Epilepsy Surgery Outcome of Traumatic Intradiploic Meningoencephalocele: A Case Report and Literature Review

We highlight an under-recognized epileptic pathology in a 56-year-old left-handed female with progressive right facial numbness and weekly focal seizures characterized by episodic aphasia. She was found to have a left frontoparietal intradiploic meningoencephalocele (IDME). Her only epilepsy risk factor was minor head trauma 10 years prior to presentation. She underwent craniotomy for encephalocele resection and mesh cranioplasty without residual neurological deficits and excellent seizure outcome: at 3-year follow-up, she was still seizure-free since surgery, except for an isolated breakthrough seizure at 7 postoperative months when she discontinued her preoperative regimen of Lacosamide monotherapy. Traumatic IDME is a rare condition and rarely presents with seizures. Symptoms may arise up to decades following minor head trauma and are progressive in nature. The likely definitive treatment is cranioplasty and dural repair with or without resecting the protruding parenchyma.

Meningoencephalocele and supernumerary ectopic limb arising from the occipital bone in a Jacob sheep lamb

This report describes the clinical, computed tomography, and magnetic resonance imaging findings for a Jacob sheep lamb diagnosed with meningoencephalocele and supernumerary ectopic limb. Key clinical message: This case demonstrates the utility of tomographic imaging in diagnosing congenital malformations in sheep and can be used to assess the extent of the lesion. This may help to determine any viable treatment, or, as in the case presented here, determine that the extent of the lesion precludes surgical intervention.

Intrasacral meningoceles: Clinical presentation, surgical management, and postoperative outcome: The Giannina Gaslini Hospital's experience

INTRODUCTION

Intrasacral meningoceles are cysts associated with herniating arachnoid with no nerve root within due to an area of weakness of the dura mater. They are thought to be congenital, but they are usually not symptomatic until adulthood. Surgical treatment is generally indicated in the presence of symptoms.

METHODS

We selected cases belonging to the IB category of Nabors et al.'s classification who underwent surgery between 2008 and 2021 at Giannina Gaslini Hospital. Exclusion criteria were prior history of trauma, infections, or operations. Patients' clinical details, associated conditions, surgical techniques, peri- and postoperative complications, and outcomes were collected retrospectively from clinical charts. We compared our series to literature: keywords "intrasacral meningocele" were used on the search engine MEDLINE - Pubmed.

RESULTS

We identified 23 cases: 5 of the 14 symptomatic patients had a complete resolution, and 5 had a substantial clinical improvement after surgery. Cyst recurrence and major postoperative complication occurred in none. Among 59 articles considered for evaluation, 50 were excluded and remaining 9 articles underwent full-text analysis.

DISCUSSION AND CONCLUSION

The pathogenesis of instrasacral meningoceles is still not completely understood and the spectrum of symptoms is wide. A posterior surgical approach with sacral laminectomy is preferred, although in selected cases it is possible to perform a supplemental anterior approach (sometimes endoscopic). In our surgical series, the largest one published in the literature, a good clinical outcome was achieved in most patients with no cyst's recurrence, pointing out the importance of surgical interruption of communication between cyst and subdural space.

Cerebrospinal fluid hypotension following fall in a child: Case report

CSF hypotension arises in the context of a leak of CSF which causes negative intracranial pressure. Sacral fractures result from high-energy trauma which are frequently underdiagnosed. A ten-year-old boy presented with hip pain, after a fall. He mobilized both lower limbs, reported no leg pain, irradiation nor lack of sphincter control. The neurological examination was normal. When asked to stand, he began biparietal headache, nausea and vomiting, which improved laying down. CT scan showed an occult intrasacral meningocele; the MRI revealed collections of CSF along the spine, a S3 fracture with potential laceration of the meningocele and opening of a CSF fistula. Our diagnosis was the CSF hypotension, secondary to the fistula opening. The diagnosis was challenging. The child first presented with symptoms of CSF hypotension without evident cause. The discovery of the meningocele led us to hypothesize the opening of a fistula, a rare diagnosis, later confirmed by MRI.

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

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

Clinical, radiological features and surgical strategies for 23 NF1 patients with intraorbital meningoencephalocele

Intraorbital meningoencephalocele is a rare manifestation of neurofibromatosis type 1 (NF1) caused by secondary changes in sphenoid dysplasia, and it seriously affects patients' vision and facial appearance. We retrospectively analyzed the clinical data of 23 patients with NF1 and intraorbital meningoencephalocele, summarized the surgical strategies employed, and evaluated their clinical efficacy in order to better understand its management in clinical practice, establish a reasonable surgical strategy, and assess prognosis. Before surgery, 22 patients had unilateral pulsatile exophthalmos, 18 patients had significant visual impairment, and 13 patients had ptosis associated with an orbital plexiform neurofibroma (PNF). All 23 patients underwent microsurgical craniotomy with skull base reconstruction using a soft titanium mesh. One month after surgery, the degree of exophthalmos in the 22 (95.65%) patients was significantly reduced compared with before surgery (P < 0.001), and ocular pulsation had subsided. The visual acuity did not decrease significantly (P = 0.298) compared with before surgery. Eleven (47.83%) patients received phase-II eyelid PNF resection and/or oculoplastic surgery, and the degree of ptosis was significantly reduced (P < 0.001). There was no recurrence of pulsatile exophthalmos, displacement of titanium mesh, decreased visual acuity, or increased degree of ptosis noted during follow-up. The best strategy is to reconstruct the skull base under microscopy to relieve pulsating exophthalmos and preserve existing visual function. In cases of ptosis caused by an eyelid PNF, surgical resection should be performed as soon as possible to remove the tumor, and/or oculoplastic surgery should be performed to improve the cosmetic outcome.

An Unusual Presentation as Recurrent Abortions in a Case of Giant Presacral Epidermoid Cyst Mimicking an Anterior Sacral Meningocele

BACKGROUND

An epidermoid cyst is a congenital benign tumor and is extremely rare at the presacral region. Only a few cases have been reported in the literature.

CASE DESCRIPTION

We herein report a case of a 40-year-old woman with a giant presacral epidermoid cyst mimicking an anterior sacral meningocele who presented with recurrent abortions. This increases risk to the mother and fetus. Magnetic resonance imaging is the investigation of choice.

CONCLUSIONS

The diagnosis and surgical management of this case are discussed.

Tailored Strategies to Manage Cerebrospinal Fluid Leaks or Pseudomeningocele After Surgery for Tethered Cord Syndrome

BACKGROUND

Cerebrospinal fluid (CSF) leaks are a dreaded complication after surgery for tethered cord and are associated with significant patient morbidity. Although many strategies for managing postoperative CSF leaks exist, this problem is still daunting, especially in very young patients. In this study, we compared different management techniques for CSF leaks or significant pseudomeningocele in patients with tethered cord syndrome (TCS).

METHODS

We analyzed a cohort of children who underwent surgery for TCS from January 2011 to March 2016 (n = 260) and postoperatively experienced either a CSF leak or significant pseudomeningocele. A subset of patients presented with CSF leak (n = 25). We analyzed patient age, sex, presentation, leak appearance, management, and outcome. The different techniques of management were compared for efficacy and morbidity.

RESULTS

The diseases associated with leak formation included lipomyelomeningocele (n = 16), myelocystocele (n = 4), and myelomeningocele (n = 5). Three children also had hydrocephalus. Management techniques included cystoperitoneal shunt (CPS) (n = 15), primary resuturing with local rotation flap of muscle (n = 3), external ventricular drain placement (n = 1), ventriculoperitoneal shunt (n = 3), external ventricular drainage (n = 1), and a combination of techniques (rotation flap with external drain; n = 1). Five patients who underwent primary wound revision experienced a leak and required a secondary intervention, but none of the patients who underwent CPS had any complications.

CONCLUSIONS

In carefully selected cases, CPS performed early after CSF leakage is highly successful with low morbidity. The primary closure can be attempted for low-pressure leaks without an associated pseudomeningocele.

An unusual case of temporal bone encephalomeningocele occurring together with normal pressure hydrocephalus

Temporal bone encephalomeningoceles are uncommon clinical entities that can be challenging to diagnose and treat. Common presenting complaints include symptoms of aural fullness, hearing loss, clear otorrhea and meningitis. Common etiologies are chronic middle ear disease and trauma. A significant proportion of cases are spontaneous, which occurs in relation to benign intracranial hypertension. Normal pressure hydrocephalus associated with temporal bone encepahomeningoceles has not been previously described. The authors present an unusual case of spontaneous right sided temporal bone encephalomeningocele associated with symptomatic normal pressure hydrocephalus. Surgical repair of the defect was successful. The diagnostic and management approach to this unique case are discussed.

PATTERNS OF NEURAL TUBE DEFECTS AT TWO TEACHING HOSPITALS IN ADDIS ABABA, ETHIOPIA A THREE YEARS RETROSPECTIVE STUDY

BACKGROUND

Neural tube defects (NTDs), one of the most common congenital malformations, are potentially preventable cause of perinatal morbidity and mortality.

OBJECTIVES

To give baseline description of NTDs and their outcome at two teaching hospitals in Addis Ababa, Ethiopia.

MATERIALS AND METHODS

A retrospective cross sectional descriptive study conducted from September 2009 to August 2012.

RESULTS

During the study period out of 28,961 deliveries 177 cases of NTDs were identified, giving an overall NTD prevalence of 6.1/1000. Only 12% (21/177) were diagnosed before 28 weeks of gestation. The mean gestational age at diagnosis of NTDs was 33.8 weeks (±5.5). Majority, 93.2% (165/177), had antenatal care (ANC) follow-up. Most, 72% (127/177), were diagnosed by ultrasound before delivery while 28% (50/177) were identified at the time of delivery or expulsion. Majority, 85.3% (151/177), never received folic acid supplementation. Only less than 1% (2/177) of the mothers started taking folic acid supplementation pre-conceptionally. Only a third, 33.3% (59/177), of the fetuses were born alive while only 13.6% (24/177) were discharged alive. Myelomeningocele, identified in 51.4% (91/177), was the commonest NTD in this study.

CONCLUSION AND RECOMMENDATIONS

The proportion of NTDs in this study is among the highest globally reported rates. The practice of periconceptional folic acid supplementation is negligible. And although most had ANC follow-up the vast majority of NTDs were diagnosed late in the third trimester. It is, therefore, highly recommended to consider implementing national preventive strategies to reduce the prevalence of NTDs in Ethiopia.

The cephaloceles: A clinical, epidemiological and therapeutic study of 50 cases

INTRODUCTION

Cephaloceles are congenital malformations characterized by externalization of the meninges and/or brain tissue through a congenital skull bone defect. In developed countries, this malformation is rare but in our developing countries, this pathology remains one of our concerns.

OBJECTIVE

To describe the epidemiological, clinical and therapeutic aspects of the cephaloceles.

MATERIALS AND METHOD

A retrospective study was conducted from 2007 to 2013 on all cases of cephalocele supported in the department of neurosurgery of the Yalgado Ouédraogo University Teaching Hospital of Ouagadougou. The malformations were supplemented by CT scan. All patients were operated. The surgical procedure in cephaloceles of the convexity consisted of a direct approach. Sincipital cephaloceles were operated by transcranial approach or combined approach associating transcranial and transnasal approaches.

RESULTS

Fifty patients were gathered during the 7-year period. There were 18 boys and 32 girls. The ages ranged from 1 day to 11 years. The cephaloceles were located on the vault of the skull in 78%; the lesion was sincipital in 22%. The malformation was covered with normal skin in 92%; it was pediculated in 78%. CT scan allowed the classification of cases as meningo-encephaloceles in 31 cases (62%) and meningoceles in 18 cases (36%) and one pure encephalocele. The immediate postoperative course was uneventful in 42 cases (84%); 8 postoperative deaths were recorded. At medium and long term, 4 patients (8%) developed complications of psychomotor deficiency in 3 cases and hydrocephalus in 1 case. The main reasons for the poor prognosis were superinfection, hydrocephalus and/or other brain malformations.

CONCLUSION

Cephaloceles remain relatively frequent in our practice. After surgery, mental failure and hydrocephalus can occur impairing the prognosis. The most suitable solution is a policy of prevention with folic acid treatment before and during pregnancy and following up adequate pregnancies.

Lumbosacral dysraphism as cause of neurogenic bladder: Magnetic Resonance Imaging based study from SIUT Pakistan

OBJECTIVE

To find the frequency and types of spinal dysraphism in patients presenting with neurogenic bladder dysfunction.

METHODS

The cross-sectional study was conducted at the Sindh Institute of Urology and Transplantation, Karachi, from February to September 2011, and comprised patients of either gender 5-15 years of age with neurogenic bladder suspected to be due to lumbosacral dysraphism. They all had magnetic resonance imaging of lumbosacral spine. All images were reviewed by an experienced radiologist and patients were diagnosed as having spinal dysraphism and were categorised according to the radiological features. Data was analysed using SPSS 10.

RESULTS

Of the 175 patients in the study, 96(55%) were males and 79(45%) were females with an overall mean age of 7.3±2.15 years (range: 5-15 years). Spinal bony defects were found in 110(62.8%) patients, and of these, 96(87%) had spinal dysraphism. Myelomeningocele, meningocele and sacral agenesis was found in 58(60.4%) of the 96 patient with spinal dysraphism.

CONCLUSIONS

Spinal dysraphism is the most common cause of neurogenic bladder in children up to 15 years of age and myelomeningocele, meningocele and sacral agenesis comprised more than 60% of such cases.

Truncating mutations in the last exon of NOTCH3 cause lateral meningocele syndrome

Lateral meningocele syndrome (LMS, OMIM%130720), also known as Lehman syndrome, is a very rare skeletal disorder with facial anomalies, hypotonia and meningocele-related neurologic dysfunction. The characteristic lateral meningoceles represent the severe end of the dural ectasia spectrum and are typically most severe in the lower spine. Facial features of LMS include hypertelorism and telecanthus, high arched eyebrows, ptosis, midfacial hypoplasia, micrognathia, high and narrow palate, low-set ears and a hypotonic appearance. Hyperextensibility, hernias and scoliosis reflect a connective tissue abnormality, and aortic dilation, a high-pitched nasal voice, wormian bones and osteolysis may be present. Lateral meningocele syndrome has phenotypic overlap with Hajdu-Cheney syndrome. We performed exome resequencing in five unrelated individuals with LMS and identified heterozygous truncating NOTCH3 mutations. In an additional unrelated individual Sanger sequencing revealed a deleterious variant in the same exon 33. In total, five novel de novo NOTCH3 mutations were identified in six unrelated patients. One had a 26 bp deletion (c.6461_6486del, p.G2154fsTer78), two carried the same single base pair insertion (c.6692_93insC, p.P2231fsTer11), and three individuals had a nonsense point mutation at c.6247A > T (pK2083*), c.6663C > G (p.Y2221*) or c.6732C > A, (p.Y2244*). All mutations cluster into the last coding exon, resulting in premature termination of the protein and truncation of the negative regulatory proline-glutamate-serine-threonine rich PEST domain. Our results suggest that mutant mRNA products escape nonsense mediated decay. The truncated NOTCH3 may cause gain-of-function through decreased clearance of the active intracellular product, resembling NOTCH2 mutations in the clinically related Hajdu-Cheney syndrome and contrasting the NOTCH3 missense mutations causing CADASIL.

Retropharyngeal masses in neurofibromatosis type 1: Imaging findings in 2 cases

Neurofibromatosis type 1 (NF-1) affects mesenchymal development via multisystemic manifestations. We present 2 cases of NF-1 that manifested as a retropharyngeal mass-1 as a lateral cervical meningocele in a 60-year-old man and the other as a focal neurofibroma in a 37-year-old man. Contrast-enhanced magnetic resonance imaging (MRI) was invaluable in identifying the exact nature of the 2 lesions; no contrast enhancement was seen in the case of the meningocele, and enhancement was seen in the case of the neurofibroma. These 2 cases illustrate the importance of the history and contrast-enhanced MRI in managing NF-1 patients with a retropharyngeal mass.

Coexistence of occipital and infratorcular meningocele with cervical split cord anomaly

In this case report, we present an 18-year-old girl with occipital and infratorcular meningocele and coexisting split cervical cord. She had been admitted into the hospital for cosmetic considerations due to an inborn swelling in the back of the head and neck. Her mental status and neurologic examination were surprisingly intact. We discuss a very rare case of meningocele associated with split cord anomaly in the light of the current literature.

Middle fossa repair of bilateral large congenital tegmental defects with meningoencephaloceles

Spontaneous temporal meningoencephaloceles are unusual. When they do occur, they present with a variety of signs and symptoms, which can make diagnosis and management challenging. We report the interesting case of a 49-year-old woman with bilateral congenital temporal meningoencephaloceles. She presented with a 12-month history of bilateral fluctuating hearing loss, and she more recently developed right-sided acute otitis media with meningitis. The presentation of bilateral extensive tegmental defects and meningoencephaloceles with a fluctuating hearing loss and meningitis associated with acute otitis media affecting one ear and then subsequently the other ear is extremely rare and difficult to diagnose. It requires a very careful clinical and radiologic assessment. Methods of surgical repair differ depending on the size of the defects.

Endoscopic endonasal surgery for nasal dermoids

Midline congenital lesions are rare and commonly comprise nasal dermoids (NDs), encephaloceles, and gliomas. This article discusses the epidemiology of NDs. Management is also discussed, as well as prognosis.

Cerebrospinal fluid fistulas after iliosacral screw removal in post-traumatic pseudomeningocele

Sacral fractures are rare but severe injuries. They are often associated with neurological impairment and pelvic instability. We present a case of a 28-year-old woman who sustained an H-type fracture of the sacrum with complete cauda equina syndrome treated with cauda equina decompression and pelvic percutaneous stabilization with an iliosacral screw. Two years after she underwent screw removal, but complained of back and nape pain after the operation. A lumbosacral MRI showed the presence of a lytic lesion involving the S1 and S2 bodies that was judged to be a pseudomeningocele leaning against the sacral screw hole and cerebrospinal fluid fistulas through this. To our knowledge, this is the first case of such a complication after sacral screw removal to be reported.

Prenatal diagnosis of anterior sacral meningocele

Anterior sacral meningocele is an extremely rare condition and there has been only one previous report of a prenatal diagnosis. We report the case of a 36-year-old primigravida who was referred following detection of a huge fetal pelvic cyst on routine ultrasound examination at 19 + 4 weeks' gestation. Neither fetal ultrasound nor magnetic resonance imaging (MRI) at 20 + 5 weeks' gestation could detect communication between the cyst and the spinal cord. Because extension of the pear-shaped cyst through the pelvic diaphragm down to the perineum was reminiscent of dilated vagina and uterine cervix, a tentative diagnosis of hydrometrocolpos secondary to imperforate hymen was considered. On follow-up MRI at 33 + 5 weeks' gestation, a narrow stalk connecting the pelvic cyst and the spinal canal through the anterior sacral foramen was clearly delineated, allowing us to reach the prenatal diagnosis of anterior sacral meningocele.

Lateral cephaloceles: case-based update

BACKGROUND

Masses of the lateral skull are not uncommon and include lipomas and epidermoids. However, meningoceles of the lateral skull are very rare and are often misdiagnosed. Even rarer are atretic encephaloceles of this region.

ILLUSTRATIVE CASE

We report a newborn with a right atretic encephalocele of the asterion. Lesions of the anterolateral and posterolateral fontanelles should include lateral cephaloceles/encephaloceles in the differential diagnosis. The literature and embryology of these rare entities are discussed.

The pseudomeningocoele that wasn't: case report of an adult who presented with a late infection of an implant

This case report describes an unusual case of a 55-year-old male, who presented with what appeared to be a pseudomeningocoele. The patient suffered a skull fracture secondary to a direct blow almost 30 years prior, and had been repaired with a calvarial implant at that time. He had been symptom free for most of that time, until he presented to our institution with a bulging cyst in his left frontal region. Computed tomography revealed a calvarial defect at the site of the cyst and a presumptive diagnosis of pseudomeningocoele was made. As part of his treatment, the patient underwent a lumbar puncture and lumbar peritoneal shunt. These procedures, although temporarily beneficial, ultimately proved unsuccessful in permanently decreasing the size of the cyst. After all conservative measures were exhausted, the team surgically explored the patient: while no communication between the cerebrospinal fluid and cyst could be found, which would be expected in a pseudomeningocoele, there was fibrinous exudates on the implant surface. Tissue cultures showed Staphylococcus epidermidis. This case emphasises the importance of surgical exploration to make a correct diagnosis, as in this case of a sub-clinical calvarial implant infection 30 years after insertion of the implant.

[Chronic nasal obstruction: ethmoidal encephalocele in an adult patient]

Nasal obstruction is a frequent cause of referral to the ear, nose and throat specialist. When this symptom is resistant to medical management and common causes have been ruled out, the presence of neural structures should be investigated In the nasoethmoidal meningoencephalocele, a congenital defect of the ethmoid lamina cribrosa allows the herniation of the intracranial contents into the nasal fossa. The key to clinical diagnosis is the presence of nasal obstruction with rhinorrhea and recurrent meningitis. We describe the case of a 33-year old female who was long treated for nasal polyposis and underwent a successful surgical treatment of ethmoidal meningoencephalocele.

[Sphenoid arachnoidocele: report of one case]

OBJECTIVES

To define a diagnostic strategy of a sphenoid sinus lesion and the management of CSF fluid leak in the case of a sphenoid arachnoidocele.

MATERIALS AND METHODS

A 70-year-old woman exhibited a sphenoidal sinus opacity which was discovered on the assessment of chronic headaches. It was labelled sphenoid mucocele. A cerebrospinal fluid leak occurred when the marsupialization was made. After an assessment of additional imaging (MRI, CTscan), the diagnosis of sphenoid arachnoidocele was retained.

RESULTS

The leak was repaired by navigated endoscopic endonasal surgery. We used a multilayer reconstructive technique with autologous materials (abdominal fat, fascia of muscle, middle turbinate) and fibrin glue. With a decline of eighteen months no rhinorrhea was noted.

CONCLUSION

Sphenoid arachnoidocele is a rare disease. This case shows that it's essential to know the differential diagnosis sphenoid sinus lesions and how to repair an osteomeningeal leak.

Anterior sacral meningocoele presenting as acute urinary retention. A case report

Anterior sacral meningocoele is caused by a congenital hiatus in the anterior sacrum. We report a very rare case which presented as acute urinary retention. The common findings of anterior sacral meningocele include atypical low back pain, urological and gynaecological symptoms. Acute urinary retention as a presenting symptom does not appear to have been mentioned in the English literature.

Maternal anterior sacral meningocele in pregnancy

Anterior sacral meningocele is a rare condition resulting from herniation of the meninges through a sacral defect. Women with this condition may undergo inappropriate surgery because the correct diagnosis is missed, resulting in serious complications. In labor, the cyst may rupture, with consequent meningitis and high maternal mortality. We report the case of a 31 year-old pregnant woman with an anterior sacral meningocele. We describe the role of magnetic resonance imaging in the evaluation and management planning in this condition. She was delivered by cesarean section at 34 weeks without complications. Accurate diagnosis and delivery by cesarean prior to labor are important in assuring good outcomes in women with anterior sacral meningoceles.

Spontaneous cerebrospinal fluid rhinorrhoea in anteromedial temporal occult encephalocele

A 75-year-old man was admitted because of a spontaneous rhinorrhoea without a previous history of head injury. Computed tomography showed bone rarefaction of the floor of the middle cranial fossa and magnetic resonance imaging demonstrated a right temporal encephalocele. This was treated via extradural approach, and the bone defects were plugged with temporalis fascia, muscle and the fibrin glue. No recurrence of rhinorrhoea was observed at the follow-up (1 year).

MRI study of the natural history and risk factors for pseudomeningocoele formation following postfossa surgery in children

Surgical approaches to the posterior fossa may be complicated by pseudomeningocoele formation. We report on its natural history and risk factors for its formation, as seen on serial MRI postoperatively in children with posterior fossa tumours. In a retrospective study of 84 children undergoing surgery for posterior fossa tumours, 13 (16%) developed clinically apparent pseudomeningocoeles. On postoperative MRI, pseudomeningocoeles were apparent in 34 (41%) patients at 1-5 days, but in only four patients at 10-15 months postsurgery. There was a progressive decrease in the mean depth of pseudomeningocoele measured from the MRI scans postoperatively. Patients with pseudomeningocoeles were more likely to have a postoperative CSF leak from the wound (39 v. 13%), lumbar punctures or lumbar drains (54 v. 25%), wound re-closures (23 v. 1%) and prolonged hospital stay (19.9 v. 14.5 days). On multivariate analysis, patients with pseudomeningocoeles were also more likely to have undergone a suboccipital craniectomy than those without pseudomeningocoeles (69 v. 38%). Postoperative pseudomeningocoele formation following posterior fossa surgery is more apparent radiologically than clinically, but there is clinical and radiological evidence that pseudomeningocoeles gradually resolve over the postoperative period. The risk of pseudomeningocoele formation is increased by performing a suboccipital craniectomy and there is an association with increased CSF leaks, needing re-closure of the wounds.

Occipito-clival intradiploic meningocoele following skull fracture in infancy

An adolescent presented with an intradiploic meningocoele 11 years after an occipital skull fracture. Surgical treatment consisted initially of cranioplasty, but the lesion then progressed to involve much of the skull base, requiring cystoperitoneal shunt insertion. The pathogenesis and treatment of post-traumatic intradiploic meningocoele is discussed.

[Two rare brain malformations in black and white German Holstein calves]

Two black and white female German Holstein calves showed malformations of the cerebrum. The first calf exhibited a cystencephaly and the second calf a meningoencephalocele. The animals originated from two different dairy farms. Both calves were sired by two unrelated sires used in artificial insemination. The calf affected by cystencephaly was lacking the corpus callosum which may had been caused the cystencephaly. Exept for a pressure atrophy, the remaining parts of the brain were macroscopically and histologically inconspicious. Histological examination of the cerebrum, brain stem and cerebellum in the second calf did not reveal specific changes. A further finding in the second calf was a unilateral anophthalmia. Both animals were affected by additional defects in the spinal column including brachyuria, duplications and fusions of vertebral bodies and rips as well as malformations of the heart such as ventricular-septal defects. Only mild clinical symptoms could be observed in both calves. The calves were not inbred and further calves affected by the identical anomalies could not be ascertained at the farms where the calves were born. Chromosomal anomalies could not be detected after examination of metaphase spreads using light microscopy.

Spontaneous resolution of a massive pseudomeningocoele

A pseudomeningocoele is an extradural collection of cerebrospinal fluid which results from a dural or arachnoid tear. The fluid is not contained within a protrusion of the meninges, which is typical for a real meningocoele. Although most pseudomeningocoeles probably go unrecognised, due to lack of symptoms, surgeons should maintain an index of suspicion when reviewing postoperative patients. Symptomatic pseudomeningocoeles warrant intervention, as the patients do not tolerate the symptoms. However, the literature neither suggests a trial of watching and waiting nor a suitable time frame for such a trial. The authors report the spontaneous resolution of a massive symptomatic pseudomeningocoele after 11 months. There is only one previous report of a similar case, where the pseudomeningocoele disappeared in three months.

[Posttraumatic pseudomeningocele--a case report]

Pseudomeningocele is a rare complication of head trauma. An 7-year-old male child who fell from playground equipment was admitted to hospital with lambdoid sutural diastatic fracture. As epidural and subgaleal fluid collections gradually developed from the subsequent day of admission, a subgaleal drain was placed for cerebrospinal fluid (CSF) diversion. In addition, the scalp just over the fractured segment was compressed by band after drainage whereby the CSF leak was stopped. On the basis of our experience with this case, we suggest that appropriate management enables repair of posttraumatic pseudomeningocele in early stages of injury.

Intranasal meningoencephalocoele-a rare childhood condition

Congenital or acquired intranasal meningocoele or meningoencephalocoele is a rare condition ever reported in world literature. We report a case of intranasal meningoencephalocoele in which a 10 month old male child presented with left sided progressive nasal obstruction, nasal mass and reluctant to feed. On examination slight broadening of the bridge of the nose with obliteration of left nasomaxillary fold, mucoid discharge and a pinkish, polypoidal, non tender, non pulsatile mass with prominent blood vessels on the surface occupying almost 3/4(th) of the nasal cavity was observed. On probing it appeared to be attached to roof of left nasal cavity. Computed tomography revealed a hypodense area in the nasal cavity but there was no bony defect in the skull base. Peroperatively on aspiration of nasal cystic mass revealed free flow of clear fluid which was biochemically CSF. A one stage, Lynch Howarth approach, correctional procedure was performed. We present here a discussion of findings and surgical treatment. Early diagnosis and referral are of paramount importance, because failure to identify this leads to fatal outcome if surgery performed.

Giant extracranial aneurysms of both internal carotid arteries with aberrant jugular veins in a patient with neurofibromatosis type 1

Although neurofibromatosis type 1 (NF-1) is commonly considered neurocutaneous, severe arterial and venous abnormalities have been noted. Our patient, a 28-year-old woman, had bilateral giant extracranial aneurysms of the internal carotid arteries as well as skull base meningoceles involving the jugular foramina and aberrant jugular veins. CT and MR imaging, as well as digital subtraction and/or other angiography techniques, may be required to clarify pathology in patients with suggested vascular lesions.