Abstract
While infrequent, cerebrospinal fluid (CSF) leaks are known to occur after surgical resection of vestibular schwannomas. Early signs of CSF leak often include headache and altered mental status. If untreated, life-threatening complications can occur, including brainstem herniation and meningitis. The appropriate surgical treatment for a CSF leak requires accurate localization of the source. While the most likely location of a CSF leak after lateral skull base surgery is through the aerated portions of the temporal bone, we present a unique case of a man with a prolonged CSF leak after an acoustic tumor removal who was ultimately found to have an occult spinal perineural (Tarlov) cyst as the source. Accurate localization was ultimately achieved with CT myelogram after empirically obliterating his mastoid failed to restore intracranial CSF volume. Tarlov cysts are the most common cause of idiopathic intracranial hypotension, and this case highlights the importance of considering this entity in the differential diagnosis of postoperative CSF leaks.
Highlights
Cerebrospinal fluid (CSF) leaks after resection of vestibular schwannomas occur in approximately 10% of cases [1]
While the most likely location of a cerebrospinal fluid (CSF) leak after lateral skull base surgery is through the aerated portions of the temporal bone, we present a unique case of a man with a prolonged CSF leak after an acoustic tumor removal who was found to have an occult spinal perineural (Tarlov) cyst as the source
We present a unique report of a man with prolonged CSF leak after skull base surgery from an occult spinal perineural cyst to highlight this rare but important exception to the rule
Summary
Cerebrospinal fluid (CSF) leaks after resection of vestibular schwannomas occur in approximately 10% of cases [1]. He reported occasional small volume rhinorrhea, which was not associated with straining or head position. T1-weighted magnetic resonance imaging (MRI) demonstrating the left 2.7 cm vestibular schwannoma (A) before and (B) nine months after surgical resection and reconstruction of the internal auditory canal (IAC) bone with hydroxylapatite. While the MRI did not show evidence of spinal CSF extravasation, a CT myelogram revealed multiple small perineural cysts of the thoracic spine (Figure 4). These were empirically treated with an autologous blood patch with fibrin glue followed by a surgical duraplasty of four thoracic cysts, which resolved his symptoms and his MRI findings (Figure 2B). CT myelogram in (A) axial and (B) coronal reconstruction demonstrating bilateral small perineural (Tarlov) cysts of the spine at multiple levels (white arrows)
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