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Chen S, Yang Z, Cao J, Wang M, Qu G, Zhong C. Meningocele in the Parapharyngeal Space: A Case Report and Review of the Literature. Ear Nose Throat J 2024:1455613241249094. [PMID: 38757650 DOI: 10.1177/01455613241249094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024] Open
Abstract
The parapharyngeal space has been described as an inverted pyramid shape with the base of the skull and the great cornu of the hyoid bone at the top. Tumors of the parapharyngeal space account for 0.5% of head and neck tumors and a wide range of tumor types can occur in this area, 80% of which are benign, the most common being pleomorphic adenomas of the salivary glands and neurogenic tumors. We present a 39-year-old woman who was hospitalized due to left-sided neck pain with a feeling of blockage in the left ear and hearing loss for 10 months. Imaging showed that the mass was not connected to the cranium and the patient underwent surgical resection via a transoral approach, where the contents of the mass were found to be cerebrospinal fluid, and meningocele in the parapharyngeal space is a rare occurrence. The patient presented mainly with painful symptoms, which were eventually relieved by nerve block therapy.
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Affiliation(s)
- Sijing Chen
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
- The Second Clinical Medical School, Lanzhou University, Lanzhou, China
| | - Zixuan Yang
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
| | - Jingwen Cao
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
- Ningxia Medical University, Ningxia, China
| | - Maoxin Wang
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
| | - Gaoya Qu
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
| | - Cuiping Zhong
- Department of Otolaryngology-Head and Neck Surgery, The 940th Hospital of the Joint Logistics Support Force of the Chinese People's Liberation Army, Lanzhou, China
- The Second Clinical Medical School, Lanzhou University, Lanzhou, China
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Nishikata M, Kobayashi M, Fujimaki T. Adult-onset Sacral Meningocele Causing a Specific Headache Triggered by Compression or Adoption of a Sitting or Supine Posture. NMC Case Rep J 2024; 11:75-78. [PMID: 38590924 PMCID: PMC10999460 DOI: 10.2176/jns-nmc.2023-0272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/01/2024] [Indexed: 04/10/2024] Open
Abstract
We report a rare case of adult-onset sacral meningocele where compression triggered a specific headache. A 46-year-old woman presented with a headache, which worsened when she was in a sitting or supine position. A subcutaneous mass was observed on her left buttock, the compression of which also induced headache. No neurological deficits were evident. Lumbar and sacral magnetic resonance imaging demonstrated a meningocele in the left dorsal buttock, connecting to the sacral cerebrospinal fluid (CSF) space, and spinal computed tomography revealed sacral dysplasia. Initial meningocele resection improved the patient's headache, but the cyst recurred 2 years later. Following repeated surgery to reinforce the meningocele orifice, the headache was relieved and has been absent for more than 6 years. The headache was due to intracranial pressure fluctuations due to CSF influx into and drainage from the meningocele. Meningocele development in adulthood can be owing to a spinal bone defect and pressure load on the spinal dura. Surgical resection can improve symptoms resulting from meningocele, and reinforcement of the orifice using an artificial surgical membrane effectively prevents recurrence.
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Affiliation(s)
- Masaya Nishikata
- Department of Neurosurgery, Saitama Medical University Hospital, Saitama, Japan
| | - Masahito Kobayashi
- Department of Neurosurgery, Saitama Medical University Hospital, Saitama, Japan
| | - Takamitsu Fujimaki
- Department of Neurosurgery, Saitama Medical University Hospital, Saitama, Japan
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Franklin D, Yamani AS, Boyke AE, Menaker SA, Tang D, Mamelak AN. Spontaneous sphenoid sinus meningocele with associated amenorrhea and headache: illustrative case. J Neurosurg Case Lessons 2024; 7:CASE23700. [PMID: 38346300 PMCID: PMC10865469 DOI: 10.3171/case23700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/26/2023] [Indexed: 02/16/2024]
Abstract
BACKGROUND Developmental meningoceles of the sphenoid sinus are uncommon. When encountered, they are often associated with cerebrospinal fluid (CSF) rhinorrhea. OBSERVATIONS The authors present the case of a 27-year-old female with a large meningocele eroding through the sella turcica and sphenoid sinus into the nasopharynx. The patient presented with intractable headaches and amenorrhea without CSF rhinorrhea. LESSONS The patient underwent an endoscopic endonasal transsphenoidal reduction of the meningocele with reelevation of the pituitary gland and skull base reconstruction with abdominal fat graft and nasoseptal flap.
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Affiliation(s)
- Deveney Franklin
- School of Medicine, University of North Carolina,
Chapel Hill, North Carolina
| | - Ali S Yamani
- College of Medicine, University of Cincinnati,
Cincinnati, Ohio; and
| | | | | | - Dennis Tang
- Otolaryngology, Cedars-Sinai Medical Center, Los
Angeles, California
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Hoxha M, Malaj V, Zappacosta B, Firza N. Pharmacoeconomic Evaluation of Costs of Myelo meningocele and Meningocele Treatment and Screening. Clinicoecon Outcomes Res 2024; 16:69-80. [PMID: 38352115 PMCID: PMC10863461 DOI: 10.2147/ceor.s443120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/18/2024] [Indexed: 02/16/2024] Open
Abstract
Background The prevention of myelomeningocele (MMC) and meningocele (MC) is a public health concern. A systematic review on economic factors associated with MMC and MC can help the policy makers to evaluate the cost-effectiveness of screening and treatment. To our knowledge, this is the first systematic review to provide up-to date pharmacoeconomic evidence of all economic studies present in literature on different aspects of MMC and MC. Methods We searched in the National Health Service Economic Evaluation Database (NHSEED), PubMed, Cost-effectiveness Analysis Registry (CEA Registry), Centre for Reviews and Dissemination (CRD), Health Technology Assessment Database (HTAD), Cochrane Library, and Econlit. The PRISMA guidelines were followed in the search and evaluation of literature. Only articles in English not limited by the year of publication that fulfilled the eligibility criteria were included in this systematic review. Results Nineteen papers were included in the study. The studies were very heterogeneous and reported a comparison of the costs between prenatal versus postnatal repair, the cost of fetoscopic approach versus open surgery, the cost of ventriculoperitoneal shunting (VPS) versus endoscopic third ventriculostomy (ETV), and ETV with choroid plexus cauterization (ETV/CPC), the cost of hospitalization, and the cost of diagnosis for MMC. Conclusion The results of this study can help in implementing new policies in different countries to assist MC and MMC patients with the cost of treatment and screening.
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Affiliation(s)
- Malvina Hoxha
- Department of Chemical-Toxicological and Pharmacological Evaluation of Drugs, Catholic University Our Lady of Good Counsel, Tirana, Albania
| | - Visar Malaj
- Department of Economics, University of Tirana, Tirana, Albania
- CERGE-EI, Center for Economic Research and Graduate Education-Economics Institute, Prague, Czech Republic
| | - Bruno Zappacosta
- Department of Chemical-Toxicological and Pharmacological Evaluation of Drugs, Catholic University Our Lady of Good Counsel, Tirana, Albania
| | - Najada Firza
- Department of Economics and Finance, University of Bari ”Aldo Moro”, Bari, Italy
- Department of Economics and Business, Catholic University Our Lady of Good Counsel, Tirana, Albania
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Harada A, Tomita H, Tsukizaki A, Mizuno Y, Ishihama H, Shimotakahara A, Matsuoka K, Shimojima N, Hirobe S. Treatment Strategy for Currarino Syndrome Complicated With Anorectal Stenosis. Cureus 2023; 15:e50512. [PMID: 38226073 PMCID: PMC10788246 DOI: 10.7759/cureus.50512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/17/2024] Open
Abstract
PURPOSE The present study aimed to review the treatment experience and outcomes of Currarino syndrome (CS) complicated with anorectal stenosis to evaluate the current treatment strategies. METHODS Seven cases of CS complicated with anorectal stenosis, treated at our hospital between 1998 and 2021, were retrospectively investigated. This is a case series article from a single institution. RESULTS In six and three cases and one case, the presacral mass was a mature teratoma, meningocele, and lipoma, respectively. Resection of the lesion was performed in all six cases of mature teratoma, and duraplasty was performed before resection in all three cases of meningocele. Moreover, surgery for anorectal stenosis was performed simultaneously in four patients. Surgery was performed for six cases of anorectal stenosis, with the remaining case relieved by dilation using a metal bougie. The surgical methods used were a partial resection with end-to-end anastomosis, anorectal strictureplasty, pull-through, posterior sagittal anorectoplasty, and cutback after mass resection. Pathological analysis of the anorectal stenoses revealed disorganized and rough smooth muscle fibers and the replacement of the stroma by an increased quantity of collagen fibers. CONCLUSIONS The clinical outcomes of CS can be improved by establishing a treatment flow chart and understanding the complicated pathophysiology of the disease.
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Affiliation(s)
- Atsushi Harada
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Hirofumi Tomita
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Ayano Tsukizaki
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Yuki Mizuno
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Hideo Ishihama
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | | | - Kentaro Matsuoka
- Pathology, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Naoki Shimojima
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
| | - Seiichi Hirobe
- Surgery, Tokyo Metropolitan Children's Medical Center, Tokyo, JPN
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Kabila B, Zhim M, Naggar A, el Hadad S, Allali N, Chat L. Superinfected and Ruptured Occipital Meningocele: Case Report. Glob Pediatr Health 2023; 10:2333794X231204498. [PMID: 37846398 PMCID: PMC10576911 DOI: 10.1177/2333794x231204498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/19/2023] [Accepted: 09/13/2023] [Indexed: 10/18/2023] Open
Abstract
Meningocele is a rare congenital malformation of the central nervous system resulting from a herniation of the meninges containing cerebrospinal fluid through a bony defect in the skull. It is part of neural tube closure anomalies. The overall incidence of meningocele is 0.8 to 3 per 10 000 live births; it varies based on geographical location and race, with a predominance of occipital localization. Among diagnostic methods, computed tomography (CT) and magnetic resonance imaging (MRI) remain crucial examinations. Prenatal diagnosis of this malformation primarily relies on ultrasound and screening through maternal serum alpha-fetoprotein (AFP) levels. They typically manifest very early at birth with a highly suggestive radioclinical presentation. Surgical treatment usually allows for a definitive cure. Superinfection and rupture of the meningocele are exceptional, resulting from delayed diagnosis and management. In several developed countries, prevention through genetic counseling and the intake of folic acid during the periconceptional period, along with accurate prenatal diagnosis and the legalization of therapeutic abortion, has led to a decrease in the prevalence of meningoceles. In less developed countries, where there is a delay in diagnosis in exceptional cases, superinfection and rupture may occur. We present the case of an 8-month-old infant with a complicated occipital meningocele with superinfection and rupture.
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Affiliation(s)
- Badr Kabila
- UHC Ibn Sina, Mohamed V University, Rabat, Morocco
| | - Meriem Zhim
- UHC Ibn Sina, Mohamed V University, Rabat, Morocco
| | - Amine Naggar
- UHC Ibn Sina, Mohamed V University, Rabat, Morocco
| | | | - Nazik Allali
- UHC Ibn Sina, Mohamed V University, Rabat, Morocco
| | - Latifa Chat
- UHC Ibn Sina, Mohamed V University, Rabat, Morocco
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Bokova E, Prasade N, Rosen JM, Lim IIP, Levitt MA, Rentea RM. State of the Art Bowel Management for Pediatric Colorectal Problems: Spinal Anomalies. Children (Basel) 2023; 10:1558. [PMID: 37761519 PMCID: PMC10529947 DOI: 10.3390/children10091558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Patients with spinal abnormalities often struggle with fecal and/or urinary incontinence (up to 87 and 92%, respectively) and require a collaborative approach to bowel management in conjunction. METHODS To define existing approaches and propose state-of-the-art bowel management, a literature search was performed using Medline/PubMed, Google Scholar, Cochrane, and EMBASE databases and focusing on the manuscripts published July 2013 and July 2023. RESULTS Patients with spinal anomalies have impaired innervation of the rectum and anal canal, decreasing the success rate from laxatives and rectal enemas. Thus, transanal irrigations and antegrade flushes are widely utilized in this group of patients. Based on spinal MRI, the potential for bowel control in these children depends on age, type, and lesion level. On referral for bowel management, a contrast study is performed to assess colonic motility and evacuation of stool, followed by a series of abdominal X-rays to define colonic emptying and adjust the regimen. The options for management include laxatives, rectal enemas, transanal irrigations, antegrade flushes, and the creation of a stoma. Approximately 22-71% of patients achieve social continence dependent on the type and level of the lesion. CONCLUSION Patients with spinal anomalies require a thorough assessment for continence potential and stool burden prior to initiation of bowel management. The optimal treatment option is defined according to the patient's age, anatomy, and mobility. The likelihood of independent bowel regimen administration should be discussed with the patients and their caregivers.
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Affiliation(s)
- Elizaveta Bokova
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - Ninad Prasade
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
| | - John M. Rosen
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Mercy Kansas City, Kansas City, MO 64108, USA
- Department of Pediatrics, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Irene Isabel P. Lim
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Marc A. Levitt
- Division of Colorectal and Pelvic Reconstruction, Children’s National Medical Center, Washington, DC 20010, USA
| | - Rebecca M. Rentea
- Comprehensive Colorectal Center, Department of Surgery, Children’s Mercy Hospital, Kansas City, MO 64108, USA
- Department of Surgery, University of Missouri-Kansas City, Kansas City, MO 64108, USA
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Al-Balushi N, Bouthour W, Banc A, Mosleh R, Saindane AM, Newman NJ, Biousse V. Seizures as the Initial Manifestation of Idiopathic Intracranial Hypertension Spectrum Disorder. Neuroophthalmology 2023; 47:248-254. [PMID: 38130812 PMCID: PMC10732617 DOI: 10.1080/01658107.2023.2251579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/14/2023] [Indexed: 12/23/2023] Open
Abstract
Idiopathic intracranial hypertension (IIH) is a syndrome of isolated elevated intracranial pressure of unknown aetiology. The IIH spectrum has evolved over the past decade making the diagnosis and management more challenging. The neurological examination in IIH is typically normal except for papilloedema and possible cranial nerve 6 palsy. Recent publications have highlighted skull base thinning and remodelling in patients with chronic IIH. Resulting skull base defects can cause meningo-encephalocoeles, which are potential epileptogenic foci. We describe the clinical and radiological characteristics of five IIH patients with seizures and meningo-encephalocoeles as the presenting manifestations of IIH spectrum disorder.
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Affiliation(s)
- Nisreen Al-Balushi
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Ophthalmology, Al-Nahdha Hospital, Muscat, Sultanate of Oman
| | - Walid Bouthour
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ana Banc
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Ophthalmology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Rasha Mosleh
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Goldschleger Eye Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Amit M. Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Rahimizadeh A, Ahmadi SA, Mohammadi Moghadam A, Rahimizadeh S, Williamson W, Amirzadeh M, Hajaliloo Sami S. Neglected cervical meningocele in an adult: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE23152. [PMID: 37310698 PMCID: PMC10550695 DOI: 10.3171/case23152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 05/01/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Posterior cervical meningoceles are rare in adults because most are surgically excised early in life. Such meningoceles in adults are mostly presented as a cystic mass and their presentation as a solid mass is very rare. OBSERVATIONS An asymptomatic adult with cervical meningocele presented as a congenital midline skin covered solid mass in the posterior aspect of the neck is presented. Neuroradiological surveys showed attachment of the mass to intradural spinal cord. With diagnosis of a cervical meningocele, after excision of the solid sac, the stalk extending from the core of the mass to the dura was isolated. This was followed by intradural spinal cord detethering. The mass was compatible with rudimentary meningocele in pathology. LESSONS Neglected cervical meningocele is quite rare in adults. Surgical removal of the mass in adults is usually for cosmetic reasons rather than neurological impairment. However, surgical removal of the mass without intradural cord detethering is not sufficient. In such cases, late onset quadriparesis may be appear due to the spinal cord tethering scenario.
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Affiliation(s)
- Abolfazl Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
| | - Seyed Ali Ahmadi
- Department of Pathology, Sina Hospital, Tehran University of Medical Science, Tehran, Iran
| | - Ali Mohammadi Moghadam
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
| | - Shaghayegh Rahimizadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
| | - Walter Williamson
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
| | - Mahan Amirzadeh
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
| | - Sam Hajaliloo Sami
- Pars Advanced and Minimally Invasive Medical Manners Research Center, Pars Hospital, Iran University of Medical Sciences, Tehran, Iran; and
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Castelnuovo P, Valentini M, Sileo G, Battaglia P, Bignami M, Turri-Zanoni M. Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review. Acta Otorhinolaryngol Ital 2023; 43:S14-S27. [PMID: 37698096 PMCID: PMC10159643 DOI: 10.14639/0392-100x-suppl.1-43-2023-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 09/13/2023]
Abstract
Cerebrospinal fluid leak (CSFL) is a rare pathological condition which requires prompt and adequate management due to the high rate of associated major complications. At present, CSFL can be successfully treated through endoscopic endonasal approaches with success rates higher than 90%. Despite this, CSFL recurrence may occur, and its management is critical and still represents a matter of debate. A systematic review of the literature on the management of recurrent CSFL was conducted. It included a cohort of 1,083 cases of CSFL treated with surgical or conservative approaches; 112 cases of recurrence were reported for an overall recurrence rate of 10.3%. Most of the leaks were localised in the anterior skull base (68.3%) and identification of recurrent CSFL may be troublesome. Therefore, the entire skull base must be meticulously examined and long-term follow-up is mandatory. The risk for CSFL recurrence is higher in patients affected by idiopathic intracranial hypertension (IIH), but its role in CSFL recurrence is yet to be understood. Recurrent CSFL must be repaired as soon as possible in order to reduce the risk of intracranial complications. The use of early post-operative CSF diversion by lumbar drain (LD) is currently a matter of debate even in case of CSFL recurrences.
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Affiliation(s)
- Paolo Castelnuovo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Marco Valentini
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Giorgio Sileo
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
| | - Paolo Battaglia
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Maurizio Bignami
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Lariana, Como, Italy
| | - Mario Turri-Zanoni
- Unit of Otorhinolaryngology, Department of Biotechnologies and Life Sciences, University of Insubria, ASST Sette Laghi, Varese, Italy
- Head and Neck Surgery & Forensic Dissection Research center (HNS&FDRc), Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
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Alnajjar HA, Almousa SS, Almousa AS, Al Wadany MM. Sacrococcygeal Meningocele Antenatally Misdiagnosed as Teratoma: A Case Report. Cureus 2023; 15:e36485. [PMID: 37090346 PMCID: PMC10115723 DOI: 10.7759/cureus.36485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/21/2023] [Indexed: 04/25/2023] Open
Abstract
Sacrococcygeal masses encompass a diverse range of pathologies. Prenatal ultrasound facilitates early detection of congenital sacrococcygeal masses. We present the case of a newborn of a 22-year-old woman who was identified to have a sacrococcygeal mass by prenatal ultrasound that was initially diagnosed as sacrococcygeal teratoma. On examination after delivery, a large midline mass in the sacrococcygeal region was observed, which was globular in shape and had smooth, thin skin with bluish discoloration. Magnetic resonance imaging revealed a cystic lesion that protruded through a caudal sacral defect, consistent with a sacrococcygeal meningocele. The patient underwent surgical repair of the meningocele without any intraoperative complications and had preserved motor function in the lower extremities after the procedure. This case underscores the challenge of distinguishing sacrococcygeal teratoma from meningocele based on clinical presentation and prenatal ultrasound findings. An accurate preoperative diagnosis is essential for effective surgical planning.
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Affiliation(s)
- Hani A Alnajjar
- Department of Neurosurgery, King Faisal University, Hofuf, SAU
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12
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Kamal MA, Eltayeb M, Coulter I, Jenkins A. Surgical management of anterior sacral meningoceles: an illustrated case series and review of the literature. Br J Neurosurg 2023:1-7. [PMID: 36594268 DOI: 10.1080/02688697.2022.2162852] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/08/2022] [Accepted: 12/21/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Anterior sacral meningocele (ASM) is an uncommon variant of spinal dysraphism. Surgical correction for this condition is challenging and optimal corrective approaches are uncertain. OBJECTIVE To share our experience of managing this rare condition using the posterior trans-sacral approach and provide a contemporary review of the literature. METHODS Retrospective review of case notes, operative records, and imaging of eligible patients treated via the posterior trans-sacral approach between 2006 and 2020 at our regional neurosciences centre. RESULTS Three patients, two females and one male with a mean age of 30 years (range 16-38), were treated. Presenting symptoms included lower abdominal pain and recurrent miscarriages. Patients underwent corrective surgery using the posterior approach involving a sacral laminectomy, durotomy and closure of the communicating fistula. A single patient required reoperation due to early recurrence. Another patient proved challenging because of a very large sacral fistula and required two procedures due to the development of high-pressure headaches secondary to a recurrence. All patients improved symptomatically postoperatively and remained symptom free at the last clinic follow-up and have been discharged. Following review of the literature, only two other non-syndromic cases have been described. CONCLUSIONS ASM is an uncommon congenital abnormality, typically presenting with mass effect symptoms secondary to a presacral cystic mass. Surgical management using a posterior approach to close the meningeal sac is feasible and less invasive than an anterior approach. Long term clinical outcomes in our series were satisfactory.
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Affiliation(s)
- Muhmmad Ahmad Kamal
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Mohamed Eltayeb
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Ian Coulter
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
| | - Alistair Jenkins
- Department of Neurosurgery, Royal Victoria Hospital, Newcastle upon Tyne Hospitals, Newcastle upon Tyne, UK
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Muacevic A, Adler JR, Mendieta LR. The First Case of Fetus in Fetu in Nicaragua: The Management Experience of the Pediatric Neurosurgery Team. Cureus 2023; 15:e33835. [PMID: 36819441 PMCID: PMC9931383 DOI: 10.7759/cureus.33835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
Fetus in fetu (FIF) is a rare congenital anomaly of asymmetric monozygotic twins, where the parasitic twin develops abnormally inside the body of the host twin. In most cases, it is incorporated into the sibling's abdomen, which frequently presents as a retroperitoneal mass. Currently, at least 200 cases have been reported worldwide, being this the first case in Nicaragua. We describe a case of a male newborn, born via cesarean section, with a history of multiple congenital malformations observed via ultrasound examination. At birth, a mass is observed on its dorsum that impresses a skull, but without the presence of bones, with three limbs, two upper and one lower, with an outline located transversely on the pelvic girdle and the presence of two male genitalia with agenesis of the testicles and an accessory kidney. A preoperative diagnosis of FIF and spinal dysraphism was made by computed tomography (CT) and magnetic resonance imaging (MRI). They shared a spinal cord and had the presence of an open spinal defect type meningocele with aberrant roots. After the diagnosis and discussion, the multidisciplinary team proceeded to surgery to perform the separation of the twin (FIF). The subsequent anatomopathological examination revealed that the fetus was anencephalic and had reliable FIF characteristics. The resection was performed followed by the closure of the 430 mL meningocele and complete separation of the spine and the parasitic twin. We present the first case of fetus in fetu in Nicaragua.
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Abstract
RATIONALE Neurofibromatosis type 1 (NF-1) can manifest with various neurological symptoms. However, sensory ataxia has not been reported. PATIENT CONCERNS A 44-year-old man with NF-1 presented with several weeks of unsteady gait. He was diagnosed with gastric neuroendocrine tumor with multiple hepatic metastases 6 years ago and received palliative chemotherapy. Neurological examination revealed ataxia veering to the right side with no motor weakness. DIAGNOSES Clinical manifestations and electrodiagnostic studies suggested the dysfunction of the thoracic dorsal column (DC). Initial magnetic resonance imaging showed a lateral thoracic meningocele (LTM) located in the right paravertebral area at the T3-T4 vertebral level, but the spinal cord was unremarkable. Gait disturbance worsened after 9 months, and follow-up magnetic resonance imaging showed high signal intensity involving the right DC at the level adjacent to the LTM and spinal cord atrophy distal to the DC lesion. Tests for well-characterized paraneoplastic antibodies were negative. Ultimately, the patient was assumed to have sensory neuronopathy due to compressive damage to the dorsal root ganglia within the intervertebral foramina by LTM. INTERVENTIONS Empirical treatment with vitamin B12 supplementation and corticosteroids failed to improve his condition. The patient underwent decompressive laminectomy and excision of the meningocele with dura repair. OUTCOMES The patient temporarily improved to walk with assistance postoperatively. However, he developed dyspnea and hypotension 5 weeks later. Carcinoid heart disease confined the patient to the bed. The patient died of pneumonia 3 months after the operation. LESSONS This case with NF-1 shows asymmetric sensory ataxia of subacute progression. LTM may contribute to the development of sensory neuronopathy by damaging sensory neurons of the dorsal root ganglia. The comorbidities of the patient, including gastric neuroendocrine tumor and LTM, made it challenging to investigate the pathomechanism.
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Affiliation(s)
- You-Ri Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Seong-Min Hong
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Jong-Hee Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Seung-Jin Lee
- Department of Radiology, Chonnam National University Bitgoeul Hospital, Gwangju, Korea
| | - Jae-Myung Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
| | - Kyung Wook Kang
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
| | - Tai-Seung Nam
- Department of Neurology, Chonnam National University Hospital, Gwangju, Korea
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
- *Correspondence: Tai-Seung Nam, Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, 42 Jebong-ro, Dong-gu, Gwangju 61469, Korea (e-mail: )
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Mai CT, Evans J, Alverson CJ, Yue X, Flood T, Arnold K, Nestoridi E, Denson L, Adisa O, Moore CA, Nance A, Zielke K, Rice S, Shan X, Dean JH, Ethen M, Hansen B, Isenburg J, Kirby RS. Changes in Spina Bifida Lesion Level after Folic Acid Fortification in the US. J Pediatr 2022; 249:59-66.e1. [PMID: 35772508 PMCID: PMC10250025 DOI: 10.1016/j.jpeds.2022.06.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/30/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess whether the severity of cases of spina bifida changed after the institution of mandatory folic acid fortification in the US. STUDY DESIGN Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (prefortification period) and 1999-2016 (postfortification period). The programs contributed varying years of data. Case information included both a medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing the prefortification and postfortification periods, aORs for case severity (upper-level lesions [cervical, thoracic] vs lower-level lesions [lumbar, sacral]) and prevalence ratios (PRs) were estimated. RESULTS A total of 2593 cases of spina bifida (out of 7 816 062 live births) met the inclusion criteria, including 573 cases from the prefortification period and 2020 cases from the postfortification period. Case severity decreased by 70% (aOR, 0.30; 95% CI, 0.26-0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic White mothers. Overall spina bifida prevalence declined by 23% (PR, 0.77; 95% CI, 0.71-0.85), with similar reductions seen across the early, mid, and recent postfortification periods. A statistically significant decrease in upper-level lesions occurred in the postfortification period compared with the prefortification period (PR, 0.28; 95% CI, 0.22-0.34), whereas the prevalence of lower-level lesions remained relatively similar (PR, 0.94; 95% CI, 0.84-1.05). CONCLUSIONS The severity of spina bifida cases decreased after mandatory folic acid fortification in the US. Further examination is warranted to better understand the potential effect of folic acid on spina bifida severity.
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Affiliation(s)
- Cara T Mai
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA.
| | - Jane Evans
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Clinton J Alverson
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Xin Yue
- Eagle Global Scientific, Atlanta, GA
| | - Timothy Flood
- Bureau of Public Health Statistics, Arizona Department of Health Services, Phoenix, AZ
| | - Kathryn Arnold
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Eirini Nestoridi
- Center for Birth Defects Research and Prevention, Bureau of Family Health and Nutrition, Massachusetts Department of Public Health, Boston, MA
| | - Lindsay Denson
- Oklahoma Birth Defects Registry, Oklahoma State Department of Health, Oklahoma City, OK
| | | | - Cynthia A Moore
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Amy Nance
- Utah Birth Defect Network, Office of Children with Special Health Care Needs, Utah Department of Health and Human Services, Salt Lake City, UT
| | - Katherine Zielke
- South Carolina Birth Defects Program, South Carolina Department of Health and Environmental Control, Columbia, SC
| | | | - Xiaoyi Shan
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock, AK
| | | | - Mary Ethen
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, TX
| | - Brenda Hansen
- California Birth Defects Monitoring Program, Genetic Disease Screening Program/Center for Family Health, California Department of Public Health, Sacramento, CA
| | - Jennifer Isenburg
- Division of Birth Defects and Infant Disorders, National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, GA
| | - Russell S Kirby
- College of Public Health, University of South Florida, Tampa, FL
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Shiferaw MY, Akililu YB, Worku BY, T/Mariam TL, Aklilu AT. Multiple-site neural tube defects complicated by multiple-site split cord malformations and thickened filum terminale: experience at a pediatric neurosurgical teaching hospital in Ethiopia. Illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22220. [PMID: 36593675 PMCID: PMC9514283 DOI: 10.3171/case22220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/17/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Multiple-site open neural tube defects (MNTDs) and multiple-site split cord malformations (MSCMs) are extremely rare congenital anomalies that are defined by the simultaneous noncontiguous occurrence of more than one neural tube defect (NTD) and split cord malformation (SCM), respectively, in a single case with normal neural tissue in between. This work shows the cooccurrence of MNTDs and MSCMs, which has never been reported in the literature. OBSERVATIONS A single-stage repair for a 13-day-old female neonate with a preoperative diagnosis of MNTDs (thoracic meningocele and thoracolumbar myelomeningocele) plus an additional intraoperative diagnosis of MSCMs (type 3c) of thoracic and thoracolumbar spine, and thickened filum terminale was done with a favorable smooth postoperative course. LESSONS The use of intraoperative meticulous surgical technique along with preoperative skin stigmata helped for anticipation, detection, and treatment of associated complex spinal MNTDs, especially in resource-limited settings, where preoperative magnetic resonance imaging is not routinely used. Whether to repair the MNTDs as a single- versus multiple-stage procedure is mainly a function of the patient's tolerance to the duration of anesthesia and the anticipated blood loss for the patient's age. The overall developmental biology and long-term clinical outcome of MNTDs compared to single NTD/SCM is poorly understood and needs further study.
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Xu M, Wang J, Chen XD, Xue T, Chen FQ. Comparison of two surgical approaches in the management of cerebrospinal fluid rhinorrhea in the lateral recess of sphenoid sinus: A retrospective study. Ear Nose Throat J 2022:1455613221112760. [PMID: 35796349 DOI: 10.1177/01455613221112760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leakage from the lateral recess of the sphenoid sinus (LRSS) is usually repaired using endoscopic endonasal approaches, which can be challenging. Various surgical techniques have been developed for the disease. OBJECTIVE To report our experience with repairing CSF leak from the LRSS via transethmoid sphenoidotomy approach (TESA) and transprelacrimal recess pterygoid root approach (TPLRA), to assess the efficiency of TPLRA by comparing it with TESA. METHODS This retrospective study included patients with LRSS CSF rhinorrhea who underwent TESA (n = 10) or TPLRA (n = 5) from January 2011 to December 2020. Demographic characteristics and operation-related parameters were recorded. RESULTS The mean operation time was 169.5 and 225.0 mins in the TESA and TPLRA groups, respectively, with a mean blood loss of 65 mL and 68 mL, respectively. Histopathological examinations confirmed encephalocele in 11 (73.33%) and 4 (26.67%) cases with meningocele, respectively. CSF rhinorrhea was successfully repaired in the first attempt in both groups during the mean follow-up time of 54 months. Postoperative permanent numbness of the cheek was observed in two patients in the TESA group. No cases of lacrimal overflow or subjective dry eye were observed. CONCLUSIONS The TPLRA, which could be an alternative procedure to treat CSF rhinorrhea in the LRSS, provides a straight-line trajectory and effective maneuverability. We also found that CSF rhinorrhea in the LRSS was accompanied by encephalocele or meningocele, with encephalocele presenting more commonly.
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Affiliation(s)
- Min Xu
- Department of Otolaryngology and Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jian Wang
- Department of Otolaryngology and Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiao-Dong Chen
- Department of Otolaryngology and Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Tao Xue
- Department of Otolaryngology and Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Fu-Quan Chen
- Department of Otolaryngology and Head and Neck Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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18
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Martínez JL, Domingo RA, Rowland NC, Vandergrift Iii WA. Trigeminal Neuralgia Secondary to Meckel's Cave Meningoencephaloceles: A Systematic Review and Illustrative Case. Neurol India 2022; 70:857-863. [PMID: 35864609 DOI: 10.4103/0028-3886.349629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND The culprit of trigeminal neuralgia (TGN) may occur at any point between the nerve's root entry zone (REZ) and Meckel's cave. Meckel's cave meningoencephaloceles are rare middle cranial fossa defects that usually remain asymptomatic but may contain prolapsed trigeminal nerve rootlets and result in TGN. Their management and surgical outcomes remain poorly understood. OBJECTIVES To perform a systematic review of clinical presentation and surgical outcomes of middle fossa defects presenting with trigeminal nerve-related symptoms. MATERIALS AND METHODS A systematic review was conducted in accordance with the PRISMA guidelines for all reports of middle cranial fossa defects causing trigeminal nerve-related symptoms. The pathophysiology, presentation, surgical management, and outcomes are discussed and illustrated with a case. RESULTS Initial search from inception to March 2021 identified 33 articles for screening. After applying inclusion and exclusion criteria, 6 articles were included representing a total of 8 cases in addition to our case (n = 9). All 9 patients were females and 33.3% (n = 3) presented with classic trigeminal neuralgia. "Empty sella" syndrome and radiologic signs of intracranial hypertension were present in 40%-62%. No patient presented with cerebrospinal fluid leak. The preferred treatment modality was surgical with subtemporal extradural repairs using combinations of autologous fat and muscle grafts and synthetic dura. Postoperative outcomes were only available in 55.5% (n = 5) of the cases, and nearly all reported complete symptom resolution, except for one case in which the meningoencephalocele wall was incised, along with trigeminal rootlets adhered to it. Our patient had immediate and durable symptom relief after a 4-year follow-up. CONCLUSIONS MEC containing prolapsed trigeminal nerve rootlets can cause typical trigeminal neuralgia from chronic pulsatile stress. This supports the hypothesis that the compressive or demyelinating culprit can locate more ventrally on the course of the trigeminal nerve. Subtemporal extradural surgical repairs can be safe, effective, and durable. Incising the MEC wall should be avoided as it may have trigeminal rootlets adhered to it.
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Affiliation(s)
- Jaime L Martínez
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Fl, United States of America
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Fl, United States of America
| | - Nathan C Rowland
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States of America
| | - William A Vandergrift Iii
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States of America
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19
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Bohîlțea RE, Margareta Mihai B, Munteanu O, Ducu I, Adrian Dumitru V, Gheorghe CM, Augustin Georgescu T, Varlas V, Vlădăreanu R. Early prenatal diagnosis of an atypical phenotype of sacral spina bifida. J Med Life 2022; 14:716-721. [PMID: 35027976 PMCID: PMC8742886 DOI: 10.25122/jml-2021-0292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/06/2021] [Indexed: 11/27/2022] Open
Abstract
Neural tube defects (NTDs) occur during embryogenesis, specifically during the fifth or sixth week of gestation, and are described as aberrant neural tube closing. The defect may alter the normal development of the vertebrae, spinal cord, cranium, or brain. The present study describes the case of a 41-year-old pregnant woman with fetal sacral meningocele, no associated pathologies, no family history of neural tube defects, a pregnancy under folate supplementation with the aim of highlighting the importance of ultrasound in diagnosing neural tube defects. The ultrasonographic diagnosis was not clear from the beginning. In our case, the differential diagnosis of meningocele was made with the cystic compound of a sacrococcygeal teratoma, which represents one of the most common congenital tumors in newborns. The particularity of this case was that a neural tube defect occurred despite the prophylactic administration of folic acid during pregnancy, which represents a well-documented protection against neural tube defects in fetuses.
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Affiliation(s)
- Roxana Elena Bohîlțea
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Bianca Margareta Mihai
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Octavian Munteanu
- Department of Obstetrics and Gynecology, University Emergency Hospital, Bucharest, Bucharest, Romania
| | - Ioniță Ducu
- Department of Obstetrics and Gynecology, University Emergency Hospital, Bucharest, Bucharest, Romania
| | - Vasile Adrian Dumitru
- Department of Pathology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Consuela-Mădălina Gheorghe
- Department of Marketing and Medical Technology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Valentin Varlas
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, Bucharest, Romania
| | - Radu Vlădăreanu
- Department of Obstetrics and Gynecology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Obstetrics and Gynecology, Elias University Emergency Hospital, Bucharest, Romania
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20
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Michael AP, Elbuluk O, Tsiouris AJ, Tabaee A, Kacker A, Anand VK, Schwartz TH. The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles. J Neurosurg 2021; 137:1-8. [PMID: 34767535 DOI: 10.3171/2021.7.jns211427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 07/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence. METHODS A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele. RESULTS From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher's exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred. CONCLUSIONS Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.
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Affiliation(s)
| | | | | | | | | | | | - Theodore H Schwartz
- Departments of1Neurological Surgery
- 3Otolaryngology, and
- 4Neuroscience, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
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21
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Veerabathini BC, Manthani K, Hussain A. Congenital Central Nervous System Malformations: A Rare Case of an Encephalocele and Literature Review of Its Associations, Imaging Modalities, Radiological Findings, and Treatments. Cureus 2021; 13:e15959. [PMID: 34336454 PMCID: PMC8315298 DOI: 10.7759/cureus.15959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2021] [Indexed: 11/23/2022] Open
Abstract
Congenital central nervous system (CNS) malformations are relatively rare conditions present in fetuses that may result in intrauterine fetal deaths (IUFDs). We report a case of a 42-year-old female who presented at 29 weeks gestation with lack of a fetal heart beat likely due to a congenital malformation resulting in IUFD. This case report and literature review provides a better understanding of the encephalocele as a harbinger for IUFD.
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Affiliation(s)
- Bala C Veerabathini
- Transitional Year Resident, Peconic Bay Medical Center-Northwell Health, Riverhead, USA
| | - Kaushik Manthani
- Family Medicine, Peconic Bay Medical Center-Northwell Health, Riverhead, USA
| | - Ayesha Hussain
- Maternal Fetal Medicine, Stony Brook University Medical Center, Stony Brook, USA
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22
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Deora H, Srinivas D, Shukla D, Devi BI, Mishra A, Beniwal M, Kannepalli NR, Somanna S. Multiple-site neural tube defects: embryogenesis with complete review of existing literature. Neurosurg Focus 2020; 47:E18. [PMID: 31574472 DOI: 10.3171/2019.8.focus19437] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Multiple-site neural tube defects (MNTDs) are very uncommon, with the predominant number of cases being reported in developing countries. The classic theory of neural tube closure fails to explain the occurrence of these defects. Multisite closure theory, first proposed in 1995, explains most of the occurrences with a few modifications specific to a few defects. In this paper, the authors endeavor to explain all the defects, along with their genetic and embryological bases, and to review the available literature and discuss their own experience in the management of these complex cases. METHODS The authors retrospectively reviewed the data of all the patients treated surgically for MNTDs over that past 14 years. All possible demographic data, clinical details, and radiological imaging data were reviewed. In addition, surgical parameters, complications, and status at follow-up of more than 12 months were evaluated. All previously reported cases of MNTD were analyzed, and comparisons with the present series were made. RESULTS A total of 3 major series (including the present one) on MNTDs have been from India. A total of 57 such cases (including those of the present series) have been reported in the available literature. While previous series reported a higher incidence of spinal defects, the present series had a higher rate of cephalic defects (55%). Among the reported cases, insertion of a ventriculoperitoneal shunt was necessary in 12 (26%), and only 4 patients were operated on in 2 stages. Neurological status at presentation dictated outcome. CONCLUSIONS MNTDs are extremely rare, and their embryogenesis is different from that of single neural tube defects. Simultaneous repair of 2 or even 3 defects is possible in a single-stage surgery. The requirement of a shunt is uncommon, and complications following surgery are rare. Folic acid supplementation may reduce the incidence of defects.
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23
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Rakotozanany P, Song MTY, Ranoasy NF, Rakotovao K, Ratovondrainy W. [Temporal meningocele and anophtalmia: about a case]. Pan Afr Med J 2020; 37:8. [PMID: 32983326 PMCID: PMC7501746 DOI: 10.11604/pamj.2020.37.8.24930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/20/2020] [Indexed: 11/30/2022] Open
Abstract
Les auteurs rapportent un cas d´un garcon de 12 mois pour une polymalformation congénitale à type de méningocèle temporale droite et une aplasie du globe oculaire homolatérale qui était présent depuis sa naissance. Le scanner cérébral confirmait la malformation avec un défect osseux au niveau temporal droit, une hernie de la méninge contenant du liquide cérébro-spinal et une absence du globe oculaire droit. La chirurgie était pratiquée pour la méningocèle. L´évolution était favorable. Notre objectif est de montrer la rareté de cette affection à la lumière d´une revue de la littérature.
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Affiliation(s)
- Patrick Rakotozanany
- Service de Neurochirurgie, Centre Hospitalier de Soavinandriana (CENHOSOA), Antananarivo, Madagascar
| | - Miraulle Tien Yu Song
- Service de Neurochirurgie, Centre Hospitalier de Soavinandriana (CENHOSOA), Antananarivo, Madagascar
| | | | - Ketsia Rakotovao
- Service de Neurochirurgie, Centre Hospitalier de Soavinandriana (CENHOSOA), Antananarivo, Madagascar
| | - Willy Ratovondrainy
- Service de Neurochirurgie, Centre Hospitalier de Soavinandriana (CENHOSOA), Antananarivo, Madagascar
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Akahane M, Sawaguchi T, Sakagoshi D, Goshima K, Shigemoto K, Hatsuchi Y. Treatment of a sacral fracture associated with an intrasacral meningocele: A case report. J Orthop Surg (Hong Kong) 2020; 27:2309499019860269. [PMID: 31315523 DOI: 10.1177/2309499019860269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We report a case of sacral fracture complicated by an intrasacral meningocele in a 37-year-old male. The patient had a left sacral fracture with bilateral fractures of the superior and inferior pubic rami. The sacrum was fixed with a posterior plate and both superior pubic rami were fixed with an intramedullary screw. However, computed tomography myelogram and magnetic resonance imaging showed the intrasacral meningocele with the leakage of the cerebrospinal fluid into the buttocks and developed delayed union. Reoperation utilizing a strong anterior and posterior internal fixation combined with posterior bone grafting was undertaken and bone union was obtained.
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Affiliation(s)
- Mika Akahane
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
| | - Takeshi Sawaguchi
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
| | - Daigo Sakagoshi
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
| | - Kenichi Goshima
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
| | - Kenji Shigemoto
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
| | - Yu Hatsuchi
- Department of Orthopedic Surgery, Toyama City Hospital, Toyama, Japan
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Milani HJF, Barreto EQDS, Chau LH, To NH, Moron AF, Meagher S, Da Silva Costa F, Araujo Júnior E. Prenatal diagnosis of closed spina bifida: multicenter case series and review of the literature. J Matern Fetal Neonatal Med 2020; 33:736-742. [PMID: 30001658 DOI: 10.1080/14767058.2018.1500543] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/28/2018] [Accepted: 07/10/2018] [Indexed: 10/28/2022]
Abstract
Objective: Closed spina bifida (CSB) is an abnormality of the posterior arch formation in which the defect is covered by the skin, without protrusion of nervous tissue. The prenatal diagnosis of CSB is very difficult, rarely diagnosed antenatally.Methods: We present a multicenter case series of six prenatal diagnosis of CSB using two-dimensional (2D) ultrasonography complemented with three-dimensional (3D) ultrasonography and magnetic resonance imaging (MRI). All cases of prenatal diagnosis of CSB were confirmed in the postnatal period/termination of pregnancy by both clinical and/or imaging diagnosis (ultrasonography and MRI).Results: 2D ultrasonography allowed the prenatal diagnosis of six cases. We observed two cases of subcutaneous lipomas, two cases of meningoceles, one case of fibrolipomas, and one case of false-positive CSB (meningomyelocele). 3D ultrasonography using rendering mode was important in one case of meningocele (case# 3). Three cases were delivered at term and one of them was submitted to corrective surgery. All these three newborns were discharged from the hospital well and without neurologic signs. Termination of pregnancy was performed in three cases.Conclusion: During prenatal evaluation, detailed ultrasonographic assessment of the entire spine with the identification of the position and morphology of the conus medullaris and absence of cranial signs of spinal dysraphism are the most valuable sonographic clues for the diagnostic of the CSB.
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Affiliation(s)
- Hérbene José Figuinha Milani
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Enoch Quinderé de Sá Barreto
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - La Hong Chau
- Department of Imaging Diagnostic, Tudu Maternity Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Ha To
- Department of Imaging Diagnostic, Tudu Maternity Hospital, Ho Chi Minh City, Vietnam
| | - Antonio Fernandes Moron
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Simon Meagher
- Monash Ultrasound for Women, Melbourne, Victoria, Australia
| | - Fabricio Da Silva Costa
- Monash Ultrasound for Women, Melbourne, Victoria, Australia
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
| | - Edward Araujo Júnior
- Department of Obstetrics, Paulista School of Medicine, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
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Scott KW, Tavanaiepour D, Tavanaiepour K, Halawi A, Rao D, Rahmathulla G. Spontaneous Cerebral Spinal Fluid Rhinorrhea with Meningocele Secondary to Congenital Foramen Rotundum Defect: A Case Report and Review of Literature. Asian J Neurosurg 2020; 15:187-189. [PMID: 32181200 PMCID: PMC7057889 DOI: 10.4103/ajns.ajns_228_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/18/2019] [Indexed: 11/23/2022] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a rare occurrence. We present a case of spontaneous CSF rhinorrhea in a 57-year-old patient secondary to a sphenoid osseous defect involving the foramen rotundum and maxillary nerve with an associated arachnoid cyst and meningocele compressing the maxillary nerve. The location of the defect made correction amenable to an open skull-based approach. To the best of our knowledge, this is the first reported case of a spontaneous meningocele herniating into the sphenoid osseous defect through the medial aspect of the foramen rotundum. Early detection of these defects, open or endoscopic approaches and definitive treatment by closing the defect can result in excellent outcomes.
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Affiliation(s)
- Kyle William Scott
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Daryoush Tavanaiepour
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Kourosh Tavanaiepour
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Akaber Halawi
- Department of Otolaryngology, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Dinesh Rao
- Department of Radiology, College of Medicine, University of Florida, Jacksonville, Florida, USA
| | - Gazanfar Rahmathulla
- Department of Neurosurgery, College of Medicine, University of Florida, Jacksonville, Florida, USA
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Alicandri-Ciufelli M, Fermi M, Rosa MS, Garzaro M, Presutti L. Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results. Am J Rhinol Allergy 2020; 34:382-387. [PMID: 31928352 DOI: 10.1177/1945892419900485] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Spontaneous cerebrospinal fluid leak (sCSFL) has been historically related to obesity and elevated intracranial pressure (ICP), with a lower rate of success of endoscopic repair reported in the literature. Moreover, defects related to this condition have been largely repaired with multilayer reconstructions and pedicled flaps. Long-term postoperative results have not been appropriately discussed yet. Objective The aim of this study is to investigate the outcome of a cohort of patients treated with single-layer mucoperichondrial graft. Methods A retrospective review of clinical records of a consecutive series of patients who underwent endonasal endoscopic surgery for sCSFL was carried out at a tertiary care referral center for skull base pathologies. All patients underwent reconstruction with single-layer mucoperichondrial free graft. Local flap failures and postoperative outcomes, in terms of recurrence of sCSFL or brain herniation, were registered. Results Neither intraoperative nor perioperative complications were reported. Definitive closure was achieved in 27 of 29 (93%) patients after the first attempt, while in 2 cases, a revision surgery was required. In both of these, an inadequate position of the graft was detected and was repaired likewise with the same mucoperichondrial graft. None of the patients required postoperative lumbar drain placement. After a median follow-up period of 57 months, only 1 patient developed a meningocele without CSFL about 2 years after surgery at the contralateral lateral recess of the sphenoid sinus. None of the patients reported symptoms referable to elevated ICP nor underwent ventricular derivation. Conclusions Single-layered mucoperichondrial free graft was safe and effective in the majority of the examined patients. In 7% of the study population, a surgical revision was necessary due to local failure of the graft. However, during long-term follow-up, only 1 case of recurrent meningocele without CSFL was reported in a patient who presented borderline ICP.
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Affiliation(s)
| | - Matteo Fermi
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, Modena, Italy
| | - Maria Silvia Rosa
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, Modena, Italy.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Eastern Piedmont, Novara, Italy
| | - Massimiliano Garzaro
- Department of Otorhinolaryngology-Head and Neck Surgery, University of Eastern Piedmont, Novara, Italy
| | - Livio Presutti
- Department of Otolaryngology-Head and Neck Surgery, University Hospital of Modena, Modena, Italy
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Fam MD, Woodroffe RW, Helland L, Noeller J, Dahdaleh NS, Menezes AH, Hitchon PW. Spinal arachnoid cysts in adults: diagnosis and management. A single-center experience. J Neurosurg Spine 2019; 29:711-719. [PMID: 30265227 DOI: 10.3171/2018.5.spine1820] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 05/22/2018] [Indexed: 01/12/2023]
Abstract
OBJECTIVEAdult spinal arachnoid cysts (SACs) are rare entities of indistinct etiology that present with pain or myelopathy. Diagnosis is made on imaging studies with varying degrees of specificity. In symptomatic cases, the standard treatment involves surgical exploration and relief of neural tissue compression. The aim of this study was to illustrate features of SACs in adults, surgical management, and outcomes.METHODSThe authors searched medical records for all SACs in adults in the 10-year period ending in December 2016. Radiology and pathology reports were reviewed to exclude other spine cystic disorders. Recurrent or previously treated patients were excluded. Demographic variables (age, sex) and clinical presentation (symptoms, duration, history of infection or trauma, and examination findings) were extracted. Radiological features were collected from radiology reports and direct interpretation of imaging studies. Operative reports and media were reviewed to accurately describe the surgical technique. Finally, patient-reported outcomes were collected at every clinic visit using the SF-36.RESULTSThe authors' search identified 22 patients with SACs (mean age at presentation 53.5 years). Seventeen patients were women, representing an almost 3:1 sex distribution. Symptoms comprised back pain (n = 16, 73%), weakness (n = 10, 45%), gait ataxia (n = 11, 50%), and sphincter dysfunction (n = 4, 18%). The mean duration of symptoms was 15 months. Seven patients (32%) exhibited signs of myelopathy. All patients underwent preoperative MRI; in addition, 6 underwent CT myelography. SACs were located in the thoracic spine (n = 17, 77%), and less commonly in the lumbar spine (n = 3, 14%) and cervical/cervicothoracolumbar region (n = 2, 9%). Based on imaging findings, the cysts were interpreted as intradural SACs (n = 11, 50%), extradural SACs (n = 6, 27%), or ventral spinal cord herniation (n = 2, 9%); findings in 3 patients (14%) were inconclusive. Nineteen patients underwent surgical treatment consisting of laminoplasty in addition to cyst resection (n = 13, 68%), ligation of the connecting pedicle (n = 4, 21%), or fenestration/marsupialization (n = 2, 11%). Postoperatively, patients were followed up for an average of 8.2 months (range 2-30 months). Postoperative MRI showed complete resolution of the SAC in 14 of 16 patients. Patient-reported outcomes showed improvement in SF-36 parameters. One patient suffered a delayed wound infection.CONCLUSIONSIn symptomatic patients with imaging findings suggestive of spinal arachnoid cyst, surgical exploration and complete resection is the treatment of choice. Treatment is usually well tolerated, carries low risks, and provides the best chances for optimal recovery.
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Affiliation(s)
- Maged D Fam
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Royce W Woodroffe
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Logan Helland
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Jennifer Noeller
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Nader S Dahdaleh
- 2Department of Neurosurgery, Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - Arnold H Menezes
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
| | - Patrick W Hitchon
- 1Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa; and
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Alojan AA, Alsaad IS, Alghareeb FY, Al-issawi WM, Ammar AS. "Cable Suturing Technique" a Dural Obliteration Method for the Prevention of Cerebellar Herniation through a Large Occipital Meningocele. Asian J Neurosurg 2019; 14:1044-1047. [PMID: 31497162 PMCID: PMC6702993 DOI: 10.4103/ajns.ajns_60_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The authors present a patient who had a large occipital meningocele, which was transformed into an encephalocele after primary closure due to a large skull defect. Thus, the technical importance of classifying patients with occipital meningocele with a large skull defect and a tight dural obliteration is crucial, not to leave a wide dead space with a potential risk of cerebellar herniation. Encephalocele and meningocele are embryological anomalies, which result in intracranial structures herniation due to inborn skull defect. Acquired encephalocele may develop through the same defect with normal cerebellar tissues; since the prognosis of occipital encephalocele may worsen as the size of herniation increases, the patient underwent a modified dural obliteration technique (Cable Suturing Technique) to adjust the size of the dura and to strengthen it to prevent the risk of future herniation followed by cranioplasty and the cerebellar herniation regressed significantly after the procedure.
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Affiliation(s)
- Abdulrazaq Abdulmohsen Alojan
- Department of Neurosurgery, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ibtihal Sadiq Alsaad
- Department of Neurosurgery, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fatimah Yousef Alghareeb
- Department of Neurosurgery, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Wisam Mostafa Al-issawi
- Department of Neurosurgery, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Sabry Ammar
- Department of Neurosurgery, King Fahd University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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El-Ruby M, El-Din Fayez A, El-Dessouky SH, Aglan MS, Mazen I, Ismail N, Afifi HH, Eid MM, Mostafa MI, Mehrez MI, Khalil Y, Zaki MS, Gaber KR, Abdel-Hamid MS, Abdel-Salam GMH. Identification of a novel homozygous ALX4 mutation in two unrelated patients with frontonasal dysplasia type-2. Am J Med Genet A 2019; 176:1190-1194. [PMID: 29681084 DOI: 10.1002/ajmg.a.38655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/17/2017] [Accepted: 02/07/2018] [Indexed: 11/06/2022]
Abstract
We report two unrelated boys with frontonasal dysplasias type-2 (FND-2) who shared an identical novel homozygous ALX4 mutation c.291delG (p.Q98Sfs*83). Both patients presented with a large skull defect but one had bilateral parietal meningocele-like cysts that lie along with the bony defect and increased in size with age. Scalp alopecia, hypertelorism, and clefted alae nasi were also detected in both of them. Furthermore, impalpable gonads were noted, being unilateral in one and bilateral in the other. Neuroimaging showed small dysplastic occipital lobes with dysgyria and midline subarachnoid cyst. Additional dysplastic corpus callosum and small cerebellar vermis were observed in one patient. Parietal foramina were noted in the parents of one patient. Our findings highlight the dosage effect of ALX4 and underscore the challenges of prenatal genetic counseling. Further, the indirect role of ALX4 in the development of the occipital lobe and posterior fossa is discussed.
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Affiliation(s)
- Mona El-Ruby
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Alaa El-Din Fayez
- Medical Molecular Genetics and Enzymology Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Sara H El-Dessouky
- Prenatal Diagnosis and Fetal Medicine Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Mona S Aglan
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Inas Mazen
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Nora Ismail
- Medical Molecular Genetics and Enzymology Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Hanan H Afifi
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Maha M Eid
- Human Cytogenetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Mostafa I Mostafa
- Orodental Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Mennat I Mehrez
- Orodental Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Yasmin Khalil
- Orodental Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Maha S Zaki
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Khaled R Gaber
- Prenatal Diagnosis and Fetal Medicine Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Mohamed S Abdel-Hamid
- Medical Molecular Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
| | - Ghada M H Abdel-Salam
- Clinical Genetics Department, Human Genetics and Genome Research Division, National Research Centre, Cairo, Egypt
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Chavkin U, Brenner-Ullman A, Ungar OJ, Fliss D, Handzel O. Prevalence of temporal bone tegmen defects among patients with Marfan syndrome. Acta Otolaryngol 2019; 139:421-424. [PMID: 30861355 DOI: 10.1080/00016489.2019.1575524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Marfan syndrome (MFS) is a genetic disorder affecting connective tissue. The composition of the dura can change. Consequently, lumbo-sacral dural herniations and cerebrospinal fluid (CSF) leaks are encountered, however, they have yet to been described in the temporal bone. AIMS/OBJECTIVES To define the prevalence of temporal bone meningocele or encephalocele among patients with MFS. MATERIALS AND METHODS Reviewed medical records of all adult patients, diagnosed with MFS, who were treated between 1993 and 2018 at a single academic referral institute. Head targeted CT scans were analyzed. The presence of an anterior or lateral skull base defect was recorded. RESULTS One-hundred and one patients diagnosed with MFS were identified. Twelve of which had suitable CT scans and were enrolled in the study. The median age of patients with defects was 65 years (range 41-71). Five of the twelve patients (41.6%) had tegmen defect. Of the seven defects found, the median size of the defects was 3 mm (range 2-5 mm). All defects were in the temporal bone, none in the anterior skull base. CONCLUSIONS AND SIGNIFICANCE The prevalence of radiological evidence of a temporal bone defect among patients with MFS is high. This is a new, important, and potentially life-threatening association with the syndrome.
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Affiliation(s)
- Uri Chavkin
- Department of Otolaryngology, Head and Neck, and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Department of Otolaryngology, Head and Neck Surgery, Assaf Harofe Medical Center, Beer Yaakov, Israel
| | - Adi Brenner-Ullman
- “Sackler” Faculty of Medicine, Department of Radiology, Tel Aviv “Sourasky” Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Omer Jacob Ungar
- “Sackler” Faculty of Medicine, Department of Otolaryngology, Head & Neck, and Maxillofacial Surgery, Tel Aviv “Sourasky” Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Dan Fliss
- “Sackler” Faculty of Medicine, Department of Otolaryngology, Head & Neck, and Maxillofacial Surgery, Tel Aviv “Sourasky” Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Ophir Handzel
- “Sackler” Faculty of Medicine, Department of Otolaryngology, Head & Neck, and Maxillofacial Surgery, Tel Aviv “Sourasky” Medical Center, Tel Aviv University, Tel Aviv, Israel
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Abstract
Introduction: The Frontoethmoidal encephalomeningocele (FEEM) is a congenital neural tube anomaly, with herniation of intracranial material such as the brain and leptomeninges through a defect of the dura and anterior skull base at the junction of the frontal and ethmoidal bones. It may result not only in neural defects, sensorimotor deficits, neurological morbidities, visual impairment, impaired nasal function, and a potential risk of intracranial infection, but also in significant craniofacial disfigurement with complex deformities in the frontal, orbital, and nasal regions. Materials and Method: The standard two-staged surgical protocol comprises of the first stage performed by a neurosurgeon, which aims at correcting the neural defect by a formal craniotomy; then the second stage performed by a craniomaxillofacial or plastic and reconstructive surgeon, to correct craniofacial hard and soft tissue deformities. The case discussed was managed using a modified intracranial-transcranial single stage approach, achieving both the desired objectives. Results and Conclusion: This protocol elucidates the importance and value of teamwork between the Neurosurgeon and Craniomaxillofacial surgeon, in comprehensively and efficiently managing small to moderately sized FEEMs, assuring their complete elimination, satisfactory defect closure, effective functional treatment as well as esthetic correction and reconstruction of the attendant craniofacial deformities by means of a single-stage definitive surgical approach.
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Affiliation(s)
- Priya Jeyaraj
- Command Military Dental Centre (Northern Command), Udhampur, Jammu and Kashmir, India
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Singh S, Mehrotra A, Pandey S, Gupta S, Bhaisora KS, Gajbhiye S, Sardhara JC, Das KK, Srivastava AK, Jaiswal AK, Behari S, Kumar R. Cystic Cervical Dysraphism: Experience of 12 Cases. J Pediatr Neurosci 2018; 13:39-45. [PMID: 29899770 PMCID: PMC5982491 DOI: 10.4103/jpn.jpn_30_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction: Cystic spinal dysraphism of the cervical region is a relatively rare entity, which is more frequently associated with congenital anomalies such as split cord malformation, Chiari malformation, and corpus callosum agenesis, when compared to their lumbosacral counterpart. In our study, we have highlighted the clinical spectrum, associated anomalies (both neural and extra-neural), and surgical nuances of these. Materials and Methods: This study is a retrospective analysis of 225 patients from June 2010 to April 2017. Twelve patients who were between the age of 1 month and 16 years were included in our study. Average age was 32.6 months, and there were five female patients and seven male patients. All patients underwent neurological and radiological examinations followed by surgical excision of the sac and exploration of the intradural sac using the standard microsurgical technique. Neurological, Orthopedic and urological outcomes were studied in our description. Results: Of the 12 cases, 9 patients (75%) had some associated anomaly. Four of the 12 patients (25%) had split cord malformation, 3 had corpus callosum agenesis, and 5 had Chiari malformation. Patients with cervical spina bifida cystica (SBC) present with less neurologic deficits and greater association with CCA. Conclusion: The management strategy and association with other congenital anomalies separates cervical dysraphism as a different clinical entity rather than just group. These patients rather show favorable outcome with regard to neurologic, orthopedic, and urologic problems as compared to their caudal counterpart. Early surgical intervention even before the onset of symptoms is recommended. A proper radiological and urological evaluation is warranted.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anant Mehrotra
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Satyadeo Pandey
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shruti Gupta
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kamlesh S Bhaisora
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjog Gajbhiye
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Jayesh C Sardhara
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Arun Kumar Srivastava
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh K Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Raj Kumar
- Department of Neurosurgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Paisan GM, Crandall KM, Chen S, Burks SS, Sands LR, Levi AD. Closure of a giant anterior sacral meningocele with an omental flap in a patient with Marfan syndrome: case report. J Neurosurg Spine 2018; 29:182-186. [PMID: 29799321 DOI: 10.3171/2018.1.spine171303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anterior sacral meningoceles (ASMs) are rare lesions often associated with connective tissue disorders. These lesions are typically treated posteriorly via closure of the dural stalk. However, given their insidious nature, ASMs can be quite large on presentation, and this approach may not provide adequate decompression. In this case report, the authors describe the successful treatment of a large ASM through drainage and watertight closure of the cyst with an omental flap. A 43-year-old woman with a history of Marfan syndrome and a large ASM was referred for neurosurgical intervention. The ASM was filling the pelvic cavity and causing severe compression of the bladder. The patient underwent surgical decompression of the cyst through an anterior transabdominal approach and closure of the fistulous tract with a pedicled omental flap. This is the first reported case of successful closure of an ASM with an omental flap. At the 6-month follow-up, the ASM had not recurred on imaging and the patient's symptoms had resolved. Anterior sacral meningoceles are rare lesions that often require neurosurgical intervention. Although most can be treated posteriorly, large ASMs compressing the abdominal or pelvic organs may require a transabdominal approach. Moreover, ASMs with wide dural stalks may benefit from closure with an omental flap.
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Affiliation(s)
- Gabriella M Paisan
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Kenneth M Crandall
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Stephanie Chen
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; and
| | - S Shelby Burks
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Laurence R Sands
- 3Department of General Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Allan D Levi
- 2Department of Neurological Surgery and The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, Florida; and
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Raeiq A. Posterior Fontanelle Encephalo meningocele in a Neonate: A Case Report. Cureus 2018; 10:e2315. [PMID: 29755911 PMCID: PMC5947933 DOI: 10.7759/cureus.2315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Encephalomeningoceles are subtypes of neural tube defects (NTD). We present the case of a one-day-old neonate who was found to have a posterior fontanelle encephalomeningocele that was only discovered after birth. The unique presentation of this case and the surgical management is also considered.
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Abstract
OBJECTIVES To describe a unique case of bilateral dehiscence of the malleus and incus heads into the middle fossa making contact with the temporal lobes, along with its clinical implications. METHODS An analysis of a patient case and review of pertinent literature were performed. RESULTS A patient with a history of right-sided mastoidectomy for cholesteatoma was evaluated for persistent conductive hearing loss. On computed tomography (CT) and magnetic resonance imaging (MRI), the patient had a complete dehiscence of the tegmen tympani on the right, with ossicular heads being located above the floor of the middle cranial fossa. A similar finding to a milder degree was noted on the left. The patient underwent revision tympanoplasty with mastoidectomy with removal of the incus and ossicular chain reconstruction and middle fossa craniotomy for repair of the right epitympanic dehiscence. CONCLUSIONS We present some of the unique imaging and operative findings involved in an unusual presentation of encephalocele in which the bilateral malleus and incus heads rise above the level of the middle fossa floor.
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Affiliation(s)
- Sameer A Alvi
- 1 Department of Otolaryngology - Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joel W Jones
- 1 Department of Otolaryngology - Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jim Lin
- 1 Department of Otolaryngology - Head & Neck Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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Abstract
A fetal MRI study obtained at 21 weeks' gestation revealed a suboccipital meningocele without hydrocephalus. One day after term birth, MRI demonstrated an acquired cerebellar encephalocele, and MRI obtained 5 months later showed progressive enlargement of the encephalocele, still without obvious hydrocephalus. The patient underwent an operation in which an external ventricular drain was placed, the grossly normal cerebellum was reduced into the posterior fossa without resection, and the dural defect was closed. The drain was weaned out over 5 days, and no ventriculoperitoneal shunt was placed. Postoperative MR images revealed normal cerebellum and no hydrocephalus. The patient is developmentally normal. Meningocele and encephalocele are embryologically distinct. An acquired encephalocele could develop from hydrocephalus (which was not present in this case), or secondary to the lower resistance to expansion into the dural defect of the meningocele relative to the resistance to expansion of the fetal skull. The cerebellar tissue was normal in this case, and was thus preserved. The developmental prognosis is excellent. To the authors' knowledge, this is the first reported case of this occurrence. It is important to differentiate between congenital and acquired encephalocele etiologies, because resection of the cerebellar tissue in an acquired encephalocele (as is routinely done in cases of congenital encephalocele) would be expected to result in neurological deficits.
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Affiliation(s)
- Gurpreet S Gandhoke
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Ezequiel Goldschmidt
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | - Stephanie Greene
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Heidekrueger PI, Thu M, Mühlbauer W, Holm-Mühlbauer C, Schucht P, Anderl H, Schoeneich H, Aung K, Mg Ag M, Thu Soe Myint A, Juran S, Aung T, Ehrl D, Ninkovic M, Broer PN. Safe and sustainable: the extracranial approach toward frontoethmoidal meningoencephalocele repair. J Neurosurg Pediatr 2017; 20:334-340. [PMID: 28731403 DOI: 10.3171/2017.5.peds1762] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although rare, frontoethmoidal meningoencephaloceles continue to pose a challenge to neurosurgeons and plastic reconstructive surgeons. Especially when faced with limited infrastructure and resources, establishing reliable and safe surgical techniques is of paramount importance. The authors present a case series in order to evaluate a previously proposed concise approach for meningoencephalocele repair, with a focus on sustainability of internationally driven surgical efforts. METHODS Between 2001 and 2016, a total of 246 patients with frontoethmoidal meningoencephaloceles were treated using a 1-stage extracranial approach by a single surgeon in the Department of Neurosurgery of the Yangon General Hospital in Yangon, Myanmar, initially assisted by European surgeons. Outcomes and complications were evaluated. RESULTS A total of 246 patients (138 male and 108 female) were treated. Their ages ranged from 75 days to 32 years (median 8 years). The duration of follow-up ranged between 4 weeks and 16 years (median 4 months). Eighteen patients (7.3%) showed signs of increased intracranial pressure postoperatively, and early CSF rhinorrhea was observed in 27 patients (11%), with 5 (2%) of them requiring operative dural repair. In 8 patients, a decompressive lumbar puncture was performed. There were 8 postoperative deaths (3.3%) due to meningitis. In 15 patients (6.1%), recurrent herniation of brain tissue was observed; this herniation led to blindness in 1 case. The remaining patients all showed good to very good aesthetic and functional results. CONCLUSIONS A minimally invasive, purely extracranial approach to frontoethmoidal meningoencephalocele repair may serve well, especially in middle- and low-income countries. This case series points out how the frequently critiqued lack of sustainability in the field of humanitarian surgical missions, as well as the often-cited missing aftercare and dependence on foreign supporters, can be circumvented by meticulous training of local surgeons.
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Affiliation(s)
- Paul I Heidekrueger
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich.,Center of Plastic, Hand, and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Myat Thu
- Department of Neurosurgery, Yangon General Hospital, Yangon
| | | | | | - Philippe Schucht
- Department of Neurosurgery, Yangon General Hospital, Yangon.,Department of Neurosurgery, University Hospital Inselspital and University of Bern, Switzerland
| | - Hans Anderl
- Department of Plastic and Reconstructive Surgery, Innsbruck University Hospital, Innsbruck, Austria; and
| | - Heinrich Schoeneich
- Department of Plastic and Reconstructive Surgery, Interplast Germany, Section Munich
| | - Kyawzwa Aung
- Department of Neurosurgery, Mandalay University Hospital, Mandalay, Myanmar
| | - Mg Mg Ag
- Department of Neurosurgery, Yangon General Hospital, Yangon
| | | | - Sabrina Juran
- Population and Development Branch, Technical Division, United Nations Population Fund, New York, New York
| | - Thiha Aung
- Center of Plastic, Hand, and Reconstructive Surgery, University Medical Center Regensburg, Germany
| | - Denis Ehrl
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM-Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich
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Adin ME. Congenital high airway obstruction syndrome (CHAOS) associated with cervical myelo meningocele. J Clin Ultrasound 2017; 45:507-510. [PMID: 27874207 DOI: 10.1002/jcu.22430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 10/26/2016] [Indexed: 06/06/2023]
Abstract
Congenital high airway obstruction syndrome (CHAOS) is a rare and potentially fatal entity resulting from complete or near complete developmental airway obstruction. Although most reported cases of CHAOS are sporadic, the condition may also be associated with certain syndromes and a variety of cervical masses. Meningocele and myelomeningocele have not yet been reported in association with CHAOS. We describe the typical constellation of sonographic findings in a case of early diagnosis of CHAOS associated with cervical myelomeningocele. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:507-510, 2017.
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Affiliation(s)
- Mehmet Emin Adin
- Silvan Dr. Yusuf Azizoğlu State Hospital, Department of Radiology, Silvan, Diyarbakir, Turkey
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Abstract
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.
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Affiliation(s)
- Anouke van Rumund
- Department of Neurology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Aad Verrips
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | - Wim I M Verhagen
- Department of Neurology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
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41
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Chakhalian D, Gunasekaran A, Gandhi G, Bradley L, Mizell J, Kazemi N. Multidisciplinary surgical treatment of presacral meningocele and teratoma in an adult with Currarino triad. Surg Neurol Int 2017; 8:77. [PMID: 28584680 PMCID: PMC5445655 DOI: 10.4103/sni.sni_439_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/13/2017] [Indexed: 12/03/2022] Open
Abstract
Background: Currarino syndrome (CS) is a rare genetic condition that presents with the defining triad of anorectal malformations, sacral bone deformations, and presacral masses, which may include teratoma. Neurosurgeons are involved in the surgical treatment of anterior meningoceles, which are often associated with this condition. The accepted surgical treatment is a staged anterior-posterior resection of the presacral mass and obliteration of the anterior meningocele. Case Description: This case involved a 36-year-old female who presented with late onset of symptoms attributed to CS (e.g., presacral mass, anterior sacral meningocele, and sacral agenesis). She successfully underwent multidisciplinary single-stage approach for treatment of the anterior sacral meningocele and resection of the presacral mass. This required obliteration of the meningocele and closure of the dural defect. One year later, her meningocele had fully resolved. Conclusion: While late presentations with CS are rare, early detection and multidisciplinary treatment including single-state anterior may be successful for managing these patients.
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Affiliation(s)
- Daniel Chakhalian
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Arunprasad Gunasekaran
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gautam Gandhi
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Lucas Bradley
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jason Mizell
- Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Noojan Kazemi
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
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Wani AA, Raswan UK, Malik NK, Ramzan AU, Lone I. Squamous cell carcinoma arising from neglected meningocele. Surg Neurol Int 2017; 7:S1147-S1149. [PMID: 28194302 PMCID: PMC5299146 DOI: 10.4103/2152-7806.196928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 09/13/2016] [Indexed: 11/18/2022] Open
Abstract
Background: A neural tube defect (NTD) is a common congenital anomaly with an incidence of 6.57–8.21 per 1000 live births. Patients usually present early because of obvious swelling or due to neurological deficit. However, neglecting the obvious cystic swelling on the back till its transformation into malignant tumor is rare. Case Description: We describe a case of malignant transformation of meningocele in a 60-year-old man. Magnetic resonance imaging showed sacral meningocele. Neurological examination revealed intact motor and sensory examination with normal bladder and bowel function. There were no signs of meningitis and hydrocephalus. Excision was done and biopsy revealed it as squamous cell carcinoma. Conclusion: Meningocele should be treated early and possibility of malignant change should be kept in mind in neglected cases presenting in adulthood.
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Affiliation(s)
- Abrar A Wani
- Department of Neurosurgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Uday K Raswan
- Department of Neurosurgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Nayil K Malik
- Department of Neurosurgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Altaf U Ramzan
- Department of Neurosurgery, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Iqbal Lone
- Department of Pathology, Sher-i- Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Lee JK, Towbin AJ. Currarino Syndrome and the Effect of a Large Anterior Sacral Meningocele on Distal Colostogram in an Anorectal Malformation. J Radiol Case Rep 2016; 10:16-21. [PMID: 27761181 DOI: 10.3941/jrcr.v10i6.2068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Currarino syndrome is a congenital disorder, consisting of a triad of anomalies including an anorectal malformation, sacral anomaly, and a presacral mass. Anterior sacral meningoceles are the most common presacral mass. A young child presented to our institution with an unrepaired anorectal malformation and a large anterior sacral meningocele. We describe how the anterior meningocele affected the imaging work-up.
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Affiliation(s)
- Jason K Lee
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Bessis D, Bigorre M, Malissen N, Captier G, Chiaverini C, Abasq C, Barbarot S, Boccara O, Bourrat E, El Fertit H, Eschard C, Hubiche T, Lacour JP, Leboucq N, Mahé E, Mallet S, Marque M, Martin L, Mazereeuw-Hautier J, Milla N, Phan A, Plantin P, Picot MC, Puzenat E, Rigau V, Vabres P, Fraitag S, Boralevi F. The scalp hair collar and tuft signs: A retrospective multicenter study of 78 patients with a systematic review of the literature. J Am Acad Dermatol 2016; 76:478-487. [PMID: 27742172 DOI: 10.1016/j.jaad.2016.08.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 07/27/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Hair collar sign (HCS) and hair tuft of the scalp (HTS) are cutaneous signs of an underlying neuroectodermal defect, but most available data are based on case reports. OBJECTIVE We sought to define the clinical spectrum of HCS and HTS, clarify the risk for underlying neurovascular anomalies, and provide imaging recommendations. METHODS A 10-year multicenter retrospective and prospective analysis of clinical, radiologic, and histopathologic features of HCS and HTS in pediatric patients was performed. RESULTS Of the 78 patients included in the study, 56 underwent cranial and brain imaging. Twenty-three of the 56 patients (41%) had abnormal findings, including the following: (1) cranial/bone defect (30.4%), with direct communication with the central nervous system in 28.6%; (2) venous malformations (25%); or (3) central nervous system abnormalities (12.5%). Meningeal heterotopia in 34.6% (9/26) was the most common neuroectodermal association. Sinus pericranii, paraganglioma, and combined nevus were also identified. LIMITATIONS The partial retrospective design and predominant recruitment from the dermatology department are limitations of this study. CONCLUSIONS Infants with HCS or HTS are at high risk for underlying neurovascular anomalies. Magnetic resonance imaging scans should be performed in order to refer the infant to the appropriate specialist for management.
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Affiliation(s)
- Didier Bessis
- Department of Dermatology, Saint-Eloi Hospital, Montpellier, France; Montpellier University Hospital and Institut National de la Santé et de la Recherche Médicale (INSERM) U1058, Montpellier, France.
| | - Michèle Bigorre
- Department of Infantile Plastic Surgery, Lapeyronie Hospital, Montpellier, France
| | | | - Guillaume Captier
- Department of Infantile Plastic Surgery, Lapeyronie Hospital, Montpellier, France
| | | | - Claire Abasq
- Department of Dermatology, Brest University Hospital, Brest, France
| | | | - Olivia Boccara
- Department of Pediatric Dermatology, Necker-Enfants Malades Hospital, Paris, France
| | - Emmanuelle Bourrat
- Department of Pediatric Dermatology, Robert-Debré Hospital, Paris, France
| | - Hassan El Fertit
- Department of Infantile Neurosurgery, Caremeau Hospital, Nîmes, France
| | | | - Thomas Hubiche
- Department of Dermatology and Infectious Diseases, Fréjus Hospital, Fréjus, France
| | | | - Nicolas Leboucq
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France
| | - Emmanuel Mahé
- Department of Dermatology, Argenteuil Hospital, Argenteuil, France
| | | | - Myriam Marque
- Department of Dermatology, Caremeau Hospital, Nîmes, France
| | - Ludovic Martin
- Department of Dermatology, Angers University Hospital, Angers, France
| | | | - Nathalie Milla
- Department of Dermatology, Saint-Eloi Hospital, Montpellier, France
| | - Alice Phan
- Department of Pediatric Dermatology, Femme-Mère-Enfant Hospital and Claude-Bernard Lyon 1 University, Lyonm, France
| | - Patrice Plantin
- Department of Dermatology, Quimper Hospital, Quimper, France
| | - Marie-Christine Picot
- Unit of Clinical Research and Epidemiology, Department of Medical Information, Antonin Balmes Hospital, Montpellier, France
| | - Eve Puzenat
- Department of Dermatology, Besançon University Hospital, Besançon, France
| | - Valérie Rigau
- Department of Pathology, Montpellier University Hospital, Montpellier, France
| | - Pierre Vabres
- Department of Dermatology, Bocage Hospital and Bourgogne Medical University, Dijon, France
| | - Sylvie Fraitag
- Department of Pathology, Necker-Enfants Malades University Hospital, Paris, France
| | - Franck Boralevi
- Department of Pediatric Dermatology, National Center for Rare Skin Disorders-Institut National de la Santé et de la Recherche Médicale (INSERM) U1035, Bordeaux, France
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Krekora M, Zych-Krekora K, Blitek M, Kęsiak M, Piaseczna-Piotrowska A, Łukaszek S, Krasomski G, Słodki M, Szaflik K, Respondek-Liberska M. Difficulties in prenatal diagnosis of tumour in the fetal sacrococcygeal area. Ultrasound 2016; 24:119-24. [PMID: 27482281 DOI: 10.1177/1742271x16642637] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 03/05/2016] [Indexed: 11/16/2022]
Abstract
Prenatal ultrasound at the 20th week of gestation revealed a 3-cm tumour in the sacrococcygeal area. Initially, a sacrococcygeal teratoma was suspected on the basis of fetal ultrasonography, which revealed normal heart anatomy and an increasing tumour mass. The diagnosis was then changed to fetus in fetu or teratoma. Prenatal magnetic resonance imaging at the 34th week of pregnancy confirmed the ultrasound diagnosis. No other anomalies were found. Elective caesarean section was performed at term. The care team included a paediatric surgeon, obstetricians, neonatologists, midwives, and an anesthesiologist. A female newborn was delivered in good condition. The tumour was resected in the operating room and mature teratoma was established by histopathological evaluation. Surprisingly, agenesis of the right forearm was revealed which had not been detected prenatally, despite many examinations (both in our hospital and earlier at a primary care obstetrician office).
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Affiliation(s)
- Michał Krekora
- Obstetrics and Gynecology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Katarzyna Zych-Krekora
- Pediatrics and Immunology Department with the Sub-Unit of Nephrology, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland; Prenatal Cardiology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | | | - Marcin Kęsiak
- Neonatology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Anna Piaseczna-Piotrowska
- Pediatric Surgery and Urology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Stanisław Łukaszek
- Pathomorphology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Grzegorz Krasomski
- Obstetrics and Gynecology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Maciej Słodki
- Prenatal Cardiology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland; Fetal Malformations Department, Medical University of Lodz, Łódź, Poland
| | - Krzysztof Szaflik
- Reproduction and Fetus Therapy Clinic, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland
| | - Maria Respondek-Liberska
- Prenatal Cardiology Department, Polish Mother's Memorial Hospital Research Institute, Łódź, Poland; Fetal Malformations Department, Medical University of Lodz, Łódź, Poland
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Abstract
Conclusions Spontaneous defects between the mastoid and the posterior cranial fossa are exceedingly rare. Patients with these lesions may have a lower BMI compared to those with middle cranial fossa encephaloceles, but are otherwise demographically similar. This study recommends repair via a transtemporal approach to allow for examination of the entire posterior face of the temporal bone. Objective To describe cases of spontaneous posterior cranial fossa defects. Methods This study reviewed all cases of spontaneous posterior fossa defects presenting to a tertiary referral center over the last decade and described clinical presentation, imaging, operative findings, and outcomes. We also compared these lesions to those previously reported in the literature as well as the more common spontaneous encephaloceles of the middle cranial fossa. Results This study identified five cases with a mean age of 61.4 years, female-to-male ratio of 4:1, and a mean BMI of 31. Three cases presented with spontaneous pneumocephalus, one with CSF otorrhea, and one as an incidental imaging finding. Four defects were found medial to the sigmoid sinus and one was in the lateral retrosigmoid air cells.
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Affiliation(s)
- Shruthi K Rereddy
- a Department of Otolaryngology - Head and Neck Surgery , University of Pennsylvania School of Medicine , Philadelphia , PA , USA
| | - Douglas E Mattox
- b Department of Otolaryngology-Head and Neck Surgery , Emory University , Atlanta , GA , USA
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Sunna TP, Westwick HJ, Zairi F, Berania I, Shedid D. Successful management of a giant anterior sacral meningocele with an endoscopic cutting stapler: case report. J Neurosurg Spine 2016; 24:862-6. [PMID: 26745349 DOI: 10.3171/2015.8.spine15129] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Anterior sacral meningoceles (ASMs) are rare defects in the sacrum with thecal sac herniations and symptoms that commonly include constipation, dysmenorrhea, and urinary disturbances. An ASM causing hydronephrosis and acute renal failure from compression of the lower portion of the urinary tract is a rare clinical entity. Only one other case has been reported. The authors present the case of a 37-year-old man admitted for obstructive renal failure and hydronephrosis due to a giant ASM that measured 25 × 12 × 18 cm and compressed the ureters and bladder. The ASM was successfully treated via an anterior transabdominal approach in which the authors used a novel technique for watertight closure of the meningocele pedicle with an endoscopic cutting stapler. The authors review the literature and discuss the surgical options for the treatment of ASMs, specifically the management of ASMs in the context of obstructive renal failure and hydronephrosis.
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Affiliation(s)
- Tarek P Sunna
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
| | - Harrison J Westwick
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
| | - Fahed Zairi
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
| | - Ilyes Berania
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
| | - Daniel Shedid
- Department of Surgery, Division of Neurosurgery, Centre Hospitalier de l'Université de Montréal, Hôpital Notre-Dame, Montreal, Quebec, Canada
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Mankotia DS, Satyarthee GD, Singh B, Sharma BS. A rare case of giant occipital meningocele with Dandy Walker Syndrome: Can it grow bigger than this? J Pediatr Neurosci 2016; 11:344-347. [PMID: 28217162 PMCID: PMC5314853 DOI: 10.4103/1817-1745.199471] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Association of Dandy–Walker syndrome with occipital meningocele (OMC) is extremely rare and about thirty cases are reported till date in the Western literature. However, OMC is classified by Talamonti et al. into small, large, and giant categories with respective diameters were upto 5 cm in small, large with 5–9 cm, and giant with >9 cm. Usually the size of OMC progressively increases as raised intracranial pressure leads to compensatory cerebrospinal fluid escape into sac with the growth of children. Authors report an interesting case of an 18-month-old female child with extra-gigantic OMC, whose size was almost same since birth, representing the first case of its kind, who underwent successful surgical repair. Clinical presentation, radiological features, and surgical management options in literature are reviewed briefly for this rare disease association.
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Affiliation(s)
| | - Guru Dutta Satyarthee
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Bhoopendra Singh
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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49
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Abstract
A 4-year-old girl with a history of thoracic meningocele repair at the age of 3 months presented with progressive myelopathy. An intramedullary thoracic epidermoid was identified on MRI. The patient underwent excision of the epidermoid and subsequently returned to neurological baseline. This case illustrates the potential for delayed development of intraspinal epidermoid after initial repair of a simple meningocele.
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Affiliation(s)
- Bartosz T Grobelny
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Howard L Weiner
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - David H Harter
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
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50
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Abstract
Cranial Meningocoele is a term which represents herniation of meninges and cerebrospinal fluid through the congenital defect in the cranium. Anaesthetic challenges in the management of neonates with occipital meningocoele include airway management and proper positioning of the neonate without pressure on the meningocoele sac so as to preventthe rupture of the membranes. Associated congenital anomalies also can cause anaesthesia and procedure related complications. Other difficulties include performing a difficult airway case in an unfamiliar environment outside operation theatre. We report a case of 6 day old neonate with occipital meningocoele posted for MRI brain and the successful anaesthetic management.
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Affiliation(s)
- S. Neeta
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
| | - Madusudhan Upadya
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
| | - Sri Sruthi Pachala
- Department of Anaesthesiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
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