Repair of temporosphenoidal encephalocele with a vascularized split calvarial cranioplasty: technical case report

Repair of lateral temporo-sphenoidal encephalocoele via an endoscopic transorbital approach: ex vivo 3D printed simulation followed by in vivo deployment

BACKGROUND

A temporo-sphenoidal encephalocoele occurs when temporal lobe herniates through a defect in the greater wing of the sphenoid bone into the sphenoid air sinus. The natural history is not well-understood, though presentation in adulthood with CSF rhinorrhoea and/or meningitis is typical. Lateral pneumatisation of the sphenoid sinus and elevated BMI may be contributory.

AIMS

We explored the feasibility of a transorbital approach (TOA) for repair, using a combination of 3D modelling and simulation. We then successfully deployed this technique in vivo.

METHODS

CT imaging for three patients who had previously undergone transcranial repair of lateral temporo-sphenoidal encephalocoele was used to generate data allowing 3D printed models of the skull base to be produced. The transorbital approach was simulated by performing a lateral orbitotomy followed by drilling of the sphenoid wing to expose the antero-basal middle fossa. 3D object scanning was used to create virtual models of the skull base post-surgery, from which surgical access was quantified in two ways: the area (mm2) of the middle fossa exposed by the TOA and the vertical attack angle.

RESULTS

The mean surface area of the cranial access window achieved by simulated TOA was 325mm2. The mean vertical attack angle was 25°. One patient was subsequently treated successfully via TOA with no recurrence of their CSF leak, no orbital morbidity, excellent cosmesis, but resolving V2 numbness (follow-up 7 months).

CONCLUSIONS

We have shown that the transorbital approach provides adequate surgical access. In our single case, surgical repair of a lateral temporo-sphenoidal encephalocoele via TOA was feasible, safe, and effective. This approach may offer some advantages compared with transcranial or endonasal approaches.

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.

Anterior Cranial Base Reconstruction in Complex Craniomaxillofacial Trauma: An Algorithmic Approach and Single-Surgeon's Experience

Management of traumatic skull base fractures and associated complications pose a unique reconstructive challenge. The goals of skull base reconstruction include structural support for the brain and orbit, separation of the central nervous system from the aerodigestive tract, volume to decrease dead space, and restoration of the three-dimensional appearance of the face and cranium with bone and soft tissues. An open bicoronal approach is the most commonly used technique for craniofacial disassembly of the bifrontal region, with evacuation of intracranial hemorrhage and dural repair performed prior to reconstruction. Depending on the defect size and underlying patient and operative factors, reconstruction may involve bony reconstruction using autografts, allografts, or prosthetics in addition to soft tissue reconstruction using vascularized local or distant tissues. The vast majority of traumatic anterior cranial fossa (ACF) injuries resulting in smaller defects of the cranial base itself can be successfully reconstructed using local pedicled pericranial or galeal flaps. Compared with historical nonvascularized ACF reconstructive options, vascularized reconstruction using pericranial and/or galeal flaps has decreased the rate of cerebrospinal fluid (CSF) leak from 25 to 6.5%. We review the existing literature on this uncommon entity and present our case series of n  = 6 patients undergoing traumatic reconstruction of the ACF at an urban Level 1 trauma center from 2016 to 2018. There were no postoperative CSF leaks, mucoceles, episodes of meningitis, or deaths during the study follow-up period. In conclusion, use of pericranial, galeal, and free flaps, as indicated, can provide reliable and durable reconstruction of a wide variety of injuries.

A Rare Case of Sphenoid Encephalocoele Presenting with Fifth Cranial Nerve Involvement

A 14-year-old girl presented with chronic headache, recurrent episodes of vomiting, fever, and two episodes of generalized tonic clonic seizure in the past 2 months. Neuroimaging revealed herniation of the brain along with the dura through a defect in the left greater wing of the sphenoid. Left pterional craniotomy was carried out. Herniation of the dural sac along with its contents through the bony defect in the greater sphenoid wing was identified lateral to the V2 nerve passing through the foramen rotundum. The dural defect was repaired. Bony defect was covered with a circular titanium plate. The patient did not have cerebrospinal fluid rhinorrhea postoperatively. At 6-month follow-up, she was asymptomatic.

Idiopathic intracranial hypertension presenting as bilateral spontaneous lateral intrasphenoidal and transethmoidal meningoceles: a case report and review of the literature

Background

Basal meningoceles are rare herniations of the meninges that tend to present unilaterally with cerebrospinal fluid rhinorrhea. Growing evidence suggests that intracranial hypertension contributes considerably to the formation of spontaneous basal meningoceles.

Case presentation

A 50-year-old man of Middle East ethnicity presented with a 16-week history of cerebrospinal fluid rhinorrhea, short-term memory loss, and slight decline in cognitive function. We present a case of bilateral spontaneous meningoceles with bone defects in the left lateral sphenoid sinus and right anterior cribriform plate, as well as with a remodeled sella. A neuronavigation-assisted expanded endoscopic endonasal surgery was performed to resect the meningoceles. Postoperative imaging demonstrated complete resolution of the bilateral meningoceles.

Conclusions

This case reports the first bilateral basal spontaneous meningoceles in the literature. Furthermore, based on this case’s imaging results and the literature reviewed, elevated intracranial pressure may be a determining factor behind the development of spontaneous meningoceles.

Transcranial and Epidural Approach for Spontaneous Cerebrospinal Fluid Leakage Due to Meningoencephalocele of the Lateral Sphenoid Sinus

We experienced a case of sphenoid sinus type meningoencephalocele manifesting as severe cerebrospinal fluid (CSF) rhinorrhea. A 35-year-old man became aware of serous nasal discharge 1 year previously, which had gradually worsened. The nasal discharge was diagnosed as CSF rhinorrhea. Head computed tomography (CT) showed several small depressions in the bone of the left middle cranial fossa, and the largest depression extended through the bone to the lateral sphenoid sinus. Head magnetic resonance imaging revealed that the meningoencephalocele projected to the lateral sphenoid sinus, through this small bone defect of the middle cranial fossa. We performed a combined craniotomy and epidural approach without intradural procedures using neuronavigation. Multiple meningoencephaloceles protruded into small depressions in the middle skull base. The small protrusions not passing through the sphenoid sinus were coagulated. The largest protrusion causing the CSF leakage was identified by neuronavigation. This meningoencephalocele was cut. Both the dural and bone sides were closed with double layers to prevent CSF leakage. The CSF rhinorrhea completely stopped after the surgery. In our case, identification of the leak site was easy with neuronavigation based on bone window CT. The epidural approach also has significant advantages with double layer closure, including both the dural and bone sides. If the site of CSF leakage is outside the foramen rotundum (as with the most common type of lateral sphenoid sinus meningoencephalocele), we recommend the epidural approach using neuronavigation for surgical treatment.

Lateral sphenoid sinus recess cerebrospinal fluid leak: a case series

The lateral recess of the sphenoid sinus is one of the most common sites of meningocele and spontaneous cerebrospinal fluid (CSF) leak. Despite the availability of several techniques for closure of skull base defects occurring in this location, recurrence still poses a major challenge. This report reviews the experience of surgical repair of lateral sphenoid sinus recess CSF leak at a tertiary referral center and provides a brief discussion of this rare lesion. Nine surgeries were performed for six cases of spontaneous lateral sphenoid sinus recess CSF leak (two revisions and one repair of a new defect). Two patients presented with intracranial hypertension (ICH) and four with meningocele or meningoencephalocele. The transpterygoid approach was used in two procedures. A multilayer graft was used in seven cases and a nasoseptal flap in two. Three patients received lumbar or ventricular shunts, and one received acetazolamide for ICH management. Two minor complications were recorded, and the overall surgical success rate was 78 %. We conclude that nasoseptal flaps are a valid option for repair of recurrent CSF leaks, particularly in the lateral sphenoid sinus recess. Furthermore, identification and correction of ICH plays an essential role in the success of treatment in this patient population.

Benign cysts and tumors of the paranasal sinuses

To thoroughly understand the biology of any lesion and render the appropriate management, clear and accurate definitions are paramount. For benign cysts and tumors of the oral maxillofacial region, an accurate depiction of these lesions needs to be elucidated to provide both the treating surgeon and the patient with a clear understanding of the course of treatment and the outcome.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

OBJECTIVE AND IMPORTANCE

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect.

CLINICAL PRESENTATION

A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus.

INTERVENTION

The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure.

CONCLUSION

In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

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.

Spontaneous cerebrospinal fluid rhinorrhea associated with a far lateral temporal encephalocele--case report

A 35-year-old female complained of right-sided watery nasal discharge persisting for 2 weeks. Neuroimaging investigations revealed a defect in the lateral side of middle cranial fossa, temporal lobe encephalocele protruding into the lateral extension of the sphenoid sinus, and cerebrospinal fluid (CSF) collection on the right side of the sphenoid sinus. The transcranial approach was performed for resection of the encephalocele and obliteration of the cranial base defect anterolateral to the foramen spinosum with transcranial multilayered closure of the defect using autologous fat, cranial bone graft, and vascularized split temporal muscle. At 1-year follow up, the CSF rhinorrhea had not recurred. Transcranial multilayered closure of the defect is safe and reliable, particularly for large CSF fistula at the far lateral sphenoid sinus.

Case Report: Anteromedial temporosphenoidal encephalocele with a clinically silent lateral bony defect in the greater wing of the sphenoid

Anteromedial temporosphenoidal encephalocele is the least common type of temporal encephalocele. It commonly presents with spontaneous cerebrospinal fluid rhinorrhea in adults. This article presents the CT cisternography and MRI findings of one such case, which also had an associated clinically silent defect in the greater wing of the sphenoid on the same side.

Spontaneous encephaloceles of the temporal lobe

Encephaloceles are pathological herniations of brain parenchyma through congenital or acquired osseus-dural defects of the skull base or cranial vault. Although encephaloceles are known as rare conditions, several surgical reports and clinical series focusing on spontaneous encephaloceles of the temporal lobe may be found in the otological, maxillofacial, radiological, and neurosurgical literature. A variety of symptoms such as occult or symptomatic CSF fistulas, recurrent meningitis, middle ear effusions or infections, conductive hearing loss, and medically intractable epilepsy have been described in patients harboring spontaneous encephaloceles of middle cranial fossa origin. Both open procedures and endoscopic techniques have been advocated for the treatment of such conditions. The authors discuss the pathogenesis, diagnostic assessment, and therapeutic management of spontaneous temporal lobe encephaloceles. Although diagnosis and treatment may differ on a case-by-case basis, review of the available literature suggests that spontaneous encephaloceles of middle cranial fossa origin are a more common pathology than previously believed. In particular, spontaneous cases of posteroinferior encephaloceles involving the tegmen tympani and the middle ear have been very well described in the medical literature.

Spontaneous cerebrospinal fluid rhinorrhoea due to temporosphenoidal encephalocele

A 57-year old man was referred to our hospital with spontaneous cerebrospinal fluid (CSF) rhinorrhoea of 6 years duration. He had an episode of meningitis 2 months previously. CT cisternography and cranial MRI revealed a defect in the lateral wall of the sphenoid sinus, with an anteromedial temporosphenoidal encephalocele. Surgery was performed transcranially through a pterional approach. The temporal encephalocele was amputated, the sphenoid sinus obliterated and the dural defect repaired. Lumbar drainage was used for 5 days after surgery. Spontaneous CSF rhinorrhoea is only infrequently due to temporal encephalocele. Anteromedial temporosphenoidal encephaloceles are the least common type of temporal encephalocele, with only 12 reported in the literature.

Endoscopic transpterygoid approach to the lateral sphenoid recess: surgical approach and clinical experience

OBJECTIVE

Pathology within a lateral recess of a widely pneumatized sphenoid sinus is difficult to access with the use of traditional open and current endoscopic surgical approaches. A new surgical procedure, the endoscopic transpterygoid approach, directly accesses this region. A clinical experience over several year with this approach is reported as well as a refined and updated description of the technique.

SETTING

Tertiary care center.

METHODS

Retrospective review of medical records of patients treated with the endoscopic transpterygoid approach to the lateral sphenoid recess.

RESULTS

An endoscopic transpterygoid approach was performed in 9 patients, 6 to resect a middle fossa meningoencephalocele and repair the CSF leak and associated skull base defect, 2 for possible invasive fungal sinusitis, and 1 to marsupialize a symptomatic epidermoid cyst. Patients tolerated the approach well and no significant complications occurred.

CONCLUSIONS AND SIGNIFICANCE

In selected cases, the endoscopic transpterygoid approach enables the otolaryngologist to meet modern demands to treat conditions in the lateral sphenoid using minimally invasive techniques that are well-tolerated by patients. The surgical approach and the initial experience described herein is presented in the hopes that it can aid fellow otolaryngologists to help patients with challenging conditions in this region of the body.

Endoscopic endonasal treatment of a spontaneous temporosphenoidal encephalocele with a detachable silicone balloon. Case report

Temporosphenoidal encephaloceles are rare entities that occur when the temporal lobe herniates into the sphenoid sinus through a skull base defect of the temporal bone. Both an iatrogenic and a traumatic pathogenesis have been proposed. The authors describe a spontaneously occurring temporosphenoidal encephalocele in a 63-year-old woman who had a 4-year history of rhinorrhea. Spiral computerized tomography (CT) scanning revealed a bone defect located inside the ophthalmomaxillary triangle. The intrasphenoidal encephalocele had a heterogeneously hypointense signal compared with cerebrospinal fluid (CSF) on T1-weighted magnetic resonance (MR) images and a hyperintense signal compared with CSF on T2-weighted MR images. Two previous endonasal endoscopic procedures, performed by ear, nose, and throat surgeons, had been unsuccessful. The authors performed an endoscopic endonasal right nostril procedure by using 0 degrees and 45 degrees rigid-lens endoscopes that were 4 mm in diameter and 18 cm long. The encephalocele in the sphenoid sinus was partially removed. DuraGen and fat graft were positioned in the bone defect. Two No. 2 French detachable silicone balloons (1.5 cm3 volume) inflated with surgical glue were introduced into the skull defect and into the sphenoid sinus, respectively. The CSF leakage stopped immediately. No nasal packing or postoperative CSF lumbar drainage was necessary. The patient did well. Postoperative CT and MR imaging, obtained at 24 hours and at 3 months, demonstrated that the balloon and the fat graft filled the bone defect and the sphenoid sinus. Eight months postprocedure no CSF leakage was observed. This appears to be the first case reported in the literature of a temporosphenoidal encephalocele successfully treated by an endoscopic endonasal technique involving packing of the defect with inflated detachable balloons.

Use of titanium mesh for reconstruction of large anterior cranial base defects

The authors evaluated the role of titanium mesh used in combination with vascularized pericranium to provide rigid support during reconstruction of anterior skull base defects. Thirteen patients with large anterior skull base defects caused by tumor invasion or traumatic injury involving the cribriform plate, orbital roof, and planum sphenoidale were included in the study. The reconstruction technique involved placement of titanium mesh between two layers of continuous vascularized pericranium. Surgical glue and routine lumbar cerebrospinal fluid (CSF) drainage were not used in any patient. At a mean postoperative follow-up time of 22 months (range 8-39 months), none of the patients had developed infection or meningocele. Postoperative CSF rhinorrhea occurred in two patients with extensive dural defects, which resolved with temporary lumbar drainage. Use of titanium mesh and a two-layer vascularized pericranial graft is a safe, reproducible, and feasible method for reconstructing the anterior skull base. Patients with large dural defects may need temporary CSF diversion to avoid postoperative fistula formation.

A Le Fort I osteotomy approach to lateral sphenoid sinus encephalocoeles

Meningo-encephalocoeles of the skull base may present as spontaneous cerebrospinal fluid rhinorrhoea or acute meningitis. Previous approaches to midline skull base lesions have been either intracranial, via a craniotomy, or by transfacial or endoscopic extracranial approaches. This paper presents an alternative approach to lateral sphenoid sinus encephalocoeles through a Le Fort I osteotomy approach.

Surgical treatment of cerebrospinal fluid fistulae involving lateral extension of the sphenoid sinus

OBJECTIVE AND IMPORTANCE

Four cases of spontaneous cerebrospinal fluid rhinorrhea caused by communication between the subarachnoid space of the middle cranial fossa and a lateral extension of the sphenoid sinus are presented. The cause and management of this unique type of cranial base defect are discussed.

CLINICAL PRESENTATION

During the past 10 years, four patients referred to our institution with atraumatic cerebrospinal fluid fistulae were observed to have temporal encephaloceles (encephalomeningoceles) traversing the floor of the middle cranial fossa. Three of the patients had previously undergone unsuccessful transnasal attempts to repair their fistulae by obliteration of the sphenoid sinus. The fourth patient presented before undergoing any treatment. No patient had associated hydrocephalus or tumor. Preoperative computed tomographic cisternograms revealed that all fistulae involved a lateral extension of the sphenoid sinus into the floor of the middle cranial fossa.

INTERVENTION

After definitive localization, each patient was operated on transcranially through an anterior middle cranial fossa approach with extradural and/or intradural exploration. The associated temporal encephalocele was amputated or disconnected, and the dehiscent dura and middle cranial fossa floor defect were oversewn and packed with autogenous tissue, respectively.

CONCLUSION

The surgical treatment of cerebrospinal fluid rhinorrhea secondary to middle fossa encephalocele associated with lateral extension of the sphenoidal sinus differs from the surgical strategy for more medial sphenoidal fistulae. Fistulae involving a lateral extension of the sphenoid sinus require a transcranial approach for direct visualization and obliteration of the defect, whereas fistulae involving the central portion of the sinus may be successfully obliterated transsphenoidally.