Management of hydrocephalus and subdural hygromas in pediatric patients after decompression of Chiari malformation type I: case series and review of the literature

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OBJECTIVE

Hydrocephalus associated with subdural hygromas is a rare complication after decompression of Chiari malformation type I (CM-I). There is no consensus for management of this complication. The authors present a series of 5 pediatric patients who underwent CM-I decompression with placement of a dural graft complicated by posterior fossa hygromas and hydrocephalus that were successfully managed nonoperatively.

METHODS

A retrospective review over the last 5 years of patients who presented with hydrocephalus and subdural hygromas following foramen magnum decompression with placement of a dural graft for CM-I was conducted at 2 pediatric institutions. Their preoperative presentation, perioperative hospital course, and postoperative re-presentation are discussed with attention to their treatment regimen and ultimate outcome. In addition to reporting these cases, the authors discuss all similar cases found in their literature review.

RESULTS

Over the last 5 years, the authors have encountered 194 pediatric cases of CM-I decompression with duraplasty equally distributed at the 2 institutions. Of those cases, 5 pediatric patients with a delayed postoperative complication involving hydrocephalus and subdural hygromas were identified. The 5 patients were managed nonoperatively with acetazolamide and high-dose dexamethasone; dosages of both drugs were adjusted to the age and weight of each patient. All patients were symptom free at follow-up and exhibited resolution of their pathology on imaging. Thirteen similar pediatric cases and 17 adult cases were identified in the literature review. Most reported cases were treated with CSF diversion or reoperation. There were a total of 4 cases previously reported with successful nonoperative management. Of these cases, only 1 case was reported in the pediatric population.

CONCLUSIONS

De novo hydrocephalus, in association with subdural hygromas following CM-I decompression, is rare. This presentation suggests that these complications after posterior fossa decompression with duraplasty can be treated with nonoperative medical management, therefore obviating the need for CSF diversion or reoperation.

ABBREVIATIONS CM-I = Chiari malformation type I; ETV = endoscopic third ventriculostomy; FMD = foramen magnum decompression.

Article Information

Correspondence Carolyn M. Carey: Johns Hopkins All Children’s Institute for Brain Protection Sciences, St. Petersburg, FL. ccarey12@jhmi.edu.

INCLUDE WHEN CITING Published online July 20, 2018; DOI: 10.3171/2018.4.PEDS17622.

A.C.V. and N.S. contributed equally to this work.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

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Figures

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    Case 1. Axial, sagittal, and coronal T2-weighted MRI scans obtained pre-FMD (A), and 14 days (B), 21 days (C), and 5 months (D) post-FMD, showing the progressive appearance and decrease of bilateral infratentorial subdural fluid collections in addition to normalization of hydrocephalus.

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    Case 2. Sagittal, coronal, and axial T1- and T2-weighted MRI scans obtained pre-FMD (A), and 14 days (B), 21 days (C), and 1.5 months (D) post-FMD, showing the progressive appearance and decrease of bilateral infratentorial subdural fluid collections in addition to normalization of hydrocephalus.

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    Case 3. Sagittal, coronal, and axial T1- and T2-weighted MRI scans obtained pre-FMD (A), and 32 days (B), 38 days (C), and 52 days (D) post-FMD, showing the progressive appearance and decrease of bilateral infratentorial and supratentorial subdural fluid collections with gradual normalization.

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    Case 4. Sagittal, coronal, and axial T1- and T2-weighted MRI scans obtained pre-FMD (A), and 10 days (B), 12 days (C), and 28 days (D) post-FMD, showing the progressive appearance and decrease of bilateral infratentorial subdural fluid collections in addition to normalization of hydrocephalus.

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    Case 5. Sagittal, coronal, and axial T1- and T2-weighted MRI scans obtained post-FMD in the past and prefixation of pseudomeningocele (A), and 14 days after surgery with the formation of infratentorial hygromas (B), and 3 months after surgery with partial resolution in ventricular size and partial decrease of bilateral infratentorial subdural fluid collections (C).

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