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J Neurol Surg Rep 2014; 75(02): e251-e254
DOI: 10.1055/s-0034-1387183
Case Report
Georg Thieme Verlag KG Stuttgart · New York

“Spontaneous” CSF Fistula due to Transtegmental Brain Herniation in Combination with Signs of Increased Intracranial Pressure and Petrous Bone Hyperpneumatization: An Illustrative Case Report

Diones Rivera
1   Department of Neurosurgery, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
,
Rafael Fermin-Delgado
2   Department of Radiology, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
,
Peter Stoeter
2   Department of Radiology, CEDIMAT, Plaza de la Salud, Santo Domingo, Republica Dominicana
› Author Affiliations
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Publication History

11 November 2013

09 June 2014

Publication Date:
12 November 2014 (online)

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Abstract

Background and Importance Transtegmental brain herniation into the petrous bone is a rare cause of rhinoliquorrhea. Our case presents a combination of several typical clinical and imaging findings illustrating the ongoing etiologic discussion of such cerebrospinal fluid (CSF) fistulas.

Clinical Presentation A 53-year-old man presented with nasal discharge after a strong effort to suppress coughing. Imaging revealed a transtegmental herniation of parts of the inferior temporal gyrus into the petrous bone and in addition a combination of signs of chronically increased intracranial pressure and a hyperpneumatization of the petrous bone. The fistula was closed by a middle cranial fossa approach.

Conclusion The case illustrates the two main predisposing factors for development of petrous bone CSF fistulas: increased intracranial pressure and thinning of the tegmental roof due to extensive development of air cells. Because the CSF leakage repair does not change the underlying cause, patients have to be informed about the possibility of developing increased intracranial pressure and recurrences of brain herniations at other sites.

Keywords

CSF fistula - brain herniation - increased intracranial pressure - petrous bone
 

  • References

  • 1 Brown NE, Grundfast KM, Jabre A, Megerian CA, O'Malley Jr BW, Rosenberg SI. Diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea. Laryngoscope 2004; 114 (5) 800-805
    CrossrefPubMedGoogle Scholar
  • 2 Lim ZM, Friedland PL, Boeddinghaus R, Thompson A, Rodrigues SJ, Atlas M. Otitic meningitis, superior semicircular canal dehiscence, and encephalocele: a case series. Otol Neurotol 2012; 33 (4) 610-612
    CrossrefPubMedGoogle Scholar
  • 3 Sdano MT, Pensak ML. Temporal bone encephaloceles. Curr Opin Otolaryngol Head Neck Surg 2005; 13 (5) 287-289
    CrossrefPubMedGoogle Scholar
  • 4 Wind JJ, Caputy AJ, Roberti F. Spontaneous encephaloceles of the temporal lobe. Neurosurg Focus 2008; 25 (6) E11
    PubMedGoogle Scholar
  • 5 Schuknecht HF. Spontaneous cerebrospinal fluid fistula in the tegmen tympani . [in German]. HNO 1994; 42 (5) 288-293
    PubMedGoogle Scholar
  • 6 Pérez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2013; 33 (4) 330-337
    PubMedGoogle Scholar
  • 7 Goddard JC, Meyer T, Nguyen S, Lambert PR. New considerations in the cause of spontaneous cerebrospinal fluid otorrhea. Otol Neurotol 2010; 31 (6) 940-945
    CrossrefPubMedGoogle Scholar
  • 8 Wang EW, Vandergrift III WA, Schlosser RJ. Spontaneous CSF leaks. Otolaryngol Clin North Am 2011; 44 (4) 845-856 , vii
    CrossrefPubMedGoogle Scholar
  • 9 Kenning TJ, Willcox TO, Artz GJ, Schiffmacher P, Farrell CJ, Evans JJ. Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes. Neurosurg Focus 2012; 32 (6) E6
    PubMedGoogle Scholar
  • 10 Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol 2011; 32 (11) 1986-1993
    CrossrefPubMedGoogle Scholar
  • 11 Hingwala DR, Kesavadas C, Thomas B, Kapilamoorthy TR, Sarma PS. Imaging signs in idiopathic intracranial hypertension: are these signs seen in secondary intracranial hypertension too?. Ann Indian Acad Neurol 2013; 16 (2) 229-233
    CrossrefPubMedGoogle Scholar
  • 12 Hoffmann J, Schmidt C, Kunte H , et al. Volumetric assessment of optic nerve sheath and hypophysis in idiopathic intracranial hypertension. AJNR Am J Neuroradiol 2014; 35 (3) 513-518
    CrossrefPubMedGoogle Scholar
  • 13 Li Y, Sansgiri RK, Estroff JA , et al. Outcome of fetuses with cerebral ventriculomegaly and septum pellucidum leaflet abnormalities. AJR Am J Roentgenol 2011; 196 (1) W83–W92
    PubMedGoogle Scholar
  • 14 Barkovich AJ, Norman D. Absence of the septum pellucidum: a useful sign in the diagnosis of congenital brain malformations. AJR Am J Roentgenol 1989; 152 (2) 353-360
    CrossrefPubMedGoogle Scholar
  • 15 Supprian T, Sian J, Heils A, Hofmann E, Warmuth-Metz M, Solymosi L. Isolated absence of the septum pellucidum. Neuroradiology 1999; 41 (8) 563-566
    CrossrefPubMedGoogle Scholar
  • 16 Nadaraja GS, Monfared A, Jackler RK. Spontaneous cerebrospinal fluid leak through the posterior aspect of the petrous bone. J Neurol Surg B Skull Base 2012; 73 (1) 71-75
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Lorente Muñoz A, Lisbona Alquézar MP, González Martínez L, Sevil Navarro J, Llorente Arenas EM. Atypical etiology of rhinorrhea: spontaneous bilateral temporal encephalocele. [in Spanish]. Acta Otorrinolaringol Esp 2012; 63 (3) 237-240
    CrossrefPubMedGoogle Scholar
  • 18 Yew M, Dubbs B, Tong O , et al. Arachnoid granulations of the temporal bone: a histologic study of dural and osseous penetration. Otol Neurotol 2011; 32 (4) 602-609
    CrossrefPubMedGoogle Scholar
  • 19 Stieglitz LH, Giordano M, Gerganov V , et al. Petrous bone pneumatization is a risk factor for cerebrospinal fluid fistula following vestibular schwannoma surgery. Neurosurgery 2010; 67 (2, Suppl Operative): 509-515
    PubMedGoogle Scholar
  • 20 Tóth M, Helling K, Baksa G, Mann W. Localization of congenital tegmen tympani defects. Otol Neurotol 2007; 28 (8) 1120-1123
    CrossrefPubMedGoogle Scholar
  • 21 Oliaei S, Mahboubi H, Djalilian HR. Transmastoid approach to temporal bone cerebrospinal fluid leaks. Am J Otolaryngol 2012; 33 (5) 556-561
    CrossrefPubMedGoogle Scholar
  • 22 Pelosi S, Bederson JB, Smouha EE. Cerebrospinal fluid leaks of temporal bone origin: selection of surgical approach. Skull Base 2010; 20 (4) 253-259
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Kutz Jr JW, Husain IA, Isaacson B, Roland PS. Management of spontaneous cerebrospinal fluid otorrhea. Laryngoscope 2008; 118 (12) 2195-2199
    CrossrefPubMedGoogle Scholar
  • 24 Aquilina K, Clarke DF, Wheless JW, Boop FA. Microencephaloceles: another dual pathology of intractable temporal lobe epilepsy in childhood. J Neurosurg Pediatr 2010; 5 (4) 360-364
    CrossrefPubMedGoogle Scholar
  • 25 Byrne RW, Smith AP, Roh D, Kanner A. Occult middle fossa encephaloceles in patients with temporal lobe epilepsy. World Neurosurg 2010; 73 (5) 541-546
    CrossrefPubMedGoogle Scholar