Challenges in the Management of Symptomatic Fallopian Canal Meningoceles: A Multicenter Case Series and Literature Review

OBJECTIVE

To describe the presentations, the diagnosis, our treatment approaches, and the outcomes for 11 patients with fallopian canal meningocele (FCM).

STUDY DESIGN MULTICENTER

Retrospective case series.

SETTING

Tertiary referral centers.

PATIENTS

Patients (N = 11) with radiographically or intraoperatively identified, symptomatic FCM.

INTERVENTIONS

Surgical repair of cerebrospinal fluid (CSF) leak and meningocele versus observation.

MAIN OUTCOME MEASURES

Presentation (including symptoms, radiographic imaging, and comorbidities), management (including surgical approach, technique for packing, use of lumbar drain), clinical outcomes (control of CSF leak, meningitis, facial nerve function), and revision surgery.

RESULTS

Patients presented with spontaneous CSF leak (n = 7), conductive (N = 11) and sensorineural hearing loss (n = 3), nonpositional intermittent vertigo (n = 3), headaches (n = 4), and recurrent meningitis (n = 1). Risk factors in our series included obesity (n = 4), Chiari 1 malformation (n = 1), and head trauma (n = 2). Noncontrast computed tomography of the temporal bone and magnetic resonance imaging were positive for FCM in 10 patients. Eight patients were managed surgically via a transmastoid approach (n = 4), combined transmastoid and middle fossa (N = 3), or middle fossa alone (n = 1); three were managed conservatively with observation. Postoperative complications included worsened facial nerve palsy (n = 1), recurrent meningitis (n = 1), and persistent CSF leak that necessitated revision (n = 1).

CONCLUSIONS

Facial nerve meningoceles are rare with variable presentation, often including CSF otorrhea. Management can be challenging and guided by symptomatology and comorbidities. Risk factors for FCM include obesity and head trauma, and Chiari 1 malformation may present with nonspecific otologic symptoms, in some cases, meningitis and facial palsy. Layered surgical repair leads to high rates of success; however, this may be complicated by worsening facial palsy.

Carolyn's window approach for spontaneous frontal sinus meningoencephalocele

Spontaneous meningoencephaloceles (MECs) are sparsely documented in the literature. Those occurring in the frontal sinus are an exceedingly rare entity. MECs are commonly associated with cerebrospinal fluid (CSF) rhinorrhoea. CSF rhinorrhoea is frequently misdiagnosed, causing delays in diagnosis and management. The subsequently increased risk of bacterial meningitis can be life-threatening to patients. We report the case of a woman in her late 70s with a spontaneous frontal sinus MEC, presenting with a 6-month history of CSF rhinorrhoea. The patient was successfully treated using the novel Carolyn's window approach endoscopically; 9-month follow-up revealed no skull-base breach. Our case emphasises the importance of considering MEC as a differential diagnosis for clear rhinorrhoea and demonstrates successful repair through a novel surgical approach.

Bone fusion in transcele reconstruction of frontoethmoidal meningoencephalocele

OBJECTIVE

In surgical correction of frontoethmoidal encephalocele with transcranial approach, advanced facilities are required. While with extracranial approach, though deemed as a safe option in area with limited facilities, procedure was associated with cerebrospinal fluid (CSF) leakage. In this case series, we evaluate the results of transcele reconstruction of frontoethmoidal encephalocele, our approach to reduce the incidence of CSF leaks by focusing on the closure of layers by its embryological derivatives, by its bone fusion.

METHODS

A case series of 14 patients with various types of frontoethmoidal encephalocele who underwent surgery for defect closure using transcele approach between June 2015 and December 2018 was carried out. Surgery was done by a single surgeon in the Department of Neurosurgery of Cipto Mangunkusumo Hospital in Jakarta, Indonesia. We collected the data of intraoperative blood loss and any signs of infection and CSF leak during the patients' one-year follow up. Bone fusion in the defect was evaluated from 3D rendering of head CT scan that was performed before and in 1 year after surgery.

RESULTS

The median percentage of intraoperative blood loss was 5.9% (0.5-18.7%). All 3D rendering of head CT post-surgery during 1 year follow up showed bone fusion and no patient experienced CSF leaks or CNS infections.

CONCLUSIONS

This study showed that using transcele approach in frontoethmoidal reconstruction could give good bone fusion with minimal blood loss and no CSF leaks. We assumed that closure of the layers by its embryological derivative played an important part in bone fusion and in reducing the incidence of CSF leaks, although this finding has to be validated with large-scale studies.

Bilateral Optic Nerve Sheath Meningoceles in an Asymptomatic Patient

This case report discusses a diagnosis of bilateral optic nerve sheath meningoceles in a man aged 82 years with stable visual acuity and asymptomatic bilateral choroidal folds.

A clinical clue toward recognition of split cord malformation type-I resembling meningocele in neonates

This is a letter to share the clinical experience we had with neonates born with a specific feature of spina bifida. The lesion is like a meningocele containing skim amount of fluid, with a tiny dimple around the center of the cutaneous lesion which causes inward retraction of the dysplastic coverage. This feature is in favor of accompanied split cord malformation (SCM) type I, and the central nidus is in continuous with the dural sleeve around the bony septum of SCM. By recognition of this clinical clue, surgical repair can be planned to perform with appropriate provision, particularly foreseeing the amount of intraoperative bleeding and duration of anesthesia in the newborn patients.

Combined Endoscopic Endonasal and Transpalatal Repair of Congenital Anterior Cranial Fossa Agenesis

BACKGROUND

Congenital basal meningoceles and encephaloceles are rare pathologies that may present in isolation or with characteristic-associated clinical features. Rarely, children with congenital midline defects may present with massive encephaloceles secondary to anterior cranial fossa agenesis. Traditionally, transcranial approaches with frontal craniotomies were used to reduce the herniated contents and repair the skull base defect. However, high rates of morbidity and mortality associated with craniotomies have favored the development and adoption of less-invasive techniques.

OBJECTIVE

To present a novel technique for combined endoscopic endonasal and transpalatal repair of a giant basal meningocele through an extensive sphenoethmoidal skull base defect.

METHODS

A representative case of congenital anterior cranial fossa agenesis with a giant meningocele was selected. Clinical and radiological presentations were reviewed, and the intraoperative surgical technique was documented and recorded.

RESULTS

A surgical video highlighting each surgical step was included to complement the description of the technique. The surgical outcome from the selected case is also presented.

CONCLUSION

This report describes a combined endoscopic endonasal and transpalatal approach to repair an extensive anterior skull base defect with herniation of intracranial content. This technique capitalizes on the advantages of each approach to address this complex pathology.

The Need for Emphasis on Intracranial Hypertension Management in Spontaneous Skull Base Meningoencephaloceles

OBJECTIVE

To provide an analysis of patients with spontaneous skull base meningoencephaloceles (MECs) to determine whether definitive surgical treatment requires management of elevated intracranial pressure (ICP).

METHODS

Data of 10 subjects with spontaneous MECs were collected and retrospectively evaluated. Measurement of ICP, prior interventions, treatment with acetazolamide, and characteristics of long-term elevated ICP, among others, were analyzed. Our own indications for cerebrospinal fluid (CSF) diversion and use of postoperative external lumbar drain were analyzed as well.

RESULTS

The sphenoid region was the most common location of MECs. CSF leak was diagnosed in all subjects. The most common graphical signs of elevated ICP were empty sella and arachnoid pits, both of which were present in 90% of cases. Lumbar puncture with opening pressure measurement was performed in 7 patients. Ventriculoperitoneal shunt insertion was indicated in 4 cases before skull base repair and in 2 cases after skull base repair. Two postoperative CSF leaks were managed with external lumbar drain and subsequent shunt installation.

CONCLUSIONS

Spontaneous MECs are often associated with CSF leak. ICP assessment should be a standard of care to ensure successful operative repair of MECs. Insertion of a CSF diversion device must be considered where direct or indirect signs of intracranial hypertension are present.

Posterior Surgical Ligation and Cyst Decompression -via Needle Puncture- of a Large Anterior Sacral Pelvic Meningocele Through Posterior Sacral Laminectomy

The first documented description of an anterior sacral meningocele was Bryant's in 1823. Anterior sacral meningocele patients have constipation as a universal symptom; urinary incontinence is also common. All the symptoms are directly related to the pressure from a pelvic mass on adjacent structures. When the patient stands, a headache often develops because the spinal fluid pressure decreases as the meningocele sac fills. Finally, a scimitar-shaped sacrum on a neuroradiological anteroposterior plain assessment is pathognomonic. The coccyx may be absent, and the lower sacral laminae may be absent or incomplete. The surgical options for this rare clinical condition are still matter of debate.Anterior sacral meningocele is a pathology that lacks a current classification and neurosurgical therapeutic standards, even though a similar dynamic has been shown by the related traumatic pseudomeningocele. Anterior approaches (retro- and transperitoneal meningocele neck occlusion with internal cerebrospinal fluid (CSF) cyst drainage) and posterior approaches (posterior sacral laminectomy, dural sac ligation, and CSF cyst drainage) are the available surgical strategies.We now report the case of an adult patient for whom a posterior approach was suggested and performed and report her postoperative surgical follow-up. The surgical rationale is also discussed.

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.

Management of lateral meningocele syndrome in a child without neurological symptoms and literature review

PURPOSE

Lateral meningocele syndrome (LMS) is a rare genetic connective tissue disorder which is associated with meningocele-related neurologic dysfunction. Several patients with LMS have been reported. But, guidelines for screening and treatment of LMS have not been established.

METHOD AND RESULTS

We review the current knowledge of LMS in the article. Then, we describe a boy for whom a genomic analysis which allowed us to make a diagnosis of LMS and to begin monitoring of his condition for possible neurological complications.

CONCLUSION

It would be difficult to make a diagnosis of LMS on the basis of clinical manifestations alone. The natural history of dural ectasia in patients with LMS needs to be better defined to establish surgical indications. Based upon the current literature, ventriculoperitoneal shunting (V-Ps) has been recommended as the first-line surgical treatment option for patients with symptomatic thoracolumbar meningoceles.

Utility of 3D-T2 space MRI sequence in diagnosing a rare cause of lower backache: horseshoe cord and meningocoele manqué in a case of composite split cord malformation

Diastematomyelia is the asymmetric or symmetric lateral duplication of the spinal cord into two hemicords. Pang divided it into three types: type-1, type-2 and composite split cord malformation (SCM). Composite SCMs are uncommon and are defined by the coexistence of multiple types of split cord with normal cord in between. When partially bridged, they are called a horseshoe cord. We report a case of a young woman who presented with backache and was diagnosed with composite SCM with horseshoe cord and type-2 SCM with intervening normal cord. In our case, 3D-SPACE due to its superior topographical evaluation, allowed us to visualise and characterise the thin meningocoele manque bands and detect horseshoe cords, asymmetric cords and demarcate the precise extent of syrinx, which were suboptimally imaged on isolated T2 and T1WI sequences. If left untreated during surgery, bands can be the potential cause for persistent backache.

Early diagnosis of lateral meningocele syndrome in an infant without neurological symptoms based on genomic analysis

Lateral meningocele syndrome is characterized by multiple lateral meningoceles with a distinctive craniofacial appearance, hyperextensibility of the skin, and hypermobility of the joints. The syndrome is caused by heterozygous truncating variants in the last exon, exon 33, of the NOTCH3 gene. Here, we present a 2-year-old girl for whom an early genomic analysis allowed us to recognize the presence of lateral meningoceles and to begin early monitoring of her condition for possible neurological complications. She had a characteristic facial appearance, hyperextensibility of the skin and mobility of the joints, and developmental delays. Given that lateral meningocele syndrome is a rare syndrome, the existence of lateral meningoceles is suspected only when the causative gene is detected by genetic testing. MRI scans are unlikely to be performed in infancy in the absence of neurological symptoms suggestive of meningoceles. No formal guidelines have been established for the neurosurgical indications for lateral meningocele syndrome. Given the features of hyperextensibility of the skin and hypermobility of the joints, lateral meningocele syndrome can be categorized as a connective tissue disease and may be progressive, as with the dural ectasia in Marfan syndrome and Loeys-Dietz syndrome. Watchful monitoring of dural ectasia may be warranted in patients with lateral meningocele syndrome.

Spontaneous Unilateral Intrasphenoidal Meningocele

The sphenoid sinus is an uncommon location for protrusion of a meningocele. When this does occur, it nearly always presents with leakage of cerebrospinal fluid through the nasal cavity. We present a case of a 38-year-old female found to have a meningocele protruding into the left sphenoid sinus, who presented with intractable headache but no CSF rhinorrhea. The lesion was discovered on computed tomography angiography, which was performed in order to rule out intracranial pathology as the etiology of her headache. Prior imaging, including pre- and post-contrast MRI, demonstrated the fluid within the sphenoid sinus, but did not reveal the communication through a defect in the base of the skull. Thus, it was assumed to be strictly related to sinus disease in the past. Our case represents a phenomenon whereby meningoceles protruding through the basilar skull into the sphenoid sinus or any other location are potentially misdiagnosed due to poor visualization of the osseous defect and lack of awareness of this entity.

Prenatal evaluation of the Sakoda complex

Sakoda complex is a rare but distinct combination of birth defects consisting of a basal cephalocele, agenesis of the corpus callosum, and midline cleft lip/palate. It has been reported in association with ophthalmologic abnormalities, cognitive deficits and severe epilepsy. Here we describe both prenatal and postnatal MRI findings of a classic case of Sakoda complex in a child with characteristic findings on fetal MRI; prenatal findings have not been described in the literature. Diagnosis of this entity has important implications for prenatal counseling and perinatal management, as is demonstrated in this case.

Endoscopic Endonasal Repair of a Persistent Craniopharyngeal Canal and Sphenoid Meningoencephalocele: Case Report and Review of Literature

BACKGROUND

A persistent craniopharyngeal canal (PCC) is a rare cause of cerebrospinal fluid rhinorrhea in children. The condition often coexists with other midline facial defects, such as cleft palate. Children with PCC may also have pituitary dysfunction or neoplasms, such as craniopharyngiomas within the canal.

CASE DESCRIPTION

A 5-year-old girl presented with bacterial meningitis and active cerebrospinal fluid rhinorrhea from her left nostril. Imaging showed a large nasopharyngeal meningoencephalocele, communicating with the subarachnoid space through a persistent craniopharyngeal canal. An endonasal approach was chosen to excise the PCC and meningoencephalocele and to repair the resulting skull base defect.

CONCLUSIONS

The extended endonasal approach can be used to treat PCC with nasopharyngeal encephaloceles in young children. The approach is suitable to address both conditions at the same time. The extended endonasal approach avoids potentially morbid transfacial approaches and can help in earlier recovery after surgery.

How to Explore Fetal Sacral Agenesis Without Open Dysraphism: Key Prenatal Imaging and Clinical Implications

The estimated prevalence of fetal caudal dysgenesis is 1 per 100,000 births. The functional prognosis of sacral agenesis is dominated by the large spectrum of associated caudal malformations. Except for cases associated with hydrocephalus secondary to open spinal dysraphism or chromosomal anomalies, association with mental deficiency is rare. We propose a systematic prenatal approach to cases of fetal sacral agenesis based on 9 etiologic items: clinical context, type of sacral dysgenesis, associated spinal cord malformations, mobility of lower limbs, investigation of the presacral region, analysis of the gastrointestinal tract, analysis of the genitourinary tract, associated vertebral defects, and cytogenetic analysis.

Recurrent Abortion and Tethered Cord Syndrome Caused by Anterior Sacral Meningocele: A Report of a Rare Case with a Review of the Literature

BACKGROUND

Anterior sacral meningocele is a rare congenital anomaly.

CASE DESCRIPTION

This rare anomaly is described in a young woman who presented with recurrent abortion and later with a huge palpable mass of pelvic origin, measuring 14 × 12 cm.

CONCLUSIONS

The various radiologic features, associations such as presacral dermoid as a part of incomplete Currarino syndrome, and the management options available are also discussed.

[A pregnant woman with increasing constipation]

A 29-year-old gravida 2 para 1 presented with symptoms of increasing constipation in the first trimester of pregnancy. Shortly before this pregnancy, she was suspected of a retroperitoneal cyst. In the analysis of the increased constipation combined with this recent medical history, MRI was performed, which showed an anterior sacral meningocele.

Currarino Syndrome and the Effect of a Large Anterior Sacral Meningocele on Distal Colostogram in an Anorectal Malformation

Currarino syndrome is a congenital disorder, consisting of a triad of anomalies including an anorectal malformation, sacral anomaly, and a presacral mass. Anterior sacral meningoceles are the most common presacral mass. A young child presented to our institution with an unrepaired anorectal malformation and a large anterior sacral meningocele. We describe how the anterior meningocele affected the imaging work-up.

3D steady-state MR cisternography in CSF rhinorrhoea

Purpose: To determine the utility of 3D steady-state MR cisternography in the demonstration and localisation of cerebrospinal fluid (CSF) leak in patients with clinically suspected CSF rhinorrhoea.

Material and Methods: Six consecutive patients with clinically suspected CSF rhinorrhoea were examined with routine MR evaluation and MR cisternography (MRC). All MR examinations included fast spin-echo (SE) T1WI in axial and sagittal planes, fast SE T2WI in axial and coronal planes and fluid attenuated inversion recovery (FLAIR) images in the axial plane. 3D evaluation was done using the CISS technique with 0.7-mm thickness in the sagittal and coronal planes. The site and extent of the defect, and any brain herniation detected on MRC were correlated with surgical findings.

Results: In the 6 patients who underwent surgical exploration and repair, intraoperative findings correlated with the defect revealed by MRC in all cases.

Conclusion: In clinically suspected CSF rhinorrhoea, MRC is highly accurate in localising the site and extent of CSF fistula and may be used as the first investigation due to its efficacy and non-invasive nature.

Lateral temporal encephaloceles: case-based review

PURPOSE

Lateral temporal encephalocele is an extremely rare clinical condition, with only 18 cases presented in the literature to date. No review articles have examined lateral temporal encephalocele in depth. We therefore reviewed past cases of lateral encephalocele to clarify the clinical characteristics of this extremely rare deformity. We also present a case of lateral encephalocele with arachnoid cyst which has never been reported in past reports.

METHODS

We identified 8 reports describing 18 cases of lateral temporal encephalocele. We therefore reviewed 19 cases of lateral temporal encephalocele, including our own experience, and discussed the clinical characteristics of this pathology.

RESULTS

All the cases with lateral temporal encephalocele were detected at birth except for an occult case. The majority occurred at the pterion, and occurrence at the asterion appears much rarer. Due to the preference for the pterion, the ipsilateral orbital wall was also distorted in some cases. Lateral temporal encephalocele seems to have fewer associated malformations: only 3 cases of lateral temporal encephalocele had associated malformations, including our case which was associated with intracranial arachnoid cyst. The only case of lateral temporal encephalocele to have shown hydrocephalus was our own case. Patients with this deformity have relatively good prognoses: only 3 of the 19 cases showed delayed psychomotor development during follow-up.

CONCLUSIONS

Provision of adequate treatment is likely to achieve a good prognosis in patients with lateral temporal encephalocele, so we should keep in mind this deformity when encountering pediatric patients with mass lesions on the temporal cranium.

[Headhache secondary to intracranial hypotension in a Lumbar Spinal Stenosis Surgery]

Intracraneal hypotension headache is a well known syndrome in neurosurgery practice. In most cases cerebrospinal fluid leaks are caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine. Clinical symptoms tipically show orthostatic headache that resolves in supine position, and other symptoms like neck tightness, vertigo and diplopia. RMI diagnostic confirms paquimeningeal enhancement and subdural hygromas. Conservative treatment usually includes bed resting, hydratation and administration of caffeine or glucocorticoids, resolving spontaneously in one to four months. The importance of the diagnosis lies in the differential diagnosis with other causes of headache, as symptomatic limiting factor in the rehabilitation of the patient and the same favorable prognosis.

Sonographic spectrum of first-trimester fetal cephalocele: review of 35 cases

OBJECTIVE

To describe the sonographic features of fetal cephalocele diagnosed at the time of first-trimester ultrasound screening for aneuploidy.

METHODS

This was a retrospective review of cases of cephalocele diagnosed in the first trimester at four fetal medicine referral centers. Once diagnosis was suspected, a transvaginal ultrasound examination was offered to improve depiction of the cranial defect and enhance examination of fetal anatomy, with special attention given to the location, size and content of defects. To assure consistency in diagnosis, representative pictures and videoclip sequences of the cranial defect were obtained and reviewed by at least two authors. Cases were classified and compared with the assessment made at diagnosis.

RESULTS

Of the 35 affected fetuses identified, 33 were of a singleton pregnancy and two were of twin pregnancies in which the other fetus was unaffected. The lesion was classified as a cranial meningocele in 13 (37%) cases and as an encephalocele in 22 (63%). The bone defect was occipital in 27 (77%), frontal in three (9%), parietal in three (9%) and non-classifiable in two (6%). Twelve (34%) were considered as small in size, 11 (31%) as medium and 12 (34%) as large. There were no reported cases of aneuploidy; however, four (11%) cases were associated with Meckel-Gruber syndrome, two (6%) with a disruptive syndrome and one (3%) with skeletal dysplasia. Eight (23%) pregnancies were lost to follow-up. Parents opted for termination of pregnancy in 21 of the 27 remaining cases and, of the six ongoing pregnancies, four patients miscarried or the fetus died in utero during the second trimester, one liveborn infant died shortly after delivery and one underwent neonatal surgery for an isolated cranial meningocele and is currently doing well.

CONCLUSIONS

First-trimester sonographic diagnosis of cephalocele is accomplished easily with a detailed examination of the skull contour at the time of routine assessment of the axial and sagittal views of the head for measurement of the biparietal diameter and nuchal translucency, respectively. However, the sonographic features are highly variable. A significant proportion of cases are associated with genetic or disruptive syndromes. Prenatal diagnosis of cephalocele in the first trimester was associated with a high rate of termination of pregnancy and early intrauterine fetal demise. Only one fetus in this series survived and is neurologically intact; therefore, the prognosis of this condition remains poor.

Anterior sacral meningocele mimicking ovarian cyst: a case report

Anterior sacral meningocele (ASM) is a rare congenital anomaly, characterized by herniation through a defect in the anterior aspect of the sacrum. We reported a case of ASM associated with neurofibromatosis, which was mimicking a complex ovarian cyst in ultrasonography. ASM can easily be misdiagnosed as an ovarian cyst and needle aspiration can cause intracranial hypotension syndrome or even death.

Transorbital and transnasal endoscopic repair of a meningoencephalocele

A 71-year-old female with a history of thyroid eye disease (TED) presented for evaluation of a skull base mass noted on neuroimaging. She had previously undergone bilateral orbital decompressions and strabismus surgery and had no neurologic symptoms. Successful resection of the menigoencephalocele and repair of the skull base defect was performed through a combined transnasal endoscopic and transorbital approach, obviating the need for craniotomy.

[Cervical meningocele with filiform connection. Case report]

The meningocele is the least common form of spina bifida cystica and represents less than 10% of cases of this disorder. A case of a female patient aged 26 with a history of two pregnancies and two previous cesarean sections, present pregnancy unplanned, uncontrolled during the first trimester prenatal and without supplementation with folic acid. Family history of consanguinity with her husband (second cousins) and psychomotor reassessed in four maternal cousins. The first follow-up visit the patient was at 34 weeks of pregnancy. The ultrasonographic findings were: cervical meningocele posterior filiform connection between the first and second cervical vertebrae, lateral ventriculomegaly and third and fourth ventricles and hydrocephalus secondary. Cesarean section was performed at 37 weeks gestation and was a newborn male 3.000 g, 52 cm, head circumference of 36 cm, Apgar 8/9, Capurro 37 weeks of gestation. In the posterior cervical region tumor was located a soft 5 x 5 cm with intact skin, adhered to deep planes. Movement of all four extremities without neurological involvement. He referred to the department of neurosurgery for shunt placement and subsequently performed surgical excision of the meningocele.

[Surgery at the skull base with transnasal endoscopic control]

INTRODUCTION

Skull base surgery is targeted to diseases in the posterior, lateral or anterior skull base. Development of endoscopic paranasal sinus surgery has contributed to expand the indications for transnasal surgery at the anterior skull base. Patients do not have visible scars and have less postoperative pain after endoscopic surgery and a decreased postoperative morbidity in general results in a shorter hospital stay.

MATERIAL AND METHODS

An overview is given of transnasal endoscopic skull base surgery, based on literature retrieved from PubMed and illustrated by three patients operated at the University Hospital of Northern Norway.

RESULTS AND INTERPRETATION

Transethmoid meningoencephalocele, pituitary conditions and the need for biopsy from the cavernous sinus are presented as suitable indications for transnasal endoscopic skull base procedures. From an anatomical point of view, the skull base is situated between the orbit, the ear and the paranasal sinuses on one side and the brain on the other side. Several specialties are therefore involved in skull base surgery, and interdisciplinary cooperation is important. Computer-assisted surgical instruments and navigation systems based on digital imaging enable an improved perioperative orientation and thereby improves the safety of skull base surgery. Endoscopic surgery at the skull base may contribute to reduce surgical morbidity and hospitalization and thereby has a health economic potential.

Early antenatal diagnosis of spina bifida presenting with a "step" in the posterior contour of an 8-week embryo

We report a case of spina bifida in the upper thoracic spine with an accompanying meningocoele suspected at 8 weeks' gestation via transvaginal sonography and confirmed at 13 weeks' gestation via 3-dimensional sonography. The fetal cranial vault and intracranial structures were normal. The only finding in the 8-week sonogram was a subtle angulation or "step" in the posterior contour of the embryo; this may be attributed to kyphosis, which often accompanies this condition. The presence of a "step" in the fetal contour must alert the sonologist to the possibility of spina bifida. To our knowledge, this is the earliest antenatal diagnosis of spina bifida.

Transnasal endoscopic approach for anterior skull base angiomatosis complicated by a meningocele

A 42-year-old woman presented with symptoms of left-sided nasal obstruction, cerebrospinal fluid (CSF) rhinorrhea, and frequent sinus infections. Radiologic investigation revealed a tumor destructing the left cribriform plate and forming opacifications in the olfactory area. She had left-sided submucosal meningocele, deviating the septum to the right side. Intracranial involvement was not observed. Under endoscopic visualization, the tumor and the meningocele was meticulously dissected and excised using bipolar cautery. The CSF fistula in the anterior skull base was repaired with the same approach. Thanks to increasing experience with endoscopic sinus surgery, excision and removal of noncomplex tumors of the anterior skull base have become possible. This case report illustrates transnasal endoscopic approach to the anterior skull base using minimally invasive technique.

[Intranasal meningocele presenting as a nasal polyp--case report]

Intranasal meningocele occurs rarely. It is difficult to diagnose because its appearance resembles common polyps. If it coexists with other inborn cranio-facial malformation they are easier to diagnose. In the case investigated by us, the 32 year-old woman's ailments suggested intranasal polyps and we discovered the meningocele localized intranasal on the right. The CT scan of the nasal sinuses is the most reliable examination for the developing diagnosis. The CT findings revealed the meningocele protruding from the anterior cranial fosse through the lamina cribrosa to the right nasal cavity. During the operation the meningocele was removed and the durra mater was sutured. The bony-mucosal lesion was covered with composite graft taken from bony part of nasal septum and mucosal part of the inferior turbinate. The graft has been incorporated into the surrounding tissue. Neither a cerebrospinal fluid leak nor any other complications have been reported within the past 6 years. Therefore, we consider this a successful procedure.

Anterior sacral meningocele: management in gynecological practice

We describe the case of a young woman with anterior sacral meningocele (ASM), initially identified during a routine ultrasound examination and subsequently diagnosed using magnetic resonance imaging (MRI). ASM is a rare disorder characterized by uni- or multilocular extensions of the meninges from the sacral spinal canal to the retroperitoneal presacral space. Common symptoms include lower back and pelvic pain, constipation, difficulties in defecation, dysmenorrhea and dyspareunia, and urinary incontinence, retention or urgency. Perineal and lower-extremity paresthesias may present when nerve roots are affected. Despite its more posterior location, ASM can mimic an ovarian cyst or other adnexal cystic mass, and in the obstetric patient can present a mechanical obstacle to delivery with a risk of rupture and infection during labor and delivery. Although it is a rare condition, we feel that awareness of the etiology, presentation and imaging characteristics of ASM is of importance and have therefore carried out a review of the literature, taking into account case findings and the obstetric and gynecological management of this disorder.

Laparoscopic treatment of anterior sacral meningocele

BACKGROUND

Anterior sacral meningocele is a rare congenital malformation, whose open surgical treatment is well accepted. We present a laparoscopic approach as an adjunctive approach.

METHODS

Five women who underwent laparoscopic transperitoneal surgery were clinically, radiologically, and surgically evaluated.

RESULT

All 5 patients underwent laparoscopic transperitoneal surgery and showed satisfactory results. They had no major complications. Three patients had headaches as minor complications, but it was gone in at most 3 days. Decrease in operative time, blood loss, and length of hospitalization were the advantages of the procedure.

CONCLUSIONS

The laparoscopic approach to treating anterior sacral meningocele was feasible and safe, with only minor complications.

Occult intrasacral meningocele: case report and review of the literature

Occult intrasacral meningocele, characterised by the presence of a cyst within the sacral spinal canal, is an unusual congenital lesion. A 26-year-old female presented with a history of low back pain and sensory disturbance in the lower extremities, and urinary incontinence. CT scan of the sacral region showed an asymmetrical widening of the sacral canal and the existence of a thinned bone contour. Magnetic resonance (MR) imaging revealed an intrasacral mass as a low signal intensity area on the T1-weighted image and a high signal intensity area on the T2-weighted image, suggesting a cyst containing cerebrospinal fluid (CSF). The patient underwent sacral laminectomy and posterior exploration showed the presence of sacral erosion and an intrasacral cyst containing CSF devoid of neural contents. Partial surgical excision of the cyst was carried out, but the patient's postoperative course was complicated by a CSF leak due to a small connection that was obliterated in a second operation. Control MR imaging confirmed the removal of the cystic lesion. The clinical, neuroradiological and surgical features of this rare condition are discussed and the importance of a differential diagnosis is stressed.

Anterior sacral meningocele. A case report

A case of anterior sacral meningocele in a 6-year-old girl is reported. The laminotomies of L5, S1, and S2 vertebrae were performed through a median posterior approach. The communication between the subarachnoid space and the meningocele was closed using dural fibrin patch, which has not yet been described in the literature. The relevant literature is reviewed.

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.

Dynamic motion analysis of fetuses with central nervous system disorders by cine magnetic resonance imaging using fast imaging employing steady-state acquisition and parallel imaging: a preliminary result

OBJECT

The authors present a novel cine magnetic resonance (MR) imaging, two-dimensional (2D) fast imaging employing steady-state acquisition (FIESTA) technique with parallel imaging. It achieves temporal resolution at less than half a second as well as high spatial resolution cine imaging free of motion artifacts for evaluating the dynamic motion of fetuses in utero. The information obtained is used to predict postnatal outcome.

METHODS

Twenty-five fetuses with anomalies were studied. Ultrasonography demonstrated severe abnormalities in five of the fetuses; the other 20 fetuses constituted a control group. The cine fetal MR imaging demonstrated fetal head, neck, trunk, extremity, and finger as well as swallowing motions. Imaging findings were evaluated and compared in fetuses with major central nervous system (CNS) anomalies in five cases and minor CNS, non-CNS, or no anomalies in 20 cases. Normal motility was observed in the latter group. For fetuses in the former group, those with abnormal motility failed to survive after delivery, whereas those with normal motility survived with functioning preserved. The power deposition of radiofrequency, presented as specific absorption rate (SAR), was calculated. The SAR of FIESTA was approximately 13 times lower than that of conventional MR imaging of fetuses obtained using single-shot fast spin echo sequences.

CONCLUSIONS

The following conclusions are drawn: 1) Fetal motion is no longer a limitation for prenatal imaging after the implementation of parallel imaging with 2D FIESTA, 2) Cine MR imaging illustrates fetal motion in utero with high clinical reliability, 3) For cases involving major CNS anomalies, cine MR imaging provides information on extremity motility in fetuses and serves as a prognostic indicator of postnatal outcome, and 4) The cine MR used to observe fetal activity is technically 2D and conceptually three-dimensional. It provides four-dimensional information for making proper and timely obstetrical and/or postnatal management decisions.