1
|
Rodrigues A, Antunes D, Pereira DJ, Jesus-Ribeiro J. Giant lumbar postoperative pseudomeningocele inducing positional syncope. BMJ Case Rep 2024; 17:e259235. [PMID: 38290984 PMCID: PMC10828859 DOI: 10.1136/bcr-2023-259235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Affiliation(s)
- Ana Rodrigues
- Internal Medicine, Centro Hospitalar Leiria EPE, Leiria, Portugal
| | - Daniela Antunes
- Internal Medicine, Centro Hospitalar Leiria EPE, Leiria, Portugal
| | - Daniela Jardim Pereira
- Neuroradiology Functional Unit, Medical Imaging Service, Centro Hospitalar e Universitário de Coimbra EPE, Coimbra, Portugal
- Diaton MRI Unit, Centro Hospitalar Leiria EPE, Leiria, Portugal
| | - Joana Jesus-Ribeiro
- Neurology, Centro Hospitalar Leiria EPE, Leiria, Portugal
- Coimbra Institute for Clinical and Biomedical Research (iCBR) and Center of Investigation in Environment, Genetics and Oncobiology (CIMAGO), University of Coimbra Faculty of Medicine, Coimbra, Portugal
| |
Collapse
|
2
|
Ehsanian R, Ali A, Singh H, McKenna SL, Mian MN. Anterior cervical pseudomeningocele causing syncope after spinal surgery: A case report. Int J Surg Case Rep 2022; 91:106789. [PMID: 35093704 PMCID: PMC8802085 DOI: 10.1016/j.ijscr.2022.106789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 01/20/2022] [Accepted: 01/20/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Pseudomeningocele formation from incidental durotomy is a known risk in spine surgery. We present a case of incidental durotomy leading to anterior neck pseudomeningocele, compressing the carotid body (CB) resulting in syncopal episodes. To our knowledge, this is the first case report implicating syncopal episodes to CB compression via a pseudomeningocele. CASE PRESENTATION A mid sixty-year-old patient with history of obesity, hypertension, and diabetes presented with gait impairment and hand weakness. Ossification of posterior longitudinal ligament (OPLL) was diagnosed with computed tomography imaging (CT) and magnetic resonance imaging (MRI). Elective surgery was completed with an anterior and posterior approach for decompression and fusion. Hospital course (San Jose, CA, USA) was complicated by respiratory depression and incomplete tetraplegia. On post-operative day (POD) six, CT revealed anterolateral soft tissue neck swelling; subsequent CT and MRI showed fluid collection expansion, with associated syncopal episodes on POD thirty-nine. Despite interventional radiology drainage, the fluid collection and symptoms returned five days later. The patient ultimately underwent durotomy revision and repair with muscle patch. CLINICAL DISCUSSION This case highlights the challenges in managing anterior cervical dural tears resulting in pseudomeningocele. Risk factors include anterior cervical corpectomy and decompression, as well as an underlying diagnosis of OPLL. Untreated dural tears may develop into pseudomeningoceles which can contribute to life-threatening outcomes. CONCLUSION This case report presents the serious consequences of incidental durotomy, the unique post-surgical complication of syncope due to compression of the CB from a pseudomeningocele, and the challenges of managing a persistent pseudomeningocele.
Collapse
Affiliation(s)
- Reza Ehsanian
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedics & Rehabilitation, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Arshad Ali
- Rehabilitation Research Center, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Harminder Singh
- Division of Neurosurgery, Santa Clara Valley Medical Center, San Jose, CA, USA; Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Stephen L McKenna
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA; Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, USA
| | - Mariam N Mian
- Department of Physical Medicine and Rehabilitation, Santa Clara Valley Medical Center, San Jose, CA, USA.
| |
Collapse
|
3
|
d'Esneval M, Zegarek G, Pugin D, Vargas MI, Tessitore E, Vulliemoz S. Giant Lumbar Pseudomeningocele Compression Mimicking Stroke and Seizure. Neurol Clin Pract 2021; 11:e763-e765. [PMID: 34840902 DOI: 10.1212/cpj.0000000000001062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 01/14/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Mathilde d'Esneval
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| | - Gregory Zegarek
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| | - Deborah Pugin
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| | - Maria Isabel Vargas
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| | - Enrico Tessitore
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| | - Serge Vulliemoz
- Department of Neurology (MdE, SV), Department of Neurosurgery (GZ, ET), Intensive Care Unit (DP), Department of Acute Medicine, Division of Neuroradiology (MIV), Geneva University Hospitals, Switzerland
| |
Collapse
|
4
|
Yeh YC, Lin YJ, Yeh CH, Hsieh PS, Wu CT. Anterior sacral meningocele repair assisted by intraoperative intrathecal fluorescence and 3D printing model: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE20159. [PMID: 35855020 PMCID: PMC9245847 DOI: 10.3171/case20159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 01/25/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Marfan syndrome is rarely accompanied by anterior sacral meningocele (ASM) resulting from erosion of the sacrum by dural ectasia. ASM may induce symptoms due to severe mass effects. ASM may also mimic ovarian cysts, and the risk of cerebrospinal fluid (CSF) leakage is high if spontaneous rupture of the cyst occurs. In this study, the authors presented a rare case of ASM with iatrogenic CSF leakage in a 34-year-old woman with suspected Marfan syndrome. OBSERVATIONS The patient initially presented with a giant ASM that was first misdiagnosed as an ovarian cyst. Previously, it had been partially resected, which was followed by iatrogenic CSF leakage. Symptoms of intracranial hypotension, including postural headache and dizziness, developed within 1 month. Brain magnetic resonance imaging (MRI) showed pituitary enlargement, bilateral subdural effusion, and tonsillar herniation. Preoperative computed tomography myelography provided three-dimensional (3D) examination of the deformed sacrum and CSF leakage site. Transabdominal approaches led to primary repair, and repair of the meningocele was achieved by intraoperative fluorescein fluorescence and 3D printed model–guided polymethyl methacrylate bone cement reconstruction. No CSF leakage or recurrent ASM was found at the 1.5-year follow-up visit. LESSONS Intraoperative intrathecal fluorescence and 3D-printed models are useful for ASM repair. Preoperative MRI is helpful for differentiating ASM from other causes of a huge pelvic mass, including ovarian cyst.
Collapse
Affiliation(s)
- Yu-Chaing Yeh
- Department of Neurosurgery, Chang-Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| | - Ya-Jui Lin
- Department of Neurosurgery, Chang-Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan City, Taiwan
- The Graduate Institute of Biomedical Sciences and
| | - Chih-Hua Yeh
- Department of Neuroradiology and
- Department of Neuroradiology and
| | - Pao-Shiu Hsieh
- Division of Colon and Rectal Surgery, Chang Gung Memorial Hospital, Guishan Township, Taoyuan City, Taiwan
| | - Chieh-Tsai Wu
- Department of Neurosurgery, Chang-Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan City, Taiwan
| |
Collapse
|
5
|
Rudrappa S, Govindasamy R, Sekar A, Tukkapuram R, Vikrama A. Hydrocephalic Attack-An Uncommon Complication of Spine Surgery: A Case Series and Review of Literature. World Neurosurg 2019; 126:101-106. [PMID: 30857997 DOI: 10.1016/j.wneu.2019.02.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 02/14/2019] [Accepted: 02/15/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Spinal pseudomeningocele refers to an abnormal accumulation of cerebrospinal fluid (CSF) in a fibrous sac without arachnoid lining that occurs mostly as a result of an accidental dural opening. When accidental dural openings are found intraoperatively, they should be repaired to prevent further complications. Sometimes inadequately dealt dural openings, unnoticed, or postoperative dural openings may produce complications. CASE DESCRIPTION Three patients had complications as a result of spine surgery and presented several days after the surgery with episodic symptoms of raised intracranial pressure, including headache, opisthotonos, altered breathing patterns, and altered sensorium. These symptoms increased whenever pressure was applied on the operated area suggesting hydrocephalic attacks. All 3 patients had a giant pseudomeningocele at the operated area, a complication that resulted from the spine surgery. Magnetic resonance imaging CSF flow study revealed hyperdynamic flow and increase in absolute stroke volume across the cerebral aqueduct when constant pressure was applied on the pseudomeningocele sac. CONCLUSIONS Usually pseudomeningoceles are asymptomatic, and if symptomatic, the common presentations are local swelling, back pain, radiculopathy, and orthostatic headache. To our knowledge, this is the first article in the literature reporting the uncommon presentation of hydrocephalic attacks in 3 cases subsequent to CSF backflow from the sac, confirmed with MRI CSF flow study. This case series emphasizes rare presentations can result from transiently increased intracranial pressure related to postoperative pseudomeningocele in spine surgeries.
Collapse
Affiliation(s)
- Satish Rudrappa
- Department of Neurosurgery, Sakra World Hospital, Bangalore, India
| | | | - Arunkumar Sekar
- Department of Neurosurgery, Sakra World Hospital, Bangalore, India
| | | | - Amita Vikrama
- Department of Radiology, Sakra World Hospital, Bangalore, India
| |
Collapse
|
6
|
Rupture of Giant Anterior Sacral Meningocele in a Patient with Marfan Syndrome: Diagnosis and Management. World Neurosurg 2018; 119:137-141. [PMID: 30092475 DOI: 10.1016/j.wneu.2018.07.249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/26/2018] [Accepted: 07/27/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Marfan syndrome is a genetic disorder that results in the weakening of connective tissues. Dural ectasia has been defined as a feature of Marfan syndrome and is present in up to 92% of patients. Rarely, dural ectasia can erode through the sacrum expanding into an anterior sacral meningocele. CASE DESCRIPTION Information for this case report was gathered from patient notes and imaging from the patient chart. This is a case of a 46-year-old woman who presented with urinary incontinence, early satiety, and back pain in the setting of a known anterior sacral meningocele. Before operative management, the anterior sacral meningocele ruptured with the patient presenting signs and symptoms of intracranial hypotension. Conservative management did not alleviate the pain. She was ultimately managed with posterior sacroplasty followed by anterior sacral meningocele resection and placement of a lumboperitoneal shunt. The patient did not have reaccumulation of the meningocele or recurrent symptoms at the latest follow-up. CONCLUSIONS The progression of dural ectasia in Marfan syndrome to an anterior sacral meningocele is uncommon. It is important to identify the characteristics associated with an expanding dural ectasia as this patient's symptoms progressed over time and the meningocele grew large. Given its rarity, there are no guidelines in place regarding size at which repair of an anterior sacral meningocele should occur prophylactically. It is important to review these cases in order continue to learn about progression, management, and outcomes of patients with an anterior sacral meningocele.
Collapse
|
7
|
Hamdan A, Saxena A, Rao G, Ivanov M. Compression of a giant pseudomeningocele causing transient anoxic seizures-a case report. Acta Neurochir (Wien) 2018; 160:479-485. [PMID: 29299677 DOI: 10.1007/s00701-017-3446-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/21/2017] [Indexed: 11/28/2022]
Abstract
Transient anoxic seizure upon application of pressure on a giant pseudomeningocele has never been reported in the literature; such abrupt changes in intracranial pressure due to large volume of cerebrospinal fluid (CSF) translocation, if left untreated may lead to permanent cerebral hypoxic injury and death. Here we describe a case of a 26-year-old woman who had undergone lumbar disc surgery in another unit few months ago and developed a large lump around her back. Any pressure on the lump resulted in headaches and at times episodes of seizures. Clinical examination revealed a very large fluid-filled lump consistent with a giant pseudomeningocele, confirmed by an MRI. A video EEG while applying pressure on the lump was recorded. The patient developed a typical seizure attack with a characteristic pattern of cerebral anoxia, and a paired ECG showed irregular rhythm with junctional and ventricular ectopic beats during the latter part of the attack, raising a suspicion of asystole. Upon relieving the pressure off the lump, the patient gradually regained consciousness with no permanent neurological deficit. We then discuss the pathophysiology of anoxic seizures and highlight the need to be vigilant in managing patients with such lesions in order to prevent permanent cerebral hypoxic injury and death.
Collapse
Affiliation(s)
- Alhafidz Hamdan
- Department of Spinal Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - A Saxena
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - G Rao
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - M Ivanov
- Department of Spinal Surgery, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
8
|
Klekamp J. A New Classification for Pathologies of Spinal Meninges, Part 1: Dural Cysts, Dissections, and Ectasias. Neurosurgery 2017; 81:29-44. [DOI: 10.1093/neuros/nyx049] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 01/30/2017] [Indexed: 12/19/2022] Open
Abstract
Abstract
BACKGROUND: The clinical significance of pathologies of the spinal dura is often unclear and their management controversial.
OBJECTIVE: To classify spinal dural pathologies analogous to vascular aneurysms, present their symptoms and surgical results.
METHODS: Among 1519 patients with spinal space-occupying lesions, 66 patients demonstrated dural pathologies. Neuroradiological and surgical features were reviewed and clinical data analyzed.
RESULTS: Saccular dural diverticula (type I, n = 28) caused by defects of both dural layers, dissections between dural layers (type II, n = 29) due to defects of the inner layer, and dural ectasias (type III, n = 9) related to structural changes of the dura were distinguished. For all types, symptoms consisted of local pain followed by signs of radiculopathy or myelopathy, while one patient with dural ectasia presented a low-pressure syndrome and 10 patients with dural dissections additional spinal cord herniation. Type I and type II pathologies required occlusion of their dural defects via extradural (type I) or intradural (type II) approaches. For type III pathologies of the dural sac no surgery was recommended. Favorable results were obtained in all 14 patients with type I and 13 of 15 patients with type II pathologies undergoing surgery.
CONCLUSION: The majority of dural pathologies involving root sleeves remain asymptomatic, while those of the dural sac commonly lead to pain and neurological symptoms. Type I and type II pathologies were treated with good long-term results occluding their dural defects, while ectasias of the dural sac (type III) were managed conservatively.
Collapse
Affiliation(s)
- Jörg Klekamp
- Department of Neurosurgery, Christliches Krankenhaus Quakenbrück, Quakenbr-ück, Germany
| |
Collapse
|
9
|
Stone JG, Bergmann LL, Takamori R, Donovan DJ. Giant pseudomeningocele causing urinary obstruction in a patient with Marfan syndrome. J Neurosurg Spine 2015; 23:77-80. [PMID: 25909269 DOI: 10.3171/2014.11.spine131086] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Defective collagen biosynthesis in Marfan syndrome predisposes to dural defects such as dural ectasia, meningocele, and pseudomeningocele; thus, an increased index of suspicion for these conditions should be present in the clinical setting of Marfan syndrome. The authors describe a young woman with Marfan syndrome who was being treated with anticoagulants for a prosthetic heart valve and who presented with a spontaneous retroperitoneal hemorrhage requiring surgical evacuation. No CSF leak was encountered at surgery, but she developed progressively more severe positional headaches over the following year. She then experienced the sudden onset of acute urinary obstruction, at which time CT revealed a 17 × 15 × 13-cm presacral pseudomeningocele communicating with the thecal sac through a sacral bone defect. An anterior surgical approach was used for drainage of the pseudomeningocele as well as for primary closure of the dural defect with a bovine pericardial patch and autologous subcutaneous fat graft. After a short period of lumbar subarachnoid drainage of the CSF, the patient was able to resume normal activity without recurrent symptoms. To the authors' knowledge, such a pseudomeningocele in a patient with Marfan syndrome has been reported only twice, and this case features the largest pseudomeningocele to date. They also review the pertinent literature regarding presentation, diagnosis, and management of these lesions.
Collapse
Affiliation(s)
- Jeremy G Stone
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine; and
| | - Liisa L Bergmann
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine; and
| | - Ryan Takamori
- Department of Surgery, Kaiser Permanente Moanalua Medical Center, Honolulu, Hawaii
| | - Daniel J Donovan
- Department of Surgery, University of Hawaii, John A. Burns School of Medicine; and
| |
Collapse
|
10
|
Drummond JC, Ciacci JD, Lee RR. Direct pressure on a pseudomeningocele resulting in intraoperative cerebral ischemia. Can J Anaesth 2014; 61:656-9. [PMID: 24744102 DOI: 10.1007/s12630-014-0164-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/31/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE When positioning patients with meningocele and meningomyelocele, it is standard practice to avoid direct pressure on the lesions. That caution is intended to prevent injury to neural elements within the lesion and violation of the cerebrospinal fluid space. We herein report an additional hazard of direct intraoperative pressure on such lesions. An adult patient with a lumbosacral pseudomeningocele sustained a cerebral ischemic injury as a consequence of direct pressure on the lesion during general anesthesia. CLINICAL FEATURES A 32-yr-old male with spina bifida and a pseudomeningocele related to recent lumbar surgery underwent a urologic procedure in the lithotomy position. Because the lesion was recognized to lie to the left of the midline, cushioning was placed under the patient's left hip and buttock. The patient was slow to awaken and has sustained significant long-term cognitive deficits. Imaging is consistent with a diffuse cerebral ischemic insult. CONCLUSION In retrospect, the size and leftward extent of the pseudomeningocele were not appreciated preoperatively, and in spite of the care taken, intraoperative pressure was placed on the lesion. This report cautions that intraoperative pressure related to positioning patients with extra-axial lesions containing cerebrospinal fluid (CSF), e.g., meningoceles and pseudomeningoceles, can result in increases in CSF pressure and thereby a reduction in cerebral perfusion pressure sufficient to result in cerebral ischemia.
Collapse
Affiliation(s)
- John C Drummond
- VA Medical Center, Anesthesia Service - 125, University of California, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA,
| | | | | |
Collapse
|