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|LETTER TO EDITOR
|Year : 2022 | Volume
| Issue : 4 | Page : 1712-1713
Ruptured Intracranial Dermoid Cyst – Unusual Cause of Obstructive Hydrocephalus
Pooja Jain, Ankita Aggarwal, Swarna G Jain, Savyasachi Jain
Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi, India
|Date of Submission||21-May-2020|
|Date of Decision||17-Aug-2020|
|Date of Acceptance||27-Sep-2021|
|Date of Web Publication||30-Aug-2022|
Department of Radiodiagnosis, VMMC and Safdarjung Hospital, Ansari Nagar East, Near AIIMS Metro Station, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Jain P, Aggarwal A, Jain SG, Jain S. Ruptured Intracranial Dermoid Cyst – Unusual Cause of Obstructive Hydrocephalus. Neurol India 2022;70:1712-3
A 35-year-old gentleman presented to the ER with complaints of seizures and loss of consciousness. Past history of headaches and memory loss was present. Noncontrast CT Brain revealed a well-circumscribed fat attenuation lesion measuring 3 × 4.7 × 3 cm3 (AP × TR × CC) in the left anterior temporal extra-axial space with focal wall calcifications [Figure 1]a. Additionally, multiple such fat attenuating and calcific foci were seen in bilateral subarachnoid cisternal and sulcal spaces [Figure 1]b and [Figure 1]c. Gross obstructive hydrocephalus was seen with transition at foramen at Monro and fat-CSF levels in both lateral ventricles [Figure 1]d. Features of raised intracranial pressure, including diffuse effacement of sulcal spaces and cisterns, and bilateral uncal herniations were seen [Figure 1]e and [Figure 1]f. Final diagnosis of “ruptured dermoid cyst (DC) causing acute obstructive hydrocephalus with raised intracranial pressure” was given. The patient underwent emergency ventriculoperitoneal (VP) shunt surgery for CSF diversion and the postoperative period was uneventful.
|Figure 1: NCCT-Brain Axial image (a) Fat attenuation lesion in left anterior temporal extra-axial space with wall calcifications (red arrow) causing scalloping of the temporal bone (yellow arrow). MinIP-Axial image (b) Subarachnoid extension of fat foci with fat-CSF levels in lateral ventricles. Coronal image (c) Fat foci with calcifications in bilateral periventricular regions (yellow-arrows) Mid-sagittal image (d) Narrowing at the level of the foramen of Monro with inferior descent of pineal gland (red arrow). Axial sections (e and f) Effacement of sulci and cisterns and bilateral uncal herniations (red arrowheads)|
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Intracranial DCs are rare, benign, slow-growing lesions derived from the inclusion of ectodermally committed cells during neural tube closure. DCs are much less common than epidermoids and occur in a younger age group, around the second and third decades.,, They are usually extra-axial midline lesions, with common intracranial sites being the suprasellar cistern, posterior fossa, and frontonasal region.,, Lumbosacral region is the most common site for spinal DCs. Most remain asymptomatic until rupture,, with symptoms arising due to its irritative or compressive effects. DC rupture commonly results in chemical meningitis causing communicating hydrocephalus.,, Other complications include vasospasm, infarction, and even death.,,
On CT, DCs appear intensely hypodense with predominant fat attenuation due to lipid content.,,, Presence of hair, calcification, and debris can cause heterogeneity. Approximately 20% of cases show calcifications in capsule., Cyst rupture dissemination of fat droplets is seen in the cortical and cisternal subarachnoid spaces and as fat-CSF levels in the ventricles.,,
On MRI, DCs are hyperintense on T1WI, with signal intensity on T2WI varying depending on cyst contents.,,, Signal heterogeneity with linear or striated laminations may represent the presence of hair within the cyst. Ruptured DCs demonstrate sulcal FLAIR hyperintensity and bloom on GRE/SWI sequences.
Most DCs do not enhance,,, though leptomeningeal enhancement may be seen with ruptured DCs.,
Close differentials include epidermoid, lipoma, teratoma, and craniopharyngioma.,
Complete surgical resection of the cyst is the goal as recurrence rates are low.,,
Presentation of obstructive hydrocephalus in our case is highly unusual as ruptured DCs more commonly present with communicating hydrocephalus secondary to chemical meningitis.
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Conflicts of interest
There are no conflicts of interest.
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