Presacral meningocele presenting after rupture into the retroperitoneal space with acute debilitating intracranial hypotension: illustrative case.

BACKGROUND: Presacral meningoceles are rare congenital cystic lesions caused by herniation of the thecal sac through an anterior sacral defect. Presentations range from asymptomatic to rupture and meningitis. Treatment aims to eliminate subarachnoid communication, recurrence, and complications.

OBSERVATIONS: The authors report the case of a 21-year-old female who developed acute, debilitating, positional headaches requiring flat bed rest. MRI revealed a ruptured presacral meningocele with intra-abdominal fluid accumulation. She underwent surgical repair via a transsacral approach with sacroplasty and CSF diversion. The cyst was fenestrated, nerve roots were dissected, and a large dural defect was reconstructed with intra- and extradural repair. A tethered cord with a fatty filum terminale was released; the repair was reinforced with autologous fat graft, fibrin sealant, and synthetic hydrogel; and the sacroplasty was stabilized with titanium mini-plates. Postoperatively, the patient had immediate resolution of headaches and was able to ambulate upright. Five-month follow-up MRI confirmed cyst resolution with complete symptom relief.

LESSONS: This case demonstrates successful management of a ruptured congenital presacral meningocele, a rare but debilitating condition. Rupture may cause intracranial hypotension or meningitis with severe symptoms. Surgical intervention provides definitive resolution. Meningoceles should be distinguished from perineural or Tarlov cysts, which differ in clinical behavior and surgical management. https://thejns.org/doi/10.3171/CASE26114.