Where is the Leak?


R. Murali, M.D.

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