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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 2  |  Page : 245-247

An unusual case of post-traumatic intradiploic leptomeningeal cyst and review of the literature


Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae-Bareilly Road, Lucknow, India

Date of Submission28-Nov-2011
Date of Decision20-Dec-2011
Date of Acceptance28-Mar-2012
Date of Web Publication19-May-2012

Correspondence Address:
A K Srivastav
Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae-Bareilly Road, Lucknow
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.96428

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How to cite this article:
Kumar R, Sahu R N, Srivastav A K, Mehrotra A, Das KK. An unusual case of post-traumatic intradiploic leptomeningeal cyst and review of the literature. Neurol India 2012;60:245-7

How to cite this URL:
Kumar R, Sahu R N, Srivastav A K, Mehrotra A, Das KK. An unusual case of post-traumatic intradiploic leptomeningeal cyst and review of the literature. Neurol India [serial online] 2012 [cited 2021 Sep 20];60:245-7. Available from: https://www.neurologyindia.com/text.asp?2012/60/2/245/96428


Sir,

Post-traumatic intradiploic leptomeningeal cyst (PTIDLMC) is a rare variant of a growing skull fracture and occurs in pediatric patients following severe head injury. [1] To the best of our knowledge, about 21 cases have been reported till date, [2] hence this report.

A 17-year-old boy presented with one episode of generalized tonic-clonic seizure (GTCS) two months prior to admission. He also complained of a slowly progressing painless hard swelling over the right parietal area since 12 years. His father recalled of a fall from the roof of the house at the age of four years leading to injury over the head which was managed conservatively. Examination revealed an ill-defined, non-tender, smooth bony hard lump over the right parietal region with a palpable ridge indicating linear widened fracture. Neurological examination was normal. Computed tomography (CT) head revealed an intradiploic expansile cerebrospinal fluid (CSF) density collection in the right temporal bone with a break in the continuity of the posteromedial parietal bone involving both tables. The outer table of the temporal bone was significantly thinned out. The cystic expansile collection was encroaching the mastoid air cells with porencephalic cyst formation [Figure 1]. Reconstructed CT head showed a widened fracture line in the right posterolateral parietal bone with gross thinning of the outer table of the mastoid and squamous part of the right temporal bone [Figure 2]. Magnetic resonance imaging (MRI) brain confirmed the presence of CSF within the expanded intradiploic space that was continuing with the porencephalic cyst and lateral ventricle [Figure 3]. With the diagnosis of a PTIDLMC, operative repair was planned. Intraoperatively, the outer tables of the temporoparietal bones were grossly thinned out and dural defect was seen near the midline. A wide temporoparietal craniotomy was made and dural defect was identified. Mastoid air cells were drilled and packed with fat and fibrin glue. Gliotic brain was excised and duroplasty and cranioplasty was done (outer table of the bone flap). Postoperatively he was discharged on an antiepileptic. Postoperative CT head showed the bone flap to be in place [Figure 4]. At the six-month follow-up, the patient was doing well and had no seizures.
Figure 1: Reconstructed CT head shows through and through fracture involving the right parietal bone with expanding intradiploic cyst involving the temporal squama. The outer table is seen as porous and grossly thinned out

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Figure 2: Axial CT head shows expanded intradiploic space (CSF density) of the right temporal bone with resultant gross thinning of the tables. The mastoid air cells are seen in very close proximity

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Figure 3: T2-weighted axial MRI film shows CSF intensity collection in the expanded intradiploic space of the right temporal bone in communication with the right lateral ventricle

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Figure 4: Postoperative CT showing cranioplasty with autologous outer table

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Growing skull fractures are rare but well-known complications of severe pediatric head injury. [1] PTIDLMC is a variant of the growing fracture. These lesions are extremely uncommon. [2] These cysts are characterized by fracture involving only the inner table of the bony calvarium, in contrast to the classical growing fractures where the fracture tends to involve both the tables. Pathophysiologically, this is possible only in a skull bone which is both very strong and thick or has strong muscular support buttressing the outer table. Hence, it is not surprising to see most such cases being reported in the occipital bone. [3] Progressive herniation of leptomeninges, as a result of normal brain growth and CSF pulsations, causes expansion and intradiploic cyst formation. Occasionally, in addition to CSF, such cysts may contain gliotic brain tissue. [4] On rare occasions, such cysts have developed from ventriculo-peritoneal shunt malfunction. [5]

Our patient had two unusual features: firstly, the cyst developed in the temporal squama, a bone known to be rather thin and secondly, the fracture involved both tables. Whereas it is difficult to explain the former, we hypothesize a mechanism for the latter. The fracture line on the outer table probably was a simple crack at the time of impact and the leptomeninges might have made way into the intradiploic space through the wider and unsupported inner table fracture, and there it gradually mushroomed. In due course, expansion of the intradiploic space might have caused the apparent widening of the outer table fracture.

Surgical repairs, in such cases, must ensure a watertight dural closure. [6],[7] Cranioplasty may be done with synthetic constructs or autologous bone (outer table/rib). Associated hydrocephalus usually requires placement of shunt. [2] Our patient demonstrates that PTIDLMC is possible in a thinner bone like the temporal bone and even with a through and through fracture of the bone.

 
  References Top

1.Houra K, Beros V, Sajko T, Cupic H Traumatic leptomeningeal cyst in a 24-year-old man: Case report. Neurosurgery 2006;58:E201.   Back to cited text no. 1
    
2.Aggarwal D, Misra S. Post-Traumatic Intradiploic Pseudomeningocele. Indian Pediatr 2010;47:271-3.  Back to cited text no. 2
    
3.Mahapatra AK, Tandon PN. Post-traumatic intradiploic pseudomeningocele in children. Acta Neurochir (Wien) 1989;100:120-6.  Back to cited text no. 3
[PUBMED]    
4.Patil AA, Etemadrezaie H. Posttraumatic intradiploic meningoencephalocele. Case report. J Neurosurg 1996;84:284-7.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Sato TS, Moritani T, Hitchon P. Occipital intradiploic CSF pseudocyst: An unusual complication of a ventriculoperitoneal shunt malfunction. AJNR Am J Neuroradiol 2009;30:635-6.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Nalls G, Lightfoot J, Lee A, Blackwell L. Leptomeningeal cyst: Nonenhanced and enhanced computed tomography findings. Am J Emerg Med 1990;8:34-5.  Back to cited text no. 6
[PUBMED]    
7.Naim-Ur-Rahman, Jamjoom Z, Jamjoom A, Murshid WR. Growing skull fractures: Classification and management. Br J Neurosurg 1994;8:667-79.  Back to cited text no. 7
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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