An unusual post-traumatic occipitocervical pseudomeningocele: case report

Posttraumatic Intradiploic Pseudomeningocele of the Occipito-Cervical Region

Pseudomeningocele is a collection of the cerebrospinal fluid in the extradural space due to a defect in the dura-arachnoid layer of the meninge, and manifests as a fibrous capsule in the space of subcutaneous tissues. Classically, growing skull fracture caused by the pseudomeningocele is not uncommon in the pediatric age group. However, a posttraumatic intradiploic pseudomeningoceles is extremely rare, and only a few patients have been described. Herein, the authors present a 6-year-old girl who developed an intradiploic pseudomeningocele of the occipito-cervical region after a severe head trauma.

Anterior spinal pseudomeningocele after C0-C2 traumatic injuries: role of the "dural transitional zone" in the etiopathogenesis

PURPOSE

Spinal pseudomeningoceles (SPM) are extradural collections of CSF (cerebrospinal fluid); a frequent association with upper cervical injuries (UCI) has been observed. We propose a possible etiopathogenetic mechanism supporting the formation of cervical SPM based on some considerations.

METHODS

We present four cases of SPM. All patients sustained a severe UCI. Three patients were symptomatic with delayed and progressive clinical signs.

RESULTS

One patient was misinterpreted as epidural hematoma and operated on due to progressive signs with postoperative clinical improvement. The rest of patients were treated conservatively; spontaneous reduction of CSF collection occurred. From a radiological standpoint: (1) a line of demarcation separated the intradural cervical compartment from the anterior epidural space, (2) CSF epidural collection was never evident at C0-C2 level and extended from C2 downwards, and (3) shape of collection was similar to epidural hematomas suggesting a ball-valve mechanism.

CONCLUSIONS

The dural layer at C0-C2 level is adherent to the thick ligamentous apparatus, as opposed to the segments below where it is solely covered by the posterior longitudinal ligament. A "transitional zone" of dura exists between the C0-C2 region and subaxial segment of the cervical spine. This watershed area constitutes a point of minor resistance. Lacerations of the meningeal layers, caused by severe UCI at the "transitional zone", drain CSF into the anterior epidural space and form SPM.

Calcified pseudomeningocele of the lumbar spine: a review

PURPOSE

In this article, we review the English literature of calcified pseudomeningoceles in the lumbar region.

METHODS

A systematic review using the Medline Database using the varied nomenclature for pseudomeningoceles, as well as reviewing the reference lists of relevant article found.

RESULTS

We discuss the different pathological theories on formation of a pseudomeningocele, the formation of a calcified wall and the optimal management for this entity. To date, 17 cases have been described, of which 13 are reviewed here. Calcification of pseudomeningocele is a rare entity and in the lumbar spine this occurs postsurgically. The only predisposing factor is prior surgery to the lumbar spine. Computer tomography, magnetic resonance imaging (MRI) and MRI myelography in combination are the preoperative investigations of choice. The radiological work-up can be preoperatively diagnostic and is important in the surgical planning.

CONCLUSIONS

The treatment is surgicel removal and the decision to treat is based on patient symptoms and correlating these with imaging. There is an average reported follow-up of 1.7 years postoperatively for these patients and the reported outcome after surgery is good.

Pseudomeningoceles of the sphenoid sinus masquerading as sinus pathology

OBJECTIVES/HYPOTHESIS

To describe the clinical presentation, pathophysiology, and treatment of spontaneous cerebrospinal fluid (CSF) leaks of the sphenoid bone, with an emphasis on a previously undescribed form in this location, in which CSF is trapped under the mucosa of the sinonasal cavity or in the soft tissue of the skull base.

STUDY DESIGN

Case series and literature review.

METHODS

Analysis of cases through medical records and literature review.

RESULTS

Four examples of unusual spontaneous CSF leaks of the skull base are presented. In each case, a CSF collection was contained behind the sinonasal mucosa of the sphenoid sinus, resembling a nasal polyp or mucocele on exam or imaging. In one case, the fluid collection was also associated with significant bone resorption and extravasation into the soft tissue of the infratemporal fossa. In each case, small defects of the ventral skull base (sphenoid bone) were the source of the CSF leaks. Successful treatment was achieved after transnasal endoscopic repair of the skull base defects using a combination of free abdominal fat grafts, free fascial grafts, and pedicled nasoseptal flaps. Postoperatively, a ventriculoperitoneal shunt was placed if the intracranial pressure was elevated.

CONCLUSIONS

Spontaneous CSF leaks arising in the sphenoid sinus may not always present with overt CSF rhinorrhea but with a submucosal fluid collection (pseudomeningocele) that may mimic a mucocele or nasal polyp. These bona fide pseudomeningoceles of the skull base may be associated with elevated intracranial pressure and can be managed using endoscopic endonasal surgery.

An unusual stab wound causing a traumatic pseudomeningocele at the craniocervical junction

A stab wound to the craniocervical junction complicated by a pseudomeningocele has been reported rarely. A 65-year-old man was stabbed with a knife, and the blade penetrated the space between the occipital bone and the atlas. On admission, he presented with quadriparesis; the left arm was predominantly affected. The sensory level was at C2 on the left side. T2-weighted MRI showed a focal area of hyperintensity at the cervicomedullary junction, localized to the left of the spinal cord. The wound was carefully cleaned and closed. Follow-up MRI revealed a large pseudomeningocele along the trajectory, which resorbed completely without intervention. The quadriparesis improved progressively, except for the left arm, which improved only slightly. The asymptomatic insignificant meningocele completely improved spontaneously without surgery.

Post-traumatic pseudomeningocele presenting as a cyst of external auditory canal: Report of a case

Pseudomeningoceles are formed by extravasation of cerebrospinal fluid through a dural defect into soft tissue. They mostly form as a result of surgical trauma to the dural covering of the lumbar or cervical spine surgery, especially during laminectomy. Howerver, post-traumatic pseudomeningocele rarely occurs in the head and neck. A 32-year-old female presented with a 10-year history of right ear fullness following head trauma. A soft, non-pulsatile and cystic mass was noted in the right external auditory canal. The MRI scan demonstrated the connection between subarachnoid space and cyst of the right external auditory canal. The right ear was explored and mastoid antrum was partially filled with a cyst connected to the dural defect. The extradural portion of the mass was removed, the dural defect was repaired with a temporalis fascia-cartilage graft. Clinical manifestations, diagnosis and surgical approaches for post-traumatic pseudomeningocele arising in the head and neck region are briefly discussed.