Trochlear Nerve Palsy Caused by Quadrigeminal Cistern Lipoma

PURPOSE: To report a case of trochlear nerve palsy caused by quadrigeminal cistern lipoma located in the dorsal midbrain. CASE SUMMARY: A 65-year-old male visited our clinic for intermittent vertical diplopia over 2-year period. Symptoms of diplopia had worsened over the past two weeks. He had no previous medical history except having had diabetes for 1 month. The best-corrected visual acuity was 20/25 in the right eye and 20/20 in the left eye. Pupillary examination was not remarkable. Extraocular examination showed 4 prism diopters (PD) left hypertropia at distant gaze and 4 PD exotropia at near gaze, with adduction elevation of the left eye. The Bielschowsky head tilt test revealed 6 PD left hypertropia on the left gaze and orthotropia on the right tilt. Fundus examination showed excyclotorsion of the right eye and incyclotorsion of the left eye. Brain magnetic resonance imaging revealed quadrigeminal cistern lipoma. Prism glasses were prescribed to alleviate diplopia, and we followed up the lesions without further treatment. CONCLUSIONS: Trochlear nerve palsy can be caused by quadrigeminal cistern lipoma; however, it is uncommon for this condition to be caused by a compressive lesion. Prompt neuroimaging can be helpful to rule out the causes of this condition in patients with atypical symptoms.

Quadrigeminal cisterna lipoma: report of two cases and literature review / Lipoma da cisterna quadrigeminal: relato de dois casos e revisão da literatura

Intracranial lipomas are congenital, benign and slow-growing tumors. The incidence were 0.1 to 0.5 percent of all primary brain tumors and are often diagnosed in incidental findings of neuroradiological investigation. Lipoma in quadrigeminal region occurs in 25 percent of intracranial lipomas and has been reported as lipomas in quadrigeminal cistern (perimesencephalic cistern), quadrigeminal plate, ambiens cistern or superior medullary velum. MRI is the most major exam. The treatment is conservative in most cases, surgical removal is hampered by their deep location and contiguous with adjacent neurovascular structures. The authors report two cases of lipoma in the quadrigeminal region, incidental findings and discuss the clinical findings, neuroimaging and treatment.

Lipomas intracranianos são tumores congênito, benigno e de crescimento lento. Sua incidência é de 0.1 a 0.5 por cento de todos os tumores cerebrais primários e são frequentemente diagnosticados em achados incidental de investigação neuroradiológica. Lipoma na região quadrigeminal ocorre em 25 por cento dos lipomas intracranianos e tem sido relatados como lipomas na cisterna quadrigeminal (cisterna perimesencefálica), placa quadrigeminal, cisterna ambiens ou véu medular superior. O exame de eleição é ressonância magnética. O tratamento é conservador na maioria dos casos, a remoção cirúrgica é dificultada pela sua localização profunda e da contiguidade com estruturas neurovasculares adjacentes. Os autores relatam dois casos de lipoma na região quadrigeminal achados incidentalmente e discutem os achados clínicos, imagem e tratamento.

Lesión como malformación de Chiari secundaria a quiste aracnoidal de la cisterna cuadrigémina / Chiari malformation-like lesion secondary to arachnoid cyst of the quadrigeminal cistern

Se presenta el caso de una mujer de 31 años de edad con cefalea y cervicalgia que se agravaba con la maniobra de Valsalva, presentando además mareos, encontrándose una malformación de Chiari secundario a un quiste aracnoideo cuadrigeminal. Después de efectuada la resonancia magnética diagnóstica, la paciente fue sometida a descompresión del agujero magno y extirpación del quiste cuadrigeminal, seguido por la resolución tanto de la malformación de Chiari y el quiste. Los síntomas desaparecieron después de la cirugía y han permanecido completamente resuelto hasta la actualidad. En pacientes adultos que presentan signos y síntomas de una malformación de Chiari debido a la compresión de la médula por las las amígdalas cerebelosas, la presencia de un quiste aracnoideo de cisterna cuadrigéminal es una rara patología asociada que puede ser tratada quirúrgicamente.

We report a rare case of a 31-year-old woman with headache and pain manifested by cervicalgia that worsened with the Valsalva maneuver and dizziness, who was found to have a Chiari malformation secondary to a posterior fossa arachnoid cyst. After magnetic resonance imagining (MRI), the patient was submitted to foramen magnum decompression and arachnoid cyst removal that were followed by resolution of both the Chiari malformation and the cyst. The symptoms disappeared after surgery and have remained completely resolved to the present day. In adult patients who present with signs and symptoms of Chiari malformation due to direct medulla compression by the tonsils, a quadrigeminal cistern arachnoid cyst is a rare associated pathology that can be treated surgically.

Clinical and Neuroradiologic Evaluations of Intracranial Lipoma

BACKGROUND: Intracranial lipomas are uncommon benign lesions of the central nervous system. They preferentially occur near the midline, most frequently in the pericallosal cistern, and are often associated with various neurologic and systemic anomalies. Since the advent of CT scanning and MR imaging, unexpected findings of intracralial lipomas have increased. We identified 11 cases of intracranial lipomas diagnosed by CT and MR and analyzed their characteristic clinical and radiologic findings. METHODS: We retrospectively reviewed 11 cases of intracranial lipomas. MR was used in all cases and CT in three. RESULTS: There were seven men and four women whose ages ranged from six months to 76 years, with a mean of 39 years. Six (55%) lipomas were located in the quadrigeminal plate and five (45%) in the pericallosal area. The pericallosal lipomas were divided into three cases of curvilinear type and two cases of tubulonodular type. Of the six quadrigeminal lipomas, five cases (83%) were associated with either hypoplasia of the unilateral (four) or bilateral (one) superior and/or inferior colliculus. One case of quadrigeminal lipoma was associated with hypoplasia of the cerebellar vermis, agenesis of the septum pellucidum, and glioblastoma multiforme. All cases of pericallosal tubulonodular type were associated with dysgenesis of the corpus callosum and enlarged ventricles. However, all cases of pericallosal curvilinear type were not associated with other anomalies. Four (36%) cases found incidentally were asymptomatic. Seizure was the most frequent clinical presentation in five (45%) cases, followed by headaches in three (27%) and mental retardation in one (9%). Of five seizures cases, three had secondary generalized seizures and two had generalized tonic clonic seizures. CONCLUSIONS: Quadrigeminal and pericallosal lipomas were the most common types of intracranial lipomas. Sixty-three percent of the lesions were associated with adjacent brain malformations of varying degrees. Four cases were asymptomatic, while the others presented with seizures, headache, and mental retardation. (J Korean Neurol Assoc 19(2):149~154, 2001)

Clinical and Neuroradiologic Evaluations of Intracranial Lipoma

BACKGROUND: Intracranial lipomas are uncommon benign lesions of the central nervous system. They preferentially occur near the midline, most frequently in the pericallosal cistern, and are often associated with various neurologic and systemic anomalies. Since the advent of CT scanning and MR imaging, unexpected findings of intracralial lipomas have increased. We identified 11 cases of intracranial lipomas diagnosed by CT and MR and analyzed their characteristic clinical and radiologic findings. METHODS: We retrospectively reviewed 11 cases of intracranial lipomas. MR was used in all cases and CT in three. RESULTS: There were seven men and four women whose ages ranged from six months to 76 years, with a mean of 39 years. Six (55%) lipomas were located in the quadrigeminal plate and five (45%) in the pericallosal area. The pericallosal lipomas were divided into three cases of curvilinear type and two cases of tubulonodular type. Of the six quadrigeminal lipomas, five cases (83%) were associated with either hypoplasia of the unilateral (four) or bilateral (one) superior and/or inferior colliculus. One case of quadrigeminal lipoma was associated with hypoplasia of the cerebellar vermis, agenesis of the septum pellucidum, and glioblastoma multiforme. All cases of pericallosal tubulonodular type were associated with dysgenesis of the corpus callosum and enlarged ventricles. However, all cases of pericallosal curvilinear type were not associated with other anomalies. Four (36%) cases found incidentally were asymptomatic. Seizure was the most frequent clinical presentation in five (45%) cases, followed by headaches in three (27%) and mental retardation in one (9%). Of five seizures cases, three had secondary generalized seizures and two had generalized tonic clonic seizures. CONCLUSIONS: Quadrigeminal and pericallosal lipomas were the most common types of intracranial lipomas. Sixty-three percent of the lesions were associated with adjacent brain malformations of varying degrees. Four cases were asymptomatic, while the others presented with seizures, headache, and mental retardation. (J Korean Neurol Assoc 19(2):149~154, 2001)

Predictors of Outcome of Spontaneous Cerebellar Hemorrhage

It is generally agreed that a small hematoma can be treated conservatively, whereas a larger one requires aggressive surgery; the surgical indication for those that are medium-sized remains controversial. To determine the criteria for conservative or surgical management, the authors analyzed 64 cases of spontaneous cerebellar hemorrhage diagnosed by CT scan between January 1990 and May 1996. An assessment was made of the relationship of initial GCS(Glasgow Coma Scale) score and GOS(Glasgow Outcome Scale) to hypertension, the location and size of the hematoma, obstructive hydrocephalus, intraventricular hemorrhage and the CT appearance of the quadrigeminal cistern. The results may be summarized as follows: 1) The incidence of spontaneous cerebellar hemorrhage was 6.37%(64/1005 spontaneous intracerebral hemorrhage). 2) The location of hematoma and hypertension did not correlated with initial GCS and GOS(p>0.05, p>0.05). 3) Obstructive hydrocephalus, intraventricular hemorrhage and obliteration of the quadrigeminal cistern correlated with intial GCS and GOS(p<0.01, p<0.001). 4) In case of spontaneous cerebellar hemorrhage, the mortality rate was 17.2%(11/64). 5) Poor prognostic factors were initial GCS score of less than 10(p<0.05), hematoma volume greater than 15 ml (p<0.01), the occurrance of intraventricular hemorrhage(p<0.05), and obliteration of the quadrigeminal cistern(p<0.001).

Prognosis of Spontaneous Cerebellar Hemorrhage

The authors analyzed 34 cases of spontaneous cerebellar hemorrhage which was diagnosed by brain CT scan, and assessed the relationship of outcome to the volume of hematoma, location of hematoma, level of consciousness and the CT apperance of the quadrigeminal cistern. The results were summerized as followed : 1) Hydrocephalic changes were observed in 25 patients(73.5%) and were identidied in 21 patients of the 22 patients with intraventricular extension of gemorrhage. 2) The volume of cerebellar hematoma sigificantly correlated to the level of consciousness on admission and prognosis. Patients with large hematoma showed poor prognosis. 3) Obliteration of quadrigeminal cistern on brain CT scan significantly correlated to the level of consciousness and prognosis. The patient with complete obliteration of quadrigeminal cistern on CT scan revealed unfavorable outcome. 4) The level of consciousness was the most important prognostic factor and the decreased level of consciousness was the indicator of poor result. 5) The location of hematoma did not correlated to the prognosis.

Methods of Treatment and Outcome of Primary Cerebellar Hemorrhage

We analysed a series of 35 patients with primary cerebellar hemorrhage, diagnosed by computerized tomography scanning from 1985 to 1988. They constituted 6.6% of spontaneous intracerebral hemorrhage(35 out of 530) who were admitted during the same period. There were 13 men and 22 women. The site of hemorrhage was vermis in 15 patients and hemisphere in 20 patients. On admission, the Glasgow Coma Scale(GCS) value was less than 10 in 15 patients(42.3%) and not less than 10 in 20 patients(57.1%). Quadrigeminal cistern was normal in 11 patients(31.4%), partially obliterated in 15 patients(42.9%) and completely obliterated in 9 patients(25.7%). The largest diameter of the hematoma was less than 3cm in 15 patients(42.9%) and larger than 3cm in 20 patients(57.2%). Hydrocephalic change was observed in 21 patients(60%). The hematoma was removed via suboccipital craniectomy in 16 patients(45.7%) and managed conservatively in 11 patients(31.4%). In 8 patients(22.9%), external ventricular drainage was performed. The method of treatment was different according to the GCS value on admission, the status of the quadrigeminal cistern, the presence of hydrocephalic change, and the size of hematoma. Overall mortality rate was 22.9%. These results suggested that the conservative treatment can be done in patients with (1) high GCS value(not less than 10), (2) patent quadrigeminal cistern, (3) absent hydrocephalic change, and (4) small sized hematoma(less than 3cm). If not surgical treatment should be considered.