Presentation
Rhinorrhea with headache for one week. Deny history of recent trauma or nasal infection.
Patient Data
A well-defined cystic lesion is seen at the left anterior ethmoidal air cells, measuring 12x 12 x 17 mm (AP x W x CC). No definite enhancement or internal calcification. This lesion communicates with the left anterior cranial fossa via the left vertical lamina defect. The defect measures 4.3 mm. No protrusion of brain parenchyma into the aforementioned cystic lesion. No intraorbital extension.
Fluid density is seen at the left frontal and left maxillary sinuses.
Minimal mucosal thickening is seen at the left agger nasi air cells and right maxillary sinus.
Bilateral agger nasi air cells and Onodi cells were noted. No concha bullosa.
No intracranial hemorrhage. No focal brain enhancing parenchymal lesion or abnormal leptomeningeal enhancement. No midline shift. No mass effect. Ventricles are not dilated. Basal cisterns are not effaced.
A well-defined T1 hypointense and T2 hyperintense lesion is seen at the left anterior ethmoidal air cells, measuring 12 x 12 x 16 mm (AP x W x CC). The lesion shows almost total signal suppression on the FLAIR sequence. No definite enhancement. There is communication with floor of the left anterior cranial fossa with its neck measuring 4.3mm. Small focal defect seen at the inferior aspect of this lesion, which appears communicating with left medial meatus. Presence of cerebrospinal fluid within the left-sided ethmoidal sinus. No evidence of encephalocele. No intraorbital extension.
Minimal mucosal thickening is noted at both agger nasi and bilateral maxillary sinuses. Fluid intensity is seen at the left maxillary sinus.
Bilateral osteo-meatal complexes are preserved. Minimal nasal septum deviation to the left.
Left inferior nasal turbinate hypertrophy. No concha bullosa.
Small non-specific T2/ FLAIR hyperintense focus is observed at deep white matter of left centrum semiovale. The rest of brain parenchyma is normal.
Case Discussion
Imaging features are suggestive of ethmoidal meningocele without brain tissue herniation complicated with CSF leakage (CSF rhinorrhea).
The patient was planned for a semi-emergency operation of skull base repair. Unfortunately, patient developed pulmonary embolism before the operation. She is now on anticoagulant as treatment for pulmonary embolism and under ENT clinic follow up.
Ethmoidal meningocele represents extracranial herniation of meninges and CSF through a cranial defect in the anterior cranial fossa.
Its complications include meningitis and CSF leakage.
It could be an incidental finding, which mimics ethmoidal mucosal thickening or ethmoidal mucocele. Findings of cranial defect can confirm the diagnosis.
CT and MRI are helpful to diagnose meningocele 1.
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