CSF overdrainage in shunted intracranial arachnoid cysts: a series and review.
BACKGROUND
Cerebrospinal fluid (CSF) overdrainage in hydrocephalus is well recognized. Overshunting following cysto-peritoneal (CP) drainage in patients with arachnoid cysts (AC) is rarely documented.


OBJECTIVE
We report five patients with acquired Chiari malformation I and three with posterior fossa overcrowding due to excessive CSF drainage in shunted intracranial ACs. We review our observations and discuss the current knowledge on the pathogenesis and management of this complication.


METHODS
The medical records of the eight patients were analyzed in regard to clinical manifestation, cyst and shunt characteristics, management, and outcomes.


RESULTS
Mean age of the patients was 5.5 years. After an average interval of 5 years, five patients developed symptoms related to hindbrain herniation and three to severe shunt overdrainage following CP shunting. Several management modalities were utilized that achieved a good result in seven instances.


CONCLUSIONS
Some shunted ACs may evolve with overdrainage syndromes. Posterior fossa overcrowding and tonsillar herniation constitute their most severe forms. CSF hypotension, bone changes, venous engorgement, and probably cerebral chronic edema at the posterior fossa constitute the main factors involved in the pathogenesis of this entity. We also review previous instances of acquired Chiari malformation originating after AC shunting.


CONCLUSIONS
Posterior fossa overcrowding and acquired Chiari I malformation can develop after excessive CSF drainage of intracranial ACs. Overshunting manifestations require prompt recognition and management. Preventive measures consist of making a stringent selection of cases being considered for surgery, avoiding CP drainage, and placing of a programmable valve as initial treatment of intracranial ACs if shunting is considered.
Martínez-Lage
Juan F
JF
Regional Service of Neurosurgery, Virgen de la Arrixaca University Hospital, Murcia's Service of Health, El Palmar 30120, Murcia, Spain. juanf.martinezlage@cablemurcia.com
Ruíz-Espejo
Antonio M
AM
Almagro
María-José
MJ
Alfaro
Raúl
R
Felipe-Murcia
Matías
M
López-Guerrero
A López
AL
D000293:Adolescent; D000328:Adult; D016080:Arachnoid Cysts / Q000473:pathology / Q000601:surgery*; D001139:Arnold-Chiari Malformation / Q000209:etiology; D001921:Brain / Q000000981:diagnostic imaging / Q000473:pathology; D001927:Brain Diseases / Q000209:etiology* / Q000473:pathology / Q000503:physiopathology; D002550:Cerebral Veins / Q000503:physiopathology; D002555:Cerebrospinal Fluid; D015170:Cerebrospinal Fluid Pressure; D002557:Cerebrospinal Fluid Shunts; D002648:Child; D002675:Child, Preschool; D004677:Encephalocele / Q000209:etiology / Q000473:pathology; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D011183:Postoperative Complications; D011859:Radiography; D012886:Skull / Q000473:pathology; D055815:Young Adult