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Table of Contents    
LETTERS TO EDITOR
Year : 2015  |  Volume : 63  |  Issue : 6  |  Page : 958-960

Migrated autologous fat graft presenting as a ring enhancing lesion of brain: A novel complication of endoscopic transnasal duroplasty for posttraumatic cerebrospinal fluid rhinorrhoea


1 Department of Radiodiagnosis, Kasturba  Medical College, Manipal University, Manipal, Karnataka, India
2 Department of Neurosurgery, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
3 Department of Pathology, Melaka Manipal Medical College, Manipal University, Manipal, Karnataka, India

Date of Web Publication20-Nov-2015

Correspondence Address:
Sandeep Kumar
Department of Radiodiagnosis, Kasturba  Medical College, Manipal University, Manipal, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.170083

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How to cite this article:
Kumar S, Nair RP, Maddukuri SB, Hasan R. Migrated autologous fat graft presenting as a ring enhancing lesion of brain: A novel complication of endoscopic transnasal duroplasty for posttraumatic cerebrospinal fluid rhinorrhoea. Neurol India 2015;63:958-60

How to cite this URL:
Kumar S, Nair RP, Maddukuri SB, Hasan R. Migrated autologous fat graft presenting as a ring enhancing lesion of brain: A novel complication of endoscopic transnasal duroplasty for posttraumatic cerebrospinal fluid rhinorrhoea. Neurol India [serial online] 2015 [cited 2019 Aug 23];63:958-60. Available from: http://www.neurologyindia.com/text.asp?2015/63/6/958/170083


Sir,

Cerebrospinal fluid (CSF) rhinorrhoea results from a fistulous communication between the subarachnoid space and sinonasal cavity. The various causes include trauma, endoscopic sinus surgery, congenital defects in dura mater, tumor invasion of skull base, and hydrocephalus.[1] Trauma is the most common cause of CSF rhinorrhoea, accounting for almost 90% of all such cases, with the reported incidence of 1–3% in all closed head injuries and 30% in all skull base fractures.[1],[2] Majority of the patients with a traumatic CSF rhinorrhoea respond well to conservative therapy, which is aided by the natural healing process of blood clot formation, inflammatory plugging, or herniating leptomeninges/brain tissue which cover the defect. However, approximately one-third of patients with traumatic CSF rhinorrhoea require surgical intervention as persistent leak can have grave sequel such as meningitis (4–50%), encephalitis, and brain abscess.[1] Endoscopic endonasal duroplasty repair has become the established standard-of-care for CSF rhinorrhoea, replacing the classic open skull base surgical procedures, due to its low morbidity and high success rates. The various graft materials used for duroplasty include cartilage, bone, septal mucosa, abdominal fat, fascia, mucoperichondrium, pedicled tissue, and composite grafts. We present a novel complication of intracranial migration of autologous fat graft for CSF rhinorrhoea, presenting as a frontal lobe ring enhancing lesion with small fatty droplets at its periphery, resembling a "garland sign."

A 22-year-old man presented to our neurosurgery outpatient clinic with a history of fever, headache, and vomiting of 4 days duration. He had a history of closed head injury 4 months back, following which he had developed CSF rhinorrhoea. Initially, he was managed conservatively for his CSF rhinorrhoea and his condition improved. The rhinorrhea, however, recurred after a month. He subsequently underwent an endoscopic endonasal repair using an autologous abdominal fat graft. He was given oral acetazolamide and underwent repeated lumbar punctures to decrease his CSF pressure. He was discharged on the 12th postoperative day in a neurologically stable condition. The patient was symptom-free for 2 months, following which he developed protracted vomiting and headache. He was diagnosed as having meningitis, underwent a diagnostic lumbar puncture, and was started on antibiotics as per the CSF culture report, to which he responded well. However, his symptoms recurred within a month, and he came to our hospital for further management. At presentation, he had a low-grade fever with headache, nausea, and vomiting. He had no neck rigidity, diplopia or CSF rhinorrhoea on clinical examination. There was no history of seizures and no focal motor or sensory neurological deficits. Laboratory investigations were normal except for mild leukocytosis. Magnetic resonance imaging revealed a well-defined intra-axial mass lesion of size 2.7 cm × 2.5 cm × 1.9 cm in the left basifrontal region, appearing hypointense on T1-weighted and hyperintense on T2-weighted images, showing a rim of fat droplets in the periphery with peripheral vasogenic edema [Figure 1]a and [Figure 1]b. The lesion showed central diffusion restriction and there were multiple small intraventricular fat droplets seen in the frontal and temporal horns, and the body of left lateral ventricle [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d. Following contrast administration, the lesion showed a thick, regular, wall enhancement with the fat droplets placed along its inner margins. There was a depressed fracture of the posterior ethmoidal roof and planum sphenoidale, and the inferior margin of the ring enhancing lesion was seen extending across the bony defect into the sphenoid sinus [Figure 3]a,[Figure 3]b,[Figure 3]c,[Figure 3]d. The computed tomography (CT) scan revealed the anterior skull base fractures with multiple small fat droplets outlining the intra-axial hypodense lesion [Figure 4]a and [Figure 4]b.
Figure  1: (a) Axial T1-weighted magnetic resonance image reveals a well-defined hypointense lesion rimmed by multiple hyperintense foci of fat droplets in the left basifrontal region;   (b) axial T2-weighted magnetic resonance image shows the central hyperintensity within the lesion with moderate perilesional white matter edema

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Figure  2: (a) Axial diffusion weighted imaging; and, (b) apparent diffusion coefficient mapping reveal central diffusion restriction within the mass lesion; (c and d) sagittal T1-weighted magnetic resonance image shows multiple small hyperintense fat droplets around the periphery of left basifrontal mass lesion  (white arrow) and in the frontal horn and body of left lateral ventricle  (black arrow)

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Figure  3: Postgadolinium axial T1-weighted magnetic resonance image  (a) without and  (b) with fat saturation reveals smooth peripheral rim enhancement of the lesion with the fat droplets lining the inner margin of the enhancing wall  (arrow). Postcontrast sagittal  (c) and coronal  (d) images reveal extension of the ring enhancing lesion into the sphenoid sinus across the bony defect in planum sphenoidale

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Figure  4: Computed tomography scan  (a) axial and  (b) coronal images reveal the multiple small hypodense fat droplets outlining the intra-axial lesion in the left frontal lobe with fracture in roof of the sphenoid sinus on the left side of midline

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The condition was diagnosed as being an intraventricular and intraparenchymal migrated fat graft, complicated with brain abscess formation. Since, such an imaging feature has never been reported in the literature, an alternative diagnosis of an infected, ruptured dermoid cyst was also offered. However, it was considered as being highly unlikely as the initial CT scan done after the trauma did not show any such pathology in the brain. CSF cultures were sterile and did not yield any growth.

The patient was managed conservatively on crystalline penicillin, chloramphenicol, and metronidazole to cover the spectrum of microorganisms and he responded well. He was discharged on the 8th day of admission. At a follow-up of 2 months, he had no further signs of meningitis.

An autologous fat graft is considered to be very effective in the repair of CSF leaks as it is associated with fewer complications and has a high primary success rate.[3] The reported complication rate following fat graft repair for CSF rhinorrhoea is approximately 1% and is related to fat necrosis, sterile wound discharge, local fistula formation, CSF leakage, and lipoid meningitis.[4],[5] Autologous fat graft migration is a recognized postoperative complication following skull base and lumbar spinal surgeries, leading to complications such as brainstem compression, recurrent sciatica, cervical cord compression, and cauda equina syndrome.[4],[6],[7] In a situation similar to our case, it has been postulated that repeated lumbar punctures or lumbar drainage creates a negative pressure, which acts as the suction force to dislodge the fat droplets from the graft site into the intraparenchymal and the subarachnoid space.[4],[8]

A finding unique to our case, apart from the intraventricular migration of the fat droplets, was the left frontal lobe abscess, which showed an inner rim of fat droplets arranged in a garlanding fashion along its enhancing wall. This is the first description of its kind in English literature, and we propose to call it the "fat garlanding sign."

In the available literature, there is only a single report of intraventricular and intraparenchymal migration of autologous fat graft described and there is no consensus on the management of intracranial fat migration.[4] Since our patient was the first case of an intraparenchymal migrated fat graft associated with a frontal lobe abscess, we could not find any defined management protocol for the entity. As the CSF cultures did not reveal any organisms and the patient had clinical signs of meningitis, he was started on empiric broad spectrum antibiotics, to which he responded very well. He did not have any active CSF rhinorrhoea, suggesting the spontaneous plugging of the endoscopic implantation tract; hence, a repeat surgery was not contemplated. When discharged, the patient had no neurological deficit and is currently well at follow-up.

To conclude, we would like to highlight the challenges faced in the management of skull base fractures complicated with CSF rhinorrhoea and emphasize the importance of close follow-up of patients treated with endoscopic, endonasal autologous fat grafting. We describe a unique complication after the patient underwent CSF leak repair that had a novel imaging appearance. The clinicians and radiologists should be aware of the imaging characteristics of this entity so that treatment is instituted without any delay. We have observed a good clinical response with conservative management in our case but the role of revision surgery needs to be further defined.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal fluid leaks in adults. Radiology 2008;248:725-36.  Back to cited text no. 1
    
2.
Paul P, Upadhyay K. Endoscopic endonasal repair of traumatic CSF rhinorrhoea. Indian J Neurotrauma 2010;7:67-9.  Back to cited text no. 2
    
3.
Black P. Cerebrospinal fluid leaks following spinal surgery: Use of fat grafts for prevention and repair. Technical note. J Neurosurg 2002;96:250-2.  Back to cited text no. 3
    
4.
Ludwig CA, Aujla P, Moreno M, Veeravagu A, Li G. Intracranial fat migration: A newly described complication of autologous fat repair of a cerebrospinal fluid leak following supracerebellar infratentorial approach. Int J Surg Case Rep 2015;7C:1-5.  Back to cited text no. 4
    
5.
Taha AN, Al Mefty R, Pravdenkova S, Al-Mefty O. Sequelae of autologous fat graft used for reconstruction in skull base surgery. World Neurosurg 2011;75:692-5.  Back to cited text no. 5
    
6.
Chen TC, Maceri DR, Levy ML, Giannotta SL. Brain stem compression secondary to adipose graft prolapse after translabyrinthine craniotomy: Case report. Neurosurgery 1994;35:521-3.  Back to cited text no. 6
    
7.
Kansal R, Nama S, Mahore A, Dange N, Kukreja S. Fat graft migration causing recurrent cervical cord compression. Turk Neurosurg 2012;22:502-5.  Back to cited text no. 7
    
8.
Ricaurte JC, Murali R, Mandell W. Uncomplicated postoperative lipoid meningitis secondary to autologous fat graft necrosis. Clin Infect Dis 2000;30:613-5.  Back to cited text no. 8
    


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