Intraventricular lipids: A clue to early diagnosis of asymptomatic spinal dural teratoma rupture

Objective: To describe a unique case where incidental intraventricular lipid droplets lead to early diagnosis of spinal dural teratoma. Background: Rupture of spinal mature cystic teratomas leading to intracranial lipid dissemination involving subarachnoid and intraventricular spaces has been reported only few times in literature with a theoretical hypothesis of retrograde flow of lipids through foramen of Lushka and Magendie. Lipids in CSF spaces can cause recurrent aseptic lymphocytic meningitis and occasional hydrocephalus. Design/Methods: Case report Results: 64-year-old man with prior history of bladder cancer (in remission) presented after vasovagal syncope resulting in a fall. Neurological exam was normal and CT Head performed due to the fall showed non-dependent hypo-densities in bilateral lateral ventricles that were suggestive of fat (more than air) based on the Hounsfield units. MRI confirmed both intraventricular and disseminated subarachnoid T1 hyper-intensities suggestive of fat droplets prompting MRI of the spinal axis which revealed an intra-dural extra-medullary heterogeneous mass at L1–2 with mild mass effect on the spinal cord with resultant syrinx distal to the level. His fall was presumed to have caused traumatic rupture of cystic teratoma. Surgical resection was deferred initially since patient was asymptomatic but was undertaken 6 months later due to subjective lower extremity numbness, increase in size of mass and prior history of bladder cancer. Pathology showed mature cystic teratoma with adipose tissue, bone and squamous epithelial tissue. Clinical exam and radiographic lipid dissemination pattern remained stable post-operatively with no recurrence at the end of 2 years. Conclusions: Our case highlights a unique scenario where a syncope related fall led to traumatic, yet asymptomatic, rupture of spinal dural teratoma causing intracranial lipid dissemination; which in turn led to early identification of the spinal teratoma itself and eventual timely resection. Intracranial lipids, even if incidental, should warrant a comprehensive work-up for potential underlying etiologies. Disclosure: Dr. Vaddiparti has nothing to disclose. Dr. Daniel has nothing to disclose.