Sincipital encephalomeningoceles

Growth and Psychological Development in Postoperative Patients With Anterior Encephaloceles

PURPOSE

Anterior encephaloceles are rare malformations that are frequently associated with other brain anomalies. This study evaluates the growth and psychological development of children following encephalocele repair.

MATERIALS & METHODS

Growth and psychological assessment was done in 24 children with only encephalocele (group I); nine children with encephalocele and hydrocephalus (group II); seven children with encephalocele, hydrocephalus, and secondary malformations (group III); and 40 apparently healthy control subjects. Psychological assessment was done by evaluating intelligence and temperament.

RESULTS

Single-stage repair was performed in 38 children, and two underwent multistage repair. Major postoperative complications were noted in three individuals. The follow-up period ranged from 12 to 168 months, and during this time the growth velocity declined significantly among group II and group III patients when compared with control subjects. After adjusting the body mass index for age, our data revealed that group III participants had a significantly (P = 0.02) lower body mass index than the control group. Group III also had poor indices for intelligence quotient (P ≤ 0.01) and temperament (P ≤ 0.01). Female patients had lower temperament indices when compared with unaffected females with regard to approach withdrawal (P ≤ 0.01), mood (P = 0.026), and intensity (P = 0.03). Overall, increased disease severity adversely affected the psychological indices.

CONCLUSION

Individuals with anterior encephalocele without associated intracranial defects had excellent postoperative outcomes in terms of growth and psychological developments. Hydrocephalus and agenesis of corpus callosum had the least impact on psychological development. However, the presence of secondary brain defects led to developmental delays. Gender differences in temperament may suggest a need for distinct treatment regimens to assess psychosocial well-being for males and females.

Prenatal Diagnosis of A Case with Frontoethmoidal Encephalocele and the Neonatal Outcome

Encephalocele is a rare congenital defect characterized by a sac-like protrusion of the neural tissue and/or meninges through a defect in the skull. We reported a case with a naso-frontal anterior encephalocele which was diagnosed by prenatally and confirmed by postnatal evaluation and complications such as hypoadrenalism, diabetes insipidus and arterial thrombosis in the lower limbs were diagnosed in the neonatal period.

Anterior encephaloceles in children of Assamese tea workers

OBJECT

Anterior encephaloceles are rare congenital malformations. Most of the cases in the literature are reported from Southeast Asia. In India it is seen more frequently among manual laborers in the tea gardens of Assam. A brief background of the patients, clinical presentation, operative treatment, and outcome are discussed, with a review of the relevant literature. The causes and pathogenesis of anterior encephaloceles are discussed. The authors' surgical approach to repair of the defect, postoperative complications, and results are described.

METHODS

Twenty-eight patients (mean age 38 months, range 1 month-12 years) with anterior encephaloceles who presented between 1998 and 2007 are included in the study. Patients were assessed for physical and psychological growth and development; any associated anomalies were noted. A detailed history of the patient's family, including the prenatal history, was obtained. Lesions were classified with the help of neuroimaging studies (skull x-ray, CT, ultrasonography, and MR imaging studies) and confirmed at surgery.

RESULTS

Sixteen patients had nasofrontal, 9 had nasoethmoidal, and 3 had nasoorbital encephaloceles, and 12 patients had associated hydrocephalus. The modes of presentation were nasofrontal swelling, watering from the eyes, CSF leakage, fever, and vomiting. Parents of all the patients were ethnic tea garden workers. The average parental age at the time of marriage was 24 years for men and 18 years for women. Consanguinity was present in 6 patients. Alcohol consumption and tobacco chewing were a common practice in both parents. A total of 42 surgical procedures were done in 16 patients, one of whom died of postoperative meningitis. The mean follow-up duration was 38 months (1-92 months).

CONCLUSIONS

Anterior encephaloceles are rare in Western countries and other states in India, but this defect is more commonly seen among the ethnic tea garden workers in Assam. Transcranial repair is the treatment of choice. Unlike encephaloceles in other locations, anterior encephaloceles have a better clinical outcome after surgery.

Seasonal variations in frontoethmoidal meningoencephalocele births in Cambodia

OBJECT

Frontoethmoidal meningoencephalocele (fMEC) is relatively common in many Southeast Asian countries, with devastating aesthetic and social consequences for affected children. No cause has been detected to date. Among other factors, the authors of this paper attempt to identify a statistically significant difference in the spread of fMEC births throughout the year compared with other births. This seasonal variation in the incidence of fMEC births may provide clues to the causes of this condition.

METHODS

From a group of 175 children with fMEC who underwent surgery at the authors' humanitarian institution (Children's Surgical Centre) in Phnom Penh between 2004 and 2008, 86 children were studied. These children were born at full term and had an accurately recorded date of birth. The birth dates of this fMEC group were compared with a group of > 15,000 other live births at one of the main maternity units in Phnom Penh in 2005 and 2006.

RESULTS

Seasonal variation in incidence of fMEC by month of birth was highly statistically significant (p < 0.001), with the peak of births occurring in the dry season (between March and May). This is in contrast to the control group, in which there was an equal distribution of births throughout the year. More than 85% of the parents of children with fMEC who the authors treated were farmers, but this figure reflects the composition of the Cambodian population.

CONCLUSIONS

Uneven spread in the incidence of fMEC births throughout the year suggests that a seasonal factor during the wet season may be suspected in the pathogenesis of fMEC in Cambodia.

Perioperative management for surgical correction of frontoethmoidal encephalomeningocele in children: a review of 102 cases

BACKGROUND

Frontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube defect characterized by herniation of brain and meninges through an anterior skull defect. The extruding mass results in a cutaneous expanding lesion and facial deformity. The objective of this study was to review perioperative management for surgical correction of this condition.

METHODS

We reviewed the charts of FEEM children who were treated by surgical correction in King Chulalongkorn Memorial Hospital during 1995-2005. The collected data were categorized into preoperative, intraoperative and postoperative data. In addition, average blood loss was calculated.

RESULTS

A total of 102 charts were reviewed. Preoperative data: The mean age of the patients was 4.62 years. Forty-six patients (45%) were smaller than average weight or height. Preoperative-associated abnormal conditions were found in 69 cases (68%). Intraoperative data: The mean duration of the anesthesia and surgery were 6.35 h and 5.51 h, respectively. The estimated mean red cell mass loss was 13.04 ml.kg(-1). There is one case of difficult intubation. No major anesthetic complication was found. Postoperative data: The average intensive care unit stay and hospital stay were 1.55 days and 11.51 days, respectively. The main postoperative complications were tonic-clonic seizure and serious infection including septic shock from wound infection and meningitis.

CONCLUSIONS

We reported perioperative management in 102 FEEM children. Comprehensive care during preoperative, intraoperative and postoperative period is essential for successful outcome.

Treatment of frontoethmoidal meningoencephalocele in Cambodia: a low-cost procedure for developing countries

OBJECT

Frontoethmoidal meningoencephaloceles (MECs) are a relatively common abnormality in southeast Asia, with disastrous consequences for the sufferer. In Cambodia, a lack of skilled neuro- and craniofacial surgeons, and the cost of surgery limit the possibilities for appropriate treatment of patients with these lesions. The authors developed a low-cost humanitarian program with the goals of treating frontoethmoidal MECs, ensuring careful postoperative follow-up, and teaching Khmer surgeons how to treat these malformations.

METHODS

This program was facilitated by two nongovernmental organizations: Rose Charities Cambodia provided the facilities, patients, and local staff, and "Médecins du Monde" provided visiting surgeons and anesthesiologists. All operations were free of charge for all patients. A strict follow-up program was organized to evaluate the surgical results, the social impact of the surgery, and the satisfaction levels of the children and their parents.

RESULTS

Forty-five children and seven young adults with MECs were treated using a rather simple surgical technique. Of the three types of MECs encountered, the most frequent was the nasoethmoidal type (43 cases). The most common postoperative issue was a temporary CSF leak (in 16 patients). Cosmetic results were considered excellent or good in 40 patients, average in nine, and poor in one; two patients were lost to follow-up. The overall cost of each operation was estimated to be $380 (US dollars), far less than a standard MEC operation would cost in a more developed country. At the end of this humanitarian program, Khmer surgeons were able to treat standard cases of frontoethmoidal MECs without the help of foreigners.

CONCLUSIONS

Patients in developing nations who have limited access to standard neurosurgical care can be treated for frontoethmoidal MECs with few complications and a satisfactory cost-to-benefit ratio.

Frontoethmoidal encephalomeningocele: new morphological findings and a new classification

Given a lack of a comprehensive classification for the frontoethmoidal encephalomeningocele (FEEM), clinical, photographic, and computed tomography (CT) data of 23 nonoperated patients were reviewed. Extracranial pathological findings of interest included herniation masses, facial deformities, and frontonasal bone morphology. Intracranial pathological findings of interest included morphology of the anterior cranial floor and brain malformations. Stereographic software processed data from a new-generation CT scanner into three-dimensional pictures that revealed some interesting morphological findings not often appreciated (eg, herniation mass without underlying external bone defect; mass at location far from external bone defect ["sequestrated cephalocele"]; new type of external bone defect characterized by a combination of nasoethmoidal and naso-orbital defects; correlation between mass, external bone defect, and exit pathway of herniation). Given these observations plus current knowledge available in the medical literature, a new classification system was developed that covers phenotypes and severity of the disease. The "FEEM classification" is an alphanumeric system based on facial deformities, external bone defect, exit pathway of herniation, and malformation of brain. It was tested in 42 patients for usability and validity. When combined with a newly designed "FEEM diagram," relevant pathological findings can be recorded in an objective manner so that diagnosis becomes more precise and uniform and comparison of outcome is possible. It also emphasizes the fact that FEEM has a range of manifestations governed by dynamic interaction between structural defects and herniation. Each clinical entity is a final result of its own disease course (stable, progressive, or regressive FEEM), with a varying degree of communication between the external mass and the central nervous system.

Frontoethmoidal encephalomeningocele: surgical correction by the Chula technique

This study reevaluates a surgical technique known as the Chula technique, previously reported in 1991 for correction of frontoethmoidal encephalomeningocele. From 1986 to 1999, 108 patients were operated on with this technique, which could remove the herniation mass, repair dural and bone defects, reconstruct the naso-orbital area, and restore aesthetic facial appearance in a single stage. Formal frontal craniotomy was not necessary. The result has been very satisfying in terms of safety, cure rate, and aesthetic outcome. Spontaneous improvement of lacrimal passage obstruction occurred in 85.2 percent of cases, and dacryocystorhinostomy was required in the rest. There was no mortality. Complications (e.g., wound infection, 6.5 percent; wire extrusion, 3.7 percent; meningitis, 2.8 percent; cerebrospinal fluid leakage, 2.8 percent; and postoperative increased intracranial pressure, 2.8 percent) were much less frequent than in other reports. With a mean follow-up period of 439 days (maximum, 12 years), there has been no recurrence.

Sincipital encephalocele mismanaged as a facial hemangioma

A 3-month-old male infant was found to have a protruding mass with irregular contour at the root of his nose since birth. The mass protruded more when he cried. It was diagnosed and treated as a hemangioma by laser surgery in another hospital. However, the lesion recurred 1 week later. Reviewing the previous computed tomographic study of the brain, it revealed that the protruding mass communicated with the brain. Sincipital encephalocele was diagnosed, and craniotomy for excising the encephalocele and repair of the dura were undertaken successfully. We report this patient with sincipital encephalocele that was misdiagnosed and treated as a vascular malformation on the face. Fortunately, there was no complication. The authors stress the importance of accurate diagnosis of a lesion near the craniofacial junction to avoid unnecessary surgery and possible catastrophes.

An unusual presentation of an encephalocele to the otolaryngologist

An unusual case of encephalocele causing obstruction of the upper airway in a neonate is described. The patient presented with a large mass in the neck, which extended from the base of the skull to the level of the larynx. Although there was no evidence of a defect of the skull base, subsequent excision and histological examination confirmed an encephalocele.

Unilateral naso-orbital meningocele and bilateral congenital fistulae of the lacrimal passages

Orbital meningocele is the protrusion of a sac containing cerebrospinal fluid into the orbit, through a defect called cranium bifidum. Although the occipital and frontal basis of the cranial cavity constitute the two most frequent localizations, this pathology may rarely be located in the naso-orbital region. Other developmental anomalies of the eyes may accompany the anomalies of the bony orbit. The case described in the present paper had a right naso-orbital meningocele associated with bilateral fistulae of the lacrimal passages which represents a very rare condition.

Management of anterior encephalocele

The authors report their experience with anterior encephalocele, comprising 11 congenital and 11 traumatic cases. Unlike occipital encephaloceles, anterior lesions are usually associated with normal mental development. Surgery aims to restore normal anatomy with repair of the defective dura, bone and skin. Indications, surgical methods and outcome are discussed.

Sincipital encephalocoeles: a review of clinical presentations and methods of surgical repair in Ibadan, Nigeria

Between January 1972 and September 1987, 10 sincipital (fronto-ethmoidal) encephalocoeles were encountered at the neurosurgical unit of the University College Hospital, Ibadan, Nigeria. Seven of the eight patients whose clinical records were available for study were females. The age at presentation varied from 7 days to 5 years. All patients exhibited a mass at the root of the nose. An increase in the size of the lesion was noted, prior to surgery. Clinically, there was no hydrocephalus. Associated birth defects were minor. Five patients underwent intracranial repair. One patient's lesion was excised extracranially. In all these patients, a lump remained or recurred after surgery. Only one patient returned for a recommended second stage of repair at which the residual mass was completely excised. The default rate from follow-up was high. A combined intracranial and extracranial repair during the same hospital admission may offer the best chance for cure.

Anterior encephalocele

Eighteen cases of anterior encephalocele treated at the University of Malaya Hospital between 1970 and 1980 are discussed, and the literature concerning this defect is reviewed. A detailed analysis of the microscopic abnormalities present in the surgical specimens is included, along with the relevant radiographic and demographic data. Anterior encephalocele is more common in Southeast Asia than elsewhere. The possible ethnographic and geographic implications are presented, as well as a discussion of the relevant embryology, in attempting to define possible etiologies for this malformation. The author's surgical approach to the repair of this defect and reasons for preferring a transcranial, intradural approach are described. Potential complications are enumerated.

Nasal encephalocoele. Treatment by trans-cranial operation

Results are described of 86 intracranial operations for the repair of nasal encephalocoele children at the Lahore Neurosurgical Centre in the last 13 years. These midline lesions at the base of the anterior cranial fossa have been considered in the past to be inoperable and even when operable, unpleasantly difficult. The intracranial approach has made it possible to treat this condition satisfactorily with comparatively few complications. Attempts at extra-cranial repair have met little success as they do not take into account the basic embryology and anatomy of the condition and fail to tackle the sac at the patent foramen caecum, the neck of the sac. This paper describes the embryology, anatomy, basic pathology and clinical features of the condition with characteristic X-rays showing the patent foramen caecum and outlines the operative repair.

Heterotopic brain tissue in the submandibular region and lung. Report of two cases and comments about pathogenesis

Two cases of extracranial heterotopia of the brain are reported. Case 1, in an otherwise normal female baby, had a brain heterotopia in the submandibular region. Case 2, in a still-born female baby with anencephaly, had the heterotopia in the lung. The lesion in case 1 is believed to be an encephalocele that has been pinched off through a cleft in the bone or through a foramen of the skull; the pathogenesis is similar to that of the so-called "nasal glioma". Concerning the pathogenesis of case 2, contrary to the generally supported embolism theory, observation of serial sections of the tumor in the lung favors the aspiration theory according to which amniotic brain tissue fragments, which are dislocated into the amnion because of nonclosure of the ventricle or following destruction of the fetal brain, are aspirated by fetal respiratory movements in the 4th to 6th month of intra-uterine life.

Nasal encephalocoeles associated with unilateral absence of the cochlea

A case of nasal encephalocoele associated with unilateral absence of the cochlea is described. The association of congenital abnormalities of the skull and the spine with deformities of the inner ear is discussed together with the value of tomography in the assessment of these children.