Fat-Fluid Level in Intracranial Epidermoid Cyst

STEVEN H. CORNELL,’ CARL J. GRAF,2 AND KENNETH D. DOLAN’

Intracranial dermoids and epidermoids are rare tumors. pant and a craniad lemon yellow part. the anterior-inferior wall
In reviewing the literature we have not found a case with of which had a solid yellowish-white component. Aspiration from

a fluid level on plain films of the skull. the craniad portion yielded an opalescent yellow oily material
in which floated flecks of chalky material. The fluid clotted on
standing. When the interior of the cyst was inspected, there
Case Report
was a gush of fluid with large globules resembling free fat
A 31-year-old woman was seen in the ophthalmology depart- floating on the surface. The volume of fluid in the cyst was
ment because of progressively diminishing vision of the right 25-30 ml.
eye. There was a history of “sinus headaches” and chronic The cyst wall was removed except for a segment on the left
postnasal drip, but no recent increase in drainage and no optic nerve which was laterally deviated and stretched 4-5 cm.
tenderness or fever. The patient had been in an automobile The right optic nerve had been markedly compressed and was
accident during the past year but had not injured her head. barely seen before the cyst was removed. The cyst fluid con-
At her first visit visual acuity on the right was 20/30, and small tamed cholesterol and triglycerides (181 mg/100 ml and 25
white areas were seen around the macula suggesting a diagnosis g/100 ml, respectively). Pathologic examination revealed an
of serous retinopathy. After 2 months her visual acuity had epidermoid cyst lined by squamous epithelium beneath which
deteriorated to 20/200, and a large central scotoma was found, were areas of heaped up fat-containing cells. The patient’s
resulting in the diagnosis of optic neuritis on compression. visual acuity was normal at follow-up examination 2 months
Electroencephalogram and nadionuclide brain scan were nega- postoperatively.
tive. Skull radiographs revealed a fluid level low and toward the
left in the midfrontal region (fig. 1 ). Because this was thought
Discussion
to be an air-fluid level, polytomography of the skull base was
American Journal of Roentgenology 1977.128:502-503.

performed; no break in the continuity of the bones was found. The incidence of dermoid and epidermoid tumors has
A CT scan again revealed a striking fluid level (fig. 2). The been estimated to be 0.4% of all intracranial growths [1 1.
nadiolucent area above the level had EMI absorption values The true incidence is probably not known, as pointed out
ranging from -30 to -70. These values are considerably by Miller and Epstein [2] who found six epidermoids and
higher than of air and consistent with a lipid substance. It was three dermoids during a 30 year period.
apparent that a fat-containing intracranial mass such as a A dermoid cyst producing a radiolucency on the skull
lipoma. teratoma, denmoid, or epidermoid must be present. An
radiograph was first reported by Gross [3]. The mass was
angiognam demonstrated an avascular mass in the subfrontal
situated infeniorly in the left frontal lobe. It contained
region (fig. 3). A pneumoencephalognam revealed no communi-
about 50 ml of colorless fluid and 60 ml of semisolid fatty
cation between the ventricles or subanachnoid spaces and
the mass. material with some hair. The content of epidermoid cysts
Through frontal craniotomy, a tense cystic mass was found was vividly described by Fleming and Botterell [4]. Char-
covering the medial frontal fossa and extending into the inter- actenistically the cysts contain a mixture of cholesterol
hemispheric fissure. It consisted of a caudad blue thin-walled crystals, epithelial debris, and semisolid or liquid fatty

Fig. 1 . -A. Frontal view of skull with fluid level primarily left of midline (arrows), opposite side of patient’s symptoms B, I aterat view with fluid level
in frontal region (arrows)

Received October 5. 1976, accepted after revision December 9. 1976.

I Department of Radiology. University of Iowa Hospitals and Clinics. Iowa City. Iowa 52242
2 Division of Neurosurgery. University of Iowa Hospitals and Clinics, Iowa City. Iowa 52242

Am J Roentgenol 1 28:502-503. March 1977 502

 CASE REPORTS 503

I
,
r

r f
_ -.
::..

_ii_ i,,,

..1 :
T

I
F.-

bL{* . _‘______i

:
American Journal of Roentgenology 1977.128:502-503.

..--- -::

L
Fig 3 - Angiogram with patient supine demonstrating avascular mass
displacing anterior cerebral and frontopolar arteries upward and
Fig 2 -CT scan with patient supine EMI absorption values of lucent
posteriorly Fluid level barely visible
area above fluid level ranged from 30 to -
70, indicating lipid substance

material somewhat resembling cottage cheese. Zylak et al. ACKNOWLEDGMENT

[5] reported another case of a dermoid cyst seen as a We thank Dr. David L. Witte for analyzing the lipids in the
nadiolucent mass on plain films. It was also situated above cyst fluid.
the floor of the left anterior fossa and contained fatty
material and hair. No calcium or teeth were present. REFERENCES
To our knowledge there has been no report of an intra- 1 . Rand CW, Reeves DL: Dermoid and epidermoid tumors
cranial dermoid or epidermoid with a fluid level, perhaps (cholesteatomas) of central nervous system: report of 23
because films were not taken in the sitting position, as cases. Arch Surg 46:350-370, 1943
done in our case. The level persisted with changes in the 2. Miller NA, Epstein MH: Giant intracranial denmoid cyst: case
position of the patient’s head, the radiolucent portion report and review of the literature on intracranial denmoids
always uppermost. It was due to liquid fat layered on and epidermoids. Can J Neurol Sci 2:1 27-1 34, 1975
semisolid material. 3. Gross SW: Radiographic visualization of an intracerebral
dermoid cyst. J Neurosurg 2:72-75, 1945
A case of fat-containing teratoma studied by CT has
4. Fleming JFR, Botterell EH: Cranial dermoid and epidermoid
been described by Gawler et al. [61. These spherical zones
tumors. Surg Gynecol Obstet 1 09:403-41 1 , 1959
of very low density suggested the presence of fat. Five
5. Zylak CJ. Childe AE, Ross AT. Parkinson D: Lucent unilateral
intracranial epidermoid tumors studied by CT were de- supratentonial dermoid cyst. Report of an unusual case. Am J
scribed by Davis et al. [7]. A fluid level was not present Roentgenol 106:329-332, 1969
in any of these. In our case the radiolucent area was 6. Gawler J, DuBoulay GH. Bull JWD, Marshall J: Computer
thought to represent air until the absorption values mdi- assisted tomography (EMI scanner). Its place in investigation
cated otherwise. The CT scan enabled us to make a correct of suspected intracranial tumors. Lancet 2:419-423, 1974
preoperative diagnosis. 7. Davis KR, Roberson GH, Taveras JM, New PFJ, Trevor A:
Diagnosis of epidermoid tumor by computed tomography.
Analysis and evaluation of findings. Radiology 1 1 9:347-3 53,
1976