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Table of Contents    
LETTER TO EDITOR
Year : 2013  |  Volume : 61  |  Issue : 5  |  Page : 543-545

Nasal encephalocele with herniated anterior cerebral arteries in an adult: A technical case report with special emphasis on technique of management of herniated cerebral vessels


1 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research, Dr RML Hospital, New Delhi, India
2 Department of Neurosurgery, Vikram Hospital, Bengaluru, Karnataka, India
3 Department of Ear, Nose and Throat, Vikram Hospital, Bengaluru, Karnataka, India

Date of Submission19-May-2013
Date of Decision10-Jul-2013
Date of Acceptance09-Oct-2013
Date of Web Publication22-Nov-2013

Correspondence Address:
B A Chandramouli
Department of Neurosurgery, Vikram Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.121947

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How to cite this article:
Sharma R, Chandramouli B A, Nayak P. Nasal encephalocele with herniated anterior cerebral arteries in an adult: A technical case report with special emphasis on technique of management of herniated cerebral vessels. Neurol India 2013;61:543-5

How to cite this URL:
Sharma R, Chandramouli B A, Nayak P. Nasal encephalocele with herniated anterior cerebral arteries in an adult: A technical case report with special emphasis on technique of management of herniated cerebral vessels. Neurol India [serial online] 2013 [cited 2021 Nov 28];61:543-5. Available from: https://www.neurologyindia.com/text.asp?2013/61/5/543/121947


Sir,

Nasal encephaloceles are herniations of the intracranial contents through a defect in the anterior skull base [1] and presenting for the first time in adult life is rare. [2] A large encephalocele may contain a major blood vessel supplying adjacent cerebral tissue. [3] We report one such case and discuss the management of the herniated anterior cerebral arteries.

A 54-years-old lady underwent bifrontal craniotomy, partial encephalocele evacuation, and anterior cranial fossa base repair using fascia lata graft 2 years back at another hospital for intermittent right nostril cerebrospinal (CSF) rhinorrhoea of 6 years duration. As cerebral vessels were seen herniating into the encephalocele tissue, it was not excised totally and herniating vessels were not reduced at that time. She presented to us with recurrent CSF rhinorrhoea since last 8 months. Examination revealed intermittent clear CSF rhinorrhoea from right nostril, impaired smell and nasal twang in voice. Contrast computed tomography/magnetic resonance imaging of head and paranasal sinuses showed right medial basifrontal brain parenchyma herniating into right ethmoid cells, right nasal cavity, and posterior nasopharynx through an anterior cranial fossa bone defect extending from posterior part of right cribriform plate to planum sphenoidale. Herniated encephalocele tissue core was containing bilateral anterior cerebral arteries and their branches within, herniating down into nasal cavity. There was no hydrocephalus or enhancing intracranial lesion [Figure 1] and [Figure 2]. DSA showed herniation of bilateral anterior cerebral arteries through anterior cranial fossa base bone defect into nasal cavity up to the orbital floor [Figure 3] a-d.
Figure 1: CT head and paranasal sinuses coronal (a - c) images bone windows showing skull base defect involving cribriform plate and ethmoid sinuses

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Figure 2: MRI brain and paranasal sinuses coronal (a) and sagittal (b) image showing brain parenchyma and blood vessel herniating through skull base defect into nasal cavity

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Figure 3: DSA (a - d) showing herniation of bilateral anterior cerebral arteries through anterior cranial fossa base bone defect into nasal cavity up to floor of the orbit

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She underwent combined transcranial and endonasal endoscopic approach by a combined team of neurosurgeons and endoscopic ENT surgeon. After lumbar drain placement, bifrontal craniotomy was reopened and midline subfrontal exposure was achieved. Anterior skull base defect margin and herniating brain tissue were identified using microscope. There were no obvious cerebral vessels on the anterior surface of the herniating brain. The herniating encephalocele tissue was then dissected at hernial hiatus; and the herniating anterior cerebral vessels were identified within it. They were thick walled and pulsatile, thus arteries. The circumferential peripheral encephalocele tissue was shrinked by bipolar coagulation to make space for dissection without injuring the cerebral vessels. Microscopic dissection was then continued vertically along these herniating cerebral vessels from base of herniating encephalocele tissue down till its tip and the complete loops of these herniating cerebral vessels were dissected free from the peripheral encephalocele tissue. The herniating encephalocele tissue was then disconnected from basifrontal brain and resected endonasally under endoscopic guidance in piecemeal fashion. The herniated anterior cerebral vessels loops and small surrounding encephalocele tissue were then reduced back into the cranial cavity. Anterior skull base defect margins were identified and the defect was repaired with fascia lata graft. The skull base defect was then strengthened by using a titanium mesh over the fascia lata. It was fixed to skull base using 4 mm miniscrews. This mesh was then sandwiched (covered by another layer of fascia lata), thus completing transcranial skull base defect repair. Both the layers of fascia lata graft were fixed to basal dura using 4-0 polypropylene stitches. After craniotomy closure, superior turbinate was endoscopically mobilized on a pedicle and placed to cover the skull base bone defect from below. Postoperative recovery was uneventful. Lumbar drain was removed on 7 th day. There was no CSF rhinorrhoea or nasal blockage at 9 months follow up.

Anterior cerebral arteries and their branches, which course along the under surface of the frontal lobe are likely to herniate along with nasal encephalocele due to traction force applied by herniated portion of brain parenchyma. [3] Vessel coagulation or injury during surgery can result in cerebral infarct or hemorrhage. Thus, special consideration should be given to these herniating cerebral vessels if they are noticed on imaging or are encountered during encephalocele excision. In this patient, the nasal encephalocele is congenital manifesting later in adult life and lack of prior history of craniofacial trauma and any sinonasal surgery rules out the likely possibility of acquired encephalocele. We used endonasal endoscopic approach as an adjuvant to transcranial approach as we wanted to secure cerebral vessels first thus avoiding any cerebral vessel injury during endoscope-guided endonasal encephalocele resection. Transcranial repair ensured skull base defect closure. Endoscopic endonasal superior turbinate pedicled graft closure of bone defect from below further strengthened our transcranial repair. Lumbar drain placed at start of procedure to drain out CSF also ensured healing at defect site and uptake of titanium mesh (sandwiched between two layers of fascia lata grafts). Junaid et al. [2] reported a 50-year-old female with right nostril CSF rhinorrhoea for 6-7 years, she was found to have a meningocele medial to middle turbinate, which was pushed back into the cranial cavity and a large bone defect in the posterior part of cribriform plate was repaired by combined endoscopic and transcranial approach. Bolger et al. [3] reported two cases of acquired encephaloceles with herniated cerebral vascular structures, which were managed endoscopically. [3]

To the best of our knowledge, this is the first case report of a congenital nasal encephalocele with herniated cerebral vessels in an adult, successfully managed by combined transcranial and endonasal endoscopic approach. Also, the microneurosurgical technique of identification of cerebral vessels within the encephalocele tissue at hernial hiatus followed by complete vessel loop dissection within the encephalocele tissue was technically demanding and unique.

 
  References Top

1.Gursan N, Aydin MD, Altas S, Ertas A. Intranasal encephalocele: A case report. Turk J Med Sci 2003;33:191-4.  Back to cited text no. 1
    
2.Junaid M, Sobani ZU, Shamim AA, Kazi M, Khan MJ. Nasal encephaloceles presenting at later ages: Experience of otorhinolaryngology department at a tertiary care center in Karachi, Pakistan. J Pak Med Assoc 2012;62:74-6.  Back to cited text no. 2
[PUBMED]    
3.Bolger WE. Management of cerebral vascular structures during endoscopic treatment of encephaloceles: A clinical report. Ann Otol Rhinol Laryngol 2006;115:167-70.  Back to cited text no. 3
[PUBMED]    


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