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A case of
Trapped temporal horn
Dr.
Purav P Patel,
Dept. Neurosurgery,
Apollo Hospitals, Chennai, India.
This 22 yr old female, is a known case of TB meningitis and
treated with ATT for 13 months in 1994.
In
1999, she developed communicating hydrocephalus, and was initially
treated conservatively with steroids, and later with a
ventriculo-peritoneal shunt elsewhere in June
2003.
She
developed bifrontal headache of two weeks duration, which was on
& off in nature, and associated with vomiting.
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CT brain (plain) showed trapped Rt. temporal horn with
mass effect, and she was referred to us for further
treatment.
There was no other relevant history.
On examination, she was conscious, alert, oriented with
a visual field defect (Left Superior temporal quadrantanopia)
and brisk deep tendon reflexes.
On 27/06/2003, a Rt. Temporal horn –Peritoneal shunt (Chhabra) was
done, and she improved.
Post op CT(28/06/2003) revealed the Shunt tube in situ with less dilated Rt.
Temporal horn with surrounding hypodense area suggestive of
gliosis. |
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CT brain (plain) showed trapped Rt. temporal horn
with mass
effect, | |
On
18/07/2003,
she was readmitted with severe Rt. sided headache and mild weakness
of Lt Hand.
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MRI brain showed dilated Rt. Temporal horn
with mass effect. MRI showed Trapped temporal horn with
mass effect.
On 20/07/2003: Revision of
shunt:
Rt Temporal horn to Lt. Pleural low pressure shunt.
Post-operatively, she improved. |
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dilated Rt. Temporal
horn | |
24/07/2003: CT brain (p) revealed minimal decrease in size of
Rt. Temporal horn with small intraventricular bleed.
She
was managed conservatively & discharged.
On
12/08/2003,
severe continuous headache, associated with continuous vomiting
relapsed.
CT
brain (p) revealed dilated trapped Rt. Temporal horn with shunt tube
slightly displaced out of ventricle, with minimal mass effect. She
improved with mannitol & steroids.
On
24/08/2003,
she again presented with severe headache with continuous
vomiting.
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CT brain (p) suggested dilatation of temporal
horn of Rt. Lateral ventricle (slightly increased size
as compared to CT on 13/08/2003) with shunt tube tip in
superior aspect of possibly outside temporal
horn.
Patient had low grade fever for 2 days. Analysis
of CSF fluid aspirated from Rt. Temporal & Lt.
Pleural end revealed mature lymphocytes. Culture studies
revealed no growth. She was treated with
antibiotics.
On 11/09/2003, a Rt. Temporal horn to peritoneal shunt was
done. |
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CT brain (plain) showed trapped Rt.
temporal horn with mass
effect. | | |
CSF
analysis showed persistent cells with negative culture; PCR for TB
was negative.
On
suspicion of colonization of V-P shunt tube as the cause of
persistent cells, removal of the old Rt. Ventriculo peritoneal shunt
and removal of the temporal horn to peritoneal shunt were carried
out done on 28/09/2003.
CT
brain on 30-9-03 showed dilated Rt. Temporal horn with mass effect
without dilatation of other parts of the
ventricles
To Summarize......
22-yr old lady with VP shunt done in 99 for?
TBM-Hydrocephalus presented with Trapped Temporal Horn – Rt.
side.
Repeated shunting of the TTH to peritoneal / pleural cavities
failed.
CSF
from the TTH revealed persistent cells with negative
culture
For Discussion....
Ø What is the cause of persistent cells?
Ø Is
it TBM? Is it Shunt infection?
Ø Can
Endoscopy done at this stage?
Ø What is the management at this stage?
Ø Patient is symptomatic and CT shows persistent TTH with mass
effect
Management
On
29/09/2003, exploration of Rt. trapped temporal horn was done.
There was a cyst within the temporal horn, which was
removed. Partial temporal lobectomy to communicate the
temporal horn to Subarachnoid space was done along with fenestration
to basal cistern.
Post op. period was uneventful.
HPE: suggestive of cysticerciosis, and she was treated
with a course of Albendazole for any systemic
cysticerosis
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Histopathology |
the cyst at
surgery |
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Patient is asymptomatic and her visual fields recovered. Follow up CT after 2 weeks showed no
Hydrocephalus.
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