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CASE REPORT |
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Year : 2014 | Volume
: 4
| Issue : 3 | Page : 193-196 |
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Subdural hygroma following posterior fossa tumor resection
Anokha Oomman, Viswa Rajalingam
Department of Neurosurgery, University Hospital of Wales, Cardiff, United Kingdom
Date of Web Publication | 8-Dec-2014 |
Correspondence Address: Dr. Anokha Oomman Department of Surgery, Withybush General Hospital, Haverford West, SA61 2PZ United Kingdom
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/2278-9596.146446
Subdural hygroma is an unusual complication of posterior fossa tumor surgery. We present two cases where patients developed subdural hygroma following posterior fossa surgery for brain tumors. This rare complication manifested with headaches, nausea, unsteadiness and nystagmus two weeks after seemingly uncomplicated surgery. There have been a few such cases described in the literature; mostly following foramen magnum decompression. The exact etiology of subdural hygroma post-posterior fossa surgery remains unknown; however, there are speculations that external hydrocephalus and intracranial hypotension may play a part. After exhausting conservative options, both patients underwent ventriculo-peritoneal shunting, which resulted in the resolution of their symptoms with corresponding resolution of the subdural hygroma on radiological imaging. We present two cases where subdural hygroma following surgery was successfully treated with a ventriculo-peritoneal shunt. We also highlight the paucity in literature regarding subdural hygroma as a complication of posterior fossa surgery and suggest management of such patients. Keywords: Posterior fossa surgery, subdural hygroma, ventriculo-peritoneal shunt
How to cite this article: Oomman A, Rajalingam V. Subdural hygroma following posterior fossa tumor resection. Arch Int Surg 2014;4:193-6 |
Introduction | | |
Subdural hygromas are unusual complication of posterior fossa tumor surgery. It presents with non-specific symptoms of raised intracranial pressure (ICP) and cerebellar compression. The exact etiology of subdural hygroma post-posterior fossa surgery remains unknown; however, there are speculations that external hydrocephalus and intracranial hypotension may play a part. This is a rare complication and has mostly been described following foramen magnum decompression (FMD) for Chiari malformation More Details. Out of the 12 cases described in the literature, only one case of subdural hygroma has been described following tumor surgery. [1],[2]
There is limited literature and varied recommendations regarding management; with the management ultimately being determined by the clinician. We present two cases where subdural hygroma following surgery was successfully treated with a ventriculo-peritoneal shunt. We also highlight the paucity in literature regarding subdural hygroma as a complication of posterior fossa surgery and suggest management of such patients.
Case Reports | | |
Case 1
A 65-year-old female was referred by the Oncology team with a 2-week history of a gradually worsening headache, associated with ataxia, nausea and lethargy. There were no associated features of a raised intracranial pressure. Her neurological examination demonstrated right upper limb dysmetria and ataxia. Her medical history included ovarian cancer; for which she had undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy 2 years prior. There were recurrent ovarian tumors in the pelvis of the patient. The admission brain CT showed a right-sided cerebellar tumor probably secondary to ovarian cancer.
The patient underwent a craniotomy for the removal of the posterior fossa tumor. Histological examination revealed secondary cerebellar tumor. Postoperatively, she made an uneventful recovery and was discharged home, and continued to have carboplatin and paclitaxel under the Oncology team as well as full brain radiotherapy.
Seventeen days after discharge, she presented with ataxia, lethargy and a pseudomeningocele. The brain CT showed right-sided supratentorial subdural hygroma and bilateral infratentorial subdurals with mass effect [Figure 1]. She was initially treated with acetazolamide 500 mg OD for 4 weeks, without any improvement of her symptoms. | Figure 1: Right-sided postoperative supratentorial and bilateral infratentorial subdural hygromas
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Eventually, she was taken to theater where a ventriculo-peritoneal (VP) was shunt inserted. Following this, the patient's symptoms became better, and she made a good recovery. The follow-up scans demonstrated a resolution of the subdural collection. Unfortunately, the patient died three months later with metastatic ovarian cancer [Figure 2]. | Figure 2: Postoperative scan after ventriculo-peritoneal (VP) shunt insertion for subdural collection
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Case 2
A young 27-year-old female was referred by the GP with intermittent episodes of facial tingling, headache and dysarthria. She was otherwise well and had no significant medical history and her neurological examination was unremarkable. She was investigated with a CT head, and a tumor was demonstrated in the fourth ventricle [Figure 3].
The patient underwent a posterior fossa craniotomy and excision of the lesion. She made an uneventful recovery postoperatively and was discharged home.
Two months after the operation, she presented to her local hospital with worsening headache, lethargy and difficulty in mobilizing due to incoordination. The brain CT demonstrated dilated ventricles with a posterior meningocele with both supratentorial and infratentorial subdural hygromas [Figure 4]. | Figure 4: Dilated ventricles with a posterior meningocele with both supratentorial and infratentorial subdural hygromas
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A VP shunt was inserted [Figure 5]. The patient's symptoms resolved and she was much better clinically after surgery. Follow-up scans also demonstrated a resolution of the subdural hygromas. The patient continues to remain asymptomatic and has returned back to her normal routine at 6 months follow-up. | Figure 5: Postoperative scan after insertion of ventriculo-peritoneal shunt
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Discussion | | |
Both patients developed infratentorial and supratentorial cerebrospinal fluid (CSF) collections following posterior fossa tumor surgery. This is a rare complication and has mostly been described following foramen magnum decompression (FMD) for Chiari malformation. Out of the 12 cases described in the literature, only one case of subdural hygroma has been described following tumor surgery. [2] In most cases, patients presented within the first few weeks following surgery with headaches and cerebellar symptoms. [3],[4],[5] The exact pathophysiology of hygromas post-FMD where durotomy was not performed is unknown. However, it has been widely hypothesized that microscopic breaches caused during the procedure might have contributed to their formation. [4]
These defects act like a one-way valve and allow CSF flow into the extra-arachnoid subdural space with every pulsation. The CSF may also enter the supratentorial compartment via the temporal notch. Although the defect may eventually heal over, the resulting hygroma may exert a pressure effect on the cerebellum causing cerebellar symptoms. Furthermore, pressure on the fourth ventricle and cerebral aqueduct results in a non-communicating external hydrocephalus, which may present with high intracranial pressure (ICP) symptoms. [2],[4]
In tumor surgery, there is a wide opening of the arachnoid, as such the above theory does not explain hygroma formation. It is possible that during healing, a small residual defect may have formed, leading to a CSF hygroma. This effect is enhanced further by the compression of the fourth ventricle and aqueduct, effectively trapping the CSF in subdural space.
The management of the cases described in the literature has been varied [Table 1]. While some have been managed conservatively, others underwent durotomy to undermine the suspected one-way valve effect by allowing bi-directional CSF flow. Although this may be appropriate for FMDs where the dura was never formally opened, it is unlikely to benefit postoperative tumor patients. [2],[4],[6],[7],[8],[9]
Furthermore in our first case, the patient was receiving full brain radiotherapy, which increased risk of poor wound healing and infection. After a trial of conservative management failed to provide any relief of her symptoms, a VP shunt was inserted. It was felt that, on a balance of risk, was the safest option for her.
Both patients underwent VP shunting with good outcomes. By diverting CSF flow away from the hygromas, it is likely that the previously compressed fourth ventricle and aqueduct recanalized and decompressed the hygromas. The cessation of flow through the arachnoid defect could allow the defect to heal.
Conclusion | | |
Subdural hygroma is an unusual complication of posterior fossa tumor surgery. It manifests with headaches, nausea, unsteadiness and nystagmus. The exact etiology of this process remains unknown, but it is likely to be due to incomplete healing of the dura or the presence of small dural defects. Surgical options include VP shunting and the use of burr hole to drain the CSF collection. A bigger case series is needed to assess the effectiveness of the various treatment options.
References | | |
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4. | Ranjan A, Cast IP. Symptomatic subdural hygroma as a complication of foramen magnum decompression for hindbrain herniation (Arnold-Chiari deformity). Br J Neurosurg 1996;10:301-3. |
5. | Tejada-Solís S, Díez-Valle R, Domínguez-Echavarri PD, García de Eulate-Ruiz MR, Gómez-Ibáñez A. Infratentorial hygroma secondary to decompressive craniectomy after cerebellar infarction. Neurocirugia (Astur) 2009;20:470-3. |
6. | Marshman LA, Benjamin JC, Chawda SJ, David KM. Acute obstructive hydrocephalus associated with infratentorial subdural hygromas complicating Chiari malformation Type I decompression: Report of two cases and literature review. J Neurosurg 2005;103:752-5. |
7. | Filis AK, Moon K, Cohen AR. Symptomatic subdural hygroma and hydrocephalus following Chiari I decompression. Pediatr Neurosurg 2009;45:425-8. |
8. | Suzuki F, Kitagawa T, Takagi K, Nozaki K. Subacute subdural hygroma and presyrinx formation after foramen magnum decompression with duraplasty for Chiari type 1 malformation. Neurol Med Chir (Tokyo) 2011;51:389-93. |
9. | Bahuleyan B, Menon G, Hariharan E, Sharma M, Nair S. Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following foramen magnum decompression for Chiari malformation Type I: Report of 2 cases. J Neurosurg 2011;114:510-3. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1]
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