Traumatic encephalocele related to orbital roof fractures: report of six cases and literature review

Massive nasal meningoencephalocele in a 4-month-old infant: A case report

A massive nasal meningoencephalocele is a rare congenital anomaly characterized by the herniation of brain tissue and meninges through a defect in the skull base into the nasal cavity. It typically manifests as nasal obstruction and respiratory distress in infancy and is diagnosed via imaging techniques such as magnetic resonance imaging, often necessitating surgical intervention for treatment. This document outlines the endoscopic treatment of a 4-month-old child with a significant nasal meningoencephalocele.

An unusual presentation of orbital encephalocele following a self-inflicted gunshot wound injury: A case report and literature review

While orbital encephaloceles secondary to orbital roof fractures, in the setting of gunshot wound injuries, are rare, it is important to discuss diagnosis, treatment, and outcomes. This comprehensive manuscript aims to accomplish these objectives.

Successful Management of Post-Traumatic Residual Orbital Roof Defects with Cosmetic Disfigurement and Functional Deficits Using Innovative Titanium Plate Orbitoplasty

Introduction

Late presentations of post-traumatic residual orbital roof deformities ensuing from old, unaddressed orbital injuries, can be extremely challenging to manage and quite complicated to correct, owing to proximity of the brain and frontal sinus, malunion or bony fusion of the displaced, delicate orbital fracture fragments, necrosis of entrapped extraocular muscles and progressive intraorbital soft tissue fibrosis and adhesions. There exists a paucity in literature on delayed repair of displaced and comminuted orbital roof fractures and late reconstruction of the three-dimensional architecture of the orbital frame and internal orbit.

Aim & Objectives

To present an unusual case of severe post-traumatic residual orbital roof deformity, resulting in longstanding aesthetic disfigurement and persisting functional deficits, and its successful management.

Material & Methods

The patient had sustained orbital injuries sixteen months ago, on being punched in the face at a boxing tournament. The increased orbital volume produced by an impure blowout fracture of the left orbital roof, with comminution of the upper and lower orbital rims, had resulted in considerable cosmetic deformity, discomfort as well as functional debility, all of which were successfully and efficaciously managed by an innovative use of a Titanium Orbital Plate for orbital roof reconstruction.

Discussion

Overlooked, undetected or ignored derangements in intraorbital volume and contour, can lead to severe cosmetic disfigurement in the form of enophthalmos, hypoglobus, entropion, telecanthus, palpebral fissure width narrowing and ptosis; in addition to crippling functional deficits, such as diplopia, blurred vision, levator dysfunction, restricted ocular motility and reduced visual range and acuity.

Results & Conclusions

An innovative Titanium mesh orbitoplasty enabled achievement of both, the aesthetic and functional goals of reconstruction of the distorted bony orbit, with successful correction of severe functional and aesthetic deficits.

Transpalpebral transorbital neuroendoscopic (TONES) repair of orbital meningoencephalocele: a technical note

PURPOSE

Intraorbital encephalocele (OMEC) is a rare entity in adults, usually secondary to an orbital pathology or prior trauma, in particular orbital roof fractures. Treatment of the OMEC is warranted to alleviate the pulsating exophthalmos and prevent potential visual decline. OMEC and orbital roof fractures have been predominantly treated via a craniotomy with a reconstruction of the orbital roof using various implants. With the advances in the endoscopic techniques, neuroendoscopy found its application in the treatment of orbital pathologies. We report a minimally invasive alternative: endoscopic transorbital repair of OMEC.

MATERIAL AND METHODS

The repair technique is described with illustrations and clinical images. Narrated operative video demonstrating the procedure is provided.

RESULTS

Illustrative case: 50-year-old female presented with progressive right eye proptosis over 6 months. Computed tomography (CT) demonstrated bony erosion in the lateral orbital roof, and magnetic resonance imaging (MRI) showed a small hyperintense T2-weighted and T1-weighted contrast enhancing lesion in the orbit, in the area of the bony erosion. Intraoperatively, the lesion was found to be an orbital encephalocele. The orbital defect was successfully repaired by employing the 'sandwich' technique, in which a dural substitute reinforced with tissue glue were deployed without repair of the osseous orbital roof. The patient tolerated the procedure well with ultimate resolution of proptosis. The cosmetic outcome was excellent.

CONCLUSION

The transorbital neuroendoscopic approach (TONES) presents a feasible, minimally invasive alternative treatment option for circumscribed intraorbital encephaloceles with minimal side effects, well tolerated by patients.

Natural History of Traumatic Encephaloceles: A Systematic Literature Review

Encephaloceles rarely develop following traumatic skull fractures. Given their low incidence, the clinical presentations and management strategies of these lesions are confined to case reports and limited case series. A systematic literature review was performed using PubMed, Ovid, and Web of Science databases to identify relevant articles using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 37 articles met inclusion criteria, including the case presented herein. These articles reported 52 traumatic encephaloceles. Mean patient age was 25.3 years (range 6 mo-66 y) with a male predominance (63%, 33/52). The most common bony defects resulting in encephalocele formation were the orbital roof (52%, 27/52), ethmoid (35%, 18/52), and sphenoid (10%, 5/52). Mean time from traumatic injury to initial presentation was 21.3 months (range 0 d-36 y) with a bimodal distribution split between immediately following the traumatic injury (57%, 26/46) or in a delayed manner (43%, 20/46). Common presentations of orbital roof, frontonasal, and temporal bone encephaloceles were exophthalmos (85%, 23/27), cerebrospinal fluid rhinorrhea (71%, 17/24), and hearing loss (100%, 4/4), respectively. Operative approach, repair technique, and materials used for encephalocele reduction were highly variable. Surgical intervention afforded definitive symptomatic improvement or resolution in the majority of cases (89%, 42/47). Clinical outcomes did not differ between orbital, frontonasal, or temporal bone encephaloceles ( P =0.438). Traumatic encephaloceles are a rare entity with diverse presenting symptomatology dependent upon the location of fracture dehiscence. Surgical intervention affords symptomatic improvement in the majority of cases irrespective of encephalocele location, time to presentation, or operative approach.

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

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

A case of brain hamartoma in a child leading to compressive optic neuropathy mimicking amblyopia

Hamartomas are benign neoplastic malformations characterized by disorganized growths of tissue in their native location. They may grow in numerous sites throughout the body. We report the case of a 3-year-old boy with unilateral compressive optic neuropathy caused by a brain hamartoma that mimicked strabismic amblyopia. To our knowledge, this is the first case report in the literature of prechiasmal optic nerve compression from a brain hamartoma without ipsilateral bony defect or encephalocele.

Posterior occipital gunshot wound causing orbital roof blow-in fracture with encephalocele

Isolated orbital roof fractures are rare fractures that usually occur in conjunction with other facial bone fractures during high velocity trauma. This report concerns a patient with an isolated orbital roof fracture with encephalocele, including its diagnosis, surgical management, and clinical follow-up. This case required a multidisciplinary approach to safely repair the fracture, reduce the encephalocele, restore the orbital volume, and restore the patient's form and function.

Surgical Treatment and Visual Outcomes of Adult Orbital Roof Fractures

BACKGROUND

Fractures of the orbital roof require high-energy trauma and have been linked to high rates of neurologic and ocular complications. However, there is a paucity of literature exploring the association between injury, management, and visual prognosis.

METHODS

The authors performed a 3-year retrospective review of orbital roof fracture admissions to a Level I trauma center. Fracture displacement, comminution, and frontobasal type were ascertained from computed tomographic images. Pretreatment characteristics of operative orbital roof fractures were compared to those of nonoperative fractures. Risk factors for ophthalmologic complications were assessed using univariable/multivariable regression analyses.

RESULTS

In total, 225 patients fulfilled the inclusion criteria. Fractures were most commonly nondisplaced [n = 118 (52.4 percent)] and/or of type II frontobasal pattern (linear vault involving) [n = 100 (48.5 percent)]. Eight patients underwent open reduction and internal fixation of their orbital roof fractures (14.0 percent of displaced fractures). All repairs took place within 10 days from injury. Traumatic optic neuropathy [n = 19 (12.3 percent)] and retrobulbar hematoma [n = 11 (7.1 percent)] were the most common ophthalmologic complications, and led to long-term visual impairment in 51.6 percent of cases.

CONCLUSIONS

Most orbital roof fractures can be managed conservatively, with no patients in this cohort incurring long-term fracture-related complications or returning for secondary treatment. Early fracture treatment is safe and may be beneficial in patients with vertical dysmotility, globe malposition, and/or a defect surface area larger than 4 cm2. Ophthalmologic prognosis is generally favorable; however, traumatic optic neuropathy is major cause of worse visual outcome in this population.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization

OBJECTIVE

Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up.

METHODS

The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging.

RESULTS

The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage.

CONCLUSIONS

Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.

Treating Pulsatile Exophthalmos in Child with Minimally Invasive Approach and Custom-made Titanium Mesh Plate

Orbital roof fracture is a relatively rare trauma. In most cases, surgical intervention is not needed since the fracture is slight. However, invasive surgical procedures are inevitable once pulsatile exophthalmos occurs if vision impairment is to be avoided. We report our rare experience of orbital roof fracture in a child with pulsatile exophthalmos. Good reconstruction of the anterior cranial base was achieved using a custom-made titanium mesh and a minimally invasive approach. A 3-year-old girl who had been diagnosed with subdural hematoma, brain contusion, and fracture of the right orbital roof caused by facial bruising underwent emergent external decompression by coronal skin incision and a transcranial approach on the same day as the trauma. Cranioplasty using autologous frozen bone in the same approach was performed 103 days posttrauma, but this was followed by pulsatile exophthalmos. After recovering from critical stage, the girl was brought to our department for reconstruction of the anterior base. Risk of vision impairment was also one reason for reconstruction, but the neurosurgeon hesitated to approach the region using a coronal approach considering the possibility of infection in the frozen autologous bone. Through cross-team discussion, reconstruction using a subeyebrow incision was performed with a custom-made titanium mesh plate. Pulsatile exophthalmos completely disappeared. Pulsatile exophthalmos is a very rare but serious complication that carries a risk of vision impairment. By applying a custom-made titanium mesh plate, precise reconstruction was enabled with minimal invasiveness and low risk.

Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. ^©RSNA, 2018.

Isolated Orbital Roof Fracture: Can It Be Catastrophic?

Orbital encephalocele is a rare catastrophic complication of orbital roof fractures. Early diagnosis of this posttraumatic orbital encephalocele is very crucial because this condition if untreated leads to rapid loss of vision. Whenever displaced orbital roof fracture is identified in a head injury patient, an orbital encephalocele should be suspected. Although magnetic resonance imaging is the investigation of choice, computed tomography of orbit with thin axial and coronal sequences often gives the diagnosis. Frontobasal approach is the most commonly used surgical approach. Supra-transorbital approach is a minimally invasive alternative. Good results with regard to the orbital symptoms can be expected.

Basal Encephalocele Presenting with Bitemporal Hemianopsia in an Adult Male

Basal encephaloceles are uncommon malformations that are usually congenital in nature, although, occasionally, they can be traumatic. When they are congenital, they are associated with skull and facial midline defects, central nervous system abnormalities, and possible ocular and visual problems. The authors present a case of an adult male with a basal encephalocele who presented with a bitemporal hemianopsia. Ocular abnormalities, visual loss, and visual field deficits have previously been reported in patients with basal encephalocele; however, there does not appear to be any reported cases with formal visual field testing to demonstrate specific defects such as a bitemporal hemianopsia.

"Five-layer gasket seal" watertight closure for reconstruction of the skull base in complex bilateral traumatic intraorbital meningoencephaloceles: a case report and literature review

PURPOSE

Traumatic meningoencephalocele primarily occurs as a rare but complex complication of cranial base and orbital roof fractures. Traumatic intraorbital meningoencephalocele, which is rare and easily overlooked, can be life-threatening since cephalomeningitis occurs due to cerebrospinal fluid (CSF) leakage. It is obscure for the operative indications or standard surgical methods of traumatic meningoencephaloceles since the combined intricate craniofacial and basal fractures, brain injury, and CSF leak may exist. This case report proposes a new operative method for the repair of complex skull base fractures following traumatic intraorbital meningoencephalocele.

METHODS

A 30-year-old male with a history of complex trauma presented with symptoms of exophthalmos and traumatic CSF rhinorrhea was evaluated via 3D CT of the skull base and brain MRI and was diagnosed with bilateral intraorbital meningoencephaloceles and multiple craniofacial bone, skull base, and orbit fractures.

RESULTS

Successful resection of the meningoencephaloceles and reconstruction of the skull base defects were performed via craniotomy using a "five-layer gasket seal" technique that involved, from extracranial to intracranial, a gelatin sponge, muscular paste, vascularized periosteum, RapidSorb Orbital Floor Plate (OrbFloor), and Neuro-Patch layers.

CONCLUSIONS

The diagnosis and treatment of complex intraorbital meningoencephalocele require careful attention. Resection of herniated tissue is suggested due to potential contamination. The "five-layer gasket seal" watertight closure technique is recommended for successful repair of the skull base in cases involving traumatic meningoencephalocele with complex skull base fractures.

Penetrating orbital trauma leading to trans-orbital brain herniation

INTRODUCTION

Development of a posttraumatic herniation of brain parenchyma through the orbit is a rare complication of orbital roof fracture. Mostly, the injury is due to a direct impact to the frontal region resulting in orbital roof fracture with dural defect and herniation of cerebrospinal fluid or brain parenchyma. These patients present with acute or gradually progressive proptosis with impending risk of loss of vision and mandate surgical decompression of optic nerve with watertight closure of the dural defect. Bony reconstruction may be required to achieve normal contour of the orbit.

MATERIALS AND METHODS

We encountered an interesting pediatric patient who presented to us with altered sensorium and progressive proptosis 3 days after a penetrating trauma to his left orbit by falling on the handle of a bicycle. The plain computerized tomography of the head (NCCT) showed a left orbital roof defect with herniation of brain matter into the orbit displacing the globe inferolaterally. A craniotomy was performed and watertight closure of the dural rent was achieved with use of autologous bone to cover the defect.

CONCLUSIONS

The child improved gradually, and at 6 months follow-up, he had good cosmetic outcome with improvement of vision.

Pulsatile Proptosis due to Intraorbital Meningocele

We present a case of a 79-year-old man with a non-symptomatic pulsatile proptosis of the left eye. Magnetic resonance imaging revealed a meningocele into the left orbit due to an osseous defect in the orbital roof.

Acute post-traumatic encephalocele in a child: CT and MRI features

Orbital trauma is a commonly encountered entity in clinical practice, especially in cases of head trauma. Although fractures of the orbit are rare, they can present in an emergency setting owing to associated complications such as orbital encephaloceles. We present a case of a paediatric male patient who presented with post-traumatic proptosis and diminution of vision and was diagnosed with orbital encephalocele. The child's vision recovered completely and proptosis of the eye decreased, compared with the time of presentation. Despite persistent counselling, the patient and his parents did not give consent for surgical correction and he was discharged as leaving against medical advice. Post-traumatic orbital encephaloceles are caused as a result of blunt cranial trauma. Early treatment and diagnosis is extremely important in the optimum management and good long-term prognosis of the patient.

Posttraumatic giant fronto-orbito encephalocele causing cosmetic disfiguring forehead swelling with proptosis: Management

Fracture of the anterior skull base can occur following head injury. Growing skull fracture is usually observed in children under age of 3-years. It commonly involves frontal and parietal regions. However, orbit involvement is extremely uncommon. Authors report a case of giant orbital encephalocele with a forehead disfiguring swelling in a 4-years boy, who sustained head injury about 3½ years back. However, such delayed presentation of traumatic encephalocele is extremely uncommon and represents the first case in the Western literature, who had a successful postoperative outcome.

Interdisciplinary Management of Minimally Displaced Orbital Roof Fractures: Delayed Pulsatile Exophthalmos and Orbital Encephalocele

Traumatic orbital roof fractures are rare and are managed nonoperatively in most cases. They are typically associated with severe mechanisms of injury and may be associated with significant neurologic or ophthalmologic compromise including traumatic brain injury and vision loss. Rarely, traumatic encephalocele or pulsatile exophthalmos may be present at the time of injury or develop in delayed fashion, necessitating close observation of these patients. In this article, we describe two patients with minimally displaced blow-in type orbital roof fractures that were later complicated by orbital encephalocele and pulsatile exophthalmos, prompting urgent surgical intervention. We also suggest a management algorithm for adult patients with orbital roof fractures, emphasizing careful observation and interdisciplinary management involving plastic surgery, neurosurgery, and ophthalmology.

Long-Term Results of Orbital Roof Repair with Titanium Mesh in a Case of Traumatic Intraorbital Encephalocele: A Case Report and Review of Literature

Orbital roof fractures associated with cranial and maxillofacial trauma are rarely encountered. Traumatic intraorbital encephaloceles due to orbital roof fractures developing in the early posttraumatic period are even rarer. A variety of materials, such as alloplastic implants or autogenous materials, have been used for the reconstruction of orbital roof, but data regarding the long-term results of these materials are very limited. We report a case of intraorbital encephalocele developing in the early posttraumatic period (2 days) in a child patient and the long-term results of titanium mesh used for the reconstruction of the orbital roof. The case is presented with a pertinent review of literature.

Secondary adult encephalocele with abscess formation of calcified frontal sinus mucocele

INTRODUCTION

Although encephalocele is a rare congenital abnormality, secondary encephalocele is extremely rare and can cause fatal complications. Here, we report a case of secondary encephalocele caused by frontal sinus wall defect due to chronic sinusitis, which was completely removed by cranialization with autologous bone graft. A 50-year-old man with a 10-year history of chronic sinusitis visited our hospital due to suddenly altered mentality characterized by stupor. Computerized tomography scanning and magnetic resonance imaging revealed an enlarged left frontal sinus with sinusitis. The frontal sinus cavity was calcified, and the left frontal lobe had herniated into the cavity accompanied by yellow pus. A large dural defect was also found around the frontal sinus area. After removal of the abscess and some of the frontal lobe, frontal skull base repair by cranialization was performed using autologous bone graft. Streptococcus pneumoniae was cultured from the cerebrospinal fluid (CSF), necessitating treatment with antibiotics. After the operation, the mental status of the patient improved and no CSF leakage was observed.

DISCUSSION

In addition to correct diagnosis and early treatment including antibiotics, the surgical repair of defects is needed in patients with secondary encephalocele to prevent further episodes of meningitis. Surgical correction of frontal sinus encephalocele can be achieved through bifrontal craniotomy or endoscopic transnasal repair. If a patient has CSF leakage, open craniotomy may facilitate repair of the dural defect and allow for cranialization of the sinus.

CONCLUSIONS

Removal of dysplastic herniated brain tissue and cranialization of the frontal sinus may be a good option for treating secondary encephalocele and its associated complications, including meningitis, abscess formation, and infarction of the herniated brain parenchyma.

Acquired Encephalocele With Hydrocephalus and Pineal Region Epidermoid Cyst

A combination of trauma and a missed inflammatory response (nasal operation) concomitant with hydrocephalus and tumor in secondary encephalocele has not been described in the English literature yet. A 38-year-old man was admitted to the clinic with rhinorrhea that started 3 months ago. In his medical history, nothing abnormal was present except a nasal operation performed 1 year ago. Brain magnetic resonance imaging depicted left frontal encephalocele concomitant with obstructive hydrocephalus caused by an epidermoid cyst originated from the pineal region. A 2-staged surgery was planned. In the first stage, a ventriculoperitoneal shunt insertion was conveyed successfully. In the second-stage surgery, the herniated brain tissue was excised, and the frontal sinus was cleansed with serum saline combined with antibiotic. The bony defect and the dura defect were repaired. The patient's presenting complaint recovered fully, and he was discharged to home in a well condition. Acquired encephalocele is a rare entity. In case of rhinorrhea and encephalocele, even in the presence of prior history of nasal surgery, intracranial evaluation should be conveyed to exclude the presence of hydrocephalus and/or tumor. The cranial defect should be repaired to prevent future infections and brain tissue damage.

Traumatic orbital encephalocele: Presentation and imaging

OBJECTIVE

Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children.

METHODS

Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin.

RESULTS

Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele.

CONCLUSION

Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.

Combined supra-transorbital keyhole approach for treatment of delayed intraorbital encephalocele: A minimally invasive approach for an unusual complication of decompressive craniectomy

BACKGROUND

Intraorbital encephalocele is a rare entity characterized by the herniation of cerebral tissue inside the orbital cavity through a defect of the orbital roof. In patients who have experienced head trauma, intraorbital encephalocele is usually secondary to orbital roof fracture.

CASE DESCRIPTION

We describe here a case of a patient who presented an intraorbital encephalocele 2 years after severe traumatic brain injury, treated by decompressive craniectomy and subsequent autologous cranioplasty, without any evidence of orbital roof fracture. The encephalocele removal and the subsequent orbital roof reconstruction were performed by using a modification of the supraorbital keyhole approach, in which we combine an orbital osteotomy with a supraorbital minicraniotomy to facilitate view and access to both the anterior cranial fossa and orbital compartment and to preserve the already osseointegrated autologous cranioplasty.

CONCLUSIONS

The peculiarities of this case are the orbital encephalocele without an orbital roof traumatic fracture, and the combined minimally invasive approach used to fix both the encephalocele and the orbital roof defect. Delayed intraorbital encephalocele is probably a complication related to an unintentional opening of the orbit during decompressive craniectomy through which the brain herniated following the restoration of physiological intracranial pressure gradients after the bone flap repositioning. The reconstruction of the orbital roof was performed by using a combined supra-transorbital minimally invasive approach aiming at achieving adequate surgical exposure while preserving the autologous cranioplasty, already osteointegrated. To the best of our knowledge, this approach has not been previously used to address intraorbital encephalocele.

Conjunctival Mass as an Initial Presentation of Iatrogenic Orbital Encephalocele

A 46-year-old woman presented with a symptomatic conjunctival mass of the right eye, appearing 2 months after undergoing right frontal craniotomy to excise a meningioma. MRI of the brain revealed a new iatrogenic encephalocele extending into the right temporal orbit. Our opinion is that the conjunctival mass resulted directly from this encephalocele. To date this has been conservatively managed, and we believe this to be the first report of an iatrogenic encephalocele presenting in this manner.

Pilocytic astrocytoma presenting as an orbital encephalocele: a case report

We describe the case of a 29-year-old male who presented with new-onset seizures. He was subsequently found to have an orbital encephalocele containing a focus of pilocytic astrocytoma. We believe that this is the first report of a pilocytic astrocytoma located within the orbit that did not originate from the optic pathway. It is also the first case of a pilocytic astrocytoma completely contained within an encephalocele. This case suggests a close pathological examination of encephaloceles for underlying diseases.

Orbital Roof Fractures: A Clinically Based Classification and Treatment Algorithm

Orbital roof fractures are relatively uncommon in craniofacial surgery but present a management challenge due to their anatomy and potential associated injuries. Currently, neither a classification system nor treatment algorithm exists for orbital roof fractures, which this article aims to provide. This article provides a literature review and clinical experience of a tertiary trauma center in Australia. All cases admitted to the Royal Melbourne Hospital with orbital roof fractures between January 2011 and July 2013 were reviewed regarding patient characteristics, mechanism, imaging (computed tomography), and management. Forty-seven patients with orbital roof fractures were treated. Three of these were isolated cases. Forty were male and seven were female. Assault (14) and falls (13) were the most common causes of injury. Forty-two patients were treated conservatively and five had orbital roof repairs. On the basis of the literature and local experience, we propose a four-point system, with subcategories allowing for different fracture characteristics to impact management. Despite the infrequency of orbital roof fractures, their potential ophthalmological, neurological, and functional sequelae can carry a significant morbidity. As such, an algorithm for management of orbital roof fractures may help to ensure appropriate and successful management of these patients.

Immediate single-stage reconstruction of complex frontofaciobasal injuries: part I

Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.

Titanium mesh reconstruction of orbital roof fracture with traumatic encephalocele: a case report and review of literature

Orbital roof fractures are rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 21 cases published to date. Orbital roof fractures are generally encountered in males between 20 and 40 years of age following automobile collision. We report a case of an orbital roof fracture with traumatic encephalocele into the left orbit. Early diagnosis and treatment are very important because the raised intraorbital pressure may irreversibly damage the optic nerve. Computed tomography with 3-D reconstruction, the imaging modality of choice, showed the displaced fracture fragment deep into the orbit. Reconstruction of the orbital roof should be performed in every case. We used an extracranial approach to elevate the fracture with titanium mesh to stabilize the fragment. The cosmetic results were excellent but delay in treatment was responsible for delayed recovery of vision. The case report is followed by a brief overview of orbital roof fractures including pertinent review of literature.

Patterns of ecchymoses caused by manner of death and collateral injuries sustained in bruising incidents: decedent injuries, profiles, comparisons, and clinicopathologic significance

We investigated how ecchymoses could be used to predict other injuries, or help establish the cause of death. Ecchymoses, fractures, lacerations, abrasions, and other data were recorded. Eleven percent of decedents had ecchymoses. Motor vehicle accident by car (MVA-C) was the most common cause of ecchymoses and showed the most collateral injuries. Decedents of natural causes were more likely to have ecchymoses without collateral injuries. There appeared to be two groups of decedents with ecchymoses: one group is younger, comprised of victims of MVA-C and homicides, with more injuries related to ecchymoses than others; another is an older group of victims of other accidents, natural causes, and suicide. There were no indeterminate causes of death among decedents with ecchymoses. Therefore, ecchymoses may be a surrogate marker to direct the pathologist to continue to seek a cause of death should be seen, even if the case, otherwise, appears to be indeterminate.

[Traumatic orbital encephalocele in an adult: report of one case]

Orbital roof fractures after head injury is rare. Traumatic encephaloceles in the orbital cavity are even rarer, with only 24 cases published to date. We report the case of an adult with a post-traumatic orbital encephalocele. One day after a road traffic accident with head injury, the patient developed progressive pulsatile proptosis. Computed tomography and magnetic resonance imaging revealed an isolated blow-in fracture of the orbital roof with herniation of the left frontal lobe into the orbit. Neurosurgery to repair the orbital defect led to full recovery.

SURGICAL MANAGEMENT OF ANTERIOR CRANIAL BASE FRACTURES WITH CEREBROSPINAL FLUID FISTULAE

OBJECTIVE

The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience.

METHODS

We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear.

RESULTS

Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure.

CONCLUSION

The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

Traumatic orbitomaxillary encephalocele

A rare case of occult traumatic intramaxillary encephalocele and intraorbital encephalocele without obvious connection to exterior is described

Intraorbital encephalocele: an important complication of orbital roof fractures in pediatric patients

Orbital roof fractures are uncommon, and traumatic intraorbital encephalocele formation is a very rare complication of this type of injury. We treated 43 pediatric patients with orbital roof fractures at our center over a 4-year period. The aim of this study was to retrospectively investigate conditions that may lead to intraorbital encephalocele formation in children with orbital roof fractures. Each case was reviewed, and the cause of injury, associated clinical and computerized tomography findings, the Glasgow Coma Scale score on admission, neurological status, other bodily injuries, hospitalization time and type and width of the orbital roof fracture were recorded. The findings in 6 patients who developed encephaloceles were compared to corresponding findings in the 37 patients who did not develop this complication. A total of 44 orbital roof fractures were diagnosed by axial and coronal computed tomography scanning. Six of the 43 children developed intraorbital encephaloceles in the first month after head trauma. In each of these cases, magnetic resonance imaging demonstrated the intraorbital cystic lesion in communication with the subarachnoid space. The width of each orbital roof fracture was measured on axial and coronal computed tomography slices and was confirmed by measurements during surgery. The width of the fractures in the encephalocele cases ranged from 2-4 mm. Duraplasty and orbitoplasty were performed in all the patients with encephalocele. Pediatric patients with orbital roof fractures that exhibit more than 2 mm diastasis and are associated with frontal cerebral contusion may be at greater risk for developing intraorbital encephalocele. All such cases should be monitored closely and investigated further with magnetic resonance imaging.