Cephaloceles: classification, pathology, and management

Post-traumatic intra-orbital meningoencephalocele in adults: technical note on a rare entity and review of the literature

Post-traumatic orbital meningoencephaloceles related to orbital roof fractures are a challenging clinical entity because of their rarity and difficult differential diagnosis. We report a case of post-traumatic intra-orbital meningoencephalocele in a 69-year-old man, secondary to a likely trapdoor mechanism, treated with a modified one-piece orbitozygomatic craniotomy. We also performed an extensive literature review of traumatic Intra-Orbital Encephalocele related to Orbital Roof Fracture focused on adult patients on electronic databases including Scopus, MEDLINE/PubMed, and Google Scholar. Patient well recovered after surgery with immediate exophthalmos resolution and discharged without visual or neurological deficits. The literature review included 22 papers with a total of 28 patients: 22 males (78.6%) and 6 females (21.4%), with a median age of 34.7 years. Twenty-six patients (92.9%) reported ocular injuries, with associated intracranial complications in 16 cases (61.5%). Twenty-seven patients (96.4%) were surgically treated, 18 of those underwent unilateral or bilateral frontal approach. Most orbital roof fractures can be managed nanoperatively if asymptomatic. Indeed, when the intra-orbital volume decreases, for example due to an encephalocele, the intra-orbital pressure could increase and determine an orbital compartment syndrome. In our case, we performed a one-piece modified orbitozygomatic approach, which has several advantages in comparison to the frequent unilateral or bilateral frontal craniotomy like the better exposure of the brain and orbit and a minimum brain retraction.

Prenatal intracranial hypotension syndrome in congenital cephalocele: Insights into pathophysiologic mechanisms and importance of defect coverage

OBJECTIVE

To compare specific fetal cranial and cerebral findings indicative of prenatal intracranial hypotension (PICH) syndrome between open and closed cephaloceles.

METHODS

Two groups of fetuses with cephalocele who underwent magnetic resonance imaging scan were selected based on the defect coverage: covered ("closed cephalocele" group, n = 4) and uncovered by skin ("open cephalocele" group, n = 8). The presence of signs associated with PICH syndrome was evaluated and findings compared between groups.

RESULTS

Cases from the open cephalocele group showed statistically significant differences in comparison with the closed cephalocele group regarding reduction of the interpeduncular angle (p = 0.006), reduced amount of cerebrospinal fluid in the subarachnoid space (p = 0.01), collapsed/severely reduced fourth ventricle (p = 0.03), cephalocele content (p = 0.03), and identification of a vector traction (p = 0.03). There were no differences in the presence of cerebellar tonsillar descent, obstructive ventriculomegaly, and presence of the lemon sign. In comparison with gestational age-matched controls, only the biparietal diameter but not the head circumference was significantly smaller in both the open and closed cephalocele groups (p < 0.05).

CONCLUSION

Congenital cephaloceles present distinct imaging behavior depending on the defect coverage. Therefore, the classification of cephalocele should include, in addition to location and content, the presence or absence of skin fully covering the defect.

Polypectomy-induced encephalocele manifested as meningitis and CSF rhinorrhea in a pregnant woman: a case report

Encephalocele is a protrusion of the intracranial contents through a cranium defect. Encephalocele is divided into primary (congenital) and secondary (acquired) classes. From an epidemiological point of view, primary encephalocele is much more prevalent than secondary cases. Furthermore, among the secondary causes of this condition, iatrogenic encephalocele is recognized as a rare phenomenon. In this case report, we introduce a case of secondary encephalocele in a 30-year-old pregnant female who came to our emergency center at 5 weeks of gestation with a vague headache in her forehead and a runny nose. she reported a history of nasal polypectomy 9 months ago and a 10-day hospitalization for meningitis 5 months prior to admission. MRI of the patient's brain showed evidence of cerebral parenchymal herniation to the right nasal cavity, which was suggestive of encephalocele. She was scheduled for endoscopic transnasal reconstruction, and during the operation, a significant right-sided posterior ethmoidal roof defect with CSF leak and encephalocele was revealed. Eventually, the skull defect was successfully repaired with a vascularized flap, and the patient was discharged in good general condition.

Large Isolated Nasoorbital Type of Frontoethmoidal Encephalomeningocele: A Case Report With Long-Term Follow-up

ABSTRACT

Frontoethmoidal encephalomeningocele (FEEM) is a rare congenital craniofacial malformation with increased incidence in Southeast Asia, especially in Thailand. Because of its rarity, main treatment obstacles include the lack of surgical treatment techniques and long-term postoperative follow-up data. The authors present the case of a 9-month-old boy who was born with a large isolated nasoorbital type of FEEM, which had a pressure effect on his right eye, nose, and facial complex. Preoperative computed tomography of the facial bone was performed to evaluate the external bony defect. This study aims to present surgical correction of FEEM with Chula's technique and long-term 7-year postoperative follow-up including both clinical and imaging aspects.

A red herring CVA with unexpected outcome: illustrative case

BACKGROUND

Disruptions to the integrity of the inner table and trabeculae of the calvaria are rare phenomena. Increasingly rare is the phenomenon of herniation of brain parenchyma through the defects in the skull causing neurological deficit. Surgical intervention is commonly performed but is fraught with risk of brain tissue loss.

OBSERVATIONS

The authors present a case of a 78-year-old White male presenting with strokelike symptoms who was found to have an intradiploic encephalocele that was successfully treated with surgical intervention and neuroplastic reconstruction of the anatomical deficit. The patient had a marked recovery and had near-complete resolution of symptoms.

LESSONS

This notably rare phenomenon resolved with neurosurgical intervention, sparing the parenchyma, and provided the patient with perceivably normal contour of the head using a collaborative approach with neuroplastic intervention.

MRI diagnosis of spontaneous intraventricular tension-pneumocephalus in a 10-month-old male Saarloos Wolfdog

A 10-month-old male Saarloos Wolfdog was presented with a history of multiple neurologic deficits that had acutely progressed. Neurologic examination findings localized signs to the cerebrum and brainstem. Magnetic resonance imaging revealed markedly enlarged and gas-filled lateral ventricles with a mass effect leading to cerebellar herniation. A right-sided defect of the cribriform plate with a dysplastic ethmoturbinate was identified as the inlet of air and origin of the intraventricular tension pneumocephalus. Surgical findings were consistent with a ruptured, congenital, nasal meningocele.

An Integrated Approach to the Management of Meningoencephalocoeles

ABSTRACT

Meningoencephalocoeles are congenital herniations of meningeal and cerebral tissues through a cranial defect. They occur most commonly in South-East Asia, and are relatively rare amongst European ancestry populations, with an estimated prevalence of 1/40,000 live births. The treatment of congenital meningoencephalocoeles is primarily surgical and are best managed by dedicated multi-disciplinary craniofacial teams. The authors performed a retrospective case review of all primary meningoencephalocoeles managed in the Oxford University Hospitals NHS Foundation Trust between 1986 and 2012. Twenty-nine cases (13 frontal, 9 occipital, 2 parietal, and 5 basal) were included in this study. The median age at presentation was 11 months (range 0-60 years). Twenty-five cases presented with an external mass; 3 with recurrent meningitis and 1 with otorrhoea. Twenty-six cases underwent surgery, and 17 of these were managed by an integrated approach between 2 or more surgical specialties. Twenty out of 26 operations were performed via a transcranial approach. The authors describe a particularly complex case in order to highlight the challenges associated with management of meningoencephalocoeles, the surgical technique employed, and the importance of a multidisciplinary surgical approach. This is the largest reported case series of meningoencephalocoeles managed in a single hospital in the United Kingdom. Designated craniofacial units with access to multidisciplinary surgical specialties provide a safe and optimal setting for the management of meningoencephalocoeles.

Ethmoidal meningoencephalocele in a C57BL/6J mouse

An otherwise healthy two-month-old female C57BL/6J mouse presented with a left-sided head tilt. Differential diagnoses included idiopathic necrotizing arteritis, bacterial otitis media/interna (Pasteurella pneumotropica, Pseudomonas aeruginosa, Streptococcus sp., Mycoplasma pulmonis and Burkholderia gladioli), encephalitis, an abscess, neoplasia, a congenital malformation and an accidental or iatrogenic head trauma. Magnetic resonance imaging (MRI) revealed a large space-occupying right olfactory lobe intra-axial lesion with severe secondary left-sided subfalcine herniation. Following imaging, the animal was euthanized due to poor prognosis. Histopathologic examination revealed a unilateral, full-thickness bone defect at the base of the cribriform plate and nasal conchae dysplasia, resulting in the herniation of the olfactory bulb into the nasal cavity. There was also a left midline-shift of the frontal cortex and moderate catarrhal sinusitis in the left mandibular sinus. The MRI and histopathologic changes are consistent with a congenital malformation of the nasal cavity and frontal aspect of the skull known as an ethmoidal meningoencephalocele. Encephaloceles are rare abnormalities caused by herniation of contents of the brain through a defect in the skull which occur due to disruption of the neural tube closure at the level anterior neuropore or secondary to trauma, surgical complications, cleft palate or increased intracranial pressure. The etiology is incompletely understood but hypotheses include genetics, vitamin deficiency, teratogens, infectious agents and environmental factors. Ethmoidal encephaloceles have been reported in multiple species including humans but have not been reported previously in mice. There are multiple models for spontaneous and induced craniofacial malformation in mice, but none described for ethmoidal encephaloceles.

A Rare Case of Sphenoid Encephalocoele Presenting with Fifth Cranial Nerve Involvement

A 14-year-old girl presented with chronic headache, recurrent episodes of vomiting, fever, and two episodes of generalized tonic clonic seizure in the past 2 months. Neuroimaging revealed herniation of the brain along with the dura through a defect in the left greater wing of the sphenoid. Left pterional craniotomy was carried out. Herniation of the dural sac along with its contents through the bony defect in the greater sphenoid wing was identified lateral to the V2 nerve passing through the foramen rotundum. The dural defect was repaired. Bony defect was covered with a circular titanium plate. The patient did not have cerebrospinal fluid rhinorrhea postoperatively. At 6-month follow-up, she was asymptomatic.

Prenatal diagnosis and clinical significance of cephalocele-A single institution experience and literature review

OBJECTIVES

To determine the frequency of genetic and additional structural abnormalities as well as pregnancy outcomes in fetuses with prenatally diagnosed cephalocele.

METHODS

A retrospective analysis of data retrieved from ultrasound examinations and genetic testing in fetuses with cephalocele diagnosed between 2006 and 2018 in a tertiary referral hospital along with a systematic literature search in the PubMed database on fetuses with prenatally diagnosed cephalocele.

RESULTS

Twenty-one out of 36 fetuses were found to have additional structural anomalies (58.3%). In four fetuses, anomalies were consistent with limb-body wall complex, in five with Meckel-Gruber syndrome, and in one with amniotic band syndrome. Genetic abnormalities were present in 11.1% of fetuses (trisomy 6; microdeletion 22q11.21; microduplication 16p13.11; pathogenic variant in gene CC2D2A). Twenty-eight pregnancies were terminated (77.8%; 28/36); two were miscarried (5.6%; 2/36). All six children from pregnancies that continued were liveborn but only two survived the surgery and developed neurological sequence. Overall survival rate was 25% (2/8) with 0% intact survival.

CONCLUSIONS

Additional structural anomalies are common in fetuses with cephalocele. A significant number of fetuses have genetic abnormalities, and a detailed genetic testing should be performed in all cases. The prognosis is poor with high mortality rate and 0% intact survival.

Internasal: A New Type of Frontoethmoidal Encephalomeningocele

IMPORTANCE

Frontoethmoidal encephalomeningocele (FEEM) is a congenital anomaly with a skull base defect at the foramen caecum and a protrusion of meninges and brain tissue through an external defect on the face. The external defect was classified to nasofrontal, nasoethmoidal, naso-orbital, combined, and abortive type.

OBJECTIVE

The aim of our study was to present a newly discovered internasal type (IN) of FEEM.

DESIGN, SETTING, PARTICIPANTS

Ninety-six FEEM patients' preoperative 3-dimensional computer tomography scans were studied in the Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand followed by treatment from 2006 to 2016.

FINDINGS

Sixteen patients had an external bony defect between the nasal bone that could not be classified in any previous classification. We suggest a new type of FEEM called "IN." The bony defect of this IN can be located on the upper nasal bone (4 cases), middle nasal bone (5 cases), or combined with naso-orbital type (7 cases) counted in the combined type.

CONCLUSIONS AND RELEVANCE

Our study presents a newly discovered IN of FEEM. This IN can cause hypertelorism when the nasofrontal type could not. Preoperative 3-dimensional computer tomography scans are very helpful for surgical planning.

Frontoethmoidal encephalocele in a cat

Case summary

An 11-month-old female neutered domestic shorthair cat presented for further investigation of a 1 month history of generalised tonic–clonic seizures. Physical examination revealed microphthalmia of the left eye and right-sided hemiparesis. MRI of the brain and cranial neck was performed using a 1.5-Tesla system. MRI revealed a left frontoethmoidal encephalocele and microphthalmia of the left eye. Conservative treatment with antiepileptic medication was elected. The cat was managed on phenobarbitone and levetiracetam. Seizures have remained well controlled 12 months post-diagnosis.

Relevance and novel information

This is the first known case report of a frontoethmoidal encephalocele in a cat. This case was presented to increase clinical awareness of this congenital malformation and as a differential diagnosis for any young cat that presents with seizures.

Imaging Findings of Jugular Foramen Meningocele in a Neurofibromatosis Type 1 Patient

Neurofibromatosis type I (NF1) is a neurocutaneous disorder that involves autosomal dominant transmission. Skull defects, including sphenoid dysplasia and calvarial defects, are a rare finding in patients with NF1. Spinal meningocele and sphenoid wing dysplasia have been identified in NF1 but the occurrence of meningoceles at the skull base is extremely rare. A rare instance of jugular foramen meningocele being identified in an NF1 patient on imaging is described in this paper. To the best of our knowledge, only two such cases have been reported in the English literature.

Symptomatic Parietal Intradiploic Encephalocele-A Case Report and Literature Review

Encephalocele is a rare condition that consists of herniation of cerebral matter through openings of dura and skull. A majority of encephaloceles are congenital and manifest in childhood. We present a case of a 45-year-old man presenting with contralateral hemiparesis and found to have an extremely rare phenomenon of a symptomatic posttraumatic parietal intradiploic encephalocele (IE) manifesting 36 years following pediatric traumatic head injury. Computed tomography and magnetic resonance imaging confirmed herniation of brain tissue into the intradiploic space. Surgical treatment with reduction of the encephalocele achieved near resolution of preoperative hemiparesis on follow-up. The pathogenesis and a literature review of IE are discussed.

Endonasal management of pediatric congenital transsphenoidal encephaloceles: nuances of a modified reconstruction technique. Technical note and report of 3 cases

OBJECTIVE Congenital transsphenoidal encephaloceles are rare malformations, and their surgical treatment remains challenging. This paper reports 3 cases of transsphenoidal encephalocele in 8- to 24-month-old infants, who presented mainly with airway obstruction, respiratory distress, and failure to thrive. METHODS The authors discuss the surgical management of these lesions via a minimally invasive endoscopic endonasal approach, as compared with the traditional transcranial and transpalatal approaches. A unique endonasal management algorithm for these lesions is outlined. The lesions were repaired with no resection of the encephalocele sac, and the cranial base defects were reconstructed with titanium mesh plates and vascular nasoseptal flaps. RESULTS Reduction of the encephalocele and reconstruction of the skull base was successfully accomplished in all 3 cases, with favorable results. CONCLUSIONS The described endonasal management algorithm for congenital transsphenoidal encephaloceles is a safe, viable alternative to traditional transcranial and transpalatal approaches, and avoids much of the morbidity associated with these open techniques.

Clinical Features, Imaging Characteristics, and Long-term Outcome of Dogs with Cranial Meningocele or Meningoencephalocele

Background

The term meningoencephalocele (MEC) describes a herniation of cerebral tissue and meninges through a defect in the cranium, whereas a meningocele (MC) is a herniation of the meninges alone.

Hypothesis/Objectives

To describe the clinical features, magnetic resonance imaging (MRI) characteristics, and outcomes of dogs with cranial MC and MEC.

Animals

Twenty‐two client‐owned dogs diagnosed with cranial MC or MEC.

Methods

Multicentric retrospective descriptive study. Clinical records of 13 institutions were reviewed. Signalment, clinical history, neurologic findings and MRI characteristics as well as treatment and outcome were recorded and evaluated.

Results

Most affected dogs were presented at a young age (median, 6.5 months; range, 1 month – 8 years). The most common presenting complaints were seizures and behavioral abnormalities. Intranasal MEC was more common than parietal MC. Magnetic resonance imaging identified meningeal enhancement of the protruded tissue in 77% of the cases. Porencephaly was seen in all cases with parietal MC. Cerebrospinal fluid (CSF) analysis identified mild abnormalities in 4 of 11 cases. Surgery was not performed in any affected dog. Seventeen patients were treated medically, and seizures were adequately controlled with anti‐epileptic drugs in 10 dogs. Dogs with intranasal MEC and mild neurologic signs had a fair prognosis with medical treatment.

Conclusion and clinical importance

Although uncommon, MC and MEC should be considered as a differential diagnosis in young dogs presenting with seizures or alterations in behavior. Medical treatment is a valid option with a fair prognosis when the neurologic signs are mild.

Nasopharyngeal Mass Diagnosed as Transsphenoidal Encephalocele in an Adult Patient

Transsphenoidal encephalocele, a rare congenital malformation, is generally diagnosed during childhood when investigating the reason for complaints such as nasal obstruction and recurring cerebrospinal fluid fistula. In this adult patient, the authors identified an asymptomatic transsphenoidal encephalocele after requested monitoring of a pedunculated mass detected in the nasopharynx during nasal endoscopy. After evaluation, the authors decided to follow the patient. Few cases of transsphenoidal encephalocele have been reported, and even fewer have been reported in older patients, with no other anomaly or symptoms. The success of surgical treatment for these masses is debatable. The authors did not consider surgery for this asymptomatic case. With this case presentation, the authors wish to emphasize that without making radiologic assessments of any masses identified in a nasopharyngeal examination, it would be inappropriate to perform a biopsy or any intervention.

Imaging diagnosis--meningoencephalitis secondary to suppurative rhinitis and meningoencephalocele infection in a dog

Nasal encephaloceles (meningoceles or meningoencephaloceles) are rare and not reported to be infected or coupled with a facial deformity in dogs. This report describes an older dog with acute worsening of seizures due to suppurative meningoencephalitis with coexisting suppurative rhinitis and infection of a meningoencephalocele. Additionally, the dog had a facial deformity for at least 5 years. The results of necropsy, computed tomography, and postmortem magnetic resonance imaging are compared. The development of nasal encephaloceles is discussed, including the potential role of early trauma, and whether separation of neural ectoderm from the surface ectoderm is part of the pathogenesis.

Not the usual sinusitis

An encephalocele is a protrusion of the cranial contents beyond the normal confines of the skull. It is a rare cause of seizure in adults. A 38-year-old woman presented with a first-onset seizure. Brain CT was interpreted as right frontal sinus opacification suggestive of sinusitis. The patient was discharged home with an amoxicillin prescription. A few days later, she was re-admitted with another seizure. Careful evaluation of the brain CT and MRI revealed a right frontal sinus posterior wall defect and possible brain encephalocele. The patient had complained of chronic nasal discharge for years and had also noticed a watery discharge from her right nostril. We suspected cerebrospinal fluid rhinorrhea. A bifrontal craniotomy was performed, the encephalocele was resected and cranialisation of the frontal sinus was completed. The patient remained free of seizures at the last follow-up.

Transalar transphenoidal meningoencephalocele: A rare cause of respiratory distress in a neonate

Respiratory distress in an infant is a common cause of admission in neonatal intensive care facility. Obstructive lesions of the airway constitute a minority of problems in the new born but present a diagnostic challenge. We present a 30-day-old male infant admitted with respiratory distress who was diagnosed to have an oropharyngeal cystic mass which on further evaluation by computed tomography and magnetic resonance imaging revealed a transalar transsphenoidal meningoencephalocele herniating into the oral cavity through a congenital split palate. The patient was operated successfully using a transpalatal approach leading to complete resolution of respiratory distress.

Frontoethmoidal meningoencephalocele: appraisal of 200 operated cases

OBJECT

Frontoethmoidal mengingoencephaloceles (fMECs) are frequently observed in Cambodia, especially in poor families. The authors describe issues related to the surgical treatment of fMECs in Cambodia at the end of a humanitarian program that provided surgery free of charge to patients and their families.

METHODS

The authors reviewed 257 cases of fMEC involving patients who presented to their institution, the Children's Surgical Center in Phnom Penh, between 2004 and 2009. They treated 200 of these patients surgically (108 males, 92 females; 89% younger than 18 years) using a "low-cost" management plan with no routine pre- or postoperative investigations. Initially, surgery was performed by visiting foreign surgeons who taught the procedures to resident surgeons. Patients were not charged for consultations or treatment and received at least 1 follow-up examination 6 months postoperatively.

RESULTS

The nasoethmoidal type was the most frequent fMEC encountered (69%). Many patients had associated ophthalmological issues (46% of cases). Only 1 familial case was detected. Combined neurosurgical and facial procedures were successfully standardized and learned by surgeons initially unfamiliar with fMEC management. A neurosurgical approach avoided the need for a facial incision in 42 cases, improving cosmetic results. The most common postoperative issues were a temporary CSF leak (24 cases [12%]) and/or infection (28 cases [14%]). There were 3 deaths directly related to the operations. Cosmetic results were good in 145 cases, average in 27, poor in 7, and worse than preoperative appearance in 6 patients. Fifteen patients were lost to follow-up. The parents of 87% of the children were rice farmers. Questionnaire results confirmed that fMEC has important social and educational consequences for the affected children and that these consequences can be partially improved by fMEC correction.

CONCLUSIONS

This experience in fMEC management demonstrates that local surgeons can treat these malformations with limited surgical materials and in a nonspecialized infrastructure after principles of treatment have been learned and if they are carefully respected. Surgery for fMEC can thus be more accessible to a larger number of patients in developing countries. Moreover, local treatment facilitates better postoperative and follow-up care.

Congenital duplication of the superior sagittal sinus and parietal encephalocele after vacuum extraction delivery

A newly-born infant with a congenital dural and bony defect and an associated short-segmented duplication of the superior sagittal sinus suffered from herniation and infarction of parietal brain tissue secondary to vacuum extraction. This ultimately led to the formation of a subgaleal cerebrospinal fluid (CSF) collection. Initial operative closure of the encephalocele was performed by attaching a galeal flap to the periostium surrounding the congenital defect. As the bony defect developed characteristics of a growing fracture later on, dural repair, transplantation of a split-bone flap and, finally, the insertion of a ventriculoperitoneal shunt became necessary. This case affirms that stringent indication and cautious usage of vacuum-assisted delivery is strongly recommended, especially in view of the possibility that undetected congenital cranial, vascular and/or cerebral alterations may be present.

Secondary craniofacial reconstruction of huge frontoethmoidal encephalomeningocele after primary neurosurgical repair

Frontoethmoidal encephalomeningocele is a congenital herniation of intracranial contents, including meninges, brain and part of the ventricle, through a bony defect in the skull at the junction of the frontal and ethmoid bones. Management involves meticulous preoperative assessment using computed tomography scans and magnetic resonance imaging, and surgical repair of the central nervous system, skeletal deformities of the orbit, downward displacement of the medial canthi, upward displacement of the eyebrows, and nasal deformities. Frontoethmoidal encephaloceles are best operated on via a craniofacial approach which enables repair of the central nervous system and skeletal deformities in one stage. However, a two-stage reconstruction must be considered when a prolonged operative time is expected or the patient's general condition increases the risks. There have only been a few reports of two-stage reconstructions. We performed a two-stage reconstruction of a huge frontoethmoidal encephalomeningocele, with neurosurgical repair during the first procedure and craniofacial reconstruction during the second procedure. We report on the surgical procedures and the problems encountered.

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.

Jugular foramen meningocoele in a patient with neurofibromatosis type 1

Objective:

We present a rare case of a jugular foramen meningocoele in a 48-year-old female, with neurofibromatosis type 1, presenting with positional vertigo. We also postulate possible underlying pathophysiological mechanisms.

Method:

We describe the imaging findings of this rare entity and review the literature on skull base meningocoeles, particularly in the context of neurofibromatosis type 1.

Results:

A computed tomography scan revealed smooth expansion of the jugular foramen. Magnetic resonance imaging showed a fluid filled lesion expanding the jugular foramen and communicating with cerebrospinal fluid of the cerebellomedullary cistern superiorly.

Conclusion:

Skull base meningocoeles are a rare entity and we believe that this is the first reported case of a meningocoele causing enlargement of the jugular foramen in a patient with neurofibromatosis type 1. The meningocoele may have resulted from a severe form of dural ectasia or from dysplastic, weakened bone at the skull base.

Transalar Sphenoidal Encephalocele

Classification of cranial encephalocele is based on the anatomic location of the skull defect. Basal sphenoidal encephaloceles are the least common form of encephalocele whose pathogenesis can be congenital, traumatic, tumoral or spontaneous. We present a case of a very rare basal encephalocele protruding through a defect in the greater wing of the sphenoid bone into the pterygoid fossa.

Prevalence of encephalocele in Texas, 1999–2002

Encephaloceles are congenital malformations characterized by a sac-like protrusion of the brain and/or its' covering membranes through an opening in the skull. The etiology of encephalocele is considered to be complex, and in most cases the causes of this condition remain elusive. The present study was undertaken to determine the prevalence of encephalocele among deliveries to Texas residents during 1999-2002, and to identify maternal and demographic factors associated with encephalocele. Data were examined from 125 infants and fetuses with encephalocele and no identified chromosome abnormality; identified in Texas and delivered in 1999-2002. During the same period there were 1,449,943 live births. The birth prevalence of encephalocele and both crude and adjusted prevalence ratios were estimated from these data. Compared with the offspring of White women, encephaloceles were significantly more common among the offspring of Hispanic women (adjusted prevalence ratio: 1.91, 95% confidence interval (CI) 1.34-2.70). In addition, compared to the offspring of women 25-29 years of age, encephaloceles were more common among the offspring of women 20-24 years of age (adjusted prevalence ratio: 1.52, 95% CI 1.01-2.27) and those less than 20 years of age (adjusted prevalence ratio: 1.55, 95% CI 0.98-2.45). These findings add to the existing literature on the descriptive epidemiology of encephalocele.

Midfacial Degloving: The Best Alternative for Treatment of Trans-sphenoidal Meningocele of the Pterygopalatine Fossa

Trans-sphenoid anterobasal temporal lobe meningoceles are rare and can be associated with temporal lobe epilepsy or recurrent meningitis. Surgical treatment is described via complicated infratemporal or intracranial approaches with high morbidity. A 32-year-old man presented with an 18-year history of two types of seizures and confirmed epileptic activity in electroencephalogram. A trans-sphenoid meningocele in the left pterygopalatine fossa was found on computed tomography and magnetic resonance imaging. A midfacial degloving was chosen instead of a large neurosurgical approach to remove it and to repair the dura defect with lyophilized dura, collagen, and abdominal fat. The postoperative course was uneventful without visible scars and the patient remains free of seizures without antiepileptic medication 3 years after surgery. Although midfacial degloving is not described yet as a treatment of trans-sphenoid meningoceles, this approach proved to be fast, safe, effective, and reliable and should be considered as the only alternative to large external approaches.

Rare facial clefts: treatment during charity missions in developing countries

During 10 charity missions in developing countries, 14 patients of a total of 374 children with cleft lip and palate deformities were treated for rare facial clefts. There were three midline clefts (Tessier no. 0 cleft, n = 1; Tessier no. 14 cleft, n = 2), four oblique facial clefts (Tessier no. 3 cleft, n = 2; Tessier no. 5 cleft, n = 2), and seven lateral facial clefts (Tessier no. 7 cleft). Surgical treatment focused on cleft repair by soft-tissue reconstruction apart from two Tessier no. 14 clefts, in which the bony gap was also closed using bone grafts from the iliac crest. The postoperative course was uneventful except for one local wound infection that was treated successfully using oral antibiotics. This article summarizes the authors' experience with the surgical management of these malformations and considers the limitations under conditions of charity missions in developing countries. Furthermore, some rare forms of cleft formation are added to the existing literature.

Ethmoidal encephalocoele associated with seizures in a puppy

A six-month-old puppy was presented for investigation of a seizure disorder. Neurological examination indicated persistent cerebral dysfunction in the absence of any identifiable metabolic disorder and magnetic resonance imaging revealed extension of the rostral lobes of the cerebrum into the nasal cavity. Despite symptomatic treatment, the puppy continued to exhibit seizures and appeared distressed and so was euthanased. Postmortem examination confirmed the abnormal anatomy of the rostral part of the brain and absence of a cribriform plate. There was extensive grey and white matter degeneration plus intraparenchymal haemorrhage in the abnormal brain tissue. The findings are consistent with a diagnosis of ethmoldal encephalocoele--a condition that has not previously been reported in the dog.

C677T mutation in the MTHFR gene was not found in patients with frontoethmoidal encephalocele in East Java, Indonesia

BACKGROUND

Frontoethmoidal encephalocele (FEE) is a neural tube defect (NTD) characterized by a congenital bone defect in the anterior cranium and herniation of the intracranial mass through the defect. The C677T mutation in the 5,10-methylenetetrahydrofolate reductase gene (MTHFR) has been reported as a genetic risk factor for spina bifida. However, the role of the MTHFR in the pathogenesis of FEE remains to be clarified.

METHODS

A hospital-based survey of FEE patients who were referred to the Department of Neurosurgery and Plastic Surgery, Malang General Hospital, East Java, Indonesia was conducted. Genetic screening of MTHFR substitutions in 13 patients and eight mothers from 11 affected families were performed using a combination of polymerase chain reaction (PCR), denaturing high-performance liquid chromatography (DHPLC), and direct sequencing.

RESULTS

In total, 130 patients with FEE among 138 NTD patients (94.2%) were identified. The ratios of cranial encephalomeningocele to spinal meningocele (32 : 1) and of FEE to occipital encephalomeningocele (32 : 1) were higher than those in other populations. Five substitutions were detected in the MTHFR: C121T, C677T, C1060T, A1298C, and G1793A. No significant differences were found in the frequency of each nucleotide substitution between patients or mothers and controls. In addition, none of the subjects in this study were homozygous for T at nucleotide position 677.

CONCLUSION

FEE is the most common form of NTD in East Java, Indonesia. Genetic analysis of 11 affected families suggests that the MTHFR gene is not associated with the development of FEE, although the number of FEE families analyzed in this study was very limited.

Occipital extra- and intracranial lipoencephalocele associated with tectocerebellar dysraphia

OBJECTS

Tectocerebellar dysraphism was first described by Padget and Lindenberg, together with occipital encephaloceles, cerebellar midline defects, tectal beaking, posterior kinked and displaced brainstem, and inverted cerebellum. We present a unique case of lipoencephalocele associated with tectocerebellar dysraphia and discuss the etiologies of both pathologies. The importance of the developmental comprehension of posterior fossa malformations is stressed.

CASE REPORT

A 9-month-old girl in good health was referred for a huge occipital mass. On local examination, the patient had a rounded mass about 10 x 12 cm in size, covered by alopecic skin, with a small eccentric dimple without any discharge. Magnetic resonance imaging revealed a lipoencephalocele with an intra- and an extracranial part, associated with tectocerebellar dysraphia with no aspect of inverted cerebellum as originally described in the tectocerebellar dysraphia. Resection of the extracranial part of the lipoma was performed for esthetic reasons. The intracranial part remained in situ.

CONCLUSION

The association of lipoencephalocele and tectocerebellar dysraphia is extremely rare. The functional prognosis seems to be less severe for this combination than for the isolated tectocerebellar dysraphia. This association favors the dysraphic theory for the embryogenesis of the lipoma. It seems safe to restrict the surgery of this bizarre malformation to its external part.

[Orbital meningocystocele]

Encephalocele is defined as a protrusion of cranial contents beyond the normal confines of the skull. Encephaloceles occur with an incidence of approximately 1 in 3,000-10,000 births and are categorized based on location in the skull. Orbital meningoencephalocele is a rare congenital abnormality caused by a defect of the cranio-orbital bones that usually manifests soon after birth as a soft mass associated with exophthalmos. We present a case of a giant orbital meningocele presenting as an orbital mass in a 15 months-old girl. Preoperative diagnosis was confirmed by CT-scan and magnetic resonance imaging.

An unusual pterygopalatine meningocele associated with neurofibromatosis type 1. Case report

The authors describe an unusual meningocele of the lateral wall of the cavernous sinus and the anterior skull base in a young patient with typical stigmata of neurofibromatosis Type 1 (NF1). This lesion was discovered during evaluation for recurrent meningitis. It represented an anterior continuation of Meckel's cave into a large cerebrospinal fluid space within the lateral wall of the cavernous sinus, extending extracranially through an enlarged superior orbital fissure into the pterygopalatine fossa adjacent to the nasal cavity. It was successfully obliterated, via an intradural middle fossa approach, with fat packing and fenestration into the subarachnoid space. This meningocele most likely represents a variant of cranial nerve dural ectasia occasionally seen in individuals with NF1. It has as its basis the same mesodermal defect responsible for the more common sphenoid wing dysplasia and spinal dural ectasias identified with this condition. Involvement of the trigeminal nerve with expansion of the lateral wall of cavernous sinus has not been reported previously. The authors surmise, however, that it may be present in some cases of orbital meningocele associated with sphenoid wing dysplasia.

Transsphenoidal meningoencephalocele in adults

BACKGROUND

Transsphenoidal meningoencephalocele is a rare congenital anomaly, reported only in 14 adult patients. It may be subdivided into intrasphenoidal, extending into the sphenoid sinus, and true transsphenoidal, traversing the floor of the sinus and protruding into the nasal cavity or nasopharynx.

METHODS

We present the eighth case of true transsphenoidal meningoencephalocele reported in an adult. We review the literature and highlight the differences in clinical presentation and therapeutic management between patients with intrasphenoidal and true transsphenoidal meningoencephalocele.

CONCLUSION

Adult patients with intrasphenoidal meningoencephalocele often present with rhinorrhea and should be considered for transsphenoidal repair, whereas patients with true transsphenoidal meningoencephalocele should not undergo surgery, in view of the complex anatomy and the slow progression of symptoms.

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.

Three-dimensional imaging of congenital disorders involving the orbit

Three-dimensional imaging of the orbit and its adnexa provides an excellent topographic visualization of the deformity or tumor extent. This helps comprehension, communication, education, and documentation in the process of treating the patient. This article briefly describes the technique of three-dimensional imaging and classifies congenital orbital deformities which are extensively illustrated with relevant case material.

Imaging of the skull base

Skull-base imaging has been a key factor in the advancement of skull-base surgery. The analysis of MR imaging or CT of the skull base emphasizes important landmarks, which are key to surgical planning. Although the definitive diagnosis usually is done by biopsy, the radiologist can limit the list of possibilities of the identity of a skull base lesion. The apparent site of origin is a key factor. Separation of cystic abnormalities from more solid enhancing abnormalities also is critical.

Transpalatal approach for the extracranial surgical repair of transsphenoidal cephaloceles in children

The surgical treatment of transsphenoidal cephaloceles in children is controversial. Reduction and repair via a transcranial approach are associated with high postoperative rates of morbidity, mortality, and hypothalamic dysfunction. In this study, four patients, aged 3 to 35 months at surgery, underwent successful transpalatal repair of two encephaloceles and two meningoceles. Two patients presented with nasal obstruction in infancy, one presented with unexplained meningitis, and in one patient the lesion was found incidentally during evaluation for seizures. Two children had median cleft face syndrome, another had an associated Arnold-Chiari type I malformation, and the fourth had no other cranial abnormalities. All patients underwent preoperative evaluation including magnetic resonance (MR) imaging. Auditory, ophthalmological, genetic, endocrinological, or other evaluation was undertaken as indicated. Lesions were approached through the median raphe of the hard and soft palates. All cephaloceles were easily visualized and dissected after division of the nasal palatal mucosa. The dural sac and its contents were reduced by surface coagulation after division and dissection of the overlying mucosa. Once reduced, the bone defect was obliterated in three of four patients. The dura was not opened and anomalous neural elements were not resected. At follow-up evaluation, all patients demonstrated resolution of preoperative symptoms without evidence of infection or lasting morbidity. Follow-up MR imaging showed reduction in all cases. The authors conclude that this transpalatal approach is safe and reliable for the treatment of transsphenoidal cephaloceles in young children.

Ventricular volume reduction technique--a new surgical concept for the intracranial transposition of encephalocele

The authors propose a new operative technique for the intracranial transposition of an encephalocele by using the associated hydrocephalic state. In the first stage, the intracranial pressure buffering effect of the encephalocele sac is reduced by the closing of the dural defect. The repaired dural defect allows intraventricular pulse pressure to produce ventriculomegaly. In the second stage or in infants with hydrocephalus, the extracranially herniated brain is transposed into the intracranial cavity during ventricular shunting with appropriate drainage of cerebrospinal fluid.

Pathogenesis of craniofacial and body wall malformations induced by ochratoxin A in mice

Ochratoxin A (OA), a mycotoxin commonly found in soils and on moldy food such as cereal grains, is a potent teratogen. The present investigation was designed to examine the teratogenicity of OA administered acutely at early post-implantation stages in mice, with particular emphasis on the pathogenetic basis of induced malformations. Maternal OA administration on gestational day (GD) 7 or 8 resulted in excessive amounts of cell death in selected cell populations. After a single dose of 2-4 mg/kg, excessive cell death was notable within 6 hours, and persisted to 36 hours post-treatment. As observed in GD 14 or 18 fetuses, the spectrum of induced craniofacial malformations included exencephaly, midfacial clefting, cleft lip, as well as hypotelorism, and synophthalmia associated with holoprosencephaly. Body wall defects involved either the abdominal wall alone, or in combination with the thoracic wall, resulting in partial or complete exposure of the viscera. Potential mechanisms for OA-induced selective cell killing are discussed.