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Ruptured dermoid cyst of the lateral cavernous sinus wall with temporary symptoms: a case report
© The Author(s). 2016
Received: 24 December 2015
Accepted: 12 July 2016
Published: 12 August 2016
Dermoid cysts are non-neoplastic tumors that arise from defects in the separation of the neuroectoderm. Cyst rupture rarely occurs spontaneously and the most common symptom is headache, followed by seizure. Although many cases of ruptured dermoid cysts present with symptoms, reports of cases that are asymptomatic, or where symptoms disappear, are rare.
We report the case of a 66-year-old Asian man with a history of sudden onset headache who was found to have high amounts of fat material in the subarachnoid space and a fat suppression mass in the left cavernous sinus. He underwent oral steroid therapy. Five days after starting medication his headache symptoms disappeared. Routine neurological imaging was then performed without surgical procedure. Magnetic resonance imaging revealed evidence of the remains of a static lesion 6 months after his first visit. He has remained headache free for 10 months since the initial event.
Although cases of ruptured dermoid cysts presenting with consistent symptoms have been commonly reported, until now there were few reports on asymptomatic cases or cases where symptoms disappeared. We believe that surgical intervention is unnecessary for ruptured dermoid cysts with minimal symptoms.
Dermoid cysts are rare tumors, accounting for 0.04–0.6 % of all intracranial tumors that arise from ectodermally committed cells at the time of closure of the neural groove between the third and fifth week of embryonic life [1, 2]. They frequently occur at suprasellar, frontobasal, temporobasal regions, and in the posterior fossa . They are benign, slow-growing tumors which rarely rupture. Dermoid cysts produce various symptoms, especially headache, seizure, cerebral ischemia, and meningitis [3, 4]. Although rupture of dermoid cysts typically occurs spontaneously, there are a few cases of traumatic rupture of dermoid cysts [5, 6]. Surgery is recommended in patients with symptomatic ruptured dermoid cysts. On the other hand, asymptomatic patients with ruptured dermoid cyst lesions are recommended for close observation, but to the best of our knowledge only eight cases with such observation have been described [3, 7–13]. We discuss the clinical features of ruptured dermoid cysts and analyze cases without surgery.
Dermoid cystic tumors arise from defects in the separation of the neuroectoderm at the time of neural tube closure during the third to fifth week of embryonic development [1, 2]. The cysts contain thick yellowish material consisting of sebaceous gland secretions and desquamated epithelium, in which a variable number of hairs is entangled . Rupture of intracranial dermoid cysts is rare. Cyst rupture usually occurs spontaneously. A few cases of rupture after head trauma have been reported [5, 6]. Although the exact mechanism of cyst rupture remains unknown, Stendel et al. hypothesized that glandular secretions, possibly increased by age-dependent hormonal changes, may lead to rapid enlargement and rupture . The most common symptom was headache, occurring in 31.8–32.6 % of the cases, followed by seizure in 26.5–29.5 %, and cerebral ischemia with sensory and/or motor hemisyndrome in 15.9–16.3 % [2, 4]. Ruptured dermoid cyst with chemical meningitis has been reported in 7–8.2 % of the cases, with psychosyndrome and visual disturbance present in 4.5 % [2, 4, 14].
The location of dermoid cysts were reported to be frontal base, frontal lobe, suprasellar, parasellar, Sylvian fissure, middle base, temporal lobe, hypothalamus, pineal, posterior fossa, fourth ventricle, cerebellopontine angle, and clivus . They are most often found in a sellar or parasellar location as well as the frontonasal region and frequently reside near the skull base . In our case, the dermoid cyst was located in the lateral wall of the left cavernous sinus. Dermoid cysts in the cavernous sinus are rare and only ten cases have been reported [1, 17–25]. The past cases of dermoid cysts in cavernous sinus presented various symptoms, such as diplopia in six cases, headache in five cases, blurring of vision in three cases, and seizure in one case. On neurological examination, third, fourth, fifth, and sixth nerve palsy were documented. In cases which were referred to therapeutic strategy, all patients underwent surgical resection. Diplopia was usually improved in cases with gross total removal. On the other hand, Akdemir et al. reported a case with no remarkable change in ophthalmoplegia . We have an interest in dermoid cysts of the cavernous sinus and observe that there is not always a resolution of symptoms after surgery, and that patients may become asymptomatic after oral steroid therapy due to the anti-inflammatory effect.
Literature review of the ruptured dermoid cyst with conservative management
Wilms et al. 
Seizure, paresis, aphasia
Corr et al. 
Messori et al. 
Messori et al. 
Rajapakse et al. 
Kucera et al. 
Indullar et al. 
Wang et al. 
Ruptured dermoid cysts presenting with asymptomatic or disappearing symptoms are rare. The number of reports that evaluate observation with regular neurological imaging is small and the natural history of ruptured dermoid cysts is uncertain. We believe conservative treatment without surgery should be considered a therapeutic alternative in asymptomatic cases of ruptured dermoid cyst, or where symptoms disappear.
YK drafted and edited the manuscript. HO, TS, MU, HT, HI, KO and YT contributed to the writing of the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Consent for publication
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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