Communicating Hydrocephalus Accompanied by Arachnoid Cyst in Aneurismal Subarachnoid Hemorrhage
A 69-year-old female with no significant prior medical history was referred to our clinic due to a headache of sudden onset. Head computed tomography (CT) scan performed at the time demonstrated an AC in the right middle fossa with a mass effect and diffuse SAH (). On clinical examination, the patient appeared lethargic and drowsy with a Glasgow coma scale score of 13 (E3, M6, V4), a Hunt-Hess grade of III, and a Fisher grade of IV.\nLeft carotid angiography revealed a left internal carotid-posterior communicating artery aneurysm, with a postero-laterally projecting dome (). Craniotomy was performed and complete aneurysm neck clipping and posterior communicating artery patency were confirmed intraoperatively by ultrasound using a micro-Doppler probe (). The post-operative period was uneventful. The patient's consciousness level gradually improved, and she was discharged on the 17th post-operative day. However, at two months after discharge, she reported that her mental status had been declining over recent weeks. A neurological examination performed at the time revealed decreased consciousness, that is, severe confusion with gait disturbance and urinary incontinence. Cranial CT revealed an interval increase in the size of the ventricle and an AC causing a midline shift (). We planned simultaneous ventriculoperitoneal shunt and cystoperitoneal shunt placement to correct the enlarged ventricle and AC. The patient was positioned supine with her head turned left to expose the right temporal scalp. A curvilinear skin incision was made over the temporo-occipital scalp for cyst access and another linear incision was made on the right Kocher's point for ventricular access by an intraoperative neuro-navigation system. Two intracranial catheters were connected using a Y-shaped titanium connector at the gate of the single valve (). A linear skin incision was made in the right upper abdomen to access the peritoneum for the distal end of the shunt catheter, and a programmable valve and distal catheter were tunnelled and passed in the usual manner.\nThe neurological deficits gradually subsided after the procedure and, two weeks later, the patient was discharged to home with no neurological deficit. Follow-up CT performed at one year post-operatively showed proper positioning of the shunt components and an interval improvement in brain condition including the hydrocephalus ().