Brain Tumor Res Treat.  2013 Oct;1(2):107-110. 10.14791/btrt.2013.1.2.107.

Fulminant Meningitis after Radiotherapy for Clival Chordoma

• Kim SM
• Park HW
• Park MS
• Chung SY
• Park KS
• Lee DS
• Oh JT

• KMID: 2048485
• DOI: http://doi.org/10.14791/btrt.2013.1.2.107

Abstract

The best treatment for clival chordoma is obtained with total surgical excision, sometimes combined with adjuvant radiotherapy. A cerebrospinal fluid (CSF) fistula is a fatal complication that may occur following extended transsphenoidal surgery (TSS) and adjuvant radiotherapy. We report a case of fulminant meningitis without a CSF fistula in a 57-year-old woman who underwent TSS and multiple radiotherapies for a clival chordoma. She presented to our emergency room with copious epistaxis and odor inside her nasal cavity and had an unexpected fatal outcome. She was diagnosed with meningitis based on CSF culture and blood culture. While treating clival chordomas with adjuvant radiotherapy, clinicians should be aware of the possibility of fulminant meningitis.

Keyword

Chordoma; Radiotherapy; Meningitis

MeSH Terms

Cerebrospinal Fluid
Chordoma*
Emergencies
Epistaxis
Fatal Outcome
Female
Fistula
Humans
Meningitis*
Middle Aged
Nasal Cavity
Odors
Radiotherapy*
Radiotherapy, Adjuvant

Figure

• 

  Fig. 1 Preoperative and postoperative MR images of the first transsphenoidal surgery. A: Preoperative contrast-enhanced sagittal T1-weighted image showing a lesion of the clivus, with destruction of the bony margins of the clivus. The lesion is found just anterior to the brainstem. B: Postoperative contrast-enhanced sagittal T1-weighted image after the tumor was removed.

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  Fig. 2 Following MR image when the patient presented with diplopia again 14 months after the first surgery and its postoperative image. A: Contrast-enhanced sagittal T1-weighted image showing evidence of recurrent tumor. B: Contrast-enhanced sagittal T1-weighted image after the second extended transsphenoidal surgery with still remained tumors in clivus and multifocal peripheral lesions.

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  Fig. 3 T2-weighted sagittal image showing that heterogeneous lesions involving the clivus and located just anterior to the basilar artery.

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  Fig. 4 A defect in the nasal septum (arrow) and synthetic materials (asterisk).

Reference

1. Walcott BP, Nahed BV, Mohyeldin A, Coumans JV, Kahle KT, Ferreira MJ. Chordoma: current concepts, management, and future directions. Lancet Oncol. 2012; 13:e69–e76.

2. St Martin M, Levine SC. Chordomas of the skull base: manifestations and management. Curr Opin Otolaryngol Head Neck Surg. 2003; 11:324–327.

3. Kono Y, Prevedello DM, Snyderman CH, et al. One thousand endoscopic skull base surgical procedures demystifying the infection potential: incidence and description of postoperative meningitis and brain abscesses. Infect Control Hosp Epidemiol. 2011; 32:77–83.

4. Hongmei Y, Zhe W, Jing W, Daokui W, Peicheng C, Yongjie L. Delayed cerebrospinal fluid rhinorrhea after gamma knife surgery in a patient with a growth hormone-secreting adenoma. J Clin Neurosci. 2012; 19:900–902.

5. Kim CH, Chung SK, Dhong HJ, Lee JI. Cerebrospinal fluid leakage after gamma knife radiosurgery for skull base metastasis from renal cell carcinoma: a case report. Laryngoscope. 2008; 118:1925–1927.

6. Ciric I, Ragin A, Baumgartner C, Pierce D. Complications of transsphenoidal surgery: results of a national survey, review of the literature, and personal experience. Neurosurgery. 1997; 40:225–236. discussion 236-7.

7. Siedek V, Pilzweger E, Betz C, Berghaus A, Leunig A. Complications in endonasal sinus surgery: a 5-year retrospective study of 2,596 patients. Eur Arch Otorhinolaryngol. 2013; 270:141–148.

8. Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and wound healing. Int Wound J. 2005; 2:112–127.

9. al-Mefty O, Kersh JE, Routh A, Smith RR. The long-term side effects of radiation therapy for benign brain tumors in adults. J Neurosurg. 1990; 73:502–512.

10. Sen C, Triana AI, Berglind N, Godbold J, Shrivastava RK. Clival chordomas: clinical management, results, and complications in 71 patients. J Neurosurg. 2010; 113:1059–1071.