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Case Reports
. 2016 Feb 24;8(2):e511.
doi: 10.7759/cureus.511.

Recurrent Craniocervical Pseudogout: Indications for Surgical Resection, Surveillance Imaging, and Craniocervical Fixation

Amitoz Manhas  1 , Prashant Kelkar  1 , Joseph Keen  1 , Steven Rostad  2 , Johnny B Delashaw  3
Affiliations
Case Reports

Recurrent Craniocervical Pseudogout: Indications for Surgical Resection, Surveillance Imaging, and Craniocervical Fixation

Amitoz Manhas et al. Cureus. .

Abstract

Background: Calcium pyrophosphate dihydrate (CPPD) crystallization is known to occur in the spine, leading to the development of visible calcification as seen by imaging. Occasionally, the deposition of this material can lead to larger accumulations that are seen as masses in the articular processes, intervertebral discs, and posterior longitudinal ligaments. A particularly significant manifestation of this process is at the craniocervical junction, where symptomatic presentations can arise.

Clinical presentation: A 74-year-old woman presented after several falls from standing, complaining of leg and arm weakness. Imaging revealed a mass arising from the C1-C2 articulation dorsal to the dens, extending to the clivus. The mass compressed the medulla and cervicomedullary junction.

Intervention: The patient underwent a left, far lateral craniotomy with C1 laminectomy to approach the cervicomedullary junction. The mass was cyst-like and contained scattered crystals and amorphous material consistent with pseudogout. There were no cells with an elevated Ki-67 index. The patient's symptoms and exam improved at follow-up two months later. However, seven months after surgery, she declined once again and was found to have a recurrence.

Conclusion: A subtotal resection of pseudogout may lead to recurrence. The recurrence can occur in a rapid fashion. Serial MRIs are indicated following resection. Occipitocervical fusion could reduce the likelihood of recurrence in such cases.

Keywords: calcium pyrophosphate dehydrate; occipitocervical; pseudogout.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1
Figure 1. February Axial CT Image 1
Foramen magnum
Figure 2
Figure 2. February Axial CT Image 2
Posterior fossa
Figure 3
Figure 3. February Sagittal CT Image
Cervicomedullary junction
Figure 4
Figure 4. Ascending pharyngeal artery embolization
Figure 5
Figure 5. February Sagittal MRI
Craniocervical junction mass
Figure 6
Figure 6. February Coronal MRI
Craniocervical junction mass
Figure 7
Figure 7. Pathology Slide - Synovial Chondroid Tissue
Figure 8
Figure 8. Pathology Slide - Birefringent Calcium Pyrophosphate
High power showing crystals within synovial-chondroid material. The crystals are birefringent on polarization optics, consistent with calcium pyrophosphate.
Figure 9
Figure 9. Pathology Slide - Amorphous material
Amorphous material within acellular region of the  tissue (no crystals visible)
Figure 10
Figure 10. Pathology Slide - Congo Red Stain
Congo red stain of 3, with polarization, showing characteristic “apple green-orange” staining of amyloid.
Figure 11
Figure 11. September Axial MRI Image 1
Posterior fossa
Figure 12
Figure 12. September Axial MRI Image 2
Foramen Magnum
Figure 13
Figure 13. September Sagittal MRI
Enhancing mass
Figure 14
Figure 14. September Coronal MRI
Enhancing mass
Figure 15
Figure 15. September Axial CT
Retrodental mass
See this image and copyright information in PMC

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