated with several etiologies, one of which is nonaccidental trauma (NAT). Performed alone or as an adjunct to surgical intervention, middle meningeal artery (MMA) embolization may be effective in resolving and preventing the recurrence of cSDH in adult patients. However, MMA embolization for pediatric cSDH has not been adequately evaluated, and there exists no consensus on the appropriate selection of pediatric patients for this minimally invasive procedure. Appreciating the variable underlying pathophysiology of pediatric cSDH will enable the development of guidelines for patient selection. OBSERVATIONS A 14-month-old female patient presented with depressed consciousness, seizure-like activity, and apneic episodes. She was diagnosed with bilateral subacute on chronic SDH associated with NAT, and imaging revealed diffuse brain atrophy. Despite undergoing burr hole drainage, she developed refractory cSDH and was treated with bilateral MMA embolization. At her 10-month follow-up, magnetic resonance imaging revealed a decrease in the size of the subdural collections, and she was tolerating feeds, at her neurological baseline, and seizure-free. LESSONS Infants and young children with symptomatic cSDH secondary to NAT, whose tissue dynamics are reminiscent of cSDH in elderly patients with diffuse brain atrophy, may derive the most benefit from MMA embolization.

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Section: Discussionmentioning

confidence: 99%

Middle meningeal artery embolization for refractory chronic subdural hematoma in a pediatric victim of nonaccidental trauma: illustrative case

Gal,

See

2023

Journal of Neurosurgery: Case Lessons

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“…This event seems to be peculiar of SACs where the risk of rupture is higher compared with intracranial arachnoid cysts located elsewhere [6,7]. The cyst rupture raises a great interest among the scientific community because of the possible emergency implications and the variable clinical presentation and course, as demonstrated by the large number of reports published even in recent years [8][9][10][11][12][13][14][15][16]. Moreover, the management of ruptured SACs still represents a controversial problem for neurosurgeons as far as the surgical indication and the type of treatment are concerned.…”

Section: Introductionmentioning

confidence: 99%

Ruptured Sylvian arachnoid cysts: an update on a real problem

et al. 2022

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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.

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“…It is noted that in the absence of neurological decline, resolution of these pediatric cSDHs can occur with conservative management. 3 Even in the presence of symptoms, medications such as acetazolamide have been shown to promote cSDH resorption in pediatric patients after arachnoid cyst rupture. 4 These reports indicate that MMA embolization should not be seen as the least invasive management option for all pediatric cSDH cases upfront.…”

mentioning

confidence: 99%

Letter: Middle Meningeal Artery Embolization for Primary Treatment of a Chronic Subdural Hematoma in a Pediatric Patient: A Systematic Review of the Literature and Case Report

Rangwala

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2023

Operative Neurosurgery

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

Cited by 4 publications

References 20 publications

Middle meningeal artery embolization for refractory chronic subdural hematoma in a pediatric victim of nonaccidental trauma: illustrative case

Middle meningeal artery embolization for refractory chronic subdural hematoma in a pediatric victim of nonaccidental trauma: illustrative case

Ruptured Sylvian arachnoid cysts: an update on a real problem

Letter: Middle Meningeal Artery Embolization for Primary Treatment of a Chronic Subdural Hematoma in a Pediatric Patient: A Systematic Review of the Literature and Case Report

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