A case of Trapped temporal horn

Posted by Dr.Purav Patel Dr.Purav Patel
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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.

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.

Management:

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.

On 18/07/2003, she was readmitted with severe Rt. sided headache and mild weakness of Lt Hand.

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.



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.

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. 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

Further 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 suggested of cysticercosis and she was treated with a course of Albendazole for any systemic cysticercosis.


Patient is asymptomatic and her visual fields recovered. Follow up CT after 2 weeks showed no ventriculomegaly.