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Open access

Rathke’s cleft cyst presenting with recurrent aseptic meningitis and inflammatory apoplexy: illustrative case

Roger Murayi, Megh M. Trivedi, Joao Paulo Almeida, Gabrielle Yeaney, Carlos Isada, and Varun R. Kshettry

BACKGROUND

Rathke’s cleft cyst (RCC) is a benign sellar/suprasellar lesion often discovered incidentally. Rarely, symptomatic cases can present with headache and may exhibit concomitant aseptic meningitis or apoplexy. The authors describe a patient with an RCC presenting with recurring episodes of aseptic meningitis and ultimately inflammatory-type apoplexy.

OBSERVATIONS

A 30-year-old female presented with three episodes of intractable headaches over 2 months. Each episode’s clinical picture was consistent with meningitis though cerebrospinal fluid cultures, and viral tests remained negative. Imaging demonstrated a sellar lesion, initially thought to be coincidental. On the third presentation, there was rapid interval growth of the lesion, adjacent cerebritis, and new endocrinopathy. Resection was then performed via an endoscopic endonasal approach. Pathology showed an RCC with acute and chronic inflammation and no evidence of hemorrhage. Cultures were negative for organisms. The patient received several weeks of antibiotic treatment with the resolution of all symptoms and no recurrence.

LESSONS

Recurrent aseptic meningitis with apoplexy-like symptoms is a rare presentation of RCC. The authors propose the term inflammatory apoplexy to describe such a presentation without evidence of abscess, necrosis, or hemorrhage. The mechanism is unclear although may be due to intermittent microleakage of cyst contents into the subarachnoid space.

Open access

Trigeminal neuralgia secondary to vascular compression and neurocysticercosis: illustrative case

Mao Vásquez, Luis J. Saavedra, Hector H. García, Evelyn Vela, Jorge E. Medina, Miguel Lozano, Carlos Hoyos, and William W. Lines-Aguilar

BACKGROUND

Trigeminal neuralgia (TN) is a frequent neurosurgical problem negatively influencing the quality of life of patients. The standard surgical treatment is microvascular decompression for primary cases and decompression of the mass effect, mainly tumors, for secondary cases. Neurocysticercosis (NCC) in the cerebellopontine angle is a rare etiology of TN. The authors report a case in which NCC cysts around the trigeminal nerve coexisted with a vascular loop, which compressed the exit of the trigeminal nerve from the pons.

OBSERVATIONS

A 78-year-old woman presented with a 3-year history of persistent severe pain in the left side of her face, refractory to medical treatment. On gadolinium-enhanced magnetic resonance imaging, cystic lesions were observed around the left trigeminal nerve and a vascular loop was also present and in contact with the nerve. A retrosigmoid approach for cyst excision plus microvascular decompression of the trigeminal nerve was successfully performed. There were no complications. The patient was discharged without facial pain.

LESSONS

Albeit rare, TN secondary to NCC cysts should be considered in the differential diagnosis in NCC-endemic regions. In this case, the cause of the neuralgia was probably both problems, because when both were treated, the patient improved.

Open access

Cerebrospinal fluid fistula as a complication of reverse transcriptase–polymerase chain reaction collection for the detection of coronavirus disease 2019: illustrative cases

Lucca B. Palavani, Camila V. F. Andrade, Renato A. Andrade, Egmond Alves, Marcio Falchi Barros, and João F. Barbieri

BACKGROUND

The most used method to detect coronavirus disease 2019 during the pandemic is reverse transcriptase–polymerase chain reaction with nasal swab. Despite being highly effective, the test does not leave the patient risk-free and can lead to serious complications. These can be traumatic nasal cerebrospinal fluid (CSF) fistula and its consequences, such as meningitis.

OBSERVATIONS

In this article, the authors present 4 case reports and a literature review. The following MeSH terms in the research were used: “CSF leak case report and covid 19.” Six results were found and after searching the references and keywords 16 articles were identified. By using them, the authors tried to clarify the etiology of the fistula, its influences, and complications.

LESSONS

The authors conclude that professionals must receive training, since CSF fistula originates from technical failure and lack of anatomical knowledge. The diagnosis cannot be neglected because it can bring complications to the patient’s health.

Open access

Intracranial aspergilloma mimicking metachronous meningioma following transsphenoidal removal of a tuberculum sellae meningioma: illustrative case

Daisuke Sato, Hirotaka Hasegawa, Hironobu Nishijima, Kyotaro Kawase, Koh Okamoto, Akiko Iwasaki, Yuki Shinya, Masahiro Abe, Yoshitsugu Miyazaki, and Nobuhito Saito

BACKGROUND

Endoscopic transsphenoidal surgery (eTSS) is a well-established approach for resection of skull-based pathologies such as tuberculum sellae meningiomas; however, central nervous system (CNS) fungal infection is a potential complication, particularly in a patient with concomitant sinusitis.

OBSERVATIONS

A 58-year-old woman with a tuberculum sellae meningioma causing progressive visual disturbance and concurrent asymptomatic chronic maxillary sinusitis underwent eTSS. Six months later, a de novo dura-based mass with peripheral edema, which was assumed to be an aggressive metachronous meningioma, developed in the middle cranial fossa. The patient underwent frontotemporal craniotomy for complete resection of the lesion, and subsequent histological examination revealed an aspergilloma. She was then treated with an antifungal agent and endoscopic sinus surgery to clear the sinusitis, and no recurrent fungal infection occurred thereafter.

LESSONS

CNS fungal infections may appear as a dura-based mass mimicking meningioma. The current case reiterates the importance of the appropriate management of sinusitis prior to eTSS.

Open access

Endoscopic endonasal resection of craniovertebral junction osteomyelitis: illustrative cases

Alexander Keister, Joshua Vignolles-Jeong, Daniel Kreatsoulas, Kyle VanKoevering, Stephanus Viljoen, Daniel Prevedello, and Andrew J. Grossbach

BACKGROUND

Operative management of craniovertebral junction (CVJ) osteomyelitis has traditionally been extracranial and focused on debriding the infection. In select patients, the endoscopic endonasal approach (EEA) with a focus on additional resection versus debridement may be preferred. The goal of this study is to present the authors’ experience with the EEA with gross or subtotal resection for the treatment of osteomyelitis at the CVJ and describe their technique in the context of the literature.

OBSERVATIONS

Two patients of the authors’ and 6 detailed case reports in the literature were identified with a mean age of 58.9 years. Most patients (n = 5; 62.5%) underwent skull base surgery and debridement (n = 5; 62.5%). Although more common, debridement was inferior to resection in terms of neurological improvement (66.7% vs. 100.0%) postoperatively. The majority (n = 7; 87.5%) of patients underwent occipitocervical fusion.

LESSONS

Osteomyelitis is an exceedingly rare lesion of the CVJ. Despite the region’s delicate biomechanical stability, resection of infected bone may be superior to debridement alone in terms of clinical outcome. Given how well established the safety of the EEA is to this region, further study of outcomes with resection is warranted.

Open access

Nocardia farcinica pituitary abscess in an immunocompetent patient: illustrative case

Kristen M. Scheitler, Megan M. J. Bauman, Lucas P. Carlstrom, Christopher S. Graffeo, and Fredric B. Meyer

BACKGROUND

Pituitary abscess is a rare clinical entity, typically precipitated by Staphylococcus, Pseudomonas, or Aspergillus infection. Although Nocardia species–associated central nervous system abscesses have been documented in immunocompromised patients, no case of Nocardia pituitary abscesses has been previously reported.

OBSERVATIONS

A 44-year-old man presented with hemoptysis and was found to have a cavitary right lung nodule, which was presumed histoplasmosis, prompting antifungal treatment. Several months later, he developed panhypopituitarism. Magnetic resonance imaging identified a pituitary mass, which subsequently underwent transsphenoidal endoscopic biopsy. Infectious workup was negative, and the patient was discharged on intravenous ertapenem therapy. Over several months, he developed progressive headaches, and updated imaging confirmed interval enlargement of the mass with new cavernous sinus invasion. He underwent repeat endoscopic biopsy, which yielded positive cultures for Nocardia farcinica and prompted successful treatment with trimethoprim-sulfamethoxazole and linezolid.

LESSONS

The current study highlights a previously unreported clinical entity, the first pituitary abscess attributable to Nocardia sp. or N. farcinica, which arose in a young, immunocompetent individual. Although rare, atypical infections represent an important component in the differential diagnosis for sellar mass lesions.

Open access

Transventricular endoscopic approach to the anterior interhemispheric fissure for neurocysticercosis: illustrative cases

Mao Vásquez, Luis J. Saavedra, Hector H. García, Alejandro Apaza, Yelimer Caucha, Jorge E. Medina, Dennis Heredia, Fernando Romero, and William W. Lines-Aguilar

BACKGROUND

Neurocysticercosis (NCC) is a global public health problem. It is a complex disease to manage and a cause of great morbidity and mortality in affected patients. Conventional surgical approaches have been used for many years, but currently, minimally invasive approaches are being used with good results. The authors present a case of NCC in the anterior interhemispheric fissure that was treated with a transventricular endoscopic approach.

OBSERVATIONS

A 32-year-old male patient was admitted for persistent moderate headache and dizziness. Gadolinium-enhanced magnetic resonance imaging (MRI) showed multiple parenchymal, ventricular, and subarachnoid cystic lesions, especially in the anterior interhemispheric space. A transventricular endoscopic approach was selected and applied. There were no complications during surgery. Pathological analysis confirmed the diagnosis of NCC. Control MRI demonstrated the absence of cysts in the anterior interhemispheric space.

LESSONS

Minimally invasive approaches are an excellent alternative for patients with NCC, especially if a patient requires more than one surgery.

Open access

Endoscope-assisted far lateral craniotomy for resection of posterior fossa neurocysticercosis: illustrative case

Jerrell Fang, Christopher Banerjee, Amanda Barrett, Bruce C. Gilbert, and Martin J. Rutkowski

BACKGROUND

Neurocysticercosis is a parasitic infection that commonly affects the ventricles, subarachnoid spaces, and spinal cord of the central nervous system. The authors report an unusual manifestation of purely posterior fossa neurocysticercosis treated with endoscope-assisted open craniotomy for resection.

OBSERVATIONS

A 67-year-old male presented with 2 months of progressive dizziness, gait ataxia, headaches, decreased hearing, and memory impairment. Imaging revealed an extra-axial cystic lesion occupying the foramen magnum and left cerebellopontine angle with significant mass effect and evidence of early hydrocephalus. Gross-total resection was accomplished via a left far lateral craniotomy with open endoscopic assistance, and pathological findings were consistent with neurocysticercosis. Postoperatively, he was noted to have a sixth nerve palsy, and adjuvant therapy included albendazole. By 9 months postoperatively, he exhibited complete resolution of an immediate postoperative sixth nerve palsy in addition to all preoperative symptoms. His hydrocephalus resolved and did not require permanent cerebrospinal fluid (CSF) diversion.

LESSONS

When combined with traditional skull base approaches, open endoscopic techniques allow for enhanced visualization and resection of complex lesions otherwise inaccessible under the microscope alone. Recognition and obliteration of central nervous system neurocysticercosis can facilitate excellent neurological recovery without the need for CSF diversion.

Open access

Chronic allergic fungal sinusitis invading the skull base in an immunocompetent male: illustrative case

Anant Naik, Darrion Bo-Yun Yang, Frank J. Bellafiore, Muhamad A. Amine, and Wael Hassaneen

BACKGROUND

Allergic fungal sinusitis (AFS) is an immunoglobulin E–mediated reaction to fungal organisms in the sinonasal region and can be categorized as acute or chronic. Acute infection is typical in immunocompromised patients, while chronic infection is classically seen in immunocompetent patients. Spread of infection to the skull base is a rare and potentially lethal complication of prolonged infection. Surgical management is frequently augmented with steroid therapy to prevent recurrence.

OBSERVATIONS

The authors present a case of a 20-year-old African American male with prolonged headaches and blurred vision who was diagnosed with chronic invasive fungal sinusitis resulting in invasion of fungal burden into the anterior skull base and the posterior aspect of the clivus, in addition to complete obliteration of the maxillary sinus. The patient was managed surgically without complication and with gradual improvement in vision.

LESSONS

Early management and detection of AFS should be a focus to prevent erosion of the fungal burden into the skull base. Neurosurgery and ear, nose, and throat surgery have a multidisciplinary role in the management of advanced AFS cases.