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A 45 year old man was operated 2 years ago elsewhere for a PINEAL region
epidermoid cyst. The surgery was done through a Right parieto-occiptal aprroach.
For the last 6 months he has been rather dull, lethargic and slow to respond for
which he has come to me. On examination he was conscious, very slow to
respond to questions but he answered appropriately. He was taking orally
but slow to swallow. His general demeanor was lethargic. He had no papilloedema
and no symptoms of raised ICP. There was no focal deficit. He has a VP shunt the
ventricular end of which is in the Right frontal horn.
On
his first admission, the CT scan showed no residual tumor but had enlarged
ventricles filled with AIR. So I aspirated the frontal horn through the reservoir
of the shunt following which he improved. Repeat CT also showed a
reduction in the amount of air. I discharged him and he came back a week
later with increase in lethargy as before. CT showed re-enlargement of the
ventricles.
This
time I injected dye into the frontal horn and
the pictures are what you see. The dye comes down up to the cribriform plate but
not into the nasal cavity even after 24 hours.
Where is the air leaking from?
Can he be operated hoping the leak will be from the cribriform plate?
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(c) 2007 M.H. Rivner
June 17, 2007