Indian J. PediatT. 44 : 320, 1977
T R A U M A T I C PSEUDOMENINGOCELE IN CHILDREN* R e p o r t o f two cases ll
DINAKAR,~r. SEETHARAM, R.P. DESHPANDE AND C.
SATYPRASAI)
Kurnool
Traumatic pseudomeningocele or leptomeningeal cyst is a well recognised entity though it is encountered infrequently (Banerji and T a n d o n 1967, Gruber 1969, Linde and Erickson 1961, R a m a m u r t h i and K a l y a n a r a m a n 1970, Rao 1976, Taveras and Ransahoff 1953). ?,lost of the reported cases ~esulted from the so called growing fi'act~wes of the skull and occurred in children. The following is a report of two cases of traumatic ]eptomeningeal cysts treated surgicalh,.
R e p o r t o f Cases Case 1.
This 8-month-old male child was admitted with a swelling in the frontal region of 3 months' duration. About a month prior to the appearance of the swelling, he sustained an injury to the head by a blow from a falling pole. He became asymptomatic after a brief spell of drowsiness. The swelling then started growing steadily. On examination there was a soft pulsatile swelling on the mid-frontal region, more to the left side. It was cystic and transilluminant and not reducible. There were no CNS deficits. Skiagrams o f the skull showed a wide fracture in the frontal *From the Kurnoool Medical College, Kurnool (Andhra Pradcsh). Received on May lG, ]977.
region
with a
soft tissue shadow
over-
lying it. Surgery was undertaken. A scalp flap was reflected towards the right exposing a thin walled cyst. The wall was excised letting out a copious amount of C.S.F. The defects in the dura and the arachnoid were identified. The dural defect was repaired with a patch graft front the excised cyst wall. Haemostasis was secured and the wound closed. Postoperatively the child had a stormy course with irregular pyrexia, C.S.F. leak and wound infection. He died on the 20th post.operative day. Case 2.
This one-year-old boy fell down and injured himself on the head. A swelling appeared over the site of injury and had been increasing in size gradually. He was admitted about 3 months after the injury for the swelling. Examination showed a healthy child with no neurological deficits. There was a cystic swelling over the left fi'onto-parietal region which was pulsatile and transilluminant. X-rays of the skull showed a linear fracture of the left frontal bone. Pneumoencephalogram revealed normal ventricles having no communication with the air in the subarachnoid space or the cyst. At operation a scalp flap was raised to expose the dural defect of 2" length and 0.5" width. The defect was repaired with a
DINAKAR ET AL.--TRAUMATIG PSEUDOMENINGOCELE IN GHILDREN
321
s t u m p from the g a l e a a p o n e u r o t i c a a n d tlae wound repaired. H e was d i s c h a r g e d after an u n e v e n t f u l p o s t o p e r a t i v e course, O n follow u p 2 m o n t h s l a t e r he was well with no deficits.
viz. in the frontal a r e a a n t e r i o r to the a n a t o m i c a l l o c a t i o n of the m o t o r cortex. T r e a t m e n t comprises e x p o s u r e a n d r e p a i r o f the d u r a l defect a n d r e s t o r a t i o n o f n o r m a l anatomy.
Discussion
Summary
T h e factors which f a v o u r the f o r m a t i o n o f a l e p t o m e n i n g e a l cyst consist of a fracture o f the skull a n d a t e a r in the d u r a . This results in t h e p r o p u l s i o n o f the cerebrospinal fluid o u t w a r d s t h r o u g h the b o n y defect in the s u b g a l e a l space w h e r e it collects. T h e ball v a l v e effect due to pulsations o f the b r a i n d r i v i n g the fluid t h r o u g h the small d u r a l defect, w h i c h is p a r t i c u l a r l y a d h e r e n t to the c r a n i u m
in c h i l d r e n pro-
m o t e s this process. 1V[ost r e p o r t e d cases w e r e y o u n g c h i l d r e n . T h e site o f the p s e u d o m e n i n g o c o e l e in a l m o s t all the cases has b e e n the p a r i e t a l region. I n our cases, h o w e v e r , b o t h were l o c a t e d in the frontal area. T h e lesion m a y be associated w i t h n e u r o l o g i c a l deficits, such as epilepsy, hemiparesis a n d h e m i a t r o p h y . I n our cases, h o w e v e r , there were no n e u r o l o g i c a l deficits p r o b a b l y d u e to the l o c a t i o n o f the cysts,
T w o cases o f t r a u m a t i c l e p t o m e n i n g e a l cysts in c h i l d r e n a r e r e p o r t e d . T h e p a t h o genesis is d e s c r i b e d . T h e absence o f n e u r o logical deficits m a y be d u e to the unusual frontal l o c a t i o n o f the lesion in these cases.
References Banerji, A.K. and Tandon, P.N. (1967). Craniocerebral erosion and post-traumatic rneningocele. Neurology India, 15, 29. Gruber, F.H. (1969). Post traumatic leptomeningeal cysts. Amey. ,]. Roent. 105, 305. Linde, A.R. and Erickson, C T. (1961). Growing fracture of skull in childhood. 07. Neurosurg 18,478. Ramamurthy, B. and Kalyanaraman, S, (1970). Rationale of surgery in growing fractures of the skull. J. Neurol. Surg. 32,427. Rao, B.D. (1976). An unusual case of growing fracture of the skull in childhood. Brit. o7 Surg. 63, 145. Taveras, J.M. and Ransahoff, J (1953). Leptomeningeal cysts of the brain following trauma with erosion of the skull. .,7. Neurosu~g. 10, 233.
rNDIAN J O U R N A L
Fig. 1.
PLATE
OF PEDIATRICS
Gas bubbles in the right chest at its base and displacement o f the heart towards the left.
Fig. 2.
Barium filled loops of gut in Ihe light hemithorax.
$|NGH ET AL.--RIGHT-SIDED CONGENITAL DIAPI'IRAGMATIG HERNIA.
I
T R A U M A T I C PSEUDOMENINGOCELE IN CHILDREN* R e p o r t o f two cases ll
DINAKAR,~r. SEETHARAM, R.P. DESHPANDE AND C.
SATYPRASAI)
Kurnool
Traumatic pseudomeningocele or leptomeningeal cyst is a well recognised entity though it is encountered infrequently (Banerji and T a n d o n 1967, Gruber 1969, Linde and Erickson 1961, R a m a m u r t h i and K a l y a n a r a m a n 1970, Rao 1976, Taveras and Ransahoff 1953). ?,lost of the reported cases ~esulted from the so called growing fi'act~wes of the skull and occurred in children. The following is a report of two cases of traumatic ]eptomeningeal cysts treated surgicalh,.
R e p o r t o f Cases Case 1.
This 8-month-old male child was admitted with a swelling in the frontal region of 3 months' duration. About a month prior to the appearance of the swelling, he sustained an injury to the head by a blow from a falling pole. He became asymptomatic after a brief spell of drowsiness. The swelling then started growing steadily. On examination there was a soft pulsatile swelling on the mid-frontal region, more to the left side. It was cystic and transilluminant and not reducible. There were no CNS deficits. Skiagrams o f the skull showed a wide fracture in the frontal *From the Kurnoool Medical College, Kurnool (Andhra Pradcsh). Received on May lG, ]977.
region
with a
soft tissue shadow
over-
lying it. Surgery was undertaken. A scalp flap was reflected towards the right exposing a thin walled cyst. The wall was excised letting out a copious amount of C.S.F. The defects in the dura and the arachnoid were identified. The dural defect was repaired with a patch graft front the excised cyst wall. Haemostasis was secured and the wound closed. Postoperatively the child had a stormy course with irregular pyrexia, C.S.F. leak and wound infection. He died on the 20th post.operative day. Case 2.
This one-year-old boy fell down and injured himself on the head. A swelling appeared over the site of injury and had been increasing in size gradually. He was admitted about 3 months after the injury for the swelling. Examination showed a healthy child with no neurological deficits. There was a cystic swelling over the left fi'onto-parietal region which was pulsatile and transilluminant. X-rays of the skull showed a linear fracture of the left frontal bone. Pneumoencephalogram revealed normal ventricles having no communication with the air in the subarachnoid space or the cyst. At operation a scalp flap was raised to expose the dural defect of 2" length and 0.5" width. The defect was repaired with a
DINAKAR ET AL.--TRAUMATIG PSEUDOMENINGOCELE IN GHILDREN
321
s t u m p from the g a l e a a p o n e u r o t i c a a n d tlae wound repaired. H e was d i s c h a r g e d after an u n e v e n t f u l p o s t o p e r a t i v e course, O n follow u p 2 m o n t h s l a t e r he was well with no deficits.
viz. in the frontal a r e a a n t e r i o r to the a n a t o m i c a l l o c a t i o n of the m o t o r cortex. T r e a t m e n t comprises e x p o s u r e a n d r e p a i r o f the d u r a l defect a n d r e s t o r a t i o n o f n o r m a l anatomy.
Discussion
Summary
T h e factors which f a v o u r the f o r m a t i o n o f a l e p t o m e n i n g e a l cyst consist of a fracture o f the skull a n d a t e a r in the d u r a . This results in t h e p r o p u l s i o n o f the cerebrospinal fluid o u t w a r d s t h r o u g h the b o n y defect in the s u b g a l e a l space w h e r e it collects. T h e ball v a l v e effect due to pulsations o f the b r a i n d r i v i n g the fluid t h r o u g h the small d u r a l defect, w h i c h is p a r t i c u l a r l y a d h e r e n t to the c r a n i u m
in c h i l d r e n pro-
m o t e s this process. 1V[ost r e p o r t e d cases w e r e y o u n g c h i l d r e n . T h e site o f the p s e u d o m e n i n g o c o e l e in a l m o s t all the cases has b e e n the p a r i e t a l region. I n our cases, h o w e v e r , b o t h were l o c a t e d in the frontal area. T h e lesion m a y be associated w i t h n e u r o l o g i c a l deficits, such as epilepsy, hemiparesis a n d h e m i a t r o p h y . I n our cases, h o w e v e r , there were no n e u r o l o g i c a l deficits p r o b a b l y d u e to the l o c a t i o n o f the cysts,
T w o cases o f t r a u m a t i c l e p t o m e n i n g e a l cysts in c h i l d r e n a r e r e p o r t e d . T h e p a t h o genesis is d e s c r i b e d . T h e absence o f n e u r o logical deficits m a y be d u e to the unusual frontal l o c a t i o n o f the lesion in these cases.
References Banerji, A.K. and Tandon, P.N. (1967). Craniocerebral erosion and post-traumatic rneningocele. Neurology India, 15, 29. Gruber, F.H. (1969). Post traumatic leptomeningeal cysts. Amey. ,]. Roent. 105, 305. Linde, A.R. and Erickson, C T. (1961). Growing fracture of skull in childhood. 07. Neurosurg 18,478. Ramamurthy, B. and Kalyanaraman, S, (1970). Rationale of surgery in growing fractures of the skull. J. Neurol. Surg. 32,427. Rao, B.D. (1976). An unusual case of growing fracture of the skull in childhood. Brit. o7 Surg. 63, 145. Taveras, J.M. and Ransahoff, J (1953). Leptomeningeal cysts of the brain following trauma with erosion of the skull. .,7. Neurosu~g. 10, 233.
rNDIAN J O U R N A L
Fig. 1.
PLATE
OF PEDIATRICS
Gas bubbles in the right chest at its base and displacement o f the heart towards the left.
Fig. 2.
Barium filled loops of gut in Ihe light hemithorax.
$|NGH ET AL.--RIGHT-SIDED CONGENITAL DIAPI'IRAGMATIG HERNIA.
I
