Transsphenoidal meningoencephalocele in adults

Large transethmoidal meningoencephalocele in a neonate involving three discrete defects in lamina cribriform: A case report

Background

Intranasal meningoencephaloceles are rarely encountered in pediatric neurosurgery. The symptoms and clinical features may mimic those of nasal polyps or dermoid cysts. Transethmoidal meningoencephalocele is a rare congenital meningoencephalocele of the anterior skull base with diverse clinical presentation. The appropriate surgical intervention is chosen according to the meningoencephalocele type and location. Radiological examinations such as computed tomography and magnetic resonance imaging are helpful for the differential diagnosis of the encephalocele sac and localization of the cranial bone defect.

Case Description

We are reporting a case of basal meningoencephalocele of the transethmoidal type, which was discovered in a 20-day-old boy presenting with cerebrospinal fluid rhinorrhea, respiratory distress, difficulty in feeding, and meningitis. The preoperative images showed a large herniated intranasal sac with bony discontinuity of the cribriform plate; however, three discrete defects of the cribriform plate with their related discrete herniated sacs were identified intraoperatively. Two staged surgeries were performed in succession: transcranial to separate the sacs from the cranial cavity and seal the anterior fossa floor, followed by transnasal to remove the remnant of the intranasal sacs. Patient symptoms and signs markedly improved after the surgeries.

Conclusion

We highlight the need for urgent intervention at a very young age if the clinical presentation mandates, and also the importance of meticulous intraoperative identification of all bony and dural defects that might be missed in preoperative images to ensure complete repair and prevent recurrence.

[Congenital basal encephaloceles involving functionally important structures]

In rare cases, basal encephaloceles can include important brain structures (pituitary gland, chiasm, third ventricle walls, cerebral vessels).

MATERIAL AND METHODS

We reviewed 43 articles (78 cases) devoted to basal encephaloceles involving functionally important structures. Analysis included transsphenoidal and sphenoethmoidal hernias.

RESULTS

Nasal breathing disorders were found in 76.9% of cases, decreased visual acuity - 53.8%, endocrine disorders - 44.9%, nasal CSF leakage - 14.1%, meningitis - 10.3%. Concomitant malformations occurred in 85.9%. Severe respiratory disorders (52.6%, p<0.05) and multiple concomitant malformations (71.7%, p<0.05) were more common among patients with sphenoethmoidal encephalocele. Among 78 patients, 73.1% underwent surgery while follow-up was preferable in 26.9% of cases. There was progression of endocrine disorders (9.5%), visual impairment (4.8%) and nasal breathing disorders (4.8%) in follow-up period. Surgical treatment also has many risks. Transcranial, transnasal, transoral and combined approaches are currently used. It was not possible to establish the most effective surgical approach due to heterogeneous clinical data. Postoperative complications occurred in 47.4% of cases (endocrine disorders - 33.3%, CSF leakage - 8.8%, visual impairment - 1.8%, infectious complications - 14%). Mortality rate was 3.5%.

CONCLUSION

Congenital basal encephalocele involving functionally important structures is an extremely rare developmental defect. Such patients often have concomitant anomalies. Comprehensive examination is necessary to estimate the structures included in hernial sac and concomitant diseases. Treatment strategy should be determined individually after thorough examination and comparison of all risks. Surgical treatment is associated with high risk of complications due to damage to the structures comprising encephalocele.

Adult transsphenoidal meningoencephalocele: Clinical image

Background

Encephalocele is herniation of cranial contents through a skull defect, classified according to their contents and location, and is usually seen in pediatric age group. The transsphenoidal type represents <5% of all basal meningoencephaloceles. Of them, the presentation in adulthood is even rarer.

Case Description

A 19-year-old female complaining of breathing difficulties during sleep and exertional dyspnea was diagnosed with a transsphenoidal meningoencephalocele, likely representing patent craniopharyngeal canal. On exploration through bifrontal craniotomy, the defect was identified in the sellar floor after completely reducing the contents into the cranial cavity and was repaired. She had immediate symptomatic relief and an uneventful postoperative course.

Conclusion

There can be significant symptomatic relief with minimal postoperative morbidity after transcranial repair of such large transsphenoidal meningoencephaloceles, through traditional skull base approaches.

Transnasal endoscopic surgery of sphenoid meningocele associated with pituitary adenoma. A case report

BACKGROUND

Transsphenoid meningoencephalocele is a congenital anomaly formed by herniation of an ependyma delimited sac through a bony defect into the sphenoid sinus. The sac contains cerebrospinal fluid and neurovascular structures. The prevalence of transsphenoid meningoencephalocele in the adult population is rare. It usually manifests as nasal liquorrhoea.

METHODS AND RESULTS

This case report presents an adult male who underwent surgery due to suspected pituitary macroadenoma. The surgery was performed endoscopically via the transnasal approach with a surprising finding of true transsphenoid meningoencephalocele. Ectopic solid tissue was found in the sphenoid sinus in which pituitary adenoma was histologically confirmed.

CONCLUSION

This paper presents a previously unpublished combination of true transsphenoid meningoencephalocele and pituitary adenoma in an adult individual.

Endoscopic management of congenital nasal meningoencephaloceles: a short series of 15 paediatric cases

PURPOSE

To retrospectively analyse surgical management of clinico-radiologically proven nasal meningoencephalocele amongst children and results of repair with single-layer septo-mucosal flap at a tertiary skull base surgery centre in north India.

METHODS

Fifteen children with clinic-radiological nasal meningoencephaloceles with or without CSF rhinorrhoea were included. Radiological scans included CT scans and MRI scans for all cases to delineate soft tissue and bony architecture. All children underwent endoscopic excision of encephaloceles and repair of the skull base defect.

RESULTS

The authors were successful in fourteen cases. Successful cases included 4 children less than 6 months of age who underwent single-layer rotated septo-mucosal flaps, thereby avoiding donor site morbidity.

CONCLUSION

As endoscopic excision of nasal encephalocele is an established management approach, the authors take the concept of minimally invasive surgery a step further by successfully managing these lesions with single-layer repair. Vascularized septo-mucosal flap seems to be the only determining factor for a successful repair for congenital meningoencephalocele. However, a prospective study comprising a larger subset of patients would substantiate the assumption.

Sphenoethmoidal meningoencephalocele with variable hypopituitarism: A case report and review of literature

Sphenoethmoidal meningoencephalocele is a rare congenital meningocele with unclear clinical course. Its clinical symptoms are diverse, and this disease is widely observed across all ages. The prognosis of this disease depends on the severity of the central nervous system complications. We reported a case of sphenoethmoidal meningoencephalocele incidentally discovered in a 2-yr-old patient, with the subsequent appearance of diabetes insipidus at school age. An endocrinological evaluation performed when the patient was nine years old using the TRH/CRH/LH-RH load test showed a low response of gonadotropins and slightly hyper-response and normal response of ACTH and TSH, respectively. GH provocative tests indicated severe GH deficiency. Desmopressin and GH treatment efficiently improved his growth rate and quality of life. His pituitary function had presumably been normal from the neonatal period to infancy, but the dysfunction gradually progressed over the next few years along with his physical growth. The symptoms were suspected to be the product of the natural course of his hypothalamus or pituitary gland degeneration, or were otherwise due to gradual damage by chronic mechanical compression or extension. These findings underscore the importance of conducting careful systemic management in the long term, specifically with respect to the endocrinological evaluation of sphenoethmoidal meningoencephalocele.

Nasal meningoencephalocele: A retrospective study of clinicopathological features and diagnosis of 16 patients

OBJECTIVE

Nasal meningoencephalocele (encephalocele or cephalocele) is a rare condition with congenital, traumatic, or spontaneous origins. We investigated the clinicopathological characteristics of nasal encephaloceles to improve pathologists' and clinicians' understanding of this disease.

METHODS

Sixteen patients with nasal encephaloceles were enrolled in this retrospective study investigating the condition's clinical and morphological features.

RESULTS

Patients' average age was 37.8 (±20.8) years. The ratio of men to women was 2.2:1, patients' mean age was 47.4 (±11.8) years, and 10/16 patients had spontaneous encephaloceles. All patients with traumatic and spontaneous encephaloceles presented with cerebrospinal fluid leak. In 9/16 patients, the skull defect site occurred on the lateral wall of the sphenoid sinus. Both congenital patients experienced nasal obstruction. Histopathology, herniated tissues were brain and/or meningeal tissue, and the brain tissue was almost mature glial tissue.

CONCLUSION

Nasal meningoencephalocele is a rare condition that can be challenging to diagnose. In patients with recurrent clear nasal discharge or in children with a unilateral nasal mass, a high index of suspicion for encephalocele is essential. In this study, spontaneous cases were most common in adults, and the lateral wall of the sphenoid sinus was the most common location.

Spontaneous transethmoidal meningoencephalocele presenting in the form of recurrent unilateral nasal discharge: discussion of the diagnosis and endoscopic surgical management

Meningoencephaloceles of the skull base most commonly occur as a sequela of head trauma or they can more rarely be congenital malformations. Several types of encephalocele exist depending on anatomic features and localisation. Clinical presentation and symptoms can vary. Different methods of management and repair of the concurring skull base defects have been described and ranging vary from endoscopic to open surgical approaches. We report the case of a 56-year-old Caucasian woman with the diagnosis of right sided spontaneous transethmoidal meninoencephalocele. Clinical presentation of this rare pathology, methods of diagnostic and management and its outcome are presented. Spontaneous skull base meningoencephaloceles are rare entities, without clear underlying etiologies. Multidisciplinary management is recommended. The transnasal endoscopic approach provides a wide skull base exposure with more advantages and less morbidity in comparison with the conventional open approach.

Delayed presentation of morning glory disc anomaly and transsphenoidal encephalocele: A management dilemma

Background Morning glory disc anomaly (MGDA) is a rare developmental abnormality of the optic disc that is associated with many other neurological and vascular conditions. Most cases are diagnosed in childhood. Case Report We report a 57-year-old woman who presented to the ophthalmology department for assessment of long-standing poor vision in the left eye and exotropia. Examination showed a left MGDA and bitemporal hemianopsia. These findings prompted magnetic resonance imaging, revealing a transsphenoidal basal meningoencephalocele with herniation of the optic chiasm and inferior hypothalamus into the dural sac. Due to the eloquence of the neurovascular structures it contained, a decision was made not to reduce the meningoencephalocele. Instead, a ventriculoperitoneal shunt was placed. The patient's ophthalmologic examination remained stable over the following year. Conclusion While rare, MGDA can be first diagnosed in late adulthood and a thorough evaluation should be completed to assess for midline cranial defects, vascular abnormalities, and other associated abnormalities. Patients presenting late in life with basal encephalocele, herniation of the optic chiasm, and bitemporal hemianopsia present a management dilemma. In this case, a ventriculoperitoneal shunt was placed with the intention of lowering intracranial pressure to prevent further herniation and reduce the risk of cerebrospinal fluid leak.

[Modern diagnosis and treatment in children with congenital basal encephalocele]

Basal encephalocele is a rare disease that predominantly occurs in children. Its most common symptoms include nasal liquorrhea, difficulty in nasal breathing, and deformity of the naso-orbital region.

MATERIAL AND METHODS

The study group included 19 patients with basal encephalocele, aged 2 months to 18 years. Ten (59%) patients were operated on through a transnasal endoscopic approach; 3 (17.5%) patients were operated on through a transcranial approach; 4 (23.5%) patients were operated on using a combined approach: the patients underwent simultaneous elimination of a cranio-orbital region deformity using the basal transcranial approach as well as hernial sac resection and hernioplasty using the transnasal endoscopic approach. Two children had no surgery due to minimal symptoms and a lack of cerebrospinal fluid leak.

RESULTS

Application of the algorithms for diagnosis and treatment of encephalocele, suggested by the authors, enabled making the timely diagnose, defining the optimal surgical tactics, and achieving good treatment results.

CONCLUSION

A differentiated approach to the choice of a surgical technique for basal encephalocele, the use of auto-tissues for skull base reconstruction, intraoperative and postoperative lumbar drainage, and simultaneous elimination of deformity of the fronto-naso-orbital region enable avoiding complications and achieving good functional and aesthetic results.

Brain and Optic Chiasm Herniation into Sella after Pituitary Tumor Apoplexy

Brain and optic chiasm herniation has been rarely reported following dopamine agonist treatment for large prolactinomas. We report a case of brain and optical chiasm herniation, secondary to an empty sella due to apoplexy of a prolactinoma, and we focus on the specific presentation of this case. A 32-year-old female presented to a neurologist complaining of headaches. Her past medical history was significant for acute vision loss in both eyes accompanied by right third nerve palsy when she was 16 years old. She does not recall any endocrine or imaging evaluation at that time and she had spontaneous partial recovery of left eye vision within 3 months, with permanent blindness of right eye. She did not return to any follow-up until her neurologist consultation. Brain magnetic resonance imaging (MRI) revealed herniation of frontal lobe and optic chiasm into the pituitary sella, as well as a pituitary hypointense lesion measuring 5 mm × 5 mm after gadolinium injection. Prolactin levels were 206 ng/ml (4.79-23.3 ng/ml). Repeated prolactin was 258 ng/ml (4.79-23.3 ng/ml). She was started on bromocriptine 2.5 mg/day. Prolactin levels and menstrual cycles normalized. A repeat brain MRI performed 5 months later showed disappearance of pituitary mass, with no changes in brain and chiasmal herniation. To our knowledge, this is the first reported case of brain associated with chiasm herniation secondary to pituitary apoplexy of a prolactinoma. In conclusion, this case highlights that frontal lobe herniation in combination with optic chiasm herniation can be a complication of pituitary tumor apoplexy. Long-term surveillance of patients with pituitary apoplexy is warranted to detect delayed complications.

Endoscopic surgery for congenital basal meningoencephaloceles in children

Conclusions Endoscopic surgery is safe and effective for children with congenital basal meningoencephaloceles (CBMs); it provides an acceptable operative outcome with a short recovery time and fewer complications and may be considered as a primary approach. Objectives To explore the safety and effectiveness of using transnasal or transoral endoscopic surgery on children with CBMs. Methods The clinical data of eight CBMs children who underwent transnasal or transoral endoscopic surgery in a hospital from January 2011 to January 2015 were collected. The presenting symptoms, lesion locations, surgical outcomes, and complications were examined retrospectively. Results Of the eight children, five (62.5%) patients were male, and their ages ranged from 1 year and 6 months to 14 years (median of 9 years). Six patients presented with the transethmoidal sub-type, and two presented with the transsphenoidal sub-type. The average hospital stay of all patients was 8.6 ± 2.6 days. There were neither intra-operative nor post-operative complications observed in any of the cases during the follow-ups that occurred between 6-54 months (mean of 15.5 months).

Magnetic resonance imaging of sellar and juxtasellar abnormalities in the paediatric population: an imaging review

The sellar and juxtasellar regions in the paediatric population are complex both anatomically and pathologically, with magnetic resonance imaging (MRI) being the "gold standard" imaging modality due to the high contrast of detail. Assessment requires a detailed understanding of the anatomy, embryology, pathophysiology and normal signal characteristics of the pituitary gland and surrounding structures in order to appropriately characterise abnormalities. This article aims to provide an overview of the imaging characteristics of developmental/congenital and acquired disease processes which affect the sellar and juxtasellar region in the paediatric population. Main Messages • The sellar region is anatomically complex and covers a wide pathology spectrum. • MRI is the key imaging modality to assess sellar and juxtasellar pathology. • Numerous developmental anomalies may not be discovered until adulthood. • Knowledge of pathology alerts and guides the clinician towards appropriate management.

Occult spontaneous lateral intrasphenoidal encephalocele: A rare presentation

Basal encephaloceles are extremely rare congenital malformations. Advanced cross-sectional imaging modalities like computed tomography and magnetic resonance imaging are necessary for diagnosing the asymptomatic, occult basal encephalocele and planning the surgical approach. We present an interesting case of clinically silent right-sided lateral intrasphenoidal encephalocele through a large bony defect.

Rathke's pouch remnant and its regression process in the prenatal period

OBJECTS

During ontogeny, part of Rathke's pouch, a physiologically superior pouching of the stomodeal ectoderm, may remain, forming the usual anomaly known as Rathke's cleft cyst. More rarely, however, the entire pouch (i.e., the craniopharyngeal canal) remains, resulting in transsphenoidal meningoencephalocele. This study is aimed to provide a better understanding of the pathogenesis.

MATERIALS AND METHODS

We histologically evaluated the inferior protrusion of the putative hypophysial fossa in 35 embryonic and fetal heads, respectively (15 at 5-8 weeks and 20 at 12-16 weeks of gestation).

RESULTS

In 3 of the 35 specimens, we observed a complete cleft originating from the adenohypophysis, passing through the sphenoid and connecting with the pharyngeal epithelium or pharyngobasilar fascia. In another 18 specimens, we observed a duct-like structure protruding from the fossa and ending in the sphenoid. The sellar protrusion contained vein-like structures and debris of red blood cells. The protrusion was located on the anterior or anterosuperior side of the notochord. No ossification center was observed around the sellar region of the embryos. Although ossification occurred in 12 of the 20 fetuses, nine of the latter showed no evidence of cleft or protrusion, indicating that the incidence of Rathke's pouch remnant was lower in the fetuses (11/20) than in the embryos (11/15).

CONCLUSION

Rathke's pouch may be closed by ossification of the sphenoid, but increased cell proliferation and/or large amounts of degenerated veins may provide a structure resistant to the mechanical pressure caused by ossification.

Intrasphenoidal Meningo-encephalocele: Report of two rare cases and review of literature

Background:

Transsphenoidal encephaloceles represent a rare clinical entity with wide range of symptoms in adult. Such lesions require accurate diagnosis and surgical treatment. The incidence of congenital encephalocele is very low occurring in approximately 1 in 3000-5000 live births. Even though 63 similar cases have been reported in the literature not all of them have been discussed completely. Due to the rare occurrence of these lesions, we will focus on the main clues in the diagnosis and management of such lesions, which are challenging.

Case Description:

We intend to present our experience with two cases of trans-sphenoidal meningoencephalocels, one located medially and the other herniating through the Sternberg's canal. The younger was 17 and the elder was 47 years old and both of them presented with cerebrospinal fluid (CSF) leakage. Both patients were treated successfully using pure endoscopic endonasal approach.

Conclusion:

Ideal surgical approach for such patients is still not clear due to lack of adequate experience in the literature, it is suggested that full preoperative imaging studies might lead the surgeons to undertake minimally invasive skull base approaches in similar patients.

Application of the endoscopic transsphenoidal approach to true type transsellar transsphenoidal meningoencephalocele in an adult: a case report and literature review

Of the transsellar transsphenoidal meningoencephaloceles (TTSMEs), the true type presents with the hernial sac extending from the intracranium to the epipharynx through the sellar floor. The true type is the most serious and difficult to manage, especially when the hernial sac contains vital structures, such as the anterior cerebral artery, pituitary gland, optic nerve, hypothalamus, and third ventricle. Surgical outcome for true type TTSME is reported to be poor. We describe a successful case of endoscopic repair for a 36-year-old man with true type TTSME. Our success with endoscopic repair for true type TTSME in an adult is the first reported case. We believe that the endoscopic transsphenoidal approach allows less invasive surgery and provides an acceptable operative outcome in comparison with other microsurgical approaches.

Middle fossa approach to a temporosphenoidal encephalocele -technical note-

Temporosphenoidal encephalocele (TSE) is a rare entity caused by herniation of the anteromedial temporal lobe into the sphenoid sinus (SS) through a middle fossa (MF) defect. A 45-year-old woman presented with a spontaneous TSE manifesting as a 4-year history of recurrent cerebrospinal fluid rhinorrhea and meningitis. Coronal computed tomography showed a skull defect in the superior wall of the right lateral recess of the SS. This homogeneous intrasphenoidal lesion appeared hypointense on T(1)-weighted magnetic resonance (MR) imaging and hyperintense on T(2)-weighted MR imaging. The patient underwent a frontotemporal craniotomy and extradural MF exploration. The encephalocele was amputated and the temporal base dura primarily sutured and reinforced with fat graft. The MF hole was plugged with temporalis fascia and a calvarial graft layered over the bone defect. Histological examination confirmed meningoencephalocele. Rhinorrhea resolved and the patient remained asymptomatic. Resection of an anteromedial TSE and closure of the craniodural defect in the MF floor via a less invasive extradural skull base approach is effective.

Transsphenoidal meningoencephalocele associated with cleft lip and palate: challenges for diagnosis and surgical treatment

PURPOSE

The aim of this study was to highlight the challenges for early diagnosis and the difficulties observed in surgical treatment of patients with transsphenoidal meningoencephalocele associated with cleft lip and/or palate.

METHOD

We evaluated six male patients treated over the course of 4 years. Five patients presented encephalic herniation with nonfunctional brain tissue; one of these presented herniation of the pituitary gland and cerebral ventricles.

RESULTS

All the patients received surgical treatment for the cleft lip and/or palate. Only one patient underwent repair of the meningoencephalocele, via nasal endoscopy. There were no postprocedural clinical or surgical complications.

CONCLUSION

The tendency is to avoid neurosurgery, opting for periodic follow-up with magnetic resonance imaging. In the presence of cleft palate, palatoplasty is essential to protect the meningoencephalocele.

Recurrent meningitis and persistence of craniopharyngeal canal: case report

OBJECTS

Craniopharyngeal Canal is a rare malformation of the sphenoid bone described in up to 0.42% of the asymptomatic population. It's been related to the development of the Rathke's pouch during embrionary period although some authors think it's a vestige of a former vascular channel.

METHODS

This report details a case of a four and a half years old child that developed recurrent meningitis associated with this anomaly. Its origin, clinical manifestations and treatment options are discussed.

CONCLUSION

Due to its low incidence and diagnostic difficulties, a high suspicion index is required while studying a case of recurrent meningitis or CSF leakage. Surgical approach is still controversial.

[Transspheinoidal transpalatal meningoencephalocele]

Transspheinoidal meningoencephalocele is a rare presentation of dysraphism of the neural tube. It is characterized by the herniation of the neural tissue through a bony defect in the sphenoid bone. The clinical presentation is variable. It may be assymptomatic or it may include an upper airway obstruction, rhinorrhea, meningitis, hypothalamic dysfunction and optic anomalies. The surgical treatment is controversial. We describe the case of a 7-year-old boy who presented a pulsate structure filling the palate, palate digenesis and hypertelorism. The diagnosis of transsphenoidal transpalatal meningoencephalocele was confirmed by a computerized tomography and a magnetic resonance imaging. The child was operated on by the transpalatal/transspheinoidal approach with a good result.

Adult intranasal meningoencephalocele presenting as a nasal polyp

We present an isolated purely intranasal meningoencephalocele, presenting as a nasal polyp in an adult, which is uncommon. Based on a review of the literature, we emphasize that nasal obstruction may be the only presenting symptom of an intranasal meningoencephalocele.

Spontaneous Bilateral Intrasphenoidal Lateral Encephaloceles: CT and MRI Findings

Lateral intrasphenoidal encephaloceles are rare anomalies. We describe a unique case in which spontaneous bilateral intrasphenoidal lateral encephaloceles were discovered in a 53-year-old man during a work-up for cerebrospinal fluid leak. We discuss our clinical findings and the results of preoperative computed tomography and magnetic resonance imaging.

Intrasphenoidal transsellar encephalocele repaired by endoscopic approach

Spontaneous sphenoidal encephaloceles are rare entities. In the case of intrasphenoidal encephaloceles, most defects are temporosphenoidal and occur in the lateral wall of the sphenoidal sinus. There have been to our knowledge only 7 reports of medial, transsellar encephaloceles in the literature. We report a case of intrasphenoidal transsellar encephalocele that was successfully managed through an endoscopic approach with complementary lumboperitoneal shunting. This disorder presents a challenge in surgical management because of the involvement of opticochiasmatic structures, the hypothalamopituitary axis, and the delicate vasculature of the circle of Willis in and around the encephalocele, besides proximity to the cavernous sinus. Rhinologists should be aware of these malformations, since the optic nerve or chiasma may be totally exposed in the sphenoidal sinus in the course of this disease. This case illustrates the need for magnetic resonance imaging in case of sphenoidal abnormalities, as well as the possibility of endonasal repair without a transcranial approach for large intrasphenoidal encephaloceles.

Intrasphenoidal encephalocele associated with cerebrospinal fluid fistula and subdural hematomas: technical case report

OBJECTIVE AND IMPORTANCE

Intrasphenoidal encephalocele is a rare clinical entity that is often complicated by rhinorrhea, recurrent meningitis, and headache, but in no case has the association of rhinorrhea with subdural hematomas been described. A surgical procedure to stop persistent cerebrospinal fluid leakage is reported.

CLINICAL PRESENTATION

A 59-year-old man sought care for intractable rhinoliquorrhea of 6 months' duration. Cranial computed tomographic and magnetic resonance imaging scans revealed a basal posterior frontal bony defect and an evocative image suggesting intrasphenoidal encephalocele.

INTERVENTION

A transnasal transsphenoidal surgical procedure was performed; the encephalocele was removed, and the sphenoid sinus was filled with an inflatable pouch made of synthetic dura mater containing abdominal fat. Postoperative reduction of the rhinoliquorrhea, but not its total disappearance, was observed. Total disappearance was achieved only after endonasal, transmucosal inflation of the pouch with human fibrin glue. One of the subdural hematomas disappeared spontaneously, and the other was treated by a surgical procedure.

CONCLUSION

The possible role of the presented technique in the treatment of cerebrospinal fluid leakage is discussed.