Case 29: hydrocephalus

posted: March 24, 1998

Resident: Bryan Payne, MD
Attending: Deepak Awasthi, MD

CLINICAL PRESENTATION: This 29 year black man presented to the emergency room with progressive and constant headaches of one week duration. These headaches were accompanied with nausea and vomiting. Patient has a history of hydrocephalus (? etiology) diagnosed in March of 1996. At that time a ventriculoperitoneal shunt was placed with improvement of symptoms of headache and nausea. Patient subsequently had two recent revisions. First one in December of 1997 (peritoneal end) and the next one in January of 1998 (proximal end with a change to a high pressure valve- patient had small ventricles and thinkink was he had a "slit-vetricle" syndrome). His headaches persisted despite these revisions and progressively worsened 1 week prior to admission. Patient's past history is significant for a family history of sarcoidosis; no history of overseas travel, lung problems, coughing, fever, chills, seizures, weakness, visual changes. Patient was no medications when admitted to the hospital.

EXAMINATION: On examination pateint was awake and in moderate distress. He was confused 9did not know palce and time). Vital signs on admission BP: 130/70; P90; T: afebrile; RR: 18
Patient had dysconjugate gaze (left eye tended to deviate outwards). Patient was able to use the extraocular muscles bilaterally. Cranial nerves II-XII intact bilateral; good motor strength bilat. Sensation intact. No dysmetria. Gait unstable (balance difficulty). Reflexes normal; no pathological reflexes. Shunt palpated; depressed and refilled quickly.

DIAGNOSTIC STUDIES: A shunt series was performed- shunt intact. Shunt tap: no sign of infection; Cranial CT scan was done. A representative view is shown below:

Cranial CT scan without contrast (left) and with contrast (right) showing the ventricular system to be decompressed with the tip of the shunt in the right frontal horn. No enhancing lesions are appreciated. Note the hypodensity in the left frontal lobe (? etiology).

How would you proceed at this time?

Please comment: dawast@lsuhsc.edu

STEPS TAKEN AT LSU: We elected to get a MRI scan of the brain (with and without contrast)- representative views are shown below:

A T1WI with contrast (coronal view) showing enhancement of the leptomeninges (red marker) and enhancing lesions in the cerebellar hemispheres (bilaterally)

Additional enhancing lesions

Enhancement in the frontal fossa bilaterally

Of note, T2WI (axial) did not reveal these lesions, nor did the non-contrast studies

What is the differential diagnosis and how would you proceed?

Please comment: dawast@lsuhsc.edu

We elected to perform an open biopsy through a right frontal approach. Intraoperatively, a thick fibrous lesion was noted inthe frontal fossa. This along with a small piece of the anterior frontal lobe and dura were send for pathology as well as TB, bacterial, fungal and parasitic cultures.

The final diagnosis is tuberculosis. No evidence on chect CT and PPD non-reactive.

Patient has been improving with anti-TB medications.

Comments and Questions about this interesting case are welcomed. Please e-mail: dawast@lsuhsc.edu

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