Spontaneous CSF rhinorrhea from the trigeminal canal in an adolescent

Trigeminal Numbness After Intracranial Repair of a Spontaneous Meningoencephalocele of the Lateral Wall of the Sphenoid Sinus

A 58-year-old female with an eight-year history of rhinorrhea and a two-day history of subjective fever, chills, and vomiting presented to the emergency department for neurosurgical evaluation. Brain MRI demonstrated herniation of the meninges and portions of the inferomedial right temporal lobe through a defect of the lateral wall of the right sphenoid sinus, extending to the sphenoethmoidal recess and posterior right ethmoid air cells. A right pterional craniotomy was performed where the herniated part of the right temporal lobe, and its associated meninges, were excised. After surgery, she had hypoesthesia at the right maxillary division of the trigeminal nerve. This finding was caused by the proximity of the trigeminal nerve to the dural dissection that we performed at the bone defect. This rare complication has never been described after intracranial surgery. Only eight literature reports have described hypoesthesia or paresthesia of the trigeminal nerve after endoscopic resection of a sphenoid sinus meningoencephalocele. The patient has not had any recurrence of rhinorrhea after a six-month follow-up period.

Endoscope-assisted microsurgical repair in trigeminal meningocele: case report

Trigeminal meningocele is a rare disease that results in rhinorrhea. Treatments with endoscopic approaches and open craniotomies have high recurrence rates, and controversy regarding the most effective surgical strategy for trigeminal meningocele is ongoing. The authors report a case of a 13-year-old female patient with a diagnosis of trigeminal meningocele determined after she presented with a history of intermittent headaches, suspected rhinorrhea, and recurrent meningitis. In addition to the conventional method of covering the efflux point of CSF and filling the inside of the meningocele with fascial tissues, the authors selectively closed the influx point of CSF from the prepontine cistern to the meningocele using an anterior transpetrosal approach. On the basis of the preoperative images, the authors hypothesized that the influx point of CSF could not be observed under the microscopic direct view and instead used a flexible endoscope. A check valve-like structure with one-way communication of CSF from the prepontine cistern into the cystic cavity was identified and was closed. At the time of this report, 36 months postoperatively, the patient had no indications of recurrence. Although cases of trigeminal meningoceles are infrequently encountered and require a tailored approach, the results in this case thus far indicate that the use of an endoscope and open craniotomy is an effective strategy for surgical treatment.

Spontaneous Cerebral Spinal Fluid Rhinorrhea with Meningocele Secondary to Congenital Foramen Rotundum Defect: A Case Report and Review of Literature

Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a rare occurrence. We present a case of spontaneous CSF rhinorrhea in a 57-year-old patient secondary to a sphenoid osseous defect involving the foramen rotundum and maxillary nerve with an associated arachnoid cyst and meningocele compressing the maxillary nerve. The location of the defect made correction amenable to an open skull-based approach. To the best of our knowledge, this is the first reported case of a spontaneous meningocele herniating into the sphenoid osseous defect through the medial aspect of the foramen rotundum. Early detection of these defects, open or endoscopic approaches and definitive treatment by closing the defect can result in excellent outcomes.

Management of sphenoid lateral recess encephalocoeles

PURPOSE OF REVIEW

Sphenoid sinus lateral recess encephalocoeles (SSLRE) are rare occurrences and pose unique challenges due to limited surgical access for endoscopic endonasal repair and also the lack of consensus on optimal perioperative managements specifically in the spontaneous cases, which are also believed to be a variant of idiopathic intracranial hypertension (IIH). Endoscopic endonasal approaches have largely replaced the transcranial route and the techniques are continuously being refined to reduce the neurovascular morbidity and improve outcome.

RECENT FINDINGS

Transpetrygoid is the most utilized approach with modifications suggested to limit bone removal, exposure and preservation of the neurovascular structures as dictated by the extent of the lateral recess. As more experience is gained, extended transphenoidal techniques were also successfully used for access. Lateral transorbital is a new approach to the lateral recess investigated in cadavers. IIH treatment is still controversial in the setting of SSLRE, but it appears rationale to evaluate, monitor and treat if necessary.

SUMMARY

SSLRE management should be tailored to the specific anatomical variances and cause. Modifications of techniques have been described giving different options to access the lateral recess. Successful repair for spontaneous SSLRE may require treatment of IIH if present, but the long-term outcome is still unclear.