Ruptured spinal dermoid cyst with disseminated intracranial fat droplets

Traumatic sacral dermoid cyst rupture with intracranial subarachnoid seeding of lipid particles: illustrative case

BACKGROUND

Intracranial deposits of fat droplets are an unusual presentation of a spinal dermoid cyst after spontaneous rupture and are even more uncommon after trauma. Here, the authors present a case with this rare clinical presentation, along with a systematic review of the literature to guide decision making in these patients.

OBSERVATIONS

A 54-year-old woman with Lynch syndrome presented with severe headache and sacrococcygeal pain after a traumatic fall. Computed tomography of the head revealed multifocal intraventricular and intracisternal fat deposits, which were confirmed by magnetic resonance imaging (MRI) of the neuroaxis; in addition, a ruptured multiloculated cyst was identified within the sacral canal with proteinaceous/hemorrhagic debris, most consistent with a sacral dermoid cyst with rupture into the cerebrospinal fluid (CSF) space. An unruptured sacral cyst was later noted on numerous previous MRI scans. In our systematic review, we identified 20 similar cases, most of which favored surgical treatment.

LESSONS

Rupture of an intraspinal dermoid cyst must be considered when intracranial fat deposits are found in the context of cauda equina syndrome, meningism, or hydrocephalus. Complete tumor removal with close postoperative follow-up is recommended to decrease the risk of complications. CSF diversion must be prioritized if life-threatening hydrocephalus is present.

Intracranial Growing Teratoma Syndrome With Intraventricular Lipid Accumulation

Growing teratoma syndrome is a well-recognized condition associated with both intracranial and extracranial nongerminomatous germ cell tumors (NGGCTs), which mostly manifest as rapid growth of cystic and solid components during or within several months after treatment. Here, we report a patient with NGGCT who experienced slow growth of intracranial growing teratoma syndrome with intraventricular lipid accumulation over 10 years without any clinical symptoms. Considering the clinicopathologic heterogeneity of this syndrome, long-term clinical and radiologic follow-up is required for all patients with intracranial NGGCT.

Clinical Presentation and Surgical Outcomes Based on Age and Tumor Topography in 59 Patients With Spinal Dermoid Cysts

BACKGROUND

Differences in presentation and outcomes in children and adults with spinal dermoid tumors have not been documented. Surgical outcomes for dermoid tumors in different spinal cord planes have also not been studied.

METHODS

Retrospective review of 59 consecutive patients who underwent surgery for intraspinal dermoid tumors at a single institution. Tumors were categorized as purely extramedullary (n = 15), purely intramedullary (n = 28) or intramedullary-extramedullary (n = 16) based on intraoperative and imaging findings.

RESULTS

The cohort was composed of 45 children and 14 adults. The presence of a dermal sinus and prior history of meningitis was significantly associated with childhood presentation (P = 0.001 and P = 0.013, respectively). Most adults had purely intramedullary tumors (n = 12, 85.7%) as compared to children (35.6%, P = 0.001). Gross total resection (GTR) was achieved in 33.3% and 41.7% of children and adults, respectively (P = 1.000). Factors associated with GTR on logistic regression analysis included short segment (≤3 levels) dermoid cysts (P = 0.037) and absence of an intramedullary component (P = 0.027). Forty-seven patients were followed up over a mean period of 72.9 ± 8.3 months. Preoperative motor deficits were more likely to improve in children than in adults (P = 0.005). Recurrences were seen in 14.9% of cases (all with intramedullary tumors) at a median interval of 58 months (range: 40-166 months) after surgery, with no differences in recurrence-free survival between children and adults (P = 0.936).

CONCLUSIONS

Presentation of dermoid cysts is distinctively different in children and adults. GTR is a challenge for intramedullary and large tumors. Recurrences may manifest several years after surgery, mandating life-long surveillance.

Ruptured dermoid cyst in the Meckel's cave presenting with trigeminal neuralgia in a pediatric patient: a case report

Intracranial dermoid cysts are benign congenital slow growing masses. They account for less than 1% of all primary intracranial lesions. They can be asymptomatic and appear incidentally on brain images. However, there are some dermoid cysts that, depending on the location, can cause a variety of symptoms, especially if they compress vital structures. Rupture of intracranial dermoid cysts is relatively uncommon; the incidence is 0.18%. Dermoid cyst in children appears in the posterior fossa, while in adults is more common to find them in the sellar, temporal, and frontobasal region. The Meckel's cave is not a frequent location for these lesions and there are only a few cases in the adult population reported in the literature. We presented a 12-year-old patient with a dermoid cyst in the Meckel's cave who first presented with symptoms of a ruptured cyst but eventually evolved with a trigeminal neuralgia. We decided to do a transzygomatic approach and a middle fossa pealing to locate and excise the lesion. After surgery, the patient resolved the symptoms. Surgery is recommended in symptomatic lesions although surgical decision-making should consider the region where the cyst is located to achieve a safe, maximal resection without adding any further damage.

Patient with Epilepsy Caused by the Spontaneous Rupture of an Intracerebral Dermoid Cyst

BACKGROUND

This is a rare case of a patient presenting with epileptic seizures and headaches who was diagnosed with spontaneous intracerebral dermoid cyst rupture via radiographic imagery, and rupture was confirmed via a pathology report.

CASE DESCRIPTION

We report the case of a woman aged 26 years who presented with a history of chronic headache for 9 years without other symptoms, and progressive worsening of her headache had occurred for 1 month prior to admission. Radiologic examination showed a large mass located in the left temporal fossa and a large amount of homogeneous matter in the subarachnoid space of the ipsilateral cerebral hemisphere, then the tumor was completely excised. A left pterional craniotomy was conducted under general anesthesia for removal of the tumor, and pathological examination showed a dermoid cyst.

CONCLUSIONS

We discuss the clinical and radiologic features, as well as the treatment of this patient.

Spectrum of Complications in a Case of Intramedullary Dermoid

BACKGROUND

Intramedullary spinal cord dermoid tumors are rare. Early diagnosis with appropriate imaging is of utmost importance for a good outcome. Gross total resection is the treatment of choice for optimal results. Neurosurgical intervention for any intramedullary lesion is fraught with problems because of the nature of the lesion and handling of the spinal cord, which is already compromised because of the intramedullary lesion. Recurrence of the intramedullary dermoid tumor is frequent because of incomplete resection of the tumor. Most commonly, patients present with worsening of neurologic deficits. Inadequate resection because of the fear of worsening the neurologic deficits is associated with significant complications.

CASE DESCRIPTION

We report a case of an intramedullary dermoid tumor in a child that was associated with myriad of complications owing to incomplete resection of the tumor. The patient underwent multiple interventions at various centers which resulted in serious multiple complications before presenting at our center for further management.

CONCLUSIONS

This report highlights the spectrum of complications that can develop in a patient varying from worsening of the deficits to meningitis and subsequent development of hydrocephalus.

Wax Droplets Lining Ventricles

Rupture of the spinal dermoid is rare. There may be intracranial deposition of fat secondary to it. We report a case of an adult male who presented with features of obstructive hydrocephalus secondary to ruptured lumbar dermoid. A 42-year-male presented with acute-onset headache and vomiting for 2 days. There was grade 3 papilledema on fundus examination. Magnetic resonance imaging showed ventriculomegaly with aqueductal obstruction. Multiple T1 and T2 hyperintense deposits were also noted along the ventricular wall. Magnetic resonance imaging of the spine showed a T1, T2 hyperintense intramedullary lesion at the lumbar region with multiple fat deposits along the spinal axis. He underwent endoscopic third ventriculostomy and is doing well at the 6-month follow-up. He is asymptomatic for the spinal lesion. Silent rupture of the spinal dermoid causing obstructive hydrocephalus is rare. These patients may remain asymptomatic for the spinal lesion and improves with cerebrospinal fluid diversion.

Ruptured Central Nervous System Dermoid Cyst of Suprasellar Region Manifesting as Unusual Epileptic Seizure

BACKGROUND

Central nervous system dermoid cysts are rare lesions derived from ectopic epithelial cells. They are slow-growing benign tumors but may cause significant morbidity through compression of neurologic and vascular structures and, rarely, rupture into the subarachnoid space.

CASE DESCRIPTION

We present a rare case of a spontaneously ruptured intracranial dermoid cyst in a 32-year-old man presenting as new-onset epileptic seizures due to chemical meningitis caused by dissemination of fat or lipid droplets.

CONCLUSIONS

The dermoid cyst is a rare entity, the rupture of which is exceptional and often spontaneous. It is manifested by a polymorphic and nonspecific clinical picture requiring the use of imaging. This is based on CT and especially MRI, which make it possible to positively diagnose the nature of the cyst and the rupture, specify the extent of the dissemination of the lipid content in the subarachnoid spaces, and detect possible complications such as hydrocephalus. It also makes it possible to carry out a precise topographic assessment to plan the therapeutic conduct and guide a possible surgical intervention.

Role of MRI in Diagnosis of Ruptured Intracranial Dermoid Cyst

Introduction:

Intracranial dermoid cystic tumors account for <1% of all intracranial masses.

Case report:

A 52-year-old male, having headaches, nausea and is presented with a history of 2 episodes of new onset seizures. On presentation, the patient had a normal physical exam, including a complete neurological and cranial nerve exam.

Methods:

Precontrast MRI; TSE/T2Wsequence in axial/coronal planes; 3D – HI-resolution T1W sagittal; FLAIR/T2W axial; FLAIR/T2W, Flash/T2W oblique coronal plane, GRE/T2W axial. Post-contrast TSE/T1W sequence in axial, coronal and sagittal planes. Diffusion weighted and ADC mapping, postcontrast: TSE/T1W sequence in axial, coronal and sagittal planes.

Results:

Subsequent MRI of the brain revealed an oval and lobulated 47x34x30mm (TRxAPxCC) non-enhancing T1-hyperintense mass in right cavernous sinus, with compression of surrounding mesial temporal lobe and right anterolateral aspect of mesencephalon. Findings are consistent with ruptured dermoid cyst, given the evacuated sebum content at its lower half. Sebum particles in millimetric sizes are seen within right Sylvian fissure, anterior horns of lateral ventricles and to a lesser extent within left Sylvian fissure, right parietal sulci, cerebral aqueduct, and basal cisterns. No restricted diffusion is seen, eliminating the possibility of epidermoid. A shunt catheter is evident traversing between right lateral ventricle and right parietal bone; besides, slit-like right lateral ventricle is noted (likely secondary to over-draining shunt catheter).

Conclusion:

Intracranial dermoid cysts are benign rare slow-growing tumors that upon rupture, however, widespread presence of T1 hyperintense droplets and leptomeningeal enhancement can be noted–making MRI the best imaging modality for diagnosis of this rare entity.

Intracranial dermoid cyst rupture-related brain ischemia: Case report and hemodynamic study

RATIONALE

Spontaneous rupture of intracranial dermoid cyst is a rare but serious clinical event that can result in cerebral ischemia. Cerebral vasospasm and vasculitis are considered as potential mechanisms of dermoid cyst rupture-related cerebral ischemia. However, the hemodynamic mechanisms between cerebral ischemia and dermoid cyst rupture are not well known.

PATIENT CONCERNS

A 55-year-old, right-handed man was admitted to our hospital with sudden receptive aphasia and right-sided hypoalgesia. Brain magnetic resonance imaging (MRI) revealed a ruptured dermoid cyst and watershed infarcts in the left hemisphere. Then brain magnetic resonance angiography disclosed mild stenosis in the left middle cerebral artery (MCA), and further high-resolution MRI demonstrated it was caused by an unstable atherosclerosis plaque. Transcranial Doppler of the patient showed a decreasing tendency of peak systolic velocity (PSV) of the left MCA at different time points after the stroke (from 290cm/s at day 6 to 120cm/s at day 30), indicating a transient vasospasm. However, the time course of dynamic cerebral autoregulation (dCA) seemed different from the PSV. The patient's dCA reached its lowest point at day 8 and was restored at day 10. The time course of dCA indicated a "called procedure" of a cerebrovascular regulating function to deal with the stimulation in subarachnoid space.

DIAGNOSES

A dermoid cyst rupture-related cerebral infarction was diagnosed in this patient.

INTERVENTIONS

Aspirin (100 mg/d) and atorvastatin (20 mg/d) were given to the patient. A neurosurgical operation was strongly recommended to minimize the risk of further injury of the ruptured dermoid cyst; however, the patient refused the recommended treatment.

OUTCOMES

The neurological deficit of the patient was significantly improved on 30 days follow-up.

LESSONS

We found that the spread of cyst contents through the subarachnoid and/or ventricular system can induce a vasospasm. Then, dCA was "called" to deal with the stimulation in the subarachnoid space. Compromised dCA seems to be one of the compensatory of cerebral vasospasm after a dermoid cyst rupture.

Rapid-onset paraparesis and quadriparesis in patients with intramedullary spinal dermoid cysts: report of 10 cases

OBJECT Intramedullary dermoid cysts are rare tumors of the spinal cord. Presentation with rapid onset of paraparesis or quadriparesis (onset within 2 weeks) is rarer still. The authors present their experience in the management and outcome of patients with such a presentation. METHODS Patient records between 2000 and 2014 were retrospectively reviewed to identify those with intraspinal dermoid cysts who presented with rapid-onset paraparesis or quadriparesis. Their clinical, radiological, operative, and follow-up data were analyzed. RESULTS Of a total of 50 patients with intraspinal dermoid cysts managed during the study period, 10 (20%) presented with rapid-onset paraparesis or quadriparesis; 9 patients ranged in age from 8 months to 2 years, and 1 patient was 25 years old. A dermal sinus was seen in the lumbar region of 4 patients, the sacral region of 3, and the thoracic region of 1, and in 1 patient no sinus was found. All except 1 patient presented with rapid-onset paraparesis secondary to infection of the intramedullary dermoid cyst. One patient presented with rupture of a dermoid cyst with extension into the central canal up to the medulla. Early surgery was done soon after presentation in all except 2 patients. Among the 9 patients who underwent surgery (1 patient did not undergo surgery), total excision of the intramedullary dermoid cyst was done in 3 patients, near-total excision in 4 patients, and partial excision in 2 patients. Of the 9 patients who underwent surgery, 8 showed significant improvement in their neurological status, and 1 patient remained stable. The 1 patient who did not undergo surgery died as a result of an uncontrolled infection after being discharged to a local facility for management of wound infection. CONCLUSIONS Early recognition of a dermal sinus and the associated intraspinal dermoid cyst and timely surgical intervention can eliminate the chances of acute deterioration of neurological function. Even after an acute onset of paraparesis or quadriparesis, appropriate antibiotic therapy and prompt surgery can provide reasonably good outcomes in these patients.

Rupture of a spinal dermoid cyst may lead to dissemination and progress of Fatty tissue in the central spinal canal and intracranial subarachnoid space. A case report

Intradural dermoid cysts may rupture and subsequent subarachnoid dissemination of lipid droplets has been described before. However, the rupture of a spinal dermoid cyst into the central spinal canal is a rare entity. In this context, dissemination of fat into the intracranial subarachnoid space with local progression is a peculiar finding that, to the best of our knowledge, has not been published so far. We describe the case of a 28-year-old man with a dermoid cyst at the upper lumbar level as part of a complex congenital craniospinal malformation, presenting with new unspecific neurologic symptoms. CT and MRI revealed disseminated intraventricular and subarachnoid lipid droplets intracranially and in the spine not present on previous CT and MRI scans obtained eight years earlier. Thus, repeated rupture of a spinal dermoid cyst with subarachnoid spread and/or secondary proliferation should be suspected.

A review on five cases of intramedullary dermoid cyst

PURPOSE

Intramedullary dermoid cyst is a type of rare congenital intraspinal lesions. Its proximity and its strong adherence to the surrounding spinal cord tissue often make a complete resection of the cyst wall problematic. We retrospectively studied five cases of intramedullary dermoid cyst, focusing the recurrence of intramedullary dermoid cyst after surgery and the probable method to prevent the recurrence.

METHODS

Five cases of intramedullary dermoid cyst with or without other concomitant deformities were retrospectively reviewed. Subjects consisted of three males and two females, aged 2–24 years. Diagnosis was confirmed by spinal MRI and pathology studies. Surgical outcomes were analyzed. In case 2, an Ommaya reservoir was implanted in the cystic cavity, and the cystic content was sucked though the Ommaya reservoir. An 18–113 months of follow-up was conducted.

RESULTS

The contents of intramedullary dermoid cyst were loose and easy to be cleared in the operations. The cyst wall was closely adhered to the spinal cord, and complete resection was difficult. During the follow-up of 18–113 months, the lesion reoccurred in three cases.

CONCLUSION

Intramedullary dermoid cyst is prone to recurrence. The presence of residual cyst wall might be the cause of dermoid cyst recurrence. When a complete resection of cyst wall becomes infeasible, placement of an intraspinal Ommaya reservoir may help to delay and minimize clinical symptoms by aspiration of cystic contents in case of recurrence.

Spontaneous rupture of intracranial dermoid tumor in a patient with vertigo. Computed tomography and magnetic resonance imaging findings

Background

Congenital dermoid cysts are very rare, constituting less than 1% of intracranial tumors. Spontaneous rupture of dermoid tumor is a potentially serious complication that can lead to meningitis, seizures, cerebral ischemia and hydrocephalus. Occasionally, dermoid tumors are incidentally discovered on computed tomography (CT) of the brain or magnetic resonance imaging (MRI) following unrelated clinical complaints. They are also discovered during radiologic investigations of unexplained headaches, seizures, and rarely olfactory delusions.

Case Report

In this report we describe a patient complaining of vertigo caused by spontaneous rupture of dermoid cyst, preoperatively diagnosed by CT and MRI. Cranial CT revealed a dense fatty lesion adjacent to the posterolateral parasellar region on the left with multiple small, dense fat droplets scattered in the subarachnoid space corresponding to a dermoid cyst rupture. Cranial MRI sections revealed a lesion with mixed-signal-intensity and multiple hyperintense droplets scattered through the cerebellar surface on the left. No enhancement was found on axial T1-weighted MRI after intravenous Gadolinium administration. Diffusion weighted image (DWI) and apparent diffusion coefficient map studies exhibited explicit restricted diffusion.

Discussion

Many studies and literature case reports concerning the rupture of dermoid cyst have been reported. However, multimodal imaging of this rare pathology in the same patient is uncommon. Although dermoid cysts are pathognomonic in appearance on a CT examination, the MRI is also of value in helping to understand the effect of extension and pressure of the mass. DWI is also important for support of the diagnosis and patient follow-up.

Intramedullary dermoid cyst with relatively atypical symptoms: a case report and review of the literature

Background

Intraspinal dermoid cysts are rare and benign tumors that occur primarily due to the defective closure of the neural tube, an ectodermal derivative, during the process of development. They are slow-growing tumors manifesting in the second and third decades of life.

Case presentation

We present here a case of a 14-year-old Sindhi boy with a six-month history of paraparesis of the lower limbs and a progressive loss of power of grade 3/5, and hypoesthesia in the L4/L5 dermatomes of his right lower limb. A plain magnetic resonance imaging scan revealed a well-demarcated intraspinal intramedullary cyst containing an abscess at the level of T12 and L1 causing localized cord compression, which was producing the symptoms. Near total excision of the cyst was successfully performed and was sent for biopsy, which revealed keratinocytes and keratin flakes. With one month of follow-up, along with physiotherapeutic management, the patient gradually improved and was able to walk without support.

Conclusions

Critical evaluation of every case with aggravating symptoms should be carried out, and neurological and radiological examinations should be conducted to ensure the well-being of patients.

Ruptured conus medullaris dermoid cyst with fat droplets in the central canal [corrected]

Spinal dermoid tumors are rare, benign, slow growing tumors. These tumors may become acutely symptomatic after rupture or infection. Excision of the lesion with long term close follow-up studies is required for the management of these lesions. We present a very rare case of ruptured conus medullaris dermoid cyst in a 22-year-old male presented with urinary retention and low back pain. Magnetic resonance imaging scan with contrast reveals a lesion in the cauda equina inseparable from conus medullaris with fat droplets within the central spinal canal extending up to the medulla. Patient was operated with laminectomy and near complete excision of the lesion was done. Patient's low back pain was relieved following surgery. However patient had persistent urinary incontinence and on clean intermittent self-catheterization. Histopathology was suggestive of dermoid cyst.

Magnetic resonance imaging of ruptured spinal dermoid tumors with spread of fatty droplets in the central spinal canal and/or spinal subarachnoidal space

OBJECTIVE

To evaluate magnetic resonance imaging (MRI) features of ruptured spinal dermoid tumors with spread of lipid droplets in the central spinal canal and/or spinal subarachnoid space and to understand the underlying mechanism.

METHODS

The MRI features of 12-ruptured spinal dermoid tumors were retrospectively analyzed. A literature review was performed to analyze the reported cases of ruptured spinal dermoid tumors along with our cases.

RESULTS

The locations of dermoids in our series are all at or below T12 level. Of the 12 cases, 10 ruptured into the central spinal canal, 1 ruptured into the central spinal canal as well as the subarachnoid space, and 1 ruptured into subarachnoid space only. Free lipid droplets exhibited hyperintensity on T1 weighted images, hypointensity on T2 weighted images, and low signal on fat-suppression sequence.

CONCLUSION

Spinal dermoid tumors ruptured into central spinal canal and/or spinal subarachnoid space have unique MRI features. The absorption of lipid droplets within central spinal canal is rather difficult, and their movement is extremely slow. We propose that fatty components within the central canal of spinal cord may be partially associated with spinal dermoid tumors developmentally.

Ruptured intracranial dermoid cyst

Rupture of an intracranial dermoid cyst is a rare event with considerable associated morbidity and potential mortality. We present a case of intracranial rupture of a dermoid cystic tumor with consequent dissemination of subarachnoid fat droplets resulting in acute aseptic chemical meningitis. Radiographic findings, operative treatment, and pathologic features are described.

Ruptured intracranial dermoid cyst manifesting as new onset seizure: a case report

Intracranial dermoid cysts are rare tumors derived from ectopic epithelial cells. They are slow-growing benign entities, but can cause significant morbidity through compression of neurovascular structures and, rarely, rupture into the subarachnoid space. We present a rare case of a spontaneously ruptured intracranial dermoid cyst presenting as new onset seizures due to chemical meningitis caused by dissemination of fat droplets.

Magnetic resonance imaging of intramedullary spinal cord lesions: a pictorial review

Magnetic resonance imaging is the current imaging modality of choice in the evaluation of patients presenting with myelopathic symptoms in the search for spinal cord lesions. It is important for the radiologist to recognize and differentiate nonneoplastic from the neoplastic process of the spinal cord as the differentiation of the 2 entities is extremely crucial to the neurosurgeon. This article presents a broad spectrum of benign intramedullary spinal abnormalities including syrinx, contusion, abscess, infarction, myelitis, multiple sclerosis, sarcoid, cavernoma, and arteriovenous malformation. Rare intramedullary neoplasms including dermoid tumor, astrocytoma, ependymoma, hemangioblastoma, lymphoma, ganglioneuroblastoma, and metastases are also illustrated. The clinical presentation and magnetic resonance signal characteristics as well as the differential diagnosis of the intramedullary lesions are discussed. The potential pitfalls in the differentiation of tumors from nonneoplastic disease of the spinal cord are also elucidated.