Intraventricular fat from a ruptured sacral dermoid cyst: clinical, radiographic, and pathological correlation. Case report

Sacral fracture associated with a Tarlov cyst causing an anterior sacral CSF fistula and intraventricular fat emboli - a case report and review of the literature

BACKGROUND

Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and cerebrospinal fluid fistula identified only few cases. Pathological fractures are uncommon and exceedingly rare in case of Tarlov cysts. Sacral fractures can be missed in oligosymptomatic patients. However, severe complications may emerge as shown by this case report.

METHODS

We present the case of a pathological sacral fracture at the level S2/3 following a low-impact trauma, associated with a Tarlov cyst, which was complicated by an anterior CSF fistula and intraventricular fat emboli.

RESULTS

The patient was treated conservatively with strict bedrest and a CT-guided blood patch. Postponed mobilization was successful with decreasing orthostatic symptoms. Follow-up MRI and CT imaging showed a complete resolution of the ventral CSF fistula and ossification of the fracture. The intraventricular fat did not resolve, however, there was no radiological sign of hydrocephalus with excellent clinical outcome at 6-months follow-up.

CONCLUSION

Although exceedingly rare, sacral Tarlov cysts may be associated with pathological fractures of the sacrum. Relevant complications can emerge and need to be properly addressed.

Ruptured Spinal Dermoid Cysts with Lipid Droplets into the Syrinx Cavity : Reports of Fourteen Cases

Objective

Dermoid cysts are uncommon in spinal cord tumors, and the phenomenon of their spontaneous rupture into the syrinx cavity is quite rare. We aimed to analyze the imaging characteristics and etiologies, and propose some surgical strategies, for this uncommon phenomenon.

Methods

We retrospectively reviewed 14 cases with spinal dermoid cysts that ruptured into the cervical and thoracic syrinx cavity. There were six male and eight female cases, aged 21 to 46 years, who had lipid droplets in the syrinx cavity from C1 to L3. The dermoid cysts were always located at the conus. Based on patients’ complaints, clinical manifestations, and imaging results, we adopted tumor excision and/or syrinx cavity aspiration in one stage or multiple stages.

Results

Three patients had only a syrinx cavity aspiration surgery due to a history of dermoid cyst excision. Eight patients had dermoid cyst resection and syrinx cavity aspiration in one stage. One patient was operated upon in two stages due to the development of new symptoms at nine months follow-up. Two patients underwent only tumor resection since they did not show similar symptoms or signs caused by the cervicothoracic syrinx. The axial magnetic resonance imaging indicated that the lipid droplets were always not at the center but were eccentric. The clinical effect was satisfactory during the follow-up period in this group.

Conclusion

The lipid droplets filled the spinal syrinx cavity, not entirely confined to the central canal. Based on the chief complaints and associated signs, we adopted different surgical strategies and had satisfactory clinical results.

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 Transthecal Fat Migration After a Sacral Fracture: 2 Case Reports

BACKGROUND The presence of fat droplets within the subarachnoid space is an uncommon finding, which is almost exclusively associated with a ruptured dermoid cyst. In a trauma setting, transthecal migration of fat droplets is an extremely rare occurrence. We present 2 case reports of intracranial transthecal migration of fatty bone marrow after sacral fractures. CASE REPORT Both patients presented to the Emergency Department (ED) after falls from a standing height. The first patient, an 84-year-old woman, suffered a stable sacral fracture extending into a large meningeal cyst within the right S2 foramen. Her initial neurological assessment and computed tomography (CT) of the head were unremarkable. As the fracture did not require surgical treatment, she was discharged home and prescribed bed rest, analgesics, and venous thromboembolism prophylaxis. Three days after the injury, she was readmitted to the ED with a mild headache, dizziness, and an episode of nausea and vomiting. A follow-up head CT revealed fat droplets in the subarachnoid space and lateral ventricles. After successful symptomatic treatment, she was discharged home in good general condition. The second patient, a 60-year-old man, underwent a head CT for a scalp hematoma, which revealed fat droplets in the 3rd ventricle and right lateral ventricle. The pelvic CT revealed a large sacral meningeal cyst with microfractures in its wall. He was discharged home on the same day and prescribed bed rest and analgesics. CONCLUSIONS The detection of intracranial intrathecal fat droplets in association with a specific trauma mechanism should initiate the search for a sacral fracture.

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.

When Fat Hits the Brain: Intraventricular and Subarachnoid Fat Migration Secondary to a Complex Sacropelvic Fracture-Diagnosis and Treatment

Massive migration of fat droplets in the ventricles and the subarachnoid space is a very rare sequel of spinal trauma. Owing to its rarity, knowledge about treatment and outcome remains limited. We report on the uncommon occurrence of massive subarachnoid and intraventricular fat dissemination in a 41-year-old man who suffered a complex sacropelvic fracture with spondylopelvic dissociation but who had no head injury. We show that early placement of an external ventricular drain with prolonged drainage for washout of the fat depots can prevent chronic hydrocephalus and subsequent shunt dependency.

Posttraumatic subarachnoid fat embolism: Case presentation and literature review

Fat embolism in the subarachnoid space has a unique pathophysiology and clinical picture when compared to fat embolism syndrome. Lipid deposits in the subarachnoid space-most commonly the sequela of dermoid rupture in the neuraxis-can cause an inflammatory reaction leading to irritation of nearby neurovascular structures. Herein, we report the only case in the United States, to our knowledge, of a patient diagnosed with subarachnoid fat emboli secondary to sacral fracture who initially presented with a normal head CT and subsequently developed visual changes.

[Dermoid cysts of the posterior cerebral fossa in children revealed by recurrent aseptic meningitis: Report of two cases and a review of the literature]

INTRODUCTION

Dermoid cysts of central nervous system are very rare. The usual clinical presentation is dominated by intracranial hypertension, epilepsy and cranial palsy. The revelation mode could be recurrent aseptic meningitis.

AIM

The aim of this case report is to consider the dermoid cyst as regards the differential diagnosis in children treated for recurrent aseptic meningitis to avoid misdiagnosis and ice qui a orienté le diagnostic à une méningitnadequate treatment.

METHODS

Two children were admitted in the pediatric department for recurrent aseptic meningitis. The MRI confirmed the presence of a posterior fossa dermoid cyst.

RESULTS

Loss of meningitis after microsurgical resection.

CONCLUSION

The diagnosis of dermoid cyst is performed and reconsidered at an early stage in aseptic meningitis in order to establish an adequate therapy, which is surgery.

Ventriculoperitoneal shunt malfunction caused by proximal catheter fat obstruction

Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus, yet shunts remain vulnerable to a variety of complications. Although fat droplet migration into the subarachnoid space and cerebrospinal fluid pathways following craniotomy has been observed, a VP shunt obstruction with fat droplets has never been reported to our knowledge. We present the first reported case of VP shunt catheter obstruction by migratory fat droplets in a 55-year-old woman who underwent suboccipital craniotomy for removal of a metastatic tumor of the left medullocerebellar region, without fat harvesting. A VP shunt was inserted 1month later due to communicating hydrocephalus. The patient presented with gait disturbance, intermittent confusion, and pseudomeningocele 21days after shunt insertion. MRI revealed retrograde fat deposition in the ventricular system and VP shunt catheter, apparently following migration of fat droplets from the fatty soft tissue of the craniotomy site. Spinal tap revealed signs of aseptic meningitis. Steroid treatment for aseptic "lipoid" meningitis provided symptom relief. MRI 2months later revealed partial fat resorption and resolution of the pseudomeningocele. VP shunt malfunction caused by fat obstruction of the ventricular catheter should be acknowledged as a possible complication in VP shunts after craniotomy, even in the absence of fat harvesting.

Hydrocephalus Caused by Fat Embolism: A Rare Complication of Atlanto-Axial Fixation for Odontoid Fractures

BACKGROUND AND IMPORTANCE

Odontoid fracture is not uncommon and surgical treatment that uses posterior screw/rod fixation is an acceptable option. This is the first report of delayed hydrocephalus due to subarachnoid fat migration as a complication of posterior atlanto-axial (AA) fixation.

CASE DESCRIPTION

A 27-year-old man underwent posterior C1 lateral mass and C2 pedicle screw fixation for a recent Anderson-D'Alonzo type 2 odontoid fracture. Autologous bone graft was wired for onlay fusion. The surgery was smooth, except that there was an incidental durotomy intraoperatively. The patient had significant relief of his neck pain, although computed tomography (CT) demonstrated a medial breach of the left C1 screw postoperation; however, he gradually developed headache and dizziness after discharge. Five weeks after operation, magnetic resonance imaging demonstrated a large pseudo-meningocele at the surgical site, which was managed conservatively. Nine weeks after the AA fixation, the patient was sent to the emergency department for altered consciousness. A brain CT demonstrated hydrocephalus and multiple fat emboli in the subarachnoid and intraventricular space. A ventriculoperitoneal shunt was inserted to manage the hydrocephalus and pseudo-meningocele. The patient recovered well and was followed up to 13 months after operation. To date, this was the first report of delayed hydrocephalus caused by fat embolism after AA fixation surgery.

CONCLUSIONS

Incidental durotomy in posterior AA fixation may predispose the patient to a serious complication of fat-cerebrospinal fluid embolism and subsequent hydrocephalus. There should be a heightened awareness for such a complication. Both CT and magnetic resonance imaging are useful for the diagnosis of subarachnoid fat droplets.

Spinal teratoma concomitant with intracranial lipid droplet dissemination

A teratoma is a neoplasm that contains tissues originating from three germ cell layers at ectopic sites. The embryology of teratomas remains unclear. Teratomas are usually composed of cystic and solid components, and they are usually associated with syringomyelia. Cystic lesions of teratomas may rupture in a spontaneous, iatrogenic, or traumatic manner. Lipid droplets in the ventricles and subarachnoid space are rare. We managed a case of a spinal teratoma in the lumbar region in a 67-year-old man. He complained of nocturia, frequent urination, and difficulty in walking for 2 months. Radiographic imaging revealed a lumbar spinal intradural mass. Intracranial lipid droplets dissemination was also existed. The patient underwent surgery, and a diagnosis of mature teratoma was confirmed histopathologically. During the operation, the cystic portion of the intradural mass ruptured. During the hospital stay, the patient's mental status declined. On radiological examination, slightly enlarged ventricle size was observed. Dissemination of lipid droplets within ventricles occurs because of spontaneous, iatrogenic, or traumatic rupture. Additional lipid droplet dissemination to the intracranial space associated with neurologic deterioration after a spinal teratoma surgery should be considered when iatrogenic rupture of the cyst portion occurs.

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.

Isolated central canal rupture of spinal dermoid

Spinal dermoid tumors are rare, benign, slow-growing tumors. Rupture of spinal dermoids, in contrast to cranial dermoids, is rarely reported. Rupture in the central canal alone is even more rare, with only a few cases reported in the literature. The presence of fat droplets within the central canal is unusual because the central canal is rudimentary in adults. The authors report 3 such cases and review the pertinent literature.

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.

Surgical findings of a lumbar mature teratoma accompanying the preoperative intracranial dissemination of Fatty droplets

There are several mechanisms for the dissemination of lipid material from a mature teratoma into the subarachnoid space or ventricles, including iatrogenic or traumatic rupture, but spontaneous rupture of a mature teratoma is rare. We report the spontaneous rupture of a spinal mature teratoma into the subarachnoid space and ventricles. However, at surgery, there was no definite evidence of rupture into the perimedullary cerebrospinal fluid. We postulate that the central canal could be a migration pathway for ruptured material into the brain.

Intraventricular and subarachnoid fat after spinal injury

The authors report an extremely rare case with intraventricular and subarachnoid fat developed after trauma to spine and soft tissue in a 54-year-old male. The initial computed tomography (CT) showed multiple low attenuation lesions, which were thought to be pneumocephalus. Cerebral magnetic resonance imaging (MRI) showed lesions with high signal intensity on T1-weighted magnetic resonance images and high signal intensity on T2-weighted images, indicating fat globules within the CSF. In this report, the clinical presentation, radiological findings, and a review of the literature are presented.

Intradural extramedullary mature cystic teratoma: not only a childhood disease

OBJECTIVE

The authors report on the first case of a spinal intradural extramedullary cystic teratoma in an aged patient. These lesions have been reported in adolescents and young adults often with a history of spinal dysraphism. They are believed to be congenital lesions; however, they have also been reported in patients with a history of posterior spinal surgery or lumbar puncture.

METHOD

An 85-year-old man was evaluated for persistent and progressive lower extremity paresis. His symptoms began after relatively minor trauma. He had no prior lumbar surgeries. Neuroimaging studies revealed an L1-L2 intradural mass. A putative diagnosis of a cystic intradural extramedullary mass was made. A lumbar laminectomy and durotomy were performed.

RESULTS

A cystic lesion containing hair follicles, cartilage, adipose, and neural tissue was encountered. Pathologic review corroborated the diagnosis of cystic teratoma.

CONCLUSIONS

The occurrence of cystic teratomas in the absence of previous surgery or lumbar puncture is uncommon. Even rarer are reports of these lesions in aged patients. Of particular interest in this case is the fact that this patient had not undergone any previous lumbar procedures nor did he have a history of spinal dysraphism. Though rare, this entity should be included in the differential of cystic intradural spinal cord lesions.

Ruptured spinal dermoid cyst with disseminated intracranial fat droplets

Fat droplets in the cerebrospinal fluid (CSF) is a well-known complication of ruptured intracranial dermoid tumours. We report an unusual case of a ruptured spinal dermoid tumour. MR images showed a tethered spinal cord and an intramedullary fat-containing mass. Fat droplets were revealed in the ventricles and the cisternal spaces on brain CT and brain MR. In the English literature, a ruptured spinal dermoid tumour accompanying a tethered spinal cord is extremely rare.

Rupture intra-médullaire d’un kyste dermoïde du cône

The authors report the case of a 40 year old patient with history of cauda equina syndrome and pyramidal signs due to intramedullary rupture of a congenital dermoid cyst of the conus without associated spinal dysraphism. Diagnosis was suggested at magnetic resonance imaging (MRI) and confirmed by histological examination and percutaneous aspiration of the intramedullary cavity.

Isolated central canal rupture of spinal dermoid: report of two cases

We report two cases of lumbar spinal dermoid cysts with asymptomatic rupture and migration of free fat droplets into the central canal. No fatty droplets were seen within the lumbar subarachnoid space. The presence of fat droplets within the central canal is unusual because the central canal is rudimentary in adults. We suggest that hydromyelia secondary to tumour and specific tumour morphology might facilitate the selective rupture of dermoids into the central canal. We recommend a follow up of these patients to detect any possible intracranial migration of fat droplets and resultant complications.

MR imaging of a ruptured intraspinal dermoid tumour with fat droplets in the central spinal canal

We report a patient with intramedullary ruptured spinal dermoid tumour. The MR imaging revealed an intra-medullary lumbar mass heterogenous in intensity in all sequences. Fat droplets were observed in the subarachnoid space as well as in the dilated central spinal canal. Fat droplets in the subarachnoid space are frequently seen in the rupture of intraspinal dermoid tumours; however, fat droplets within the central canal is quite rare and was unexpected. Magnetic resonance imaging is a useful tool in the determination of spinal pathologies before they become large enough to cause severe symptoms and/or morbidity.

Expanding experience with spontaneous dermoid rupture in the MRI era: diagnosis and follow-up

With widespread use of CT and MR imaging, experience with spontaneous dermoid rupture has significantly increased. What was previously believed to be a generally severe or even fatal accident, being the diagnosis made either at surgery or autopsy, or in patients with such consequent conditions as chemical meningitis or obstructive hydrocephalus, now appears to be more frequent than previously thought, and there is some evidence that it may also cause only a slight symptomatology or even be quite asymptomatic. We reviewed the clinical and imaging data of our series of five patients with spontaneously ruptured dermoids, spinal in one case, and intracranial supratentorial in four. These had their diagnosis following mild symptoms (number two cases) or incidentally (number two cases); the spinal tumor caused acute bladder dysfunction, possibly while undergoing rupture, and was associated with indolent intracranial fat spread. Three of the patients also had MR demonstration of asymptomatic persistence of fat spread in the subarachnoid spaces, respectively, 3, 4, and 5 years after rupture. One of the five cases, concerning a parasellar dermoid followed up over 6 years, provides the first demonstration of MR signal intensity change of the tumor prior to rupture.

Mobile intracranial oily substances from a ruptured teratoma

A patient with a ruptured intracranial teratoma is presented. The distinctive imaging and neuroendoscopic findings of mobile fatty or oily globules in the subarachnoid or ventricular space are described. Fat suppression magnetic resonance imaging (MRI) and MRI performed with the patient prone was helpful in distinguishing tumour tissue from floating oil.

Accumulation of intraventricular fat in an intracranial epidermoid tumor: case report

OBJECTIVE AND IMPORTANCE

A fat component within the ventricles or subarachnoid space in fat-containing tumors such as an epidermoid or a dermoid has been observed in rare instances. However, there have been no reports regarding an increase in the size of such a fat component. We describe the case of an epidermoid tumor with intraventricular fat that showed an increase in size and amount.

CLINICAL PRESENTATION

A 26-year-old woman was admitted with headache and diplopia. Computed tomography and magnetic resonance imaging of the brain revealed a fat-containing suprasellar tumor and widespread fat globules in adjacent sulci and cisterns and within the frontal horn of the lateral ventricle.

INTERVENTION

The patient underwent a pterional craniotomy. Removal of the suprasellar tumor was nearly total. Histopathological examination revealed an epidermoid tumor. Sequential magnetic resonance imaging throughout the ensuing 65-month period revealed no evidence of tumor recurrence; however, the intraventricular fat remained and increased in size. The patient underwent surgery via the transcallosal approach at 69 months after the initial operation, and the presence of free-floating oily fat globules was confirmed.

CONCLUSION

In the case of a fat-containing tumor with free fat in the cerebrospinal fluid spaces, careful serial examination is necessary, with particular attention to the possibility of changes in size.

Subarachnoid fat dissemination after resection of a cerebellopontine angle dysontogenic cyst: case report and review of the literature

OBJECTIVE AND IMPORTANCE

This case report illustrates the clinical and radiological relevance of extensive intracranial subarachnoid and ventricular dissemination in dysontogenic (dermoid) tumors.

CLINICAL PRESENTATION

We describe a patient with a cerebellopontine angle dysontogenic tumor. Postoperatively, the cyst disseminated fat particles extensively into the subarachnoid space. Magnetic resonance imaging (MRI) studies revealed continuous dispersion of the fat particles into the cerebral cisterns, subarachnoid space, and ventricles.

INTERVENTION

Eight years of clinical and MRI follow-up demonstrated neither neurological deterioration in the patient nor growth of the multiple lesions.

CONCLUSION

Intracranial subarachnoid dissemination of fat material may occur during the preoperative or postoperative course of dermoid and epidermoid cysts. Aseptic meningitis or other complications such as hydrocephalus, seizures, or cranial nerve deficits also may occur owing to spillage of intracranial cyst contents into the subarachnoid space. MRI can detect the presence of fat drops that may adhere to the surrounding structures or migrate with the cerebrospinal fluid flow. Intracranial disseminated fat particles can remain silent without radiological or neurological change, justifying a wait-and-see approach. During long-term postoperative follow-up, however, regular MRI studies and clinical examinations are necessary to avoid potential complications.

Spinal dermoid cysts originating intracranial fat drops causing obstructive hydrocephalus: case reports

The authors report two cases of spinal dermoid cysts whose rupture originated the migration of free fat drops into the ventricles and intracranial subarachnoid spaces. In both cases the fat drops caused obstructive hydrocephalus, which represents a quite exceptional complication. Moreover, one of the cases is unique, since the finding of intracranial fat causing hydrocephalus considerably preceded the discovery of the spinal neoplasm. The authors suggest that the finding of intracranial fat in the absence of a local source makes the search for a intraspinal dermoid or epidermoid tumor mandatory.