Letters to Editor
Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, 2Department of Neurology, The First Xiangya Hospital of Central South University, Changsha, Hunan, China, 1Department of Radiology Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States E‑mail: [email protected]
References 1. 2. 3. 4. 5. 6.
Kaiser R, Mehdian H. Permanent twelfth nerve palsy secondary to C0 and C1 fracture in patient with craniocervical pneumatisation. Eur Spine J 2014. Sadler DJ, Doyle GJ, Hall K, Crawford PJ. Craniocervical bone pneumatisation. Neuroradiology 1996;38:330‑2. Renard D, Freitag C, Castelnovo G. Mystery case: Hypoglossal nerve palsy in occipito‑temporal pneumatization. Neurology 2012;79:e109‑10. Quigley AJ, Shannon H. Craniocervical pneumatization. J Radiol Case Rep 2013;7:27‑33. Moreira B, Som PM. Unexplained extensive skull base and atlas pneumatization: Computed tomographic findings. Arch Otolaryngol Head Neck Surg 2010;136:731‑3. Littrell LA, Leutmer PH, Lane JI, Driscoll CL. Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70‑year‑old man. AJNR Am J Neuroradiol 2004;25:491‑3. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.149433
Received: 15‑08‑2014 Review completed: 15‑09‑2014 Accepted: 05‑12‑2014
Spontaneous indirect CSF rhinorrhea following excision of a giant choroid plexus papilloma of lateral ventricle Sir, Indirect cerebrospinal fluid (CSF) rhinorrhea following excision of large remote intracranial lesions is uncommon. [1] This report describes a case of CSF rhinorrhea following total excision of a giant choroid plexus papilloma (CPP). A 26‑year‑old male presented with headache and decreased visual acuity in both eyes of 6‑month duration. There was no history of CSF rhinorrhea. On examination, perception of light was absent in both the eyes. Fundus examination was suggestive of secondary optic atrophy. 700
Magnetic resonance imaging (MRI) revealed a large intensely enhancing intraventricular tumor involving the body of the right lateral ventricle with extension to trigone and temporal horn associated with perilesional edema and hydrocephalus [Figure 1a‑c]. There was significant mass effect and midline shift. Herniation of brain through multiple defects in anterior cranial fossa (ACF) base was noted [Figure 1d and e]. Right temporal craniotomy and gross total excision of the tumor was done. Bone flap was not replaced as the brain was full at the end of surgery. Initial postoperative period was uneventful. Histopathology was suggestive of CPP. On the 2nd postoperative day, patient developed profuse CSF rhinorrhea which was resistant to conservative measures. Computed tomography (CT) revealed increase in the perilesional edema and normal‑sized ventricles. CT cisternogram revealed ACF base defects near the cribriform plate [Figure 1f]. In view of large and multiple bony defects in the ACF base, craniotomy and repair of the defects was considered to be a better option than endoscopic repair. Bifrontal craniotomy and repair of the ACF base was done with a vascularized pericranial graft and fibrin glue. Large bilateral dural and bony defects in ACF base were noted during surgery. CSF rhinorrhea completely stopped after ACF base repair. CT brain done 2 weeks later showed gross hydrocephalus and complete excision of the tumor [Figure 1g and h]. Left ventriculoperitoneal shunt was done. At the time of discharge, patient had no new neurological deficits and there was no improvement in his vision. CSF rhinorrhea can be caused by neoplasms in two ways. In the direct type of CSF rhinorrhea, the neoplastic lesions like pituitary adenomas directly cause erosion of meninges and bone. In indirect type of CSF rhinorrhea, raised intracranial pressure (ICP) results in progressive erosion of skull base.[1] Thin bone near the cribriform plate is the most common site of bony erosion in indirect type of CSF rhinorrhea. Indirect type of CSF rhinorrhea commonly present before the excision of the tumor (pretreatment type) and rarely after tumor excision (posttreatment type).[1‑5] The bony defects in pretreatment type tend to be smaller as the raised ICP is reduced by CSF leak and such small defects usually heal spontaneously after tumor excision.[1,4,5] The bony defects in posttreatment type are usually larger.[1] Herniating brain due to raised ICP plugs the bony and dural defects before tumor excision. Persistent raised ICP results in further herniation of brain tissue and progressive enlargement of the bony defects.[1] Decrease in ICP following tumor excision results in unplugging of these defects and profuse CSF rhinorrhea.[1] As the mechanism of posttreatment CSF rhinorrhea is due to unplugging of the large defect, there are seldom chances of settling of CSF rhinorrhea with any conservative measures. Neurology India | Nov-Dec 2014 | Vol 62 | Issue 6
Letters to Editor
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b
c
d
e
f
g
h
Figure 1: Preoperative MRI: Axial T1‑weighted images with contrast (a and b) and coronal T2‑weighted image (c) showing a large right lateral ventricular lesion. Sagittal (d), coronal (e) MRI images showing herniation of brain (arrows) through bony defects at the base of anterior cranial fossa. CT cisternogram (f) after first surgery showing leak of contrast (arrow) from the base of anterior cranial fossa. Postoperative (2 weeks after second surgery) contrast CT (g and h) showing complete excision of the lesion and hydrocephalus. MRI = Magnetic resonance imaging, CT = computed tomography
CPPs usually present with symptoms of raised ICP due to hydrocephalus secondary to excessive CSF production or obstruction of CSF pathways by the tumor.[2‑5] CPPs presenting with indirect type of CSF rhinorrhea is uncommon.[3,5] Unlike the present case, most of the reported cases of CSF rhinorrhea associated with CPPs are of pretreatment type.[2‑5] Immediate imaging to identify the defect and repair of the defect is the preferred line of management in posttreatment type of indirect CSF rhinorrhea.
Laxminadh Sivaraju, Narayanam Anantha Sai Kiran, Ravi Dadlani, Alangar S. Hegde Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, Karnataka, India E‑mail: [email protected]
References 1. Liang CL, Lu K, Lee TC, Su TM, Chen HJ. Non‑traumatic cerebrospinal fluid rhinorrhea indirectly caused by remote brain tumor: A case report and review of the literature. Clin Neurol Neurosurg 2001;103:83‑6. 2. Kinoshita Y, Wasita B, Akatsuka K, Kambe A, Kurosaki M, Watanabe T. Choroid plexus papilloma presenting with cerebrospinal fluid rhinorrhea and otorrhea: Case report. Neurol Med Chir (Tokyo) 2010;50:930‑3. 3. Lamberts AE. Choroid plexus papilloma with cerebrospinal fluid rhinorrhea. Surg Neurol 1984;22:576‑8. 4. Rovit RL, Schechter MM, Nelson K. Spontaneous “high‑pressure cerebrospinal rhinorrhea” due to lesions obstructing flow of cerebrospinal fluid. J Neurosurg 1969;30:406‑12. 5. Symss NP, Prasad AN, Vasudevan MC, Ramamurthi R. Exophytic choroid plexus papilloma of the fourth ventricle presenting with cerebrospinal fluid rhinorrhea: A case report. Surg Neurol 2009;71:705‑8. Neurology India | Nov-Dec 2014 | Vol 62 | Issue 6
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.149434
Received: 15‑11‑2014 Review completed: 05‑12‑2014 Accepted: 17‑12‑2014
Supratentorial parenchymal CNS melanocytoma ‑ Report of a rare case Sir, Primary central nervous system (CNS) melanocytoma is a benign pigmented tumor, accounting for less than 0.1% of brain tumors, almost always extra‑axial in location with or without parenchymal invasion. Most of these tumors have dural attachment on imaging or intraoperatively.[1] We report this rare case of parenchymal melanocytoma with no dural attachment. A 49‑year‑old lady presented with history of unilateral headache since 7 years and generalized tonic clonic seizures since 5 years. On examination, she had no neurological deficits. Magnetic resonance imaging (MRI) brain [Figure 1] demonstrated a well‑defined T2 hypointense, T1 hyperintense cortex‑based intra‑axial lesion located at the left precentral gyrus with minimal perilesional edema. The lesion showed blooming artifact 701
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Department of Neurology, The Second Xiangya Hospital of Central South University, Changsha, 2Department of Neurology, The First Xiangya Hospital of Central South University, Changsha, Hunan, China, 1Department of Radiology Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States E‑mail: [email protected]
References 1. 2. 3. 4. 5. 6.
Kaiser R, Mehdian H. Permanent twelfth nerve palsy secondary to C0 and C1 fracture in patient with craniocervical pneumatisation. Eur Spine J 2014. Sadler DJ, Doyle GJ, Hall K, Crawford PJ. Craniocervical bone pneumatisation. Neuroradiology 1996;38:330‑2. Renard D, Freitag C, Castelnovo G. Mystery case: Hypoglossal nerve palsy in occipito‑temporal pneumatization. Neurology 2012;79:e109‑10. Quigley AJ, Shannon H. Craniocervical pneumatization. J Radiol Case Rep 2013;7:27‑33. Moreira B, Som PM. Unexplained extensive skull base and atlas pneumatization: Computed tomographic findings. Arch Otolaryngol Head Neck Surg 2010;136:731‑3. Littrell LA, Leutmer PH, Lane JI, Driscoll CL. Progressive calvarial and upper cervical pneumatization associated with habitual valsalva maneuver in a 70‑year‑old man. AJNR Am J Neuroradiol 2004;25:491‑3. Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.149433
Received: 15‑08‑2014 Review completed: 15‑09‑2014 Accepted: 05‑12‑2014
Spontaneous indirect CSF rhinorrhea following excision of a giant choroid plexus papilloma of lateral ventricle Sir, Indirect cerebrospinal fluid (CSF) rhinorrhea following excision of large remote intracranial lesions is uncommon. [1] This report describes a case of CSF rhinorrhea following total excision of a giant choroid plexus papilloma (CPP). A 26‑year‑old male presented with headache and decreased visual acuity in both eyes of 6‑month duration. There was no history of CSF rhinorrhea. On examination, perception of light was absent in both the eyes. Fundus examination was suggestive of secondary optic atrophy. 700
Magnetic resonance imaging (MRI) revealed a large intensely enhancing intraventricular tumor involving the body of the right lateral ventricle with extension to trigone and temporal horn associated with perilesional edema and hydrocephalus [Figure 1a‑c]. There was significant mass effect and midline shift. Herniation of brain through multiple defects in anterior cranial fossa (ACF) base was noted [Figure 1d and e]. Right temporal craniotomy and gross total excision of the tumor was done. Bone flap was not replaced as the brain was full at the end of surgery. Initial postoperative period was uneventful. Histopathology was suggestive of CPP. On the 2nd postoperative day, patient developed profuse CSF rhinorrhea which was resistant to conservative measures. Computed tomography (CT) revealed increase in the perilesional edema and normal‑sized ventricles. CT cisternogram revealed ACF base defects near the cribriform plate [Figure 1f]. In view of large and multiple bony defects in the ACF base, craniotomy and repair of the defects was considered to be a better option than endoscopic repair. Bifrontal craniotomy and repair of the ACF base was done with a vascularized pericranial graft and fibrin glue. Large bilateral dural and bony defects in ACF base were noted during surgery. CSF rhinorrhea completely stopped after ACF base repair. CT brain done 2 weeks later showed gross hydrocephalus and complete excision of the tumor [Figure 1g and h]. Left ventriculoperitoneal shunt was done. At the time of discharge, patient had no new neurological deficits and there was no improvement in his vision. CSF rhinorrhea can be caused by neoplasms in two ways. In the direct type of CSF rhinorrhea, the neoplastic lesions like pituitary adenomas directly cause erosion of meninges and bone. In indirect type of CSF rhinorrhea, raised intracranial pressure (ICP) results in progressive erosion of skull base.[1] Thin bone near the cribriform plate is the most common site of bony erosion in indirect type of CSF rhinorrhea. Indirect type of CSF rhinorrhea commonly present before the excision of the tumor (pretreatment type) and rarely after tumor excision (posttreatment type).[1‑5] The bony defects in pretreatment type tend to be smaller as the raised ICP is reduced by CSF leak and such small defects usually heal spontaneously after tumor excision.[1,4,5] The bony defects in posttreatment type are usually larger.[1] Herniating brain due to raised ICP plugs the bony and dural defects before tumor excision. Persistent raised ICP results in further herniation of brain tissue and progressive enlargement of the bony defects.[1] Decrease in ICP following tumor excision results in unplugging of these defects and profuse CSF rhinorrhea.[1] As the mechanism of posttreatment CSF rhinorrhea is due to unplugging of the large defect, there are seldom chances of settling of CSF rhinorrhea with any conservative measures. Neurology India | Nov-Dec 2014 | Vol 62 | Issue 6
Letters to Editor
a
b
c
d
e
f
g
h
Figure 1: Preoperative MRI: Axial T1‑weighted images with contrast (a and b) and coronal T2‑weighted image (c) showing a large right lateral ventricular lesion. Sagittal (d), coronal (e) MRI images showing herniation of brain (arrows) through bony defects at the base of anterior cranial fossa. CT cisternogram (f) after first surgery showing leak of contrast (arrow) from the base of anterior cranial fossa. Postoperative (2 weeks after second surgery) contrast CT (g and h) showing complete excision of the lesion and hydrocephalus. MRI = Magnetic resonance imaging, CT = computed tomography
CPPs usually present with symptoms of raised ICP due to hydrocephalus secondary to excessive CSF production or obstruction of CSF pathways by the tumor.[2‑5] CPPs presenting with indirect type of CSF rhinorrhea is uncommon.[3,5] Unlike the present case, most of the reported cases of CSF rhinorrhea associated with CPPs are of pretreatment type.[2‑5] Immediate imaging to identify the defect and repair of the defect is the preferred line of management in posttreatment type of indirect CSF rhinorrhea.
Laxminadh Sivaraju, Narayanam Anantha Sai Kiran, Ravi Dadlani, Alangar S. Hegde Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, Karnataka, India E‑mail: [email protected]
References 1. Liang CL, Lu K, Lee TC, Su TM, Chen HJ. Non‑traumatic cerebrospinal fluid rhinorrhea indirectly caused by remote brain tumor: A case report and review of the literature. Clin Neurol Neurosurg 2001;103:83‑6. 2. Kinoshita Y, Wasita B, Akatsuka K, Kambe A, Kurosaki M, Watanabe T. Choroid plexus papilloma presenting with cerebrospinal fluid rhinorrhea and otorrhea: Case report. Neurol Med Chir (Tokyo) 2010;50:930‑3. 3. Lamberts AE. Choroid plexus papilloma with cerebrospinal fluid rhinorrhea. Surg Neurol 1984;22:576‑8. 4. Rovit RL, Schechter MM, Nelson K. Spontaneous “high‑pressure cerebrospinal rhinorrhea” due to lesions obstructing flow of cerebrospinal fluid. J Neurosurg 1969;30:406‑12. 5. Symss NP, Prasad AN, Vasudevan MC, Ramamurthi R. Exophytic choroid plexus papilloma of the fourth ventricle presenting with cerebrospinal fluid rhinorrhea: A case report. Surg Neurol 2009;71:705‑8. Neurology India | Nov-Dec 2014 | Vol 62 | Issue 6
Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.149434
Received: 15‑11‑2014 Review completed: 05‑12‑2014 Accepted: 17‑12‑2014
Supratentorial parenchymal CNS melanocytoma ‑ Report of a rare case Sir, Primary central nervous system (CNS) melanocytoma is a benign pigmented tumor, accounting for less than 0.1% of brain tumors, almost always extra‑axial in location with or without parenchymal invasion. Most of these tumors have dural attachment on imaging or intraoperatively.[1] We report this rare case of parenchymal melanocytoma with no dural attachment. A 49‑year‑old lady presented with history of unilateral headache since 7 years and generalized tonic clonic seizures since 5 years. On examination, she had no neurological deficits. Magnetic resonance imaging (MRI) brain [Figure 1] demonstrated a well‑defined T2 hypointense, T1 hyperintense cortex‑based intra‑axial lesion located at the left precentral gyrus with minimal perilesional edema. The lesion showed blooming artifact 701
Copyright of Neurology India is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
