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Gupta RK, Reddy TA, Gupta A, Samant R, Perez CA, Haque A. An Ecchordosis Physaliphora, a Rare Entity, Involving the Central Nervous System: A Systematic Review of the Literature. Neurol Int 2023; 15:1200-1211. [PMID: 37873832 PMCID: PMC10594460 DOI: 10.3390/neurolint15040075] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/04/2023] [Accepted: 09/06/2023] [Indexed: 10/25/2023] Open
Abstract
Ecchordosis physaliphora (EP) is a benign notochordal remnant, which is often an incidental finding; however, it can rarely present with neurological symptoms. We performed a systematic review of the literature for cases of symptomatic EP published in PubMed, Web of Science and Embase from January 1982 to May 2023. This is the largest review to date and revealed 60 cases including ours. Headache (55%) and CSF rhinorrhea (32%) were the most frequent clinical manifestations. The majority of symptomatic EP lesions were located in the prepontine region (77%) and required surgical resection (75%). EP should be considered in patients with neurologic symptoms in the setting of prepontine or posterior sphenoid sinus lesions. While symptomatic patients often require surgical intervention, rare cases may respond to oral corticosteroids.
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Affiliation(s)
- Rajesh K. Gupta
- Division of Multiple Sclerosis and Neuroimmunology, Department of Neurology, University of Texas Health Science Center, Houston, TX 77030, USA
| | - Thejasvi A. Reddy
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
| | - Ashutosh Gupta
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
| | - Rohan Samant
- Department of Radiology, UT Health Science Center, Houston, TX 77030, USA;
| | - Carlos A. Perez
- Department of Neurology, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Anam Haque
- McGovern Medical School, UT Health Science Center, Houston, TX 77030, USA (A.H.)
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Aljawi M, Shkoukani M. Clival Defect Resulting in Spontaneous Cerebrospinal Fluid Rhinorrhea: Case Report and Review of Literature. Case Rep Otolaryngol 2023; 2023:3205191. [PMID: 37529350 PMCID: PMC10390265 DOI: 10.1155/2023/3205191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/07/2023] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) rhinorrhea develops in patients without any history of trauma. Multiple factors have been theoretically debated. Also, localizing the defect may result in a challenge for the rhinologist. The common locations are the cribriform plate and the lateral recess of the sphenoid. Clival CSF rhinorrhea is rare, and only few cases have been reported so far. A 52-year-old female presented to the otolaryngology clinic with 7 years of history of left-side clear fluid rhinorrhea as a drop, which progressed to be runnier after she had pneumonia with severe cough secondary to COVID-19 infection. CSF was confirmed by a beta-2-transferrin test. During the perioperative evaluation, she developed meningitis which was treated with IV ceftriaxone and IV vancomycin antibiotics. The magnetic resonance imaging (MRI) and computerized tomography (CT) scan showed clival defect with pseudomeningocele which was initially not easy to see on CT. The patient underwent an endoscopic approach to the skull base to repair the defect with a pedicled septal flap. Also, a lumbar drain with intrathecal fluorescein administration was utilized. The postoperative course was uneventful without any complications. There was no evidence of recurrence with a 9-month follow-up postoperatively.
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Affiliation(s)
- Maryam Aljawi
- Otolaryngology Head and Neck Surgery Cleveland Clinic, AbuDhabi, UAE
| | - Mahdi Shkoukani
- Otolaryngology Head and Neck Surgery Cleveland Clinic, AbuDhabi, UAE
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Castello Ruiz MJ, Alsavaf MB, Fadel M, Salem EH, Mongkolkul K, Naksen P, Godil SS, Otto BA, Carrau RL, Prevedello DM. Spontaneous rhinorrhea: a possible concealing initial symptom of ecchordosis physaliphora. Illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE236. [PMID: 37014027 PMCID: PMC10550575 DOI: 10.3171/case236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 02/23/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Spontaneous rhinorrhea may be the initial manifestation of ecchordosis physaliphora (EP). There are currently 47 published cases of symptomatic EP, with spontaneous rhinorrhea being one of the most prevalent symptoms. The authors report 1 case as a cause of cerebrospinal fluid (CSF) fistula. OBSERVATIONS A 46-year-old woman presented to the authors' clinic with meningitis secondary to nasal CSF leakage. The computed tomography (CT) scan indicated an imperceptibly thin/dehiscent focus along the posterior wall of the sphenoid air cell's midline. A tumor was identified during endoscopic endonasal CSF repair surgery. EP was diagnosed in the frozen and final pathology. LESSONS EP should be considered as a potential cause of spontaneous rhinorrhea. This initial clinical manifestation accounts for 35% of symptomatic EP cases. The prepontine and posterior sphenoid sinus wall appear to be the locations with the highest susceptibility. Surgical therapy of the fistula without excision of the lesion may result in insufficient issue resolution and recurrence.
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Affiliation(s)
| | - Mohammad Bilal Alsavaf
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Michael Fadel
- Department of Otolaryngology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Eman H. Salem
- Department of Otolaryngology, Faculty of Medicine, Mansoura University, Mansoura, Egypt
| | - Kittichai Mongkolkul
- Department of Otolaryngology–Head and Neck Surgery, Rajavithi Hospital, The College of Medicine of Rangsit University, Bangkok, Thailand
| | - Pakjira Naksen
- Department of Otolaryngology, Phramongkutklao Hospital, Bangkok, Thailand; and
| | - Saniya S. Godil
- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Bradley A. Otto
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Ricardo L. Carrau
- Department of Otolaryngology–Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
| | - Daniel M. Prevedello
- Department of Neurological Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio
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Hasegawa H, Van Gompel JJ, Choby G, Raghunathan A, Little JT, Atkinson JL. Unrecognized notochordal lesions as a likely cause of idiopathic clival cerebrospinal fluid leaks. Clin Neurol Neurosurg 2022; 224:107562. [PMID: 36549221 DOI: 10.1016/j.clineuro.2022.107562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine an association between idiopathic transclival cerebrospinal fluid (CSF) leak and notochordal lesions. METHODS This study consisted of the illustrations of institutional patients who underwent surgery for transclival CSF leak between January 1, 2009 and April 25, 2020 and comprehensive review of the existing literature conducted on April 25, 2020. The cases were classified based on the presumed etiologies that were originally proposed in the articles ("idiopathic" vs. "secondary"). The baseline characteristics were compared between the groups, and the surgical outcomes were summarized. RESULTS In 3 institutional cases, ecchordosis physaliphora (EP) was confirmed at the fistula either pathologically (1) or radiologically (2). Among 42 literature cases, 28 were recognized as idiopathic, while 14 were secondary cases with histologically (n = 12) or radiologically (n = 2) confirmed notochordal lesion at the fistula. Thus, any notochordal lesions were histologically confirmed in 13 among a total of 45 cases (28.9%). Fourteen of the idiopathic cases had undescribed radiographic signs suggestive of small ecchordosis physaliphora at the fistula. Both idiopathic and secondary cases demonstrated resemblance in their ages (mean, 51.4 and 56.6 years; p = 0.102), female predominance (male, 36% vs. 25%; P = 0.521), no association with obesity (7% vs. 18%; P = 0.350) or increased intracranial pressure (7% vs. 6%; P = 1.000). All the fistulas were in the midline or paramidline clivus within several millimeters below the dorsum sellae. All the patients were treated surgically with a multilayer closure, resulting in a success rate of 93% with one surgery. CONCLUSION Our analyses suggest the association of transclival CSF leak and notochord lesions. A prospective study is needed for definitive conclusion.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, the University of Tokyo Hospital, Tokyo, Japan
| | | | - Garret Choby
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason T Little
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John L Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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Veiceschi P, Arosio AD, Agosti E, Bignami M, Pistochini A, Cerati M, Castelnuovo P, Locatelli D. Symptomatic ecchordosis physaliphora of the upper clivus: an exceedingly rare entity. Acta Neurochir (Wien) 2021; 163:2475-2486. [PMID: 33900480 DOI: 10.1007/s00701-021-04857-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 04/19/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This paper highlights the management of 5 patients affected by symptomatic ecchordosis physaliphora (EP), treated via endoscopic endonasal transsphenoidal-transclival approach and contextual multilayer skull base reconstruction. A detailed analysis of each case is provided, along with the review of the current body of literature. METHODS A retrospective review of patients treated by means of endoscopic endonasal approach for EP from 2010 to 2020 in the Otolaryngology and Neurosurgery Departments of a tertiary-care referral center for endoscopic skull base surgery was analyzed. Only adult patients with a definitive histopathological and immunohistochemical diagnosis of EP were included in the study. A systematic literature review according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed for EP. RESULTS Five cases of EP were retrieved and included in the study. Four patients presented with CSF leakage: in two cases after minor head trauma, in one case with associated bacterial meningitis, and in one case as only referred symptom. One patient complained diplopia due to VI cranial nerve palsy. No complications or recurrences of the disease were observed after a median follow-up of 37.2 months (range, 18-72 months). A total of 27 studies were identified with the systematic literature review, encompassing 30 patients affected by symptomatic EP who were addressed to surgical treatment. Twenty-five patients underwent complete surgical removal of the EP, while in 5 cases, only subtotal resection was performed. CONCLUSIONS EP might result in a "locus minoris resistentiae" of the skull base, predisposing, in rare cases, to CSF leakage and meningitis, spontaneously or after minor trauma. In cases of symptomatic EP, endoscopic endonasal transsphenoidal-transclival approach represents a safe and effective technique for both EP resection and contextual skull base reconstruction.
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Affiliation(s)
- Pierlorenzo Veiceschi
- Scuola di Specializzazione in Neurochirurgia, Università di Pavia, Pavia, Italy.,Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Alberto Daniele Arosio
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Edoardo Agosti
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.
| | - Maurizio Bignami
- Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy.,Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Como, Italy
| | - Andrea Pistochini
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Michele Cerati
- Department of Surgical Pathology, ASST Sette Laghi, Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Paolo Castelnuovo
- Division of Otorhinolaryngology, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
| | - Davide Locatelli
- Division of Neurosurgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy.,Department of Biotechnology and Life Sciences, Head and Neck Surgery and Forensic Dissection Research Center (HNS&FDRc), University of Insubria, Varese, Italy
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Abstract
INTRODUCTION Cranial nerve lesions can be secondary to a space-occupying lesion of the skull base compressing adjacent nerves. CASE REPORT We report the case of an 84-year-old man, who presented with rapid and concomitant onset of dysphagia and ipsilateral recurrent laryngeal nerve paralysis, suggesting an isolated lesion of the vagus nerve. MRI revealed a diagnosis of previously unknown clival meningocele. DISCUSSION Unilateral vagus nerve paralysis constitutes an exceptional mode of presentation of meningocele. Only a few isolated cases of clival meningocele have been reported to date, with no cranial nerve repercussions. The symptomatic management adopted in this case allowed rapid improvement of the patient's disorders.
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Ghimire P, Shapey J, Bodi I, Connor S, Thomas N, Barkas K. Spontaneous tension pneumocephalus and pneumoventricle in ecchordosis physaliphora: case report of a rare presentation and review of the literature. Br J Neurosurg 2019; 34:537-542. [DOI: 10.1080/02688697.2019.1594695] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Prajwal Ghimire
- Departments of Neurosurgery, King’s College Hospital, London, UK
| | - Jonathan Shapey
- Departments of Neurosurgery, King’s College Hospital, London, UK
| | - Istvan Bodi
- Departments of Neuropathology, King’s College Hospital, London, UK
| | - Steve Connor
- Departments of Neuroradiology, King’s College Hospital, London, UK
| | - Nicholas Thomas
- Departments of Neurosurgery, King’s College Hospital, London, UK
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Galloway L, Hayhurst C. Spontaneous cerebrospinal fluid rhinorrhoea with meningitis secondary to ecchordosis physaliphora. Br J Neurosurg 2017. [DOI: 10.1080/02688697.2017.1297766] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Caroline Hayhurst
- Department of Neurosurgery, University Hospital of Wales, Cardiff, UK
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Sharma R, Singh B, Kedia S, Laythalling RK. Neck swelling due to skull base (pseudo)meningocele protruding through a congenital skull base bone defect: a case report. Childs Nerv Syst 2017; 33:369-373. [PMID: 27830332 DOI: 10.1007/s00381-016-3256-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Meningocele is defined as a protrusion of the meninges through an opening in the skull or spinal column, forming a bulge or sac filled with cerebrospinal fluid. A pseudomeningocele is defined as a cerebrospinal fluid (CSF) collection formed due to escape of CSF through a dural defect with trapping of CSF into the surrounding soft tissues. We herby report rare occurrence of a large (pseudo)meningocele in a young patient with congenital skull base defect presenting as upper lateral neck swelling. CASE PRESENTATION We present the case of a 17-year-old boy who had painless progressive swelling right side of the upper neck without any history of meningitis or CSF leak. He had a history of undergoing cranioplasty using steel plates for nontraumatic boggy swelling right parieto-occipital region at the age of 5 years at another hospital. Clinical examination showed painless swelling right side of the upper neck, with positive cough impulse and transillumination. CT head with cisternography showed a large right skull base defect through which a large pseudomeningocele was herniating, thus producing upper neck swelling and compressing oral cavity. The neck swelling and intraoral bulge reduced in size after the coperitoneal shunt. CONCLUSION Differential diagnosis of (pseudo)meningocele should be considered while evaluating a painless progressive upper neck swelling having cough impulse and transillumination in a young patient.
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Affiliation(s)
- Rajeev Sharma
- Department of Neurosurgery, AIIMS, New Delhi, 110029, India.
| | | | - Shweta Kedia
- Department of Neurosurgery, AIIMS, New Delhi, 110029, India
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Lagman C, Varshneya K, Sarmiento JM, Turtz AR, Chitale RV. Proposed Diagnostic Criteria, Classification Schema, and Review of Literature of Notochord-Derived Ecchordosis Physaliphora. Cureus 2016; 8:e547. [PMID: 27158576 PMCID: PMC4854633 DOI: 10.7759/cureus.547] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Ecchordosis physaliphora (EP) is a benign notochordal remnant derived from ectopic nests found along the craniospinal axis. It typically presents asymptomatically and is diagnosed using classic radiologic features, particularly location, T1-hypointensity, T2-hyperintensity, and lack of enhancement following gadolinium (Gd) contrast administration. Distinguishing EP from its malignant counterpart, chordoma, is of paramount importance, given the aggressive nature of the latter. Advances in imaging and immunohistochemistry have aided in diagnosis to an extent but, to our knowledge, identification of the genetic fingerprint of EP has yet to take place. Further cytological analysis of these lesions in search of a genetic link is warranted. We propose here a set of diagnostic criteria based on features consistently cited in the literature. In this literature review, 23 case reports were identified and collated into a summary of symptomatic cases of ecchordosis physaliphora. An illustrative case report of two patients was also included.
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Affiliation(s)
- Carlito Lagman
- Department of Neurosurgery, Cooper Neurological Institute, Cooper University Hospital
| | - Kunal Varshneya
- Center for Neurosurgical Outcomes Research, Maxine Dunitz Neurosurgical Institute, Cedars-Sinai Medical Center
| | | | - Alan R Turtz
- Department of Neurosurgery, Cooper Neurological Institute, Cooper University Hospital
| | - Rohan V Chitale
- Department of Neurological Surgery, Vanderbilt University Medical Center
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