Nasal encephalocoele. Treatment by trans-cranial operation

Management of cerebrospinal-fluid-related intracranial abnormalities in frontoethmoidal encephalocele using "Shunt algorithm for frontoethmoidal encephalocele" (SAFE)

A cerebrospinal-fluid-related (CSF-related) problem occurred in 25-30% of frontoethmoidal encephalocele (FEE) cases. Since there was no algorithm or guideline, the judgment to treat the CSF-related problem often relies upon the surgeon's experience. In our institution, the early shunt was preferable to treat the problem, but it added risks to the children. We developed an algorithm, "Shunt Algorithm for Frontoethmoidal Encephalocele" (SAFE), to guide the surgeon in making the most reasonable decision. To evaluate the SAFE's efficacy in reducing unnecessary early shunting for FEE with CSF-related intracranial abnormality. Medical records of FEE patients with CSF-related abnormalities treated from January 2007 to December 2019 were reviewed. The patients were divided into two groups: before the SAFE group as group 1 (2007 - 2011) and after the SAFE group as group 2 (2012 - 2019). We excluded FEE patients without CSF-related abnormalities. We compared the number of shunts and the complications between the two groups. One hundred and twenty-nine patient's medical records were reviewed. The males were predominating (79 versus 50 patients) with an average age of 58.2±7.1 months old (6 to 276 months old). Ventriculomegaly was found in 18 cases, arachnoid cysts in 46 cases, porencephalic cysts in 19 cases, and ventricular malformation in 46 cases. Group 1, with a score of 4 to 7 (19 cases), received an early shunt along with the FEE repair. Complications occurred in 7 patients of this group. Group 2, with a score of 4-7, received shunts only after the complication occurred in 3 cases (pseudomeningocele unresponsive with conservative treatment and re-operation in 2 cases; a sign of intracranial hypertension in 1 case). No complication occurred in this group. Groups 1 and 2, with scores of 8 or higher (6 and 8 cases, respectively), underwent direct shunt, with one complication (exposed shunt) in each group. The SAFE decision algorithm for FEE with CSF-related intracranial abnormalities has proven effective in reducing unnecessary shunting and the rate of shunt complications.

The extracranial versus intracranial approach In frontoethmoidal encephalocele corrective surgery: a meta-analysis

The debate between the extracranial and the intracranial approach for frontoethmoidal (FEE) encephalocele corrective surgery was not summarized yet. The extracranial approach is traditionally believed being inferior to the intracranial approach, but convincing evidence was missing. To provide robust evidence, we conducted a meta-analysis on the incidence of cerebrospinal fluid (CSF) leakage, its progression to infection, the reoperation to treat the leakage, and the recurrence rate between the two techniques. We performed a meta-proportion pooled analysis and meta-analysis on eligible literature following the recommendation of PRISMA guidelines. The outcome of interest was the incidence of CSF leakage, the CSF leakage that progressed into an infection, the reoperation rate to treat the leakage, and the recurrence rate. We included 28 studies comprising 1793 patients in the pooled prevalence calculations. Of the 28 studies, nine studies describing 730 patients were eligible for meta-analysis. The prevalence of CSF leakage was 8% (95% CI, 0.04-0.12) in the intracranial approach and 10% (95% CI, 0.01-0.23) in the extracranial approach The subgroup analysis of the intracranial approach showed higher CSF leakage prevalence in the frontal craniotomy approach (9%; 95% CI, 0.03-0.16) than the subfrontal osteotomy (6%; 95% CI, 0.03-0.12). Meta-analysis study revealed a significantly higher risk of CSF leakage (OR 2.82; 95% CI, 1.03-7.72), a higher reoperation rate (OR 5.38; 95% CI: 1.13 - 25.76), and the recurrence rate (RR 4.63; 95% CI, 1.51-14.20) for the extracranial approach. The event of infected CSF leakage (OR 3.69; 95% CI, 0.52-26.37) was higher in the extracranial than intracranial approach without any statistical significance. The extracranial approach was associated with a higher risk of CSF leakage, reoperation rate to treat the CSF leakage, and the recurrence rates. The infected CSF leakage between the extracranial and intracranial approaches showed no significant difference.

Coexistence of dermal sinus tract, dermoid cyst, and encephalocele in a patient presenting with nasal cellulitis

Dermoid cysts, encephaloceles, and dermal sinus tracts represent abnormalities that develop during the process of embryogenesis. The elucidation of the precise timing of formation for these malformations has remained elusive at the molecular level of study. Yet, clinical experience has demonstrated that these malformations do not all occur in the same patient, suggesting a shared pathway that goes awry at distinct points for different patients, resulting in 1 of the 3 malformations. Herein the authors describe a case in which all 3 malformations were present in a single patient. This is the first description in the English literature of a sincipital encephalocele occurring with a dermoid cyst and a dermal sinus tract.

Nasal encephalocoele -an atypical case

Nasal encephalocoele present at birth as a characteristic swelling over the nose and widening of intracanthal distance. Atypical nasal encephalocoeles are usually missed at birth due to absence of any external swelling and they present with diagnostic difficulties. These are very rare and present with only an intranasal mass. We report a case of an atypical nasal encephalocnele in a 8 year old boy who presented with a unilateral intranasal mass and cerebrospinal fluid rhinorrhoea.

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.

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.

Anterior encephaloceles: a study of 92 cases

Anterior encephalocele is a rare condition, and only a few large series have been published in the literature. Surprisingly, the incidence is much higher in Southeast Asian countries, including some parts of India. While the reported incidence in the West is between 1:35,000 and 1:40,000 live births, it is as high as 1:5,000 live births in Thailand. We present a series comprising 92 cases of anterior encephaloceles treated over a 30-year period (1971-2000). Frontoethmoidal encephaloceles are the commonest type, followed by the nasopharyngeal and orbital type. Among the frontoethmoidal encephaloceles, nasoethmoid is the commonest type, and these patients present with swelling over the bridge of the nose with significant hypertelorism and orbital deformities. The nasopharyngeal type remains occult and presents with nasal obstruction or CSF rhinorrhea. Rarely, the patient may present with meningitis. Since 1978, computed tomography (CT) scans have regularly been performed in our patients. CT scans delineate the skull defect and associated brain anomalies. There was associated hydrocephalus present in 12 patients and agenesis of the corpus callosum in 5 patients. In all patients, one-stage repair of the encephalocele and correction of bony anomalies by appropriate osteotomy was undertaken. Since 1988, in cases of frontoethmoidal encephalocele with significant hypertelorism, medial advancement of the medial half of the orbits on either sides was carried out, instead of a classical Tessier's operation. Postoperative morbidity included CSF leak in 20 patients, wound infection in 2 and chest infection in 3. There were 3 deaths in our study. The overall cosmetic outcome was good.

Axial skeleton and pituitary gland in human fetuses with spina bifida and cranial encephalocele

The purpose of this study was to investigate the axial skeleton and the pituitary gland in fetuses with spina bifida or cranial encephalocele in order to elucidate the pathogenesis of the conditions. The findings were related to former investigations performed on normal fetuses and on fetuses with anencephaly and rachischisis. Eight human fetuses from spontaneous or therapeutic abortions, 11-28 weeks of gestational age, were investigated. Radiographs were taken of the axial skeleton and histological investigation, including immunohistochemical marking for thyroid-stimulating hormone was performed on tissue blocks of the cranial base, including the sella turcica and the pituitary gland. Radiography revealed only minor malformations in the axial skeleton and not in all cases. The types of malformations resembled those seen in anencephaly and rachischisis. Histological investigations revealed severe malformations in the sella turcica region in spina bifida and minor ones in cranial encephalocele. Pharyngeally located adenopituitary gland tissue occurred in all fetuses. Anencephaly and cranial encephalocele seemingly are conditions resulting from different expressivity of the same multifactorial process of maldevelopment involving mesoderm (skeleton), neurectoderm (spinal cord and brain), and surface ectoderm (adenopituitary gland tissue). It is suggested that the molecular biological signaling between the notochord, the scleroderm, and the surface ectoderm is disturbed in spina bifida and cranial encephalocele.

Postmortem axial skeletal radiography can reveal fetal CNS malformations

The routinely performed autopsy of a macerated fetus will often be of dubious value, particularly as regards the examination of the central nervous system (CNS). Former studies have demonstrated a close relationship between certain CNS malformations and axial skeletal malformations revealed radiographically. In the present report a postmortem examination of a severely macerated fetus demonstrates a transsphenoidal encephalocele. A supplementary histological examination confirmed this condition and furthermore revealed absence of the pituitary gland. The findings were related to a strongly elevated serum alphafetoprotein level in the 18th gestational week. This report emphasizes the value of postmortem axial skeletal radiography of autolyzed fetuses suspected for CNS malformations.

Intranasal (transethmoidal) encephalomeningocele. Case report

Intranasal encephaloceles are rarely encountered in pediatric neurosurgery. The symptoms and clinical features may mimic those of nasal polyp. It is important to know the type of basal encephalomeningocele for appropriate surgical intervention. Computed tomographic examination is helpful for differential diagnosis of the encephalocele sac and localization of the cranial bone defect.

The repair of frontal encephaloceles in Papua New Guinea

Frontal encephaloceles are common in Papua New Guinea (PNG). Seventeen cases collected over 7 years are reported. Eleven frontal (sincipital) encephaloceles were repaired successfully via an extracranial approach. One of these patients with a frontonasal encephalocele developed a recurrence following the extracranial approach, which was subsequently repaired intracranially. Three patients with small naso-ethmoidal encephaloceles were repaired intracranially via an extradural approach. The other three cases have not yet had surgical correction. Complex craniofacial surgery which corrects hypertelorism as well as the encephalocele is unavailable in the developing world. For the general surgeon in the developing world, the extracranial approach is recommended for the frontonasal encephaloceles, and the intracranial approach for the naso-ethmoidal and naso-orbital encephaloceles. Hydrocephalus and epilepsy have not developed in the patients.

Anterior encephaloceles: a report of 30 cases

Thirty cases of anterior encephalocele treated in our centre over an 18-year period (from 1973 to 1990) are presented. At the time of surgery over 60% of the patients were under the age of 2 years, and 40% were aged under 1 year. Only one child was over 10 years of age. Twenty-six patients had the fronto-ethmoidal type of defect, while two each had frontonasal- and naso-orbital-type lesions. Twenty-five children had varying degrees of hypertelorism. Four had an enlarged head and four microcephaly. In 26 patients one-stage repair of the encephalocele and reconstruction of the orbits was undertaken. A ventriculoperitoneal shunt was performed prior to definitive surgery in three patients with gross hydrocephalus. There was no postoperative mortality. Six patients had postoperative CSF rhinorrhoea, three of them requiring a lumboperitoneal shunt. This study highlights the role of one-stage repair of this defect.

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.

The surgical correction of fronto-ethmoidal meningo-encephaloceles

One-stage correction of fronto-ethmoidal meningo-encephaloceles and related stigmata, via an orbito-cranial approach, is recommended. A bifrontal craniotomy is only required when simultaneous correction of hypertelorism is to be undertaken. A combined intra- and extracranial approach is essential. The possibility of a high relapse rate for repaired fronto-ethmoidal meningo-encephaloceles, together with the possibility of prolonged postsurgical cerebrospinal fluid leakage, meningitis and other complications is invited when either a transcranial bifrontal craniotomy surgical approach, or an extracranial approach via the facial lesion, is undertaken alone. Modification of existing craniofacial surgical approaches in order to avoid a frontal craniotomy, allowed for good repair of the encephalocele together with significant benefits in terms of simplification of the surgical procedure, operating time, blood loss, frontal lobe retraction and complications.

Cephaloceles: classification, pathology, and management

A cephalocele is defined as a herniation of cranial contents through a defect in the skull. Cephaloceles are classified according to their contents and location. We have reviewed a total of 112 patients with cephaloceles, 51 of whom had sincipital meningoencephaloceles (fronto-ethmoidal meningoencephaloceles). This group is distinctive in its demographic distribution, in the effect on growth of other facial structures, and in the combined craniofacial approach needed to treat them. This review is based on the sincipital encephaloceles with the other cephaloceles included for completeness. Despite many theories, the cause of congenital cephalocele is not known. Preoperative work-up includes 3-dimensional computed tomography scan of the facial skeleton, and surgical management is multidisciplinary in nature. The aim is to remove the lesion before the deformity has time to greatly distort facial growth, which appears to realign itself after surgery. The 50 patients who underwent surgery for fronto-ethmoidal encephalocele all survived with minimal complications.

Craniofacial approach for the neonatal management of frontonasal encephalocoeles

Three nasofrontal encephalocoeles managed at the University of South Alabama Medical Center are presented. Each consisted of abnormal brain originating from one frontal lobe, although the amount of cerebral tissue and the accompanying skin and meningeal layers varied. The encephalocoeles protruded through a defect in the anterior skull base near the cribiform plate. Repair in the neonatal period was required in two of the infants because of the size of the lesion and obstruction of the nasal airway. The operative approach utilized a bifrontal craniotomy with resection of the encephalocoele intradurally, repair of the anterior cranial fossa dura and osteoplastic repair of the foramen cecum defect. The closure of the facial defect depended upon the nature of the skin covering the herniation; either absence or excess of skin occurred. The preoperative evaluation disclosed associated congenital deformities in 2 of 3 patients in this series. Computerized tomographic scanning was of importance in preoperative planning. The operative technique can be modified to allow for each child's unique anatomy. Repair of nasofrontal encephalocoeles in the neonatal period may simplify the required operative procedures.

Nasal encephaloceles: definitive one-stage reconstruction

Nasal encephaloceles can cause complex deformities of the naso-orbital skeleton. As the encephalocele pushes through a defect in the facial skeleton it causes lateral displacement of the medial orbital walls. Correction of this skeletal deformity is necessary to achieve a normal facial contour. Two examples of nasal encephaloceles are presented and the classification, diagnosis, and treatment of this entity are discussed. The correction of these deformities at an early age is recommended. The suggested method of reconstruction is a combined intracranial and extracranial approach with mobilization of the nasal skeleton and medial orbital walls to their normal position. The remaining defects are treated with bone grafts.

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.

Fronto-ethmoidal meningoencephaloceles: morphology and treatment

Twenty-five cases of fronto-ethmoidal meningoencephaloceles have been studied. The relationship to other sincipital meningoencephaloceles is explored. In all cases the exit holes from the anterior cranial fossa are at the site of the foramen caecum. The facial component of the defect determines the sub-classification: naso-frontal, naso-ethmoidal and naso-orbital. The cranio-facial deformity may consist of hypertelorism, orbital dystopia, elongation of the face and dental malocclusion. These reflect the distorting influence of the extruded intracranial contents on facial growth. Early removal of the meningoencephalocele by the cranio-facial route is recommended to allow normal growth forces to be re-established. In older patients with established deformities translocation of the orbits may be necessary.

Primary intranasal encephalocele. Report of four cases

Four cases of primary intranasal encephalocele are presented. Three of the patients had been treated for nasal polyps. One of these three patients presented with persistent cerebrospinal fluid (CSF) rhinorrhea after fourth a polypectomy, another with recurrent CSF rhinorrhea and bacterial meningitis following a second polypectomy, and the third case with recurrence of meningitis, also following polypectomy. Recurrent bacterial meningitis was the mode of presentation in the fourth case. Encephalocele was the isolated abnormality in three, but the fourth had a degree of associated hypertelorism. The diagnosis of encephalocele should be considered in any patient with a nasal polyp, especially in children and in patients with recurrent bacterial meningitis, with or without rhinorrhea, in the absence of cranial trauma or surgery, or in the absence of external craniospinal anatomical defects.

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.