Hindawi Publishing Corporation

Case Reports in Medicine

Volume 2012, Article ID 763259, 4 pages
doi:10.1155/2012/763259

Case Report
Gigant Transethmoidal Meningoencephalocele Operated by
Full Endonasal Endoscopic Approach: Case Report

Omar Lopez Arbolay, Jorge Rojas Manresa,

Justo Gonzalez Gonzalez, and Jose Luis Bretón Rosario
Neurosurgery Department of Hermanos Ameijeiras Hospital, Havana 10348, Cuba

Correspondence should be addressed to Omar Lopez Arbolay, [email protected]

Received 18 September 2011; Accepted 6 December 2011

Academic Editor: Mark E. Shaffrey

Copyright © 2012 Omar Lopez Arbolay et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Intranasal meningoencephaloceles have historically been managed by neurosurgeons, although their main clinical manifestations
are rhinological. Recent advances in endoscopic skull base surgery has significantly improved the treatment of these lesions and
consequently diminished appreciable surgical morbidity. We report an ethmoidal meningoencephalocele case operated on by
endonasal endoscopic approach for removal of the lesion and reconstructing the associated skull base. From this experience, we
conclude that removal of the lesion and watertight closure of the skull base irrespective of the size of the mass and anterior skull
base defect are the operation’s most important aspects.

1. Introduction leading investigation because it is able to show the protruded

brain tissues and their relationship with neighboring struc-
Intranasal meningoencephaloceles are an infrequent condi- tures. A special useful test to demonstrate the bony defect
tion characterized by protrusion of meningeal and brain will be the CT scan with bone window [1].
tissue through a skull-base defect. Congenital anomalies are We present a case with transethmoidal meningoen-
the main cause [1], but they may have also a traumatic or cephalocele that was operated on by endonasal endoscopic
a spontaneous origin [2, 3]. According to the location, technique.
meningoencephaloceles are classified in: occipital, cranial
vault, posterior fosse, and basal. The incidence of this rare 2. Clinical Case
condition range between 0.1 to 0.5 of 1,000 birthrates. Basal
meningoencephalocele represents 1.5% of all these lesions, Our case is a 55-year-old female patient, who 23 years ago
and are classified as: transethmoidal, sphenoethmoidal, underwent transsphenoidal surgery for an intrasellar cyst.
transsphenoidal, and frontosphenoidal [4, 5]. In transeth- Five years after the surgery, hydrocephalus with cerebral
moidal type, a defect on the cribriform plate is observed, spinal fluid leakage occurred and it was resolved by the place-
commonly small and limited to one side [6]. Nasal CSF ment of a ventriculoperitoneal shunt. Computed tomogra-
leakage, headache, and nasal obstruction, are frequently the phy did not define the bone defect at the site of previous
chief complaints. Rarely, seizure is observed but meningitis is surgery at that time. The patient presented before us, two
common. years ago, with recurrent profuse rhinorrhea and nasal
On physical examination, it is possible to find an in- obstruction. She was admitted in Neurosurgical Department
tranasal mass, leakage of a clear liquid across the nose, with headache, fever and vomiting, and bacterial meningitis
olfaction lost, and other craniofacial defects in the congenital which was successfully treated with antibiotics was diag-
encephaloceles. Some studies may be performed to establish nosed. MRI revealed protrusion of the brain and meninges
the diagnosis, but magnetic resonance imaging (MRI) is the from the anterior cranial fossa to the upper right nasal cavity.
2 Case Reports in Medicine

Figure 1: MRI, coronal view. Figure 3: CT scan.

Figure 4: Endoscopic view of big meningoencephalocele within

right nasal cavity.

Figure 2: MRI, sagital view.

3. Discussion
A multidisciplinary management is recommended in the
diagnosis and treatment of meningoencephalocele. Surgi-
cal procedures include removal and anterior fossa defect
The T1-weighted sequences showed downward herniation of reconstruction by craniotomy and more recently endonasal
the ethmoidal roof on the right nasal cavity and T2-weighted endoscopic resection and repair or combination of these two
coronal, and sagital imaging confirmed a liquid-filled mass in techniques to remove the lesion and repair the defect [7–14].
the right ethmoidal sinus and nasal cavity projecting through Endonasal endoscopic procedures and special develop-
a defect in the ethmoidal roof (Figures 1 and 2). Computed ment of extended endonasal endoscopic approaches have
tomography confirmed these findings (Figure 3). increased the interest on treating this kind of lesion. That
An extended endonasal endoscopic approach to the ante- is why the treatment of meningoencephaloceles has become
rior cranial base was practiced. A big meningoencephalocele more popular.
within right nasal cavity was found (Figure 4). By using As the first step in the surgery, meningoencephalocele
bipolar forceps the lesions were reduced. Middle turbinate is carefully and gradually removed using bipolar cauterizing
was atrophic and middleward displaced. When the lesion up to the level of the skull base. Then, mucosa surrounding
was completely removed, a bony defect at the junction of skull-base defect is removed and the defect is prepared for
ethmoidal sinus and posterior wall of the frontal bone were the graft.
observed (Figure 5). This was reconstructed inlaying a free Selection of the graft material depends on the defected
intradural fat graft and an epidural layer of bone, which size and configuration, underlying pathophysiology and the
was then covered with a nasoseptal flap. This was supported surgeon’s preference [15]. A multilayer repair is preferred not
with balloon of 12 French Foley catheter in order to press only to stop the CSF leak, but to reinforce the thin skull base
the multilayer reconstruction against the defect. The patient and prevent meningoencephalocele recurrence [16, 17].
had an uneventual recovery. There were no cerebrospinal Autologous-free or pedicellate mucoperichondrial grafts,
rhinorrhea or any other complications and the patient was fascia, turbinate grafts, cartilage grafts, pericranial-galeal,
discharged six days after the surgery. and bone grafts have all been used successfully. Heterologus
Case Reports in Medicine 3

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4 Case Reports in Medicine

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