Surgical treatment of thoracic menigocele associated with neurofibromatosis and kyphoscoliosis

Neurofibromatosis type 1 with huge intrathoracic meningoceles misdiagnosed as pleural effusion: A case report and literature review

BACKGROUND

Neurofibromatosis type 1 is a genetic disease that affects multiple organs and systems, leading to various clinical manifestations. In Neurofibromatosis type 1, rare intrathoracic meningoceles often occur alongside bone dysplasia. These meningoceles contain cerebrospinal fluid and can be mistakenly diagnosed as 'pleural effusion'.

CASE PRESENTATION

In this case report, we mistakenly identified 'cerebrospinal fluid' as 'pleural effusion' and proceeded with drainage. This error posed significant risks to the patient and holds valuable implications for the future diagnosis and treatment of similar patients.

CONCLUSIONS

In patients with Neurofibromatosis type 1 complicated by spinal deformity, there is a high incidence of intrathoracic meningoceles. Treatment strategies may differ based on the specific features of the lesions, and collaboration among multiple disciplines can significantly improve patient outcomes.

Giant Thoracic Meningocele: A Multidisciplinary Surgical Approach with Innovative Exclusion Technique

Thoracic meningocele is a rare medical condition that is usually linked to neurofibromatosis type I.1 Respiratory and neurologic symptoms characterize it.2 Although there have been some improvements in surgical techniques, the condition has a high recurrence rate, with most cases recurring within a year of surgery.3 A 56-year-old woman was observed due to respiratory and pyramidal signs. A chest computed tomography scan and magnetic resonance imaging revealed a thoracic meningocele, occupying the lower sectors of the right hemithorax, communicating with the cerebrospinal fluid space at the T10-T11 level. Multidisciplinary surgery was performed. After selectively intubating both bronchi, the patient was placed in prone position and a posterior median thoracic spine approach was performed. After T10-T11 laminectomy, 3 dural longitudinal incisions were performed. The first incision was placed in the middle to deflate the collection, the second was made on the right side to obtain a complete view of the meningocele, and the third was made on the right lateral side to exclude the meningocele. The lateral dura at the last incision was sutured to the dura propria lining the vertebral body of T11 and T10. The paramedian and median incisions were closed, with Tachosil placed above and below the sutures. Subsequently, the patient was placed in a supine position, the right lung was deflated, and a triportal thoracoscopic approach was performed to dissect and remove the lesion.4 The breach was closed using Tachosil (Baxter Healthcare Corp, Deerfield, Illinois, USA) and fibrin glue. An early 1-month computed tomography and magnetic resonance imaging confirmed the surgery was successful.

Anesthesia management for thoracoscopic resection of a huge intrathoracic meningocele: a case report

BACKGROUND

Diagnosed intrathoracic meningocele is an uncommon complication of neurofibromatosis type 1. We report an anesthesia management for a rare case undergoing thoracoscopic resection of a huge intrathoracic meningocele.

CASE PRESENTATION

A 51-year-old woman was scheduled for thoracoscopic meningectomy under general anesthesia. We monitored intrathecal pressure during anesthesia to prevent a decrease in intrathecal pressure. During surgery, the intrathecal pressure occasionally increased by around 5 cmH2O immediately after the insertion of the drainage tube and occasionally decreased by up to 10 cmH2O during the careful slow aspiration of the cerebrospinal fluid (CSF). The pressure rapidly recovered after the interruption of the procedures. She was discharged on postoperative day 4 without major complications.

CONCLUSIONS

The CSF pressure was fluctuated by procedures during thoracoscopic resection of a huge meningocele. A CSF pressure monitoring was useful to detect the sudden change of CSF pressure immediately, which can cause intracranial hemorrhage.

Management of lateral meningocele syndrome in a child without neurological symptoms and literature review

PURPOSE

Lateral meningocele syndrome (LMS) is a rare genetic connective tissue disorder which is associated with meningocele-related neurologic dysfunction. Several patients with LMS have been reported. But, guidelines for screening and treatment of LMS have not been established.

METHOD AND RESULTS

We review the current knowledge of LMS in the article. Then, we describe a boy for whom a genomic analysis which allowed us to make a diagnosis of LMS and to begin monitoring of his condition for possible neurological complications.

CONCLUSION

It would be difficult to make a diagnosis of LMS on the basis of clinical manifestations alone. The natural history of dural ectasia in patients with LMS needs to be better defined to establish surgical indications. Based upon the current literature, ventriculoperitoneal shunting (V-Ps) has been recommended as the first-line surgical treatment option for patients with symptomatic thoracolumbar meningoceles.

Treatment of Ruptured Meningocele Post-Brachial Plexus Surgery: Potential Life-Threatening Complication-An Unique Case Report of Management of Ruptured Meningocele Post-Brachial Plexus Surgery to Avoid Dreadful Complication

Introduction:

Formation of meningocele in brachial plexus injury is known and can be diagnosed on magnetic resonance imaging (MRI). It is mainly reported in brachial plexus root avulsion injuries and does not require specific treatment. We report accurate diagnosis and management of dreadful complication due to rupture of meningocele post-brachial plexus exploration.

Case Report:

A 23-year-old engineer presented at 4 months post-bike accident right side extended brachial plexus injury involving C5, C6, and C7. On MRI, he had meningocele in C6-7 root region. We performed supraclavicular exploration of brachial plexus and distal nerve transfers for shoulder abduction and elbow flexion. During surgery, the meningocele was ruptured. As the cyst was deep and extending toward apex of lung, the diagnosis of fluid drained had to be distinguished from pleural fluid with cerebrospinal fluid (CSF). We found hemo-glucose test and beta-2-transferrin levels are mandatory to confirm the diagnosis. Post-surgery, the patient had drainage of almost 500 cc of CSF from wound every day for 3 days. This was managed by repeat MRI and finally lumbar puncture drainage helped to seal the meningocele in neck.

Conclusion:

Meningocele in brachial plexus injury is common but rupture of cyst can be fatal. To confirm the origin of fluid, beta-2-transferin level is more specific test than the hemo-glucose test. Lumbar puncture and drainage away from neck can be more reliable modality of treatment in case of intraoperative rupture of such cysts if drainage is excessive postoperatively.

Neurosurgical Management of Lateral Meningocele Syndrome: A Clinical Update for the Pediatric Neurosurgeon

BACKGROUND

Lateral meningocele syndrome (LMS) is an exceedingly rare connective tissue disease with phenotypic anomalies similar to those seen in Marfan syndrome, Ehler-Danlos syndrome, and Loeys-Dietz syndrome. However, this syndrome is invariably associated with the presence of multiple lateral thoracolumbar spinal meningoceles: a distinct point of phenotypic divergence from other connective tissue disorders. The etiopathogenesis of this syndrome has recently been linked to truncating mutations within exon 33 of NOTCH3. Despite numerous reports, neurosurgical management of multiple spinal meningoceles remains poorly defined in the literature. We conducted a literature review to provide insight into the nosology, clinical significance, and neurosurgical management strategies of this distinct connective tissue disorder.

SUMMARY

Our literature search revealed 11 articles (16 cases) of LMS, which included 9 males and 7 females, belonging to 14 different families. Half of these cases underwent genetic screening: all of which were discovered to exhibit a truncating mutation within exon 33 of NOTCH3. All patients exhibited multiple lateral thoracolumbar spinal meningoceles with craniofacial dysmorphisms. Other clinical characteristics included pathologic changes in spine morphology, Chiari I malformation, syringomyelia, hydrocephalus, and tethered cord. Operative management of multiple spinal meningoceles in LMS is complicated by the presence of such coexisting structural neurologic pathologies, which may alter cerebrospinal fluid flow dynamics and, ultimately, impact operative intervention. Key Messages: LMS is an exceedingly rare connective tissue disorder with severe spinal dural involvement. Neurosurgical management of multiple spinal meningoceles is complex, which is further complicated by the presence of coexisting neuropathology, such as pathologic transformation of spine morphology and Chiari I malformation. Patients with a connective tissue disorder phenotype found to have multiple spinal meningoceles on imaging studies may benefit from evaluation by a medical geneticist and a pediatric neurosurgeon.

Neurosurgical management in lateral meningocele syndrome: case report

Lateral meningocele syndrome (LMS) is a rare genetic connective tissue disorder. It is associated with morphological changes similar to those of other connective tissue disorders, with the unique distinction of multiple, often bilateral and large, lateral meningoceles herniating through the spinal foramina. In some cases, these lateral meningoceles can cause pain and discomfort due to their presence within retroperitoneal tissues or cause direct compression of the spinal nerve root exiting the foramen; in some cases compression may also involve motor weakness. The presence of lateral meningoceles imposes unique challenges related to CSF flow dynamics, especially with concurrent Chiari malformation, which also occurs with increased frequency in individuals with LMS. The authors present the case of a 6-month-old female with LMS with multiple lateral meningoceles throughout the thoracic and lumbar spine. The infant experienced a focal neurological abnormality due to enlargement of her lateral meningoceles following decompression of a symptomatic Chiari malformation and endoscopic third ventriculostomy. The finding was reversed through implantation of a ventriculoperitoneal shunt, which reduced the burden of CSF upon the lateral meningoceles. Such a case compels consideration that CSF flow dynamics in addition to altered connective tissue play a role in the presence of lateral meningoceles in patients within this and similar patient populations.

Collaborative treatment of huge intrathoracic meningoceles associated with neurofibromatosis type 1: a case report

Background

An intrathoracic meningocele is a relatively rare disease, and it commonly accompanies neurofibromatosis type 1. Patients tend to have no symptom but if its size is too large and compresses a lung and neighboring organs, it needs shunt drainage or surgical resection.

Case Presentation

Herein, we present the case of a 52 year-old female patient with huge intrathoracic meningoceles associated with neurofibromatosis type 1, who has complained about chest discomfort and dyspnea at rest. As for a preliminary treatment, a neurosurgeon had performed a cystoperitoneal shunt, but the symptoms continued and the size of mass and the amount of pleural effusion did not change significantly. Therefore, the huge thoracic meningoceles were successfully treated through the thoracotomic approach in combination with lumbar puncture and cerebrospinal fluid drainage.

Conclusions

It is reported that double huge intrathoracic meningoceles associated with neurofibromatosis type 1 was successfully treated by a shunting procedure followed by thoracotomic resection with collaboration of a neurosurgeon.

Computed tomography (CT) findings in 88 neurofibromatosis 1 (NF1) patients: Prevalence rates and correlations of thoracic findings

PURPOSE

To evaluate the prevalence rates and the correlations of thoracic computed tomography (CT) findings of neurofibromatosis 1 (NF1) in 88 patients.

MATERIALS AND METHODS

Chest CT images of 88 NF1 patients were independently reviewed by three observers, and the CT findings were evaluated. If abnormal findings were present, their number, size, and distribution were recorded. The prevalence rate of each CT finding was calculated, and the correlations between CT findings were analyzed.

RESULTS

Of the 88 cases, 13 were positive for cysts, 16 for emphysema, 8 for nodules, 8 for GGNs (ground glass nodules), 13 for mediastinal masses, 20 for scoliosis, 44 for subcutaneous nodules, and 34 for skin nodules. Cysts showed upper and peripheral dominant distributions. Regarding 13 mediastinal masses, 2 were diagnosed as malignant peripheral nerve sheath tumors (MPNSTs), 1 was diagnosed as primary lung cancer, 2 were diagnosed as lateral meningocele, 3 were diagnosed as neurofibromas, and the remaining 7 were considered neurofibromas. There was a significant correlation between the prevalence of subcutaneous nodules and that of skin nodules. Significant positive correlations were also seen between size and number, size and rate of central distribution, and number and rate of central distribution of cysts.

CONCLUSION

Various CT findings were found in NF-1 patients, and the prevalence rates of subcutaneous and skin nodules were higher than other findings. Though the prevalence rates of subcutaneous nodules and skin nodules were significantly correlated, the other CT findings in NF-1 occurred independently. The number, size, and distribution of the cysts showed significant positive correlations with each other.

Lateral meningocele with asymmetric canal stenosis: A case study

Lateral meningocele is a very rare disorder of unknown aetiology typified by the presence of protrusions of the arachnoid and the dura matter extending laterally through inter- or intra-vertebral foramina. We report here the case of a 52-year old male with abnormality of spine when presented with low back pain. The patient did not appear to have any neurological disorder. A computerized tomography (CT) scan was acquired from T12 to mid sacrum with multiplanar reformations. The results showed the presence of a left sided paraspinal cystic lesion projecting from the left neural foramen and extending into the left psoas muscle suggesting a lateral meningocele. In addition, a broad based central and left paracentral disc protrusion was also observed resulting in asymmetric canal stenosis. The patient is on regular follow-up while undergoing palliative treatment.