What is the treatment approach for a patient with a hygroma?

Treatment Approach for Hygroma

The treatment of subdural hygroma should be guided by the patient's symptoms and the underlying cause, with small or asymptomatic hygromas managed conservatively while treating any underlying cerebrospinal fluid (CSF) leak, and symptomatic hygromas with significant mass effect requiring surgical drainage. 1

Evaluation and Diagnosis

• MRI of the brain with contrast and whole spine should be performed when subdural hygroma is suspected, particularly to investigate spontaneous intracranial hypotension (SIH) as a potential underlying cause 1
• CT scan is useful for initial diagnosis, showing hypodense collections in the subdural space 2
• Careful examination of radiological findings is crucial to distinguish subdural hygroma from other conditions like subdural hematoma 3

Treatment Algorithm Based on Etiology and Symptoms

Asymptomatic or Small Hygromas

• Conservative management is recommended for small or asymptomatic hygromas 1, 2
• Monitor with serial imaging (CT or MRI) according to clinical presentation 2
• Most hygromas diminish in size spontaneously without intervention 2

Hygromas Associated with CSF Leak/SIH

• Treat the underlying CSF leak as the primary management strategy 1
• Epidural blood patch (EBP) should be prioritized as initial treatment 1
• Advise patients to maintain bed rest in supine position as much as possible 1
• For patients with SIH and subdural collections, referral to a specialist neuroscience center for multidisciplinary team discussion is recommended 1

Symptomatic Hygromas with Mass Effect

• Burr hole drainage is the treatment of choice for symptomatic hygromas with significant mass effect 1, 4
• Simple burr hole drainage rather than large craniotomy is often sufficient to reduce mass effect 3
• Surgical treatment should be performed in conjunction with treating any underlying CSF leak 1

Canine Elbow Hygroma (Veterinary)

• Extracorporeal shockwave therapy (ESWT) has shown promise as a non-surgical alternative for canine elbow hygromas 5
• Small hygromas in animals should not be treated at all 5
• Larger hygromas that restrict movement, are infected, painful, or ulcerated may require surgical intervention 5

Cystic Hygroma/Lymphangioma

• Bleomycin injection therapy has shown efficacy as a sclerosing agent for lymphangiomas and cystic hygromas 6
• Surgical excision has traditionally been the preferred treatment but has high recurrence rates due to infiltration of surrounding tissues 6

Post-Treatment Management

• For patients who have undergone EBP for SIH-related subdural hygromas, maintain supine position with head elevated as comfortable 1
• Consider thromboprophylaxis during immobilization 1
• Clinical review prior to discharge and follow-up the next day 1
• Advise patients to lie flat as much as possible for 1-3 days after procedure 1
• Minimize bending, straining, stretching, and other activities for 4-6 weeks 1

Complications to Monitor

• Cerebral venous thrombosis in cases associated with SIH 1
• Superficial siderosis in cases of persistent CSF leaks 1
• Reaccumulation of fluid may occur occasionally after drainage 4
• Clinical outcome is often more influenced by associated brain injuries than by the evolution of the hygroma itself 2

Special Considerations

• Changes in mental status without focal signs of brain damage are common in traumatic subdural hygromas 4
• Subdural hygromas may be associated with cerebral atrophy, cortical contusions, subdural hematomas, and overlying epidural hematomas 4
• The clinical course is often marked by stabilization without complete recovery of neurological function in over 40% of "simple hygroma" cases 4