Abstract
An 18-year-old man with an intracranial arachnoid cyst (Fig. 1) and existing cysto-peritoneal shunt for 10 years was admitted to our department because of orthostatic headache, nausea and vomiting. Neurological examination was inconspicuous. The shunt was ligated because of an assumed CSF overdrainage. Clinical symptoms persisted, so that magnetic resonance (MR) imaging as well as lumbar puncture were performed, without signs of an increasing intracranial pressure. Myelocisternography excluded CSF leakage. However, this investigation showed just a partial disabled shunt. In a second surgery the shunt was completely ligated. Intermittent diplopia occurred and neuro-ophthalmological examination revealed papilledema. MR imaging indicated an increasing arachnoid cyst and optic nerve sheath dilation, compared to the pre-operative MRI. The patient underwent a shunt revision and an adjustable valve with an opening pressure >140 mmH2O on the left side was implanted. Subsequently, diplopia, papilledema, and headaches disappeared. Two days postoperatively, the patient developed an isolated mild facial palsy on the right side (opposite to the site of the arachnoid cyst; House–Brackmann grade II) as well as headaches. Opening pressure of the valve was decreased to >120 mmH2O and the headaches disappeared. Nevertheless, the facial palsy on the right side aggravated (House–Brackmann grade III) and additionally appeared on the left side (House–Brackmann grade II). MR imaging showed a reduction of the arachnoid cyst and diminished optic nerve sheaths compared to the previous MRI. The opening pressure was readjusted again to >140 mmH2O. After readjusting the opening pressure, bilateral facial palsy was regressive and disappeared within a few days. The patient showed no clinical signs of increasing intracranial pressure and was discharged with no neurological deficits. Possible other causes of facial palsy (meningitis, viral, borreliosis, etc.) were excluded.
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