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LETTER TO EDITOR
Year : 2014  |  Volume : 62  |  Issue : 6  |  Page : 700-701

Spontaneous indirect CSF rhinorrhea following excision of a giant choroid plexus papilloma of lateral ventricle


Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, Karnataka, India

Date of Submission15-Nov-2014
Date of Decision05-Dec-2014
Date of Acceptance17-Dec-2014
Date of Web Publication16-Jan-2015

Correspondence Address:
Laxminadh Sivaraju
Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Whitefield, Bangalore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.149434

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How to cite this article:
Sivaraju L, Sai Kiran NA, Dadlani R, Hegde AS. Spontaneous indirect CSF rhinorrhea following excision of a giant choroid plexus papilloma of lateral ventricle. Neurol India 2014;62:700-1

How to cite this URL:
Sivaraju L, Sai Kiran NA, Dadlani R, Hegde AS. Spontaneous indirect CSF rhinorrhea following excision of a giant choroid plexus papilloma of lateral ventricle. Neurol India [serial online] 2014 [cited 2019 Nov 21];62:700-1. Available from: http://www.neurologyindia.com/text.asp?2014/62/6/700/149434


Sir,

Indirect cerebrospinal fluid (CSF) rhinorrhea following excision of large remote intracranial lesions is uncommon. [1] This report describes a case of CSF rhinorrhea following total excision of a giant choroid plexus papilloma (CPP).

A 26-year-old male presented with headache and decreased visual acuity in both eyes of 6-month duration. There was no history of CSF rhinorrhea. On examination, perception of light was absent in both the eyes. Fundus examination was suggestive of secondary optic atrophy. Magnetic resonance imaging (MRI) revealed a large intensely enhancing intraventricular tumor involving the body of the right lateral ventricle with extension to trigone and temporal horn associated with perilesional edema and hydrocephalus [Figure 1]a-c. There was significant mass effect and midline shift. Herniation of brain through multiple defects in anterior cranial fossa (ACF) base was noted [Figure 1]d and e.
Figure 1: Preoperative MRI: Axial T1 - weighted images with contrast (a and b) and coronal T2 - weighted image (c) showing a large right lateral ventricular lesion. Sagittal (d), coronal (e) MRI images showing herniation of brain (arrows) through bony defects at the base of anterior cranial fossa. CT cisternogram (f) after first surgery showing leak of contrast (arrow) from the base of anterior cranial fossa. Postoperative (2 weeks after second surgery) contrast CT (g and h) showing complete excision of the lesion and hydrocephalus. MRI = Magnetic resonance imaging, CT = computed tomography

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Right temporal craniotomy and gross total excision of the tumor was done. Bone flap was not replaced as the brain was full at the end of surgery. Initial postoperative period was uneventful. Histopathology was suggestive of CPP. On the 2 nd postoperative day, patient developed profuse CSF rhinorrhea which was resistant to conservative measures. Computed tomography (CT) revealed increase in the perilesional edema and normal-sized ventricles. CT cisternogram revealed ACF base defects near the cribriform plate [Figure 1]f. In view of large and multiple bony defects in the ACF base, craniotomy and repair of the defects was considered to be a better option than endoscopic repair. Bifrontal craniotomy and repair of the ACF base was done with a vascularized pericranial graft and fibrin glue. Large bilateral dural and bony defects in ACF base were noted during surgery. CSF rhinorrhea completely stopped after ACF base repair. CT brain done 2 weeks later showed gross hydrocephalus and complete excision of the tumor [Figure 1]g and h. Left ventriculoperitoneal shunt was done. At the time of discharge, patient had no new neurological deficits and there was no improvement in his vision.

CSF rhinorrhea can be caused by neoplasms in two ways. In the direct type of CSF rhinorrhea, the neoplastic lesions like pituitary adenomas directly cause erosion of meninges and bone. In indirect type of CSF rhinorrhea, raised intracranial pressure (ICP) results in progressive erosion of skull base. [1] Thin bone near the cribriform plate is the most common site of bony erosion in indirect type of CSF rhinorrhea.

Indirect type of CSF rhinorrhea commonly present before the excision of the tumor (pretreatment type) and rarely after tumor excision (posttreatment type). [1],[2],[3],[4],[5] The bony defects in pretreatment type tend to be smaller as the raised ICP is reduced by CSF leak and such small defects usually heal spontaneously after tumor excision. [1],[4],[5] The bony defects in posttreatment type are usually larger. [1] Herniating brain due to raised ICP plugs the bony and dural defects before tumor excision. Persistent raised ICP results in further herniation of brain tissue and progressive enlargement of the bony defects. [1] Decrease in ICP following tumor excision results in unplugging of these defects and profuse CSF rhinorrhea. [1] As the mechanism of posttreatment CSF rhinorrhea is due to unplugging of the large defect, there are seldom chances of settling of CSF rhinorrhea with any conservative measures.

CPPs usually present with symptoms of raised ICP due to hydrocephalus secondary to excessive CSF production or obstruction of CSF pathways by the tumor. [2],[3],[4],[5] CPPs presenting with indirect type of CSF rhinorrhea is uncommon. [3],[5] Unlike the present case, most of the reported cases of CSF rhinorrhea associated with CPPs are of pretreatment type. [2],[3],[4],[5] Immediate imaging to identify the defect and repair of the defect is the preferred line of management in posttreatment type of indirect CSF rhinorrhea.

 
  References Top

1.
Liang CL, Lu K, Lee TC, Su TM, Chen HJ. Non-traumatic cerebrospinal fluid rhinorrhea indirectly caused by remote brain tumor: A case report and review of the literature. Clin Neurol Neurosurg 2001;103:83-6.  Back to cited text no. 1
    
2.
Kinoshita Y, Wasita B, Akatsuka K, Kambe A, Kurosaki M, Watanabe T. Choroid plexus papilloma presenting with cerebrospinal fluid rhinorrhea and otorrhea: Case report. Neurol Med Chir (Tokyo) 2010;50:930-3.  Back to cited text no. 2
    
3.
Lamberts AE. Choroid plexus papilloma with cerebrospinal fluid rhinorrhea. Surg Neurol 1984;22:576-8.  Back to cited text no. 3
    
4.
Rovit RL, Schechter MM, Nelson K. Spontaneous "high-pressure cerebrospinal rhinorrhea" due to lesions obstructing flow of cerebrospinal fluid. J Neurosurg 1969;30:406-12.  Back to cited text no. 4
    
5.
Symss NP, Prasad AN, Vasudevan MC, Ramamurthi R. Exophytic choroid plexus papilloma of the fourth ventricle presenting with cerebrospinal fluid rhinorrhea: A case report. Surg Neurol 2009;71:705-8.  Back to cited text no. 5
    


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