Skip to main content
Advertisement

Main menu

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • Low-Field MRI
    • Alzheimer Disease
    • ASNR Foundation Special Collection
    • Photon-Counting CT
    • View All
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home

User menu

  • Alerts
  • Log in

Search

  • Advanced search
American Journal of Neuroradiology
American Journal of Neuroradiology

American Journal of Neuroradiology

ASHNR American Society of Functional Neuroradiology ASHNR American Society of Pediatric Neuroradiology ASSR
  • Alerts
  • Log in

Advanced Search

  • Home
  • Content
    • Current Issue
    • Accepted Manuscripts
    • Article Preview
    • Past Issue Archive
    • Video Articles
    • AJNR Case Collection
    • Case of the Week Archive
    • Case of the Month Archive
    • Classic Case Archive
  • Special Collections
    • AJNR Awards
    • Low-Field MRI
    • Alzheimer Disease
    • ASNR Foundation Special Collection
    • Photon-Counting CT
    • View All
  • Multimedia
    • AJNR Podcasts
    • AJNR SCANtastic
    • Trainee Corner
    • MRI Safety Corner
    • Imaging Protocols
  • For Authors
    • Submit a Manuscript
    • Submit a Video Article
    • Submit an eLetter to the Editor/Response
    • Manuscript Submission Guidelines
    • Statistical Tips
    • Fast Publishing of Accepted Manuscripts
    • Graphical Abstract Preparation
    • Imaging Protocol Submission
    • Author Policies
  • About Us
    • About AJNR
    • Editorial Board
    • Editorial Board Alumni
  • More
    • Become a Reviewer/Academy of Reviewers
    • Subscribers
    • Permissions
    • Alerts
    • Feedback
    • Advertisers
    • ASNR Home
  • Follow AJNR on Twitter
  • Visit AJNR on Facebook
  • Follow AJNR on Instagram
  • Join AJNR on LinkedIn
  • RSS Feeds

AJNR Awards, New Junior Editors, and more. Read the latest AJNR updates

OtherPediatric Neuroimaging

Occipital Intradiploic CSF Pseudocyst: An Unusual Complication of a Ventriculoperitoneal Shunt Malfunction

T.S. Sato, T. Moritani and P. Hitchon
American Journal of Neuroradiology March 2009, 30 (3) 635-636; DOI: https://doi.org/10.3174/ajnr.A1320
T.S. Sato
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
T. Moritani
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
P. Hitchon
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • Responses
  • References
  • PDF
Loading

Abstract

SUMMARY: We report a rare and unique complication of ventriculoperitoneal (VP) shunt malfunction. A progressively expansile, CSF-containing occipital intradiploic cyst developed in a 15-year-old boy at the site of cystoperitoneal shunt draining a Dandy-Walker cyst; the shunt was placed when the boy was 4 years old. A proposed pathogenesis of the lesion is discussed.

Many complications of ventriculoperitoneal (VP) shunts have been previously described from common complications (eg, tube disconnection/obstruction, infection, and intraperitoneal CSF pseudocyst) to more esoteric ones (eg, bowel perforations, pleural effusions, shunt migration to the heart, and extrusion into or through the anus/vagina/scrotum).1,2 We report the case of a 15-year-old boy with a previous medical history including a diagnosis of a Dandy-Walker cyst with hydrocephalus, which required a VP shunt at age 6 months and a posterior fossa Dandy-Walker cystoperitoneal shunt connecting to the VP shunt through a Y connector at age 4 years. At 15 years old, the boy had an asymptomatic large, expansile, intradiploic occipital cyst containing CSF as a result of a disconnected VP shunt tube in the chest wall and an occluded intracranial catheter of the posterior fossa cystoperitoneal shunt.

Case Report

The reported patient is a 15-year-old boy who presented for a VP shunt evaluation before trying out for a football team. At age 6 months, the patient was diagnosed with a Dandy-Walker cyst and had a VP shunt placed for relief of his hydrocephalus. At age 4 years, the patient experienced progressive headaches and projectile vomiting and was found to have a disconnected shunt. MR imaging examination showed an enlarging Dandy-Walker cyst with compression of the brain stem and cerebellum. A cystoperitoneal shunt was placed, which was connected to the repaired VP shunt via a Y connector (Fig 1). At the time of surgery, it was found that the Dandy-Walker cyst was under pressure.

Fig 1.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 1.

Lateral skull radiograph performed in our patient at age 4 years shows cystoperitoneal shunt connected to a VP shunt via a Y connector (dashed arrow, reservoir of cystoperitoneal shunt; small arrow, Y connector; large arrow, unidirectional valve).

When the patient presented for a football pregame check-up at age 15 years, he was asymptomatic and denied any signs or symptoms of shunt malfunction. Plain radiographs revealed a break in the shunt catheter at the level of the right upper chest. Skull radiographs showed a cystic expansion of the occipital diploic space measuring 10 × 10 × 5 cm in the transverse, superoinferior, and anteroposterior dimensions, respectively (Fig 2). The reservoir of the posterior fossa cystoperitoneal shunt had migrated into the enlarged diploic space. Head CT examination confirmed the intradiploic location of the reservoir and the expansion of the diploic space extending from the supraoccipital into the basioccipital part of the occipital bone, including the occipital condyle and lower clivus (Fig 3).

Fig 2.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 2.

Lateral skull radiograph performed in our patient at age 15 years shows development of intradiploic cyst of the occipital bone.

Fig 3.
  • Download figure
  • Open in new tab
  • Download powerpoint
Fig 3.

CT image shows expansile loculation in the occipital bone. The reservoir of the cystoperitoneal shunt has migrated in the diploic space.

The patient was taken to the operating room, where it was found that the protruded occipital outer table was paper thin and the expanded diploic space contained CSF under pressure. The intracranial catheter of the cystoperitoneal shunt was found to be occluded. The intracranial cystoperitoneal shunt catheter was replaced, and the VP shunt was revised.

Discussion

Occipital intradiploic expansile cysts containing CSF have been described as a rare entity, and only 14 cases have been previously reported under various search terms including “intradiploic arachnoid cyst,” “intraosseous leptomeningeal cyst,” and “intradiploic growing skull fracture.”3-8 To the best of our knowledge, no cases of intradiploic expansile CSF cysts as a complication of shunt procedures have been reported in the literature.

The clinical presentation of previously reported patients may include a palpable mass, headache, ataxia, and visual field defects. Most cases of occipital intradiploic CSF cysts have been reported in the adult population. Almost all of these patients have had a previous history of head trauma with or without occipital fracture. The history of head injury ranges from very recent to as much as 50 years previously. Radiographic, CT, and MR imaging findings of previously reported cases include expansile, intradiploic, CSF-containing cysts that may be unilocular or multilocular. The expanded outer table is generally maintained without interruption, but the inner table may be interrupted with continuation of the posterior fossa subarachnoid space to the intradiploic cyst. In some cases, communication of the cyst to the posterior fossa subarachnoid space was demonstrated by pneumoencephalography or nuclear cisternography.3,4

This entity seems to be independent from so-called growing skull fractures (leptomeningeal cysts), which develop as sequelae of diastatic fractures with disruption of the dura mater as well as the inner and outer tables, most often involving the vertex of the calvaria (membranous calvaria). These injuries are almost exclusively seen in infants younger than age 3 years.9 Intradiploic CSF-containing cysts occurring in the calvaria other than the occipital bone are extremely rare.6,10

The pathogenesis of the occipital intradiploic cyst has been hypothesized as originating from insinuation of the arachnoid membrane into the occipital diploic space through the traumatic lent of the dura mater and inner table and subsequent intradiploic expansion by CSF pulsation.5 Expansile driving forces such as coexisting hydrocephalus, brain edema, or an actively growing child's brain were thought to facilitate the growth of the cyst.6 Among the cases in which a history of a traumatic injury was absent, extension of the arachnoid diverticulum into the diploic space through a small congenital defect of the dura mater was hypothesized as the cause.11 The thick musculature covering the occiput was thought to prevent the erosion of the outer table, allowing considerable expansile growth.7

In our case report, our hypothesis is that CSF communication was established between the Dandy-Walker cyst to the occipital diploic space through the surgically created dural and inner table defect. The disconnected VP shunt resulted in increased pressure on the Dandy-Walker cyst as well as in the ventricular system, facilitating the egress of CSF around the occluded catheter of the cystoperitoneal shunt into the diploic space and increasing cyst growth.

We also believe that the occipital predilection of this entity is explainable by the unique embryogenesis of the occipital bone. The supraoccipital portion of the occipital bone between the mendosal suture and the foramen magnum is cartilaginous in origin, similar to the basioccipital portion, contrary to the membranous origin of the rest of the calvaria.12 The thicker inner and outer table and more capacious diploic space of the occipital bone allow the growth of a large, intradiploic fluid collection.

In summary, we reported a rare and unique complication of a VP shunt. A progressively expansile, CSF-containing occipital intradiploic cyst developed at the site of a cystoperitoneal shunt draining a Dandy-Walker cyst in a 15-year-old boy.

Footnotes

  • Paper previously presented at: Annual Meeting of the American Society of Neuroradiology, June 3, 2008; New Orleans, La.

References

  1. ↵
    Goeser CD, McLeary MS, Young LW. Diagnostic imaging of ventriculoperitoneal shunt malfunctions and complications. Radiographics 1998;18:635–51
    CrossRefPubMed
  2. ↵
    Agha FP, Amendola MA, Shirazi KK, et al. Unusual abdominal complications of ventriculo-peritoneal shunts. Radiology 1983;146:323–6
    PubMed
  3. ↵
    Hillman RS, Kieffer SA, Ortiz H, et al. Intraosseous leptomeningeal cysts of the posterior cranial fossa. Radiology 1975;116:655–59
    CrossRefPubMed
  4. ↵
    Azar-Kia B, Palacios E, Cooper RA. Unusual features of leptomeningeal cysts. Am J Roentgenol Radium Ther Nucl Med 1975;124:287–91
  5. ↵
    Weinand ME, Rengachary SS, McGregor DH, et al. Intradiploic arachnoid cysts. J Neurosurg 1989;70:954–58
    PubMed
  6. ↵
    Martinez-Lage JF, Perez MM, Domingo R, et al. Posttraumatic intradiploic arachnoid cyst of the posterior fossa. Child's Nerv Syst 1997;13:293–96
    CrossRefPubMed
  7. ↵
    Acikgoz B, Tekkok IH. Post-traumatic intradiploic leptomeningeal fistula and cyst. J Clin Neuroscience 2002;9:466–73
    CrossRefPubMed
  8. ↵
    Hamamcioglu MK, Hicdonmez T, Kilincer C, et al. Large intradiploic growing skull fracture of the posterior fossa. Pediatr Radiol 2006;36:68–70
    CrossRefPubMed
  9. ↵
    Barkovich AJ. Brain and spine injuries in infancy and childhood. In: Pediatric Neuroimaging, 4th ed. Philadelphia: Lippincott Williams and Wilkins;2005 :190–290
  10. ↵
    Mahapatra AK, Tandon PN. Post-traumatic intradiploic pseudomeningocele in children. Acta Neurochir 1989;100:120–26
    CrossRefPubMed
  11. ↵
    Kaufman B, Nulsen FE, Weiss MH, et al. Acquired spontaneous, nontraumatic normal-pressure cerebrospinal fluid fistulas originating from the middle fossa. Radiology 1977;122:379–87
    CrossRefPubMed
  12. ↵
    Shapiro R, Robinson F. Embryogenesis of the human occipital bone. Am J Roentgenol 1976;126:1063–68
    PubMed
  • Received August 4, 2008.
  • Accepted after revision August 13, 2008.
  • Copyright © American Society of Neuroradiology
View Abstract
PreviousNext
Back to top

In this issue

American Journal of Neuroradiology: 30 (3)
American Journal of Neuroradiology
Vol. 30, Issue 3
March 2009
  • Table of Contents
  • Index by author
Advertisement
Print
Download PDF
Email Article

Thank you for your interest in spreading the word on American Journal of Neuroradiology.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Occipital Intradiploic CSF Pseudocyst: An Unusual Complication of a Ventriculoperitoneal Shunt Malfunction
(Your Name) has sent you a message from American Journal of Neuroradiology
(Your Name) thought you would like to see the American Journal of Neuroradiology web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
Cite this article
T.S. Sato, T. Moritani, P. Hitchon
Occipital Intradiploic CSF Pseudocyst: An Unusual Complication of a Ventriculoperitoneal Shunt Malfunction
American Journal of Neuroradiology Mar 2009, 30 (3) 635-636; DOI: 10.3174/ajnr.A1320

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
0 Responses
Respond to this article
Share
Bookmark this article
Occipital Intradiploic CSF Pseudocyst: An Unusual Complication of a Ventriculoperitoneal Shunt Malfunction
T.S. Sato, T. Moritani, P. Hitchon
American Journal of Neuroradiology Mar 2009, 30 (3) 635-636; DOI: 10.3174/ajnr.A1320
del.icio.us logo Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One
Purchase

Jump to section

  • Article
    • Abstract
    • Case Report
    • Discussion
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • Responses
  • References
  • PDF

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Crossref (16)
  • Google Scholar

This article has been cited by the following articles in journals that are participating in Crossref Cited-by Linking.

  • The Most Common Comorbidities in Dandy-Walker Syndrome Patients: A Systematic Review of Case Reports
    Emelina Stambolliu, Myrsini Ioakeim-Ioannidou, Kimonas Kontokostas, Maria Dakoutrou, Antonis A. Kousoulis
    Journal of Child Neurology 2017 32 10
  • A systematic approach in the diagnosis of paediatric skull lesions: what radiologists need to know
    Gagandeep Choudhary, Unni Udayasankar, Charbel Saade, Blair Winegar, Gilbert Maroun, Jad Chokr
    Polish Journal of Radiology 2019 84
  • Intradiploic occipital pseudomeningocele in a patient with remote history of surgical treatment of Chiari malformation
    Kelly B. Mahaney, Arnold H. Menezes
    Journal of Neurosurgery: Spine 2014 21 5
  • Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications
    Hedieh Khalatbari, Marguerite T. Parisi
    American Journal of Roentgenology 2021 216 1
  • Post-Traumatic Occipital Intradiploic Encephalocele
    Sedat Giray Kandemirli, Selman Candan, Cem Bilgin
    World Neurosurgery 2019 129
  • Intradiploic growing skull fracture: review of mechanisms and literature
    Luc Le Fournier, Pierre-louis Hénaux, Claire Haegelen, Maia Proisy, Laurent Riffaud
    Child's Nervous System 2015 31 11
  • Intradiploic pseudomeningocele and ossified occipitocervical pseudomeningocele after decompressive surgery for Chiari I malformation: report of two cases and literature review
    Arthur R. Kurzbuch, Shailendra Magdum, Jayaratnam Jayamohan
    Neurosurgical Review 2017 40 2
  • The vanishing shunt valve
    Krishna Chaitanya Joshi, Kiran Khanapure, Aniruddh Tekkatte Jagannatha, Ravi Gopal Varma
    Child's Nervous System 2015 31 11
  • Intradiploic Cerebrospinal Fluid Cyst Following Occipital Encephalocele Surgery in Patient with Dandy-Walker Malformation
    Timothy L. Miao, Holger Joswig, Sachin K. Pandey, Andrew G. Parrent
    World Neurosurgery 2018 117
  • Posttraumatic Intradiploic Leptomeningeal Cyst: A Rare Complication of Head Trauma
    Jernailsingh Bava, Ashank Bansal, Santosh Bhaugaunda Patil, Kiran Ashok Kale, Anagha Rajiv Joshi
    Case Reports in Radiology 2015 2015

More in this TOC Section

  • fetal brain development of 10 weeks gestation
  • CHARGE fetal MRI clival cleft
  • Neuroimaging Delineation and Progression of SLSMD
Show more Pediatric Neuroimaging

Similar Articles

Advertisement

Indexed Content

  • Current Issue
  • Accepted Manuscripts
  • Article Preview
  • Past Issues
  • Editorials
  • Editor's Choice
  • Fellows' Journal Club
  • Letters to the Editor
  • Video Articles

Cases

  • Case Collection
  • Archive - Case of the Week
  • Archive - Case of the Month
  • Archive - Classic Case

More from AJNR

  • Trainee Corner
  • Imaging Protocols
  • MRI Safety Corner

Multimedia

  • AJNR Podcasts
  • AJNR Scantastics

Resources

  • Turnaround Time
  • Submit a Manuscript
  • Submit a Video Article
  • Submit an eLetter to the Editor/Response
  • Manuscript Submission Guidelines
  • Statistical Tips
  • Fast Publishing of Accepted Manuscripts
  • Graphical Abstract Preparation
  • Imaging Protocol Submission
  • Evidence-Based Medicine Level Guide
  • Publishing Checklists
  • Author Policies
  • Become a Reviewer/Academy of Reviewers
  • News and Updates

About Us

  • About AJNR
  • Editorial Board
  • Editorial Board Alumni
  • Alerts
  • Permissions
  • Not an AJNR Subscriber? Join Now
  • Advertise with Us
  • Librarian Resources
  • Feedback
  • Terms and Conditions
  • AJNR Editorial Board Alumni

American Society of Neuroradiology

  • Not an ASNR Member? Join Now

© 2025 by the American Society of Neuroradiology All rights, including for text and data mining, AI training, and similar technologies, are reserved.
Print ISSN: 0195-6108 Online ISSN: 1936-959X

Powered by HighWire