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1/303. Spontaneous cerebrospinal fluid (CSF) rhinorrhoea in spongiform dysplasia of the cranium: an unusual presentation of neurofibromatosis.

    A 20-year-old woman with neurofibromatosis presented with CSF rhinorrhoea. Spongiform dysplasia of the cranium was found. The dysplastic bone contained CSF. The exact site of the CSF fistula into the calvarium and into the paranasal sinuses could not be detected on investigation but nasal packing of the ethmoid and sphenoid sinuses controlled the rhinorrhoea. The unique features of this case are presented along with a brief review of the literature. ( info)

2/303. Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst.

    CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required. ( info)

3/303. Transnasal endoscopic repair of congenital defects of the skull base in children.

    OBJECTIVE: To examine imaging findings and methods of endoscopic treatment of congenital skull base defects in children. DESIGN: Retrospective study and case series. SETTING: Academic tertiary care center. patients: Four patients (aged 12 and 14 months and 8 and 13 years) were included from 1995 to 1997. Three presented with a nasal glioma, which was recurrent in 1 case. The fourth patient presented with bacterial meningitis due to a spontaneous cerebrospinal fluid leak. Computed tomography and magnetic resonance imaging were used to locate the defect of the skull base. INTERVENTION: Transnasal endoscopic resection of the glioma or the meningocele, with immediate repair of the skull base defects using free mucosal flaps and/or pediculized mucosal flaps and/or conchal cartilage together with fibrin glue and nasal packing during a 3-week period. RESULTS: None of the 4 patients has experienced recurrent cerebrospinal fluid leaks or postoperative meningitis. CONCLUSIONS: The transnasal endoscopic repair of congenital meningoceles is a reliable technique in select pediatric patients. Computed tomography and magnetic resonance imaging provide information that can be used to help the surgical procedure. ( info)

4/303. Spontaneous cerebrospinal fluid leakage detected by magnetic resonance cisternography--case report.

    A 49-year-old male with no history of head trauma suffered cerebrospinal fluid (CSF) discharge from the left nostril for one month. Coronal computed tomography (CT) showed lateral extension of the sphenoid sinus on both sides and CSF collection on the left side. CT cisternography could not identify the site of CSF leakage. Heavily T2-weighted magnetic resonance (MR) imaging (MR cisternography) in the coronal plane clearly delineated a fistulous tract through the sphenoid bone into the sphenoid sinus. Patch graft with muscle fragment completely relieved the CSF rhinorrhea. Postoperative three-dimensional CT showed the two bone defects identified during surgery. Small bony dehiscences in the sphenoid bone and lateral extension of the sphenoid sinus predisposed the present patient to CSF fistula formation. MR cisternography in the coronal and sagittal planes is superior to CT scanning or CT cisternography for detection of the site of active CSF leakage. ( info)

5/303. CSF rhinorrhoea from unusual site : report of two cases.

    CSF rhinorrhoea is associated with high morbidity and mortality. Bone and dural defects may result from trauma or enlarging 'pitholes' or breach in lateral recess of sphenoid sinus. Unless surgically corrected, they tend to cause meningitis and rhinorrhoea. Unusually delayed rhinorrhoea is a diagnostic problem. ( info)

6/303. Chronic hydrocephalus and suprasellar arachnoid cyst presenting with rhinorrhea.

    Spontaneous CSF leak with rhinorrhea may be secondary to many intracranial congenital and acquired conditions. However, no cases of chronic hydrocephalus and suprasellar arachnoid cyst presenting with rhinorrhea as the unique clinical manifestation are reported in the literature. A 29-year-old-man with four-month history of episodic rhinorrhea had a large suprasellar arachnoid cyst with chronic hydrocephalus on magnetic resonance. Endoscopic ventricular fenestration of the cyst failed to obtain remission of the CSF leak, because it was not possible to fenestrate the cyst with the almost completely obliterated suprasellar cistern. Clinical remission occurred after restoration of the CSF flow from the cyst to the cisternal spaces by a direct approach. The CSF leak in this case was secondary to the chronic compression over the dural and bone structures of the sellar region by the cyst or chronic hydrocephalus. ( info)

7/303. Intrasphenoid cephalocele: MRI in two cases.

    The intrasphenoid form of basal cephalocele is uncommon. We describe the clinical, CT and MRI findings in two cases presenting in middle age with persistent cerebrospinal fluid rhinorrhoea. Emphasis is placed upon the imaging findings which aid in discrimination of intrasphenoidal cephalocele from more common causes of a sphenoid sinus mass. ( info)

8/303. Intracranial mucocele as a complication of endoscopic repair of cerebrospinal fluid rhinorrhea: case report.

    OBJECTIVE AND IMPORTANCE: Endoscopic repair of an anterior cranial fossa cerebrospinal fluid (CSF) fistula has gained widespread acceptance. We report a case of mucocele development at the site of an endoscopic CSF leak repair. CLINICAL PRESENTATION: A 46-year-old woman underwent functional endoscopic sinus surgery for nasal obstructive symptoms. The surgery was complicated by an intraoperative CSF leak from the posterior cribriform plate/anterior sphenoid, which was repaired immediately using bone and mucosa grafts. Two years postoperatively, a 13-mm anterior cranial base mass was found incidentally. This mass increased to 20 mm over the next year. INTERVENTION: The anterior cranial base mass was excised via a right frontal craniotomy and confirmed histologically to be a mucocele. CONCLUSION: Endoscopic repair of an anterior cranial base CSF fistula with mucosal grafts may lead to formation of a mucocele. ( info)

9/303. skull base reconstruction utilizing titanium mesh in chronic CSF leakage repair.

    OBJECTIVE AND IMPORTANCE: Chronic cerebrospinal fluid leakage is a perplexing management problem in skull base surgery, as well as craniofacial and certain otolaryngologic procedures. When all less invasive techniques have been tried and have failed, craniotomy for direct repair is often done. CLINICAL PRESENTATION: This case represents one such case in which the pathology found required an unusual application of a common surgical adjunct for correction. The patient in question had experienced CSF rhinorrhea intermittently for 10 years prior to presentation. Several intracranial procedures had failed to curtail the rhinorrhea, after failure of lumbar drainage and other less invasive procedures had also failed. The patient was taken to surgery again for an attempt to directly correct the CSF leak, after demonstration of the location of the leak was accomplished with the assistance of contrasted coronal CT images of the anterior fossa. TECHNIQUE: At the time of surgery, comminuted fractures of the floor of the anterior fossa were noted. These fractures were associated with multiple sites of dural impingement. Following meticulous repair of all dural injuries, reconstruction of the floor of the anterior fossa was accomplished with the use of titanium micro mesh. The mesh placement isolated the dura from further contact with the fracture surfaces, preventing recurrent dural injury. CONCLUSION: The use of titanium mesh in skull base surgery has previously been reported in craniofacial and cranial vault procedures. Its use in skull base applications may prove useful in certain situations. This patient remains asymptomatic nearly 2 years after its use, longer than with any previous procedures to correct his chronic CSF leakage. ( info)

10/303. Intracranial malposition of a nasogastric tube following repair of choanal atresia.

    Intracranial penetration during attempted nasogastric intubation is a rare, often lethal occurrence. We report the inadvertent introduction of a nasogastric tube intracranially in a neonate following repair of unilateral choanal atresia. Following manual removal of the tube, the patient made a good recovery. ( info)
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