Running Head: PERSISTENT DULL HEADACHE
Persistent Dull Headache
Caitlin McGrath PA-S
Lock Haven University
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Persistent Dull Headache
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Abstract
In this case a 58 year old male with a 2.5 week history of a dull persistent headache is
diagnosed with a very rare intracranial tumor call a dermoid cyst on diagnostic imaging studies.
Dermoid cysts are slow-growing benign tumors that account for 0.3% of intracranial masses
(Greenburg). They contain stratified squamous epithelium, keratin, cholesterol, cellular debris,
and dermal appendages (Greenberg). Patients with dermoid cysts may present with headaches,
seizures, and hydrocephalus (Liu) as well as recurren meningitis (Greenberg). In addition to a
dull headache, this patient also complained of blurring vision and decreased depth perception.
The physical exam was within normal limits except for a regularly irregular heart rhythm
attributed to atrial fibrillation. On CT scan the radiology impression was a 4.2 x 2.9 x 4.1 cm
dermoid cyst in the right parasagittal location within the frontal lobes. The impression of an
MRI that was performed for further evaluation was a fat containing mass within the frontal
parasagittal area on the right side with adjacent tiny fat droplets that suggest minimal localized
rupture. The treatment for dermoid cysts is surgical resection, but extra care must be taken to
avoid spilling cyst contents as in doing so it may cause aseptic meningitis (Greenberg).
Case Report
A 58 year old male presents for an urgent neurosurgery consult after referral by his primary
care provider for an adventitious finding on a CT scan of the head that was performed to
investigate the cause of 2.5 week persistent headache. He described the headache as
constant, dull, ranging in intensity from 2 to 5 on a scale of 0 to 10 and occasionally
accompanied by blurring of vision in his right eye as well as decreased depth perception. The
radiology impression of the CT scan was a 4.2 x 2.9 x 4.1 cm dermoid cyst in the right
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parasagittal location within the frontal lobes. The impression of an MRI that was performed for
further evaluation was a fat containing mass within the frontal parasagittal area on the right
side with adjacent tiny fat droplets that suggest minimal localized rupture; chemical meningitis
was not suspected as there was no meningeal enhancement. On physical exam he is a wellnourished, alert, and oriented male. Vital signs include blood pressure 137/100, pulse 80,
respiratory rate 18, temperature afebrile, height 6’1,” and weight 330 pounds. On HEENT
exam, he is normocephalic, PERRLA, EOMI, central and peripheral vision grossly intact, no
exudates, hemorrhages, or increased cup to disc ratio on fundoscopic exam of the eyes
bilaterally, hearing grossly intact, tympanic membranes intact and pearly gray, nares patent
with no masses, lesions, or discharge present bilaterally, oral cavity and throat pink and moist.
Respiratory, gastrointestinal, extremity, musculoskeletal exams are within normal limits; on
cardiovascular exam S1 and S2 are clear within regularly irregular rate and rhythm, no murmur
is present. On neurological exam, his appearance and behavior, speech and language, mood,
thought and perceptions, cognitive and higher cognitive functions, sensation, motor strength,
coordination, balance, and deep tendon reflexes are within normal limits; cranial nerves 2-12
are grossly intact. The differential diagnosis is dermoid cyst, epidermoid cyst, or cholesterol
granuloma. The neurosurgeon consulted concurs with the radiologists’ diagnosis of a dermoid
cyst and a right frontal craniotomy to remove the tumor utilizing Cavitron Ultrasonic Surgical
Aspirator (CUSA) is scheduled.
Discussion
Dermoid cysts, also known as dermoid tumors, account for 0.3% of intracranial tumors
(Greenberg). Dermoid cysts are similar to epidermoid cysts in that they both contain stratified
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squamous epithelium, keratin, cholesterol, and cellular debris; however dermoid cysts also
contain dermal appendages such as sebaceous glands and hair follicles (Greenberg) as well as
fat (Sener). Dermoid and epidermoid cysts are both benign slow-growing tumors (Layadi) They
are believed to be congenital and to originate from ectodermal cells that are displaced during
the third and fifth week of development (Layadi). The most common clinical presentation of
dermoid cysts include headaches (57%), seizures (42%), hydrocephalus (29%) (Liu). Persons
with dermoid cysts may suffer from repeated episodes of bacterial meningitis (Greenberg)
because they have structures that support the colonization of bacteria within the CSF (Layadi).
Diagnosis of a dermoid cyst is made by computer tomographic scans (CT) or magnetic
resonance imaging (MRI) (Layadi). On CT scan dermoid cysts are hypodense and one T1weighted MRI hyperintense with little to no enhancement after the administration of
gadolinium (Lui). Fat droplets in the ventricles or subarachnoid space are diagnostic indicator
that a dermoid cyst has ruptured (Liu). Treatment for dermoid cysts is surgical resection and
neurosurgeons must take caution not to spill the contents of the cysts because they can cause
chemical meningitis, also known as Mollaret’s meningitis (Greenberg). Radiation is not
indicated post-operatively because dermoid cysts are benign (Greenberg).
Summary
In this case a 58 year old male is diagnosed with a very rare intracranial mass called a dermoid
cyst found on a CT scan and MRI that were ordered after a two week history of a dull persistent
headache, blurring vision, and decreased depth perception. A right frontal craniotomy to
remove the tumor utilizing Cavitron Ultrasonic Surgical Aspirator (CUSA) is scheduled.
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References
Layadi, F., Louhab N., Lmejjati M., Aniba K., Ait Elqadi A., Ait Benali S. (2006). Cerebellar
dermoid cyst with occipital dermal sinus. Pediatric Neurosurgery 42. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/17047421.
Greenburg, M.S.(1997). Handbook of Neurosurgery, 5th Edition. Lakeland, FL: Greenberg
Graphics.
Liu, J.K., Gottfried O.N., Salzman K.L., Schmidt R.H., Couldwell W.T. (2008). Ruptured
intracranial dermoid cysts: clinical, radiographic, and surgical features. Neurosurgery, 62(2).
Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/18382315.
Sener, R.N., Mechl M., Prokes B., & Valek V.A. (2004). Dermoid tumor with involvement of the
frontal lobes. Acta Radiologica, 45(2), Retrieved from
http://www.ncbi.nlh.gove/pubmed/15191108.