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|Year : 2020 | Volume
| Issue : 1 | Page : 9-10
His Master's Voice Expert Commentary on Pearls from Past
Department of Neurosurgery, AIIMS, New Delhi; National Brain Research Center (NBRC), Delhi, India
|Date of Web Publication||28-Feb-2020|
Prof. P N Tandon
Emeritus Professor, Department of Neurosurgery, AIIMS, New Delhi; President, National Brain Research Center (NBRC), 1, Jagrit Enclave, Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Tandon P N. His Master's Voice Expert Commentary on Pearls from Past. Neurol India 2020;68:9-10
| » Meningo-Encephaloceles|| |
I have described my experience with the unusual number and variety of these malformations seen during a short period of three and a half year while at KGMC, Lucknow and AIIMS, Delhi. I remember discussing this with Prof Banerji, who agreed that the paper should have the collective experiences of both AIIMS and KGMC.
A couple of years later, when I had the experience with 40 such patients, 1 had an opportunity to present it as a visiting professor at the Ulleval Hospital Oslo. My mentor there, Prof. Kristian Kristiansen suggested that it should be published in Acta Neurologica Scandinavica.
A Few years Later Prof J.D. Spillane while working on his book on Tropical Neurology, requested me to write a chapter on the subject. My Special interest increased in the management of the “Anterior” variety of these lesions. While we had successfully treated the “hernia”, I was dissatisfied with the cosmetic outcome, until I read a paper by the French Neurosurgeon Tessier. In association with our colleague and friend I.K. Dhawan, a plastic surgeon, we attempted to correct the cosmetic defect of a patient whose frontoethmoidal encephalocele I had excised and repaired earlier. It was a long operation lasting 7-8 hours on a few years' old child. This prompted us to modify the operation and perform a single-stage operation on a large series. Prof. AK. Mahapatra, then our Senior Resident assisted in these early operations and later independently treated and accumulated probably the largest experience with these lesions. He has published extensively on the subject.,,,,,
Thus, working on a “run of the mill” paper led to our increasing interest in a somewhat uncommon condition, with which few neurosurgeons in India or elsewhere except Thailand (Suwanwela and Colleagues), Casablanca had substantial experience.
To the best of our knowledge, none has such large experience with one-stage total correction of the frontoethmoidal encephaloceles.
The diagnosis is now possible antepartum by the screening of maternal serum AFP levels and antenatal ultrasound. CT scan (especially 3D CT scan) used to study the bony defect, and MRI is useful to distinguish the contents of the sac and other associated abnormalities.
In the past, the presence of hydrocephalus was recognised to be a decisive factor in the ultimate outcome of these patients, to the extent that surgery was deemed to be futile in such patients. However, nowadays, it is considered prudent to treat hydrocephalus first which will help in safe dural closure and mitigate the chances of postoperative CSF leakage. The possibility of development of hydrocephalus in the postoperative period should be kept in mind in these patients, even in the absence of preoperative hydrocephalus. The surgical outcome also depends upon the presence of associated intra-/extracranial anomalies, eloquence and amount of neural tissue present in the sac. In general occipital encephaloceles carry a much worse prognosis as compared to the frontal ones. Good outcomes are expected with normal head size at birth, absence of hydrocephalus and an intact initial neurological examination.
The principles of surgical treatment of encephaloceles are reduction of the herniation with preservation of as much viable brain as possible, water-tight dural closure with adequate skin coverage, repair of any cosmetic deformity, and cranial or craniofacial reconstruction. This can be achieved transcranially or transnasally. Mahapatraet al. have reported a series of four cases of transsellar encephalocele with good surgical outcomes for trans nasal/transpalatal approach over transcranial approach.
The increasing popularity of endoscopic endonasal approaches has provided an adjunct to the standard transcranial approaches in the treatment of these lesions, to some extent. The main limitation to endoscopic approaches is the absence of pneumatization of frontal and other sinuses till the age of 3-4 years in a child. Hence, majority of these patients require open surgical approaches.
| » References|| |
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Zoli M, Farneti P, Ghirelli M, Giulioni M, Frank G, Mazzatenta D, et al
. Meningocele and meningoencephalocele of lateral wall of sphenoid sinus. The role of endoscopic endonasal surgery. World Neurosurgery 2016;87:91-7.