Spontaneously ruptured craniopharyngioma cyst without meningitic symptoms --two case reports

Unusual circumstance for craniopharyngioma discovery on meningoencephalitis: a pediatric case report

BACKGROUND

Craniopharyngioma is a rare condition in children, but it is the most frequent tumor that occurs in the hypothalamic pituitary region. Chemical meningitis has been described as an uncommon postoperative complication, but no chemical meningitis due to a spontaneous rupture leading to craniopharyngioma diagnosis in children has been reported.

CASE PRESENTATION

This is a case of a 13-year-old boy presenting with fever, vomiting and headache for two days. The CT scan revealed a suprasellar lesion, and lumbar puncture showed aseptic meningitis. The cerebral MRI suggested a craniopharyngioma and the cerebrospinal fluid cholesterol concentration was abnormally high. A thorough medical history indicated some visual disturbance, which improved at the onset of meningitis, and an inflection of the growth curve. The anatomopathological analysis of the tumor confirmed the diagnosis of craniopharyngioma.

CONCLUSIONS

This case is the first to report the discovery of a craniopharyngioma with meningoencephalitis caused by the rupture of a craniopharyngioma cyst in a child. Diagnosis was facilitated by determining the cholesterol level in the cerebrospinal fluid, as well as fine anamnesis to identify visual and growth disturbances.

Aseptic ascites and chemical meningitis following ventriculoperitoneal shunting for craniopharyngioma: A first case report

We report the case of a 4-year-old boy who had a ventriculoperitoneal shunt due to hydrocephalus related to a cystic craniopharyngioma. Postoperative, he presented abdominal distension and meningismus. Imaging showed regression of the tumor. The cyst was drained by the shunt. No similar situations were reported in the literature.

Aseptic Meningitis Due to Spontaneous Rupture of a Multicystic Craniopharyngioma with an Ommaya Catheter: A Case Report

Craniopharyngiomas (CPs) are benign tumors that are believed to arise from embryonic remnants of the Rathke pouch epithelium. Herein, we report a case of aseptic meningitis due to spontaneous rupture of multicystic CP, which contained an Ommaya catheter. A 19-year-old boy was admitted to the hospital with a 4-day history of acute severe headache after strenuous physical exercise followed by altered sensorium, fever, and neck stiffness. Cerebrospinal fluid (CSF) analysis revealed marked pleocytosis and elevated protein levels. CSF culture was otherwise negative. Cyst reduction on subsequent imaging confirmed the diagnosis. The patient received intravenous steroid therapy and was discharged asymptomatic. This is a rare evolution of a multicystic CP, which was previously treated with intracystic therapy and had an Ommaya catheter. Clinicians should be aware of spontaneous CP rupture and look actively for the occurrence of cholesterol crystals or elevated CSF levels of cholesterol as well as prompt follow-up imaging.

Spontaneous rupture of malignant papillary craniopharyngioma with CSF seeding and metastatic deposits: A case report and literature review

Introduction

Craniopharyngiomas are benign tumours mainly confined to the cranial cavity in the suprasellar region.

Research Question and Case Description

We present a rare case of an aggressive papillary craniopharyngioma with disseminated spinal intradural disease. A 67-year-old woman presented with a 4-month history of headache, visual disturbance, acute confusion and radicular leg pain. Previous history of breast carcinoma (ER ​+ ​PR ​+ ​HER2-) was noted. The importance of histological diagnosis prior to treatment of sellar or suprasellar lesions with atypical or aggressive features is explored.

Materials and methods

MRI demonstrated a partly solid and partly cystic pituitary mass lesion in the sellar and suprasellar region with chiasmal compression and hypothalamic involvement. The sella was mildly enlarged and there were no calcifications. Whole neuraxis MRI revealed intradural deposits involving the ventricular system, spinal cord and conus. Within a month, the lesion rapidly increased in size. The patient underwent a craniotomy and transventricular resection of the sellar and suprasellar mass. Cranial lesion histology favoured papillary craniopharyngioma, confirmed by BRAF V600 mutation. Lumbar puncture CSF cytology confirmed craniopharyngioma with BRAF mutation and no evidence of metastatic breast cancer.

Results

The patient remained confused postoperatively without focal neurological deficit and underwent palliative whole brain radiotherapy. She died 4 months later. A review of the literature identified 29 reports of ruptured craniopharyngioma.

Discussion and Conclusion

Ruptured craniopharyngioma presents with a suprasellar mass and drop lesions in the spinal canal, characteristics radiologically indistinguishable from metastatic disease. The importance of histological diagnoses in directing the management of these cases is highlighted.

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Ruptured craniopharyngioma presents with a suprasellar mass and drop lesions in the spinal canal.

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The characteristics of ruptured craniopharyngiomas can be radiologically indistinguishable from metastatic cancer.

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Histological diagnoses are important in directing the management of sellar/suprasellar lesions with atypical features.

Cystic Glioblastoma Rupturing into the Ventricle

Cystic tumors, such as craniopharyngiomas and Rathke’s cleft cysts, as well as arachnoid cysts have been reported to rupture occasionally. Approximately 8–10% of glioblastomas (GBMs) are known to have a significant cystic component; however, to the best of our knowledge, no studies have reported cystic rupturing of GBMs. Here, we describe a unique case of cystic GBM rupturing and penetrating into the cerebral ventricle. A 77-year-old man with a right frontal lobe lesion suspected as GBM with a large cyst was referred to our hospital. At admission, disorientation and left facial weakness were detected. Consciousness disturbance worsened on the 8th day of hospitalization. Computed tomography (CT) revealed prominent shrinkage of the tumor and intratumoral cyst. Signs of meningeal irritation were observed, and chemical meningitis due to cystic tumor rupture and leakage of necrotic components into the ventricle was highly suspected. Surgical resection of the right frontal lobe tumor was performed on the 10th day of hospitalization. During the surgery, clear and colorless cerebrospinal fluid was obtained upon penetration of the tumoral cyst, suggesting traffic of tumor cysts and cerebral ventricle. Adjuvant chemoradiation therapy was initiated postoperatively. Local recurrence was noted at the corpus callosum 7 months postoperatively and was treated with a gamma knife. Further therapy was performed after this recurrence. However, his condition gradually deteriorated 15 months postoperatively, and he was subjected to terminal care. To the best of our knowledge, this is the first report on a cystic GBM rupture.

Spontaneous Intra-Parenchymal Rupture of Craniopharyngioma - A Rare Phenomenon

Craniopharyngioma is a relatively benign intracranial tumour that involves sellar and supra-sellar regions. Spontaneous rupture of craniopharyngioma into the sub-arachnoid space or into the ventricles is a rare phenomenon and few cases are reported in literature. We hereby report a case of sellar-suprasellar craniopharyngioma with focal intra-parenchymal rupture into brain causing aggravation of headache in a 12-year-old female child. This complication is a relatively rare phenomenon, which requires attention for early intervention. This was managed by trans-nasal endoscopic trans-sphenoidal surgery. Usually rupture of craniopharyngioma causes chemical meningitis or it can be asymptomatic. Sometimes rupture can cause complete resolution of cyst and symptoms. In the present case, there was only focal rupture and it was into brain parenchyma causing brain oedema with aggravation of headache. Magnetic Resonance Imaging (MRI) in intra-parenchymal rupture of craniopharyngioma has been emphasized in this case report.

Spontaneous intraventricular rupture of a craniopharyngioma cyst: A case report

Intraventricular rupture of craniopharyngioma cysts is an unusual event which is associated with a high risk of loculated or communicating hydrocephalus. A 75-year-old woman presented at the Emergency Department of our hospital with mental status deterioration due to chemical ventriculitis and acute hydrocephalus following the intraventricular rupture of a craniopharyngioma cyst. The patient was treated with stress-dose steroid therapy. In addition, she underwent placement of an external ventricular drain and endoscopy-assisted intra-cystic placement of an Ommaya reservoir for the aspiration of the cystic fluid. The patient's condition improved; she was shunted in an expeditious fashion and discharged from the Intensive Care Unit within 2 weeks of her admission with the reservoir in place for the continued drainage of the cyst.

Displacement of mammillary bodies by craniopharyngiomas involving the third ventricle: surgical-MRI correlation and use in topographical diagnosis

OBJECT

Accurate diagnosis of the topographical relationships of craniopharyngiomas (CPs) involving the third ventricle and/or hypothalamus remains a challenging issue that critically influences the prediction of risks associated with their radical surgical removal. This study evaluates the diagnostic accuracy of MRI to define the precise topographical relationships between intraventricular CPs, the third ventricle, and the hypothalamus.

METHODS

An extensive retrospective review of well-described CPs reported in the MRI era between 1990 and 2009 yielded 875 lesions largely or wholly involving the third ventricle. Craniopharyngiomas with midsagittal and coronal preoperative and postoperative MRI studies, in addition to detailed descriptions of clinical and surgical findings, were selected from this database (n = 130). The position of the CP and the morphological distortions caused by the tumor on the sella turcica, suprasellar cistern, optic chiasm, pituitary stalk, and third ventricle floor, including the infundibulum, tuber cinereum, and mammillary bodies (MBs), were analyzed on both preoperative and postoperative MRI studies. These changes were correlated with the definitive CP topography and type of third ventricle involvement by the lesion, as confirmed surgically.

RESULTS

The mammillary body angle (MBA) is the angle formed by the intersection of a plane tangential to the base of the MBs and a plane parallel to the floor of the fourth ventricle in midsagittal MRI studies. Measurement of the MBA represented a reliable neuroradiological sign that could be used to discriminate the type of intraventricular involvement by the CP in 83% of cases in this series (n = 109). An acute MBA (< 60°) was indicative of a primary tuberal-intraventricular topography, whereas an obtuse MBA (> 90°) denoted a primary suprasellar CP position, causing either an invagination of the third ventricle (pseudointraventricular lesion) or its invasion (secondarily intraventricular lesion; p < 0.01). A multivariate model including a combination of 5 variables (the MBA, position of the hypothalamus, presence of hydrocephalus, psychiatric symptoms, and patient age) allowed an accurate definition of the CP topography preoperatively in 74%-90% of lesions, depending on the specific type of relationship between the tumor and third ventricle.

CONCLUSIONS

The type of mammillary body displacement caused by CPs represents a valuable clue for ascertaining the topographical relationships between these lesions and the third ventricle on preoperative MRI studies. The MBA provides a useful sign to preoperatively differentiate a primary intraventricular CP originating at the infundibulotuberal area from a primary suprasellar CP, which either invaginated or secondarily invaded the third ventricle.

Spontaneous asymptomatic rupture of cystic craniopharyngioma in a child: case report and review of the literature

Spontaneous rupture of craniopharyngioma is a rare condition described mainly in adults. Chemical meningitis or improvements in clinical symptomatology are the usual events heralding such rupture. Spontaneous rupture of a craniopharyngioma cyst in a child is uncommon; such a rupture being asymptomatic being exceptionally rare. Four cases of craniopharyngioma cyst rupture in the pediatric population have been reported in the literature, only 1 of them being asymptomatic. The authors report a case of spontaneous asymptomatic craniopharyngioma cyst rupture in a 13-year-old child which was diagnosed when repeat imaging was performed before operative intervention. Although rare, such rupture is of clinical significance as it can lead to alterations in management strategy.

Rupture of brainstem cyst with clinical benefit after head injury. Case report

The authors report an interesting case of the rupture of a brainstem cyst following blunt head trauma. They discuss the case, review reports of similar events, and suggest a possible mechanism by which the cyst could have resolved without surgery.

Rupture of a craniopharyngioma cyst following trauma: a case report

There have been only 20 reported cases of non-surgical rupture of a craniopharyngioma cyst, with only 3 cases secondary to trauma. Here we present a rare case of temporary shrinkage of a cystic craniopharyngioma following head trauma. After a motor vehicle accident in May 2001, a 61-year old woman began to have blurred vision and headaches. Magnetic resonance imaging (MRI) of the head revealed a primarily cystic mass measuring approximately two centimeters, involving the sellar and suprasellar area with compression of the pituitary. Visual field testing showed a left hemianopsia and the patient was referred for surgical evaluation. Transsphenoidal drainage of the cystic lesion in November 2001 provided histologic confirmation of the craniopharyngioma. Post-operative MRI showed cyst reduction and visual fields improved. Late in 2002, the patient again experienced progressive visual loss. Repeat MRI revealed a recurrent cystic craniopharyngioma, now measuring approximately three centimeters with subfrontal and parasellar extension and compression of the optic chiasm. A bifrontal surgical approach was advocated; however, prior to the scheduled surgery, the patient sustained a fall with trauma to the head. Following this event she experienced dramatic improvement in her headache and vision and repeat MRI showed the cystic lesion to be significantly decreased in size. Spontaneous rupture of craniopharyngioma cysts is uncommon but has been reported with increasing frequency. It is, however, exceedingly rare for a cyst to rupture following trauma.