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| Year : 1999 | Volume
: 47
| Issue : 2 | Page : 160-1 |
Shunt surgery induced iatrogenic CSF cyst presenting as a mass lesion.
Babu HV, Chandy MJ
How to cite this article:
Babu H V, Chandy M J. Shunt surgery induced iatrogenic CSF cyst presenting as a mass lesion. Neurol India 1999;47:160 |
Shunt obstruction presents in a variety of ways. A high infusion rate of CSF into the brain parenchyma could result in oedema of the white matter and formation of a tissue cleft which could in course of time become a CSF cyst.[1],[2] The additional possibility of this occurring as a result of subclinical infection or reversed flow of CSF has been suggested. The present report deals with such an unusual cyst which presented as a mass lesion.
A 19 year old boy presented to the Neurosurgery department 3 years ago with CSF rhinorrhoea, headache, vomiting, fever and progressive loss of vision. On examination he was febrile, had absence of light perception in both eyes, bilateral papilloedema,upgaze paresis, impaired convergence, convergence retraction nystagmus, bilateral sixth nerve paresis, right supranuclear facial nerve paresis, right hemiparesis and signs of meningeal irritation. Plain and contrast computed tomographic (CT) scans showed a uniformly enhancing well defined mass in the mid third ventricle with marked hydrocephalus and periventricular lucency. He was aggressively treated for meningitis and a bilateral medium pressure shunt system with a Y connection was inserted to control the hydrocephalus and raised intracranial pressue. He later had a CT guided stereotactic biopsy of the mass which was reported as a Germinoma. The patient was then managed with craniospinal radiation. At discharge the patient had no CSF rhinorrhoea or evidence of meningitis. Review, six months later, showed near normal vision with no CSF rhinorrhoea or meningitis. Three yearslater he developed increasing headache, right sided weakness and papilloedema. There was no clinical evidence of meningitis and the vision was normal. MRI scan showed a left frontal cystic mass which was hypointense on T1 images, hyperintense on T2 images with no enhancement with gadolinium. The shunt tip was seen at the anterior wall of the cyst [Figure1]. The possibility of an iatrogenic CSF cyst and the rare possibility of a metastatic germinoma were considered. He therefore underwent a left frontal craniotomy and partial excision of the cyst wall and drainage of the cyst. The shunt tip which was observed to be going into the frontal horn along side the cyst wall was found to be blocked. Smear preparation of the cyst wall showed no evidence of tumour and the CSF showed no infection or presence of malignant cells. Postoperatively the patient became asymptomatic and was advised regular follow up.
It is well known that shunt obstruction can result in flow of CSF from the ventricle into the brain parenchyma resulting in brain oedema along the ventricular catheter[1],[3] or formation of brain clefts filled with CSF.[2] In the event of a bilateral shunt with a Y connection, as in the present case, partial obstruction of the peritoneal and left frontal ventricular ends could result in the right ventricular CSF going into the left frontal parenchyma through the proximal openings in the shunt tube adjacent to the shunt tube resulting in the formation of a CSF cleft enlarging to form a cyst. Considering the history of CSF rhinorrhoea and meningitis, the possibility of infection related sequestrated cyst is also a distinct possibility even in the absence of active infection on culture. This report deals with the unusual occurrence of a shunt tube related CSF cyst which presented as a mass lesion; the marsupalisation of which resulted in a satisfactory outcome.
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