CE: A.B.

; SCS-17-0573; Total nos of Pages: 2;

SCS-17-0573

BRIEF CLINICAL STUDIES

with symptomatic postoperative pseudomeningocele. To the best of

Craniocervical our knowledge, there is no previous report in the literature regarding
the role of this relatively new sequence in the assessment of a neck
Pseudomeningocele Following of postoperative pseudomeningocele.

Cerebellar Meningioma CLINICAL REPORT

Resection: Demonstration of
Neck of Pseudomeningocele
With Three-Dimensional
Isotropic T2-Weighted SPACE
Sequence at 3 Tesla (3T)
Magnetic Resonance Imaging
Veysel Ayyildiz, MD and Hayri Ogul, MDy
Abstract: Postoperative pseudomeningocele is an uncommon com-
plication of craniospinal surgery. Diagnosis is reached on a post-
operative computed tomography and magnetic resonance (MR)
imaging. Demonstration of the location and dimension of the dural
defect before surgical therapy is a very important. T1- and T2-
weighted MR images revealed a significant pseudomeningocele
extending from left cervicooccipital region. Magnitude and phase-
contrast-MR images showed a cerebrospinal fluid (CSF) flow into
pseudomeningocele, but they no revealed dural defect. Three-
dimensional isotropic T2-weighted SPACE sequence revealed a
signal void indicating CSF flow into pseudomeningocele and
location and exact size of dural tear. Three-dimensional isotropic
T2-weighted SPACE sequence is certainly the noninvasive and
optimal method for demonstrating postoperative pseudomeningo-
cele sacs. It demonstrates a pseudomeningocele regardless of an
existing communication with the dural membrane.
A 54-year-old woman with a 2-year history of dizziness and
syncope underwent an uneventful resection of a posterior fossa
meningioma at our hospital. Six months later, she was admitted to
our department with symptoms of neck pain and swelling. Non-
contrast CT scan showed a hypodense lesion in the left posterior
craniocervical junction. The initial diagnosis was postoperative
pseudomeningocele and MR imaging was performed at 3T (Mag-
netom Skyra, Siemens, Erlangen, Germany) with conventional and
advanced neuro images. Three-dimensional T1-weighted data were
obtained by using an MPRAGE sequence. A 3-plane 2-dimensional
T2-weighted TSE sequence and sagittal-axial plane flow-compen-
sated spoiled gradient-echo phase-contrast (PC)-MR imaging tech-
nique with cardiac gating were obtained with the following
parameters. Magnitude-phase and rephased images were obtained
from every PC-MR imaging sequence. After acquisition of T1-
weighted, T2-weighted, and PC-MR imaging, a 3-dimensional
SPACE sequence with isotropic voxel size was obtained in the
sagittal plane. T1- and T2-weighted MR images revealed a signifi-
cant pseudomeningocele extending from left cervicooccipital
region (Fig. 1). Magnitude and PC-MR images showed a CSF
flow into pseudomeningocele, but they no revealed dural defect
(Fig. 2). Three-dimensional isotropic T2-weighted SPACE
sequence revealed a signal void indicating CSF flow into

Key Words: 3D-isotropic T2-weighted SPACE sequence, 3T MR

imaging, postoperative pseudomeningocele

P ostoperative pseudomeningocele is an uncommon complication

of craniospinal surgery. It is an extradural cystic collection of
cerebrospinal fluid (CSF) in the paraspinal tissue of the neck that
extravasates through the dural rupture.1–3 Pseudomeningacele
occurs more rarely in the cervical than the lumbar region.4 Diag- FIGURE 1. Sagittal T1 (left) and T2-weighted (right) MR images reveal a significant
nosis of this rare disease is reached on a postoperative computed pseudomeningocele (asterisk) extending from left cervicooccipital region.
tomography (CT) and magnetic resonance (MR) imaging. Demon-
stration of the location and dimension of the dural defect before
surgical therapy is a very important. We herein successfully
demonstrate a neck of pseudomeningocele with 3-dimensional
isotropic T2-weighted SPACE sequence at 3 Tesla (3T) in a patient

From the Department of Radiology, School of Medicine, Siirt State

Hospital, Siirt; and yDepartment of Radiology, Medical Faculty, Ataturk
University, Erzurum, Turkey.
Received April 2, 2017.
Accepted for publication May 1, 2017.
Address correspondence and reprint requests to Hayri Ogul, MD, Kazim
Karabekir Mah, Terminal Cad, Site Polat, Apt, B Blok, Kat 1, No 2,
Erzurum, Turkey; E-mail: drhogul@gmail.com
The authors report no conflicts of interest.
Copyright # 2017 by Mutaz B. Habal, MD
ISSN: 1049-2275 FIGURE 2. Magnitude (left) and PC (right) MR images show a cerebrospinal
DOI: 10.1097/SCS.0000000000003961 fluid flow (arrow) into pseudomeningocele (asterisk), no reveal dural defect.

The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2017 1
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: A.B.; SCS-17-0573; Total nos of Pages: 2;
SCS-17-0573
Brief Clinical Studies The Journal of Craniofacial Surgery
FIGURE 3. Three-dimensional isotropic T2-weighted sagittal (left) and axial
(right) SPACE sequence reveals dural defect (arrowhead) and a cerebrospinal
fluid flow (arrow) into pseudomeningocele (asterisk).
pseudomeningocele. The SPACE sequence also showed clearly
location and exact size of dural tear (Fig. 3). On surgical exploration
was established communication between the dura and pseudome-
ningocele. Extirpation of postoperative pseudomeningocele sac was
surgically done. Dural membrane was repaired and reinforced. The
patient’s postoperative course was eventless and she was discharged
with the suggestions on the 2nd postoperative week.
DISCUSSION
The criterion standard technique for the diagnosis of postoperative
pseudomeningocele is conventional MR imaging scans. These
scans show only cystic sac, and often fail to reveal dural defect.
Cisternographic studies can reveal neck of postoperative pseudo-
meningocele, but these studies are very invasive and difficult to
perform in routine daily practice. With the development of MR
imaging technology, CSF circulation (in cranial and spinal spaces)
is better evaluated with 3-dimensional isotropic submillimetric data
obtained by 3T MR units.5,6 Three-dimensional isotropic T2-
weighted SPACE sequence is a noninvasive morphologic and
functional technique for reveal neck of postoperative pseudome-
ningocele. This technique also provides thin-sectioned images with
2 #
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00, Month 2017
good spatial resolution.7 Postoperative pseudomeningocele can
cause to a dysfunction of CSF flow, and can also relate with
subdural fluid collections and hydrocephalus.8 For this reason,
the treatment of the disease should not be delayed. On these
patients, closure of the dural defect with resultant elimination of
the postoperative pseudomeningocele allows for normalization of
CSF flow.
On conclusion, 3-dimensional isotropic T2-weighted SPACE
sequence in 3T MR is certainly the noninvasive and optimal method
for demonstrating postoperative pseudomeningocele lesions. It
demonstrates a pseudomeningocele regardless of an existing com-
munication with the dural membrane. This report also reveals the
additional value of advanced neuro MR imaging technology allow-
ing perfect overlay of anatomic and functional images in exact CSF
leak detection.
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2017 Mutaz B. Habal, MD