A PEEK into the well: an elegant fix for a complex pseudomeningocoele
EANS Academy. Bhatt H. 09/25/19; 275467; EP12009
Mr. Harsh Bhatt
Mr. Harsh Bhatt

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Abstract
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Symptomatic pseudomeningocoeles following midline posterior fossa craniectomies for childhood tumours can be challenging to treat and repair. This is compounded in patients with complex hydrocephalus and altered cerebrospinal fluid (CSF) dynamics. Previously described operative solutions include CSF diversion, revision duroplasty and titanium mesh or hydroxyapatite bone cement cranioplasties for lateral posterior fossa/ retrosigmoid approaches. However, for midline defects presenting with delayed symptomatic pseudomeningocoeles, custom-made polymer implants haven't been widely described, to the best of our knowledge.
We present one such case in a 28-year-old male who had a cerebellar pilocytic astrocytoma resected aged eight and subsequent ventriculo-peritoneal shunting for hydrocephalus. An indolent presentation followed with bilateral progressive sensorineural hearing loss, imbalance and classical low-pressure symptoms, and an MRI scan revealed extensive superficial siderosis. For the siderosis, a likely rare complication of his initial tumour surgery, he commenced deferiprone under neurology guidance. Multiple trials of various programmable shunt valves and antisiphon devices had failed to resolve his low-pressure symptoms. Primary closure and a previous attempt to obliterate the pseudomeningocoele cavity had also failed due to the sheer and rigid cavitation present. We theorised that one possible solution to obliterate the cavity would be to design a custom-made polyether ether ketone (PEEK) implant to fit the pseudomeningocoele.
A post-operative Indium-111-DTPA cisternogram revealed complete obliteration of the pseudomeningocoele. The patient's low-pressure symptoms gradually improved in the subsequent period, in addition to his hearing and balance to some degree. We postulate that longstanding complex pseudomeningocoeles do have significant neo-epithelial absorptive capacity, and that obliteration of such spaces with custom-made implants may provide an elegant solution.


[Pre- and post-op CTs, intra-op implant view and cisternogram recons (with patient's kind permission)]

Symptomatic pseudomeningocoeles following midline posterior fossa craniectomies for childhood tumours can be challenging to treat and repair. This is compounded in patients with complex hydrocephalus and altered cerebrospinal fluid (CSF) dynamics. Previously described operative solutions include CSF diversion, revision duroplasty and titanium mesh or hydroxyapatite bone cement cranioplasties for lateral posterior fossa/ retrosigmoid approaches. However, for midline defects presenting with delayed symptomatic pseudomeningocoeles, custom-made polymer implants haven't been widely described, to the best of our knowledge.
We present one such case in a 28-year-old male who had a cerebellar pilocytic astrocytoma resected aged eight and subsequent ventriculo-peritoneal shunting for hydrocephalus. An indolent presentation followed with bilateral progressive sensorineural hearing loss, imbalance and classical low-pressure symptoms, and an MRI scan revealed extensive superficial siderosis. For the siderosis, a likely rare complication of his initial tumour surgery, he commenced deferiprone under neurology guidance. Multiple trials of various programmable shunt valves and antisiphon devices had failed to resolve his low-pressure symptoms. Primary closure and a previous attempt to obliterate the pseudomeningocoele cavity had also failed due to the sheer and rigid cavitation present. We theorised that one possible solution to obliterate the cavity would be to design a custom-made polyether ether ketone (PEEK) implant to fit the pseudomeningocoele.
A post-operative Indium-111-DTPA cisternogram revealed complete obliteration of the pseudomeningocoele. The patient's low-pressure symptoms gradually improved in the subsequent period, in addition to his hearing and balance to some degree. We postulate that longstanding complex pseudomeningocoeles do have significant neo-epithelial absorptive capacity, and that obliteration of such spaces with custom-made implants may provide an elegant solution.


[Pre- and post-op CTs, intra-op implant view and cisternogram recons (with patient's kind permission)]

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