Spontaneous transsphenoidal meningoencephalcele is a rare entity, even rarer through the Sternberg’s canal, a congenital defect on the lateral wall of the sphenoid sinus. We report such a case in an obese 52-year-old female with spontaneous cerebrospinal fluid (CSF) rhinorrhoea and recurrent meningitis. Brain CT, MRI and CT cisternography were performed. Surgical correction and short-term follow-up were recorded. CT scan showed a defect on the lateral wall of the right sphenoid sinus filled with a soft tissue mass extending to the nasal cavity. MRI scan revealed brain parenchyma from the right temporal lobe herniated through the sphenoid bone defect. CT cisternography showed 270 mmH2O opening pressure and confirmed the CSF leakage. Surgical correction was performed with resolution of the symptoms. MRI and CT are complementary modalities for evaluating this entity, the first being the method of choice for meningoencephalcele diagnosis although bone defects are best depicted on CT scan. CT cisternography identifies the specific site of leak and confirms benign intracranial hypertension, consistently reported in meningoencephaloceles. Obesity and benign intracranial hypertension have been reported as a combined mechanism allegedly contributing to meningoencephaloceles through congenital skull base defects, by increasing intraabdominal pressure thus decreasing venous return, with augmented intracranial pressure and subsequent reduced absorption of the CSF.
We describe the case of a 68-year-old man, who presented with an ischemic stroke due to cardiac embolization related to mitral valve endocarditis. Blood cultures were always negative and post-operative valve histology did not show microorganisms. The patient also presented further recurrent peripheral embolic events. These clinical aspects were the first sign of a pancreas adenocarcinoma, which was only diagnosed in the clinical autopsy. In conclusion, these clinical findings of recurrent thromboembolic events with no microorganisms isolated suggests the diagnostic of a marantic endocarditis. LEARNING POINTS• Marantic endocarditis is characterized by the deposition of fibrin and thrombi on heart valves in the absence of microorganisms.• Is associated with higher incidence of thromboembolic events and most commonly found in patients with neoplasia in post-mortem studies.• It is a diagnostic challenge to distinguish from infective endocarditis and a high clinical suspicion is crucial to confirm the diagnosis. KEYWORDS Marantic endocarditis; thromboembolism; pancreatic adenocarcinoma CASE REPORT A 68-year-old man was admitted to the emergency department of our hospital with 1-hour evolution of left hemiparesis and hypoesthesia, left facial paralysis and mild dysarthria. Cranial Computed Tomography (CT) showed aspects suggesting right hemispheric acute ischemic stroke. The initial laboratory blood tests revealed a platelet count of 74.000/mm 3 , which contraindicated the thrombolytic treatment. The other lab results were within normal ranges values. Chest X-ray and 12-lead electrocardiography findings were normal. The patient's medical history included hypertension, chronic gastritis and small hiatus hernia; he was a former smoker, with moderate alcoholic habits. To clarify the aetiology of stroke, a transthoracic echocardiography (TTE) was done and revealed a mobile and echodense lesion on the atrial surface of posterior mitral valve leaflet suggesting a vegetation. The transesophageal echocardiography (TEE) showed the vegetation with 20mm of major diameter, mild mitral regurgitation and no leaflet destruction (Fig. 1). As such, the diagnostic of infective endocarditis was admitted and empiric antibiotic therapy was initiated, with gentamicin and vancomycin. Serial blood cultures remained sterile, despite the extension of incubation time to 21 days. Serologic tests for atypical microorganisms were negative. The immunologic evaluation was unremarkable.
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