Neurology India Medknow Publications on behalf of the Neurological Society of India ISSN: 0028-3886 EISSN: 1998-4022 Vol. 58, Num. 6, 2010, pp. 974-975

Neurology India, Vol. 58, No. 6, November-December, 2010, pp. 974-975

Letter to Editor

Unusual manifestation of an orbital roof fracture in a child: Acute orbital leptomeningeal porencephalic cyst

Manish Ranjan¹, A Arivazhagan¹, Prasad Chandrajit², BA Chandramouli¹

¹ Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, India
² Department of Neuroradiology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, India
Correspondence Address: Manish Ranjan, Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore - 560 029, India, drmanishranjan@gmail.com

Date of Acceptance: 07-Aug-2010

Code Number: ni10280

PMID: 21150082
DOI: 10.4103/0028-3886.73773

Sir,

Growing skull fracture (GSF)/leptomeningeal cyst arising from orbital roof fracture is a very rare and delayed complication of pediatric head injury, having a median time of occurrence of around 6.7 to 14 months following trauma. ^[1],[2],[3] We report a rare development of acute orbital leptomeningeal cyst in direct communication with ventricular system (acute orbital leptomeningeal porencephalic cyst).

A 12-year-old boy presented with raised intracranial pressure (ICP) features and acute nontender pulsatile right-sided extra-axial proptosis with preserved vision following a non-penetrating head injury ten days prior to presentation. He was drowsy, arousable, with Glasgow Coma Scale (GCS) score of E3M6V5 with no neurological deficits. Computerized tomography (CT) head revealed a well-defined hypodense non-enhancing lesion in the orbit with overlying bony defect of orbital roof [Figure - 1]a. The right frontal lobe was hypodense and appeared to be communicating with the orbital lesion. Bilateral lateral ventricles were dilated. He acutely deteriorated in sensorium to GCS E1M2V1 and underwent emergency external ventricular drain placement. Ventricular cerebrospinal fluid (CSF) was under high pressure and clear. A contrast ventriculogram revealed communication between the frontal horn of right ventricle and cystic orbital lesion [Figure - 1]b. Subsequent magnetic resonance imaging (MRI) better delineated the communication of the ventricle to the orbital cyst and dural breach on T2-weighted (T2W) [Figure - 2]b and CISS 3D sequences [Figure - 2]c. The communicating tract margins were hyperintense on T1-weighted (T1W) image [Figure - 2]a and hypointense on T2W image, suggesting subacute hemorrhage (representing hemorrhagic laceration of frontal lobe). He underwent ventriculoperitoneal shunt surgery, following which his raised ICP and proptosis completely resolved.

The early development of GSF is very rare and has been attributed to hygroma around fracture line, severe brain injury, increased intracranial pressure, cerebral edema or contusion, hydrocephalus or other intracranial fluid collections. ^[4] In our patient, the early occurrence of the GSF can be attributed to acute hydrocephalus. Acute posttraumatic hydrocephalus has been described in literature in association with intraventricular hemorrhage (IVH)/ clot and posttraumatic aqueductal stenosis, ^[5],[6] which even may not be seen on initial CT scanning and can develop acutely. ^[6] We believe that our patient developed acute hydrocephalus possibly due to an IVH, and communication from the ventricle to the orbital cyst is secondary to laceration of the frontal lobe as delineated in MR images.

This case represents a rare development of acute orbital leptomeningeal porencephalic cyst, to the best of our knowledge, not reported in literature. Early diagnosis is the key, as prompt treatment can prevent serious but notably reversible neuro-opthalmic complications.

References

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