Anterior sacral pseudomeningocele following minimal trauma: case report.

Sacral fractures are rare and seldom result in formation of a sacral pseudomeningocele. Treatment of these pseudomeningoceles usually consists of conservative management with flat bedrest or open operative management. The authors describe the case of a 55-year-old woman with an anterior sacral pseudomeningocele that was successfully treated using a lumbar drain for temporary continuous CSF drainage. The patient first presented to an outside institution several days after sacral trauma from an ice skating fall. Initial symptoms included throbbing headaches relieved by lying flat. Head and cervical spine CT demonstrated no abnormality. As symptoms worsened, she presented to another institution where MRI of the lumbar spine indicated sacral fracture with pseudomeningocele. The patient subsequently transferred to the authors' facility, where symptoms included headaches and occasional mild sacral pain. Given her headaches and the authors' concern for CSF leak, another head CT scan was performed. This revealed no subdural hematoma or other abnormality. A subsequent CT myelogram revealed an anterior sacral pseudomeningocele at S3-4 with an anterior irregular linear filling defect, likely representing torn dura. Treatment included placement of a lumbar drain (10 ml/hr) and flat bedrest. Resolution of the CSF leak occurred on postprocedure Day 9. At the 4-week follow-up visit, the patient had no clinical symptoms of CSF leak and no neurological complaints. To our knowledge, this is the first description of temporary continuous CSF drainage used to treat a posttraumatic sacral pseudomeningocele. This technique may reduce the need for potentially complicated surgical repair of sacral fractures associated with CSF leak in select patients.

Pseudomeningocele presenting as a cyst of the external auditory canal.

Pseudomeningocele is a cerebrospinal fluid collection in an extradural area after meningeal tear. The etiology of pseudomeningocele development is iatrogenic or traumatic in most cases. In this study, we report a case of the postsurgical pseudomeningocele presenting as a cystic mass in the external auditory canal and complete sensorineural hearing loss with a review of the relevant literature.

Extreme hypoglycorrhachia: not always bacterial meningitis.

BACKGROUND: A 55-year-old man presented with 4 months of chronic meningitis, neutrophilic pleocytosis and extreme hypoglycorrhachia-an abnormally low concentration of glucose in the cerebrospinal fluid (CSF). A previous neurological work-up had revealed no noteworthy abnormalities. Despite the brief improvements that were seen after numerous trials of antibiotics and corticosteroids, the symptoms relapsed soon after corticosteroids were discontinued. Lumbar puncture revealed cholesterol crystals in the CSF and imaging studies revealed a sickle-shaped sacrum, partial rectal stenosis, and a communicating presacral meningocele with an epidermoid-dermoid mass. Extreme hypoglycorrhachia seems almost always to be bacterial in origin, but its differential diagnosis is, nevertheless, extensive. The definition, physiology, pathophysiology and differential diagnosis of hypoglycorrhachia are reviewed here. INVESTIGATIONS: Physical examination, laboratory testing, multiple imaging studies including CT and MRI of the brain and spinal cord, as well as myelography and CSF analysis. DIAGNOSIS: Cholesterol-induced leptomeningitis in a patient with Currarino syndrome, a triad that consists of sacral bone defects, congenital hindgut anomaly, and a presacral tumor. MANAGEMENT: The patient was initially treated with multiple antimicrobials and steroids. However, once the cholesterol crystals and communicating presacral cyst were identified, the condition was successfully managed with surgically resection of the cyst.

Spinal pseudomeningocoele: a diagnostic dilemma.

STUDY DESIGN: Case report. OBJECTIVE: To describe the difficulty in diagnosing spinal pseudomeningocoele. SETTING: Department of Rehabilitation Medicine, University of Malaya Medical Centre, Kuala Lumpur, Malaysia. CASE REPORT: A case of progressive sacral swelling in a paraplegic man who sustained spinal cord injury 14 years ago is presented. Although his clinical features were suggestive of pseudomeningocoele, we were unable to confirm the diagnosis preoperatively. CONCLUSION: Traumatic spinal pseudomeningocoele is very rare. Even with the available modern diagnostic imaging techniques, it is still difficult to diagnose a spinal pseudomeningocoele.

Surgically verified case of optic sheath nerve meningocele: case report with review of the literature.

Optic sheath meningocele is rare; only approximately 31 cases have been reported. The term optic sheath meningocele has recently been proposed by Garrity and Forbes to describe primary CSF cysts of the optic nerve sheath, without apical mass or malformation of the cranio-orbital junction. Presenting symptoms are often related to involvement of the optic nerve, with a slow or rapid decrease of visual acuity. CT and MRI studies reveal a tubular-cystic enlargement of the optic nerve/optic sheath complex (on/onsc), with thickening of the optic nerve. Radiological differential diagnosis should include optic nerve tumors such as gliomas, meningiomas, and arachnoid cysts involving the optic nerve sheath. Up to now, it seems that early surgical management by means of optic nerve/optic nerve sheath decompression affords an improvement of visual function with minimal morbidity in patients who present a rapid decrease of visual acuity within 3-6 months. We present an additional case and discuss the clinical, radiological, and operative features of this pathological condition of the optic nerve sheath.

[Toxic aluminum encephalopathy. Predominant involvement of the limbic system on MRI]. / Encéphalopathie toxique à l'aluminium. Atteinte prédominante du système limbique en IRM.

Two patients underwent acoustic schwannoma surgery by transmastoid approach. Petrous bone defect was filled in with aluminium-containing bone cement (Ionocem). A pseudomeningocele by CSF accumulation in subcutaneous temporoparietal area appeared after the procedure and, in subsequent weeks, encephalopathy with confusion and seizures. MRI showed cerebral involvement with herpes-like disposition. Temporal stereotactic biopsy in a case did not confirm viral encephalitis but disclosed cellular accumulation of lipofucsin and particles highly suggestive of aluminum-inclusions. Aluminium's levels in blood and CSF of both patients were very high and confirm the brain's toxic involvement. Aluminium's toxicity would be advocated in patients with neurologic disorders who have undergone maxillofacial or skull bone-cementoplasty by an aluminum-containing biomaterial, if this cement is in contact with CSF.

Brachial plexopathy in infants after traumatic delivery: evaluation with MR imaging.

PURPOSE: To determine the value of magnetic resonance (MR) imaging in diagnosing traumatic pseudomeningocele. MATERIAL AND METHODS: Five newborn infants with brachial plexopathy secondary to traumatic delivery underwent MR imaging of the spine and serial neurologic examinations, and the findings were compared. RESULTS: Cervical MR images showed focal collections of cerebrospinal fluid lateral to the spinal cord and extending into the neural foramina. These were believed to represent pseudomeningoceles in four infants, all of whom have persistent major neurologic deficits. The infant with normal cervical MR images has had nearly complete spontaneous recovery. CONCLUSION: Spinal MR images can show pseudomeningoceles, which have been associated with partial or complete nerve root avulsion in infants with birth-related brachial plexopathy.

Empty sella syndrome, diagnosed as allergic rhinitis.

Unilateral cerebrospinal fluid (CSF) rhinorrhea as the only manifestation of the primary empty sella syndrome is a rare event. A case of a middle-aged male patient complaining for intermittent unilateral rhinorrhea, which started 5 months earlier, is reported. The persistence of this state was attributed to an allergic rhinitis. The initial work-up excluded the above diagnosis and an erroneous radiological diagnosis led to a puncture of the left maxillary sinus. A lateral X-ray of the skull and CT scan led to the diagnosis of empty sella syndrome, possibly due to an adenoma or a meningocele.

[Feasibility and limitations of the preoperative diagnosis of meningocele]. / Vozmozhnosti i predely dooperatsionnoi diagnostiki meningotsele.

The paper is concerned with clinical and x-ray analysis, performed in 10 patients (9 women and 1 man) aged 40 to 50, with meningocele, a congenital abnormality. The final diagnosis of this disease was made possible only by means of transthoracic needle biopsy of cerebrospinal fluid, which was effectively performed in 5 patients.

Optic nerve sheath meningoceles. Clinical and radiographic features in 13 cases with a review of the literature.

Thirteen patients with dilated intraorbital optic nerve sheaths with an expanded, patulous cerebrospinal fluid (CSF) space were studied with high-resolution computed tomography (CT) or magnetic resonance imaging (MRI). Eleven patients had bilateral findings. Headache or visual complaints, or both, were present in all patients. Signs of optic nerve dysfunction were present in eight patients. Three patients had visual acuity worse than 20/200. Cerebrospinal fluid pressure was mildly elevated in two patients. Three patients underwent a surgical procedure; visual acuity improved in one. The authors propose the term meningocele for this condition and suggest MRI with fat-suppression techniques and off-axis sagittal views as the radiographic procedure of choice.

Espinha bífida: relato de um caso / Spina bifida: a case report

Destaca-se a importância do diagnóstico feito à simples inspeçäo, como também o encaminhamento precoce do paciente afetado por meningocele com extravasamento de líquido cefalorraquidiano para o tratamento cirúrgico de urgência

Isoelectric focusing of cerebrospinal fluid proteins in children with nontumoral hydrocephalus. A preliminary report.

The cerebrospinal fluid (CSF) protein patterns of 42 children with nontumoral hydrocephalus, 33% with associated congenital malformations (meningocele, myelomeningocele, spina bifida, monoventricular prosencephalon) were determined by isoelectric focusing and polyacrylamide gel electrophoresis. 50% of the patients showed a barrier damage pattern, 19% showed a degenerative pattern, a block pattern or a normal pattern were less frequently found. 14 children presented hydrocephalus associated with other malformations, 44% of these cases showed a degenerative pattern. Combining results from quantitative polyacrylamide gel electrophoresis and qualitative isoelectric focusing, resulted in better characterization of CSF protein abnormalities, the high resolution capacity of these techniques may give a new approach to the evaluation of the blood CSF barrier in the management of hydrocephalus.

Cerebrospinal fluid pressure-gradients in spina bifida cystica, with special reference to the Arnold-Chiari malformation and aqueductal stenosis.

Ten infants with spina bifida cystica were investigated during life by simultaneous ventricular and intraspinal CSF pressure recordings, and 11 post-mortem specimens were studied by means of crystic resin castings of the ventricles. The results indicate marked pressure differentials between the lateral ventricles and intraspinal CSF pathways, which contribute to the moulding of the Arnold-Chiari malformation as a sliding hernia. Similar pressure differentials may exist at the incisura, with moulding of tissues producing blockage of the aqueduct and the subarachnoid pathways. A valvular action was demonstrated, in which baseline pressure differences were exaggerated by the infant's straining (e.g. crying, sucking), and it seems that complete dissociation between the two pressures may develop as a result of periods of partial dissociation. Removal of the meningocele sac increased the peaks in recordings of intraspinal pressure produced by straining. If it is carried out when there is a valvular effect, it seems that it will hasten the onset of established ventriculo-spinal pressure dissociation and uncompensated hydrocephalus by leading to impaction of the Arnold-Chiari malformation in the foramen magnum. The results indicate that even after birth the CSF pathways of babies with spina bifida cystica are in a plastic and changeable condition, with competition between constricting and distending forces. The demonstration that pressures tend to be low in the spine and to become lower before exacerbation of hydrocephalus suggests that all the intracranial manifestations of spina bifida cystica may be due to low intraspinal pressure, which results from initial failure of the neural tube to close during embryogenesis.