Elsevier

World Neurosurgery

Volume 108, December 2017, Pages 990.e1-990.e9
World Neurosurgery

Case Report
Treating Cerebrospinal Fluid Rhinorrhea without Dura Repair: A Case Report of Posterior Fossa Choroid Plexus Papilloma and Review of the Literature

https://doi.org/10.1016/j.wneu.2017.08.121Get rights and content

Background

Choroid plexus papilloma revealed by nontraumatic cerebrospinal fluid (CSF) rhinorrhea has only been described 5 times, to our knowledge, in the literature. The challenges in this situation are to recognize CSF leak, to rapidly understand the pathophysiology of the leak, and to choose the best treatment strategy in emergency. We report an original case of posterior fossa choroid plexus papilloma revealed by CSF leak. We then discuss the surgical strategy and the pathophysiology of CSF leak, which is explained, in this case, by both hyperproduction of CSF and local skull base erosion.

Case Description

We report the case of a 47-year-old man who has developed spontaneous rhinorrhea, right hearing loss, and confusion. A choroid plexus papilloma of the right cerebellomedullary cistern was diagnosed. Hydrocephalus and pneumocephalus were associated with an erosion of the homolateral skull base. The patient underwent surgical total tumor removal by a median suboccipital approach after implantation of a temporary external ventricular drainage. The patient recovered completely without any recurrence of CSF rhinorrhea. The 5-month postoperative images show total bone re-growth and resolution of hydrocephalus.

Conclusions

Our case shows that 1) causal reasoning is of major importance when dealing with CSF rhinorrhea and that 2) dura repair can be avoided when treating CSF leak secondary to posterior fossa choroid plexus papilloma.

Introduction

Nontraumatic cerebrospinal fluid (CSF) rhinorrhea1 represents only 3%–4% of rhinorrheas. They have different classifications, mostly according to CSF pressure.2 The causes of high-pressure CSF leaks are hydrocephalus, tumors, and idiopathic intracranial hypertension.3, 4, 5, 6, 7 This latter entity demonstrates that elevation of the intracranial pressure can, by itself, cause the leak. In the case of tumor, the mechanism of CSF leak could be direct, by erosion of meninges and bone, or indirect, by pressure erosion of anatomically fragile areas of the skull base.2, 8, 9 The treatment of a CSF leak is an emergency because of the risk of meningitis. The 2 challenges in this situation are 1) to rapidly identify the cause of the CSF leak and 2) to treat the leak to avoid or to help antibiotic treatment of meningitis.

We report the case of a patient treated for a spontaneous CSF rhinorrhea who presented with a posterior fossa choroid plexus papilloma (CPP). Only 5 cases of CSF rhinorrhea secondary to a CPP have been previously reported, to our knowledge.9, 10, 11, 12 Beyond the rarity of this clinical entity, the main interest of this case is to demonstrate that treatment of the CSF leak can be achieved by treating the cause, i.e., removal of the CPP, without dura repair.

Section snippets

Case Report

Written informed consent was obtained from the patient for publication of this case report and the accompanying images.

Discussion

We report the case of a patient with spontaneous CSF leak treated by etiological treatment—surgical removal of a CPP of the cerebellomedullary cistern—without dura repair. Beyond the difficulty of diagnosis, the originalities of this case are 1) to discuss the pathophysiology of CSF leak associated with CPP and 2) to show that, in this case, surgery should focus on removing the CPP rather than on trying to treat at any cost both the primary cause and the dural fistula.

We found 5 cases of CSF

Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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