Sealing the Box: Microsurgical Repair of Skull Base Encephaloceles: 2-Dimensional Operative Video.

Abstract

Encephaloceles are pathologic herniations of brain parenchyma through a bone defect.1 Spontaneous encephaloceles occur most commonly in the lateral recess of the sphenoid and the ethmoid roof.2-4 Surgical repair is necessary to eliminate the risk of recurrent or fatal meningitis.5 Standard transsphenoidal approaches provide limited visualization of certain areas,6 and failure to obtain a durable repair is not uncommon.2,7-9 Notwithstanding the good results reported with endoscopic repairs and the increased popularity of this approach,10-14 additional pterygoid and pterygopalatine fossa dissection may be required, with concomitant risk of vidian or maxillary nerve dysfunction and postoperative dry eye.10,15 This is particularly relevant with laterally located encephaloceles. The ideal operative approach requires complete exposure of the encephalocele, permits surgical amputation, and allows definitive repair by inlay grafting supported by a vascularized epidural flap. The exact site of the defect must be precisely determined by detailed imaging studies, frequently requiring cisternography in cases of small defects.16 Coincident empty sella syndrome is common in spontaneous cerebrospinal fluid leaks but does not necessarily indicate the site of origin.3,17,18 When the defect is located laterally (eg, medial middle fossa, temporal bone, and middle ear) or anteriorly (frontal or ethmoidal regions), we favor a microsurgical approach for its limited dissection through a smaller craniotomy, low complication risk because of largely extradural dissection, and ready availability of an anodyne-vascularized temporal or pericranial flap.19 We describe 2 cases of microsurgical repair of spontaneous encephaloceles, one in the frontoethmoidal region and the other in the anteromedial middle fossa. The patients consented to surgical repair. Images at 2:14 and 2:29 © Ossama Al-Mefty, 1997. Used with permission. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_ofvgxssh"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]}