Surgical Management of a Traumatic Brain Herniation Through the Bregmatic Fontanelle in a Dog.

A 1 yr old female Chihuahua was presented for traumatic skull injury. Computed tomography revealed brain herniation through the bregmatic fontanelle. The hernia was manually reduced, and the defect was repaired using a polypropylene mesh. To the authors' knowledge, this is the first reported case of brain herniation through the bregmatic fontanelle in a dog.

Transillumination of an Anterior Fontanelle Dermoid Cyst.

Dermoid cysts are slowly growing benign lesions of ectodermal tissue that often occur in the anterior fontanelle. Clinicians often rely on a negative transillumination test to begin the process of correctly diagnosing a dermoid cyst. However, here the authors present a case of a 7-month-old girl who presents with a transilluminating dermoid cyst.

Improvement in ventriculomegaly following cervicomedullary decompressive surgery in children with achondroplasia and foramen magnum stenosis.

The role of cervicomedullary decompression (CMD) in the care of hydrocephalic achondroplastic children who present with simultaneous foramen magnum stenosis is not well understood. We sought to determine the percentage of symptomatic achondroplastic children with foramen magnum stenosis who had stabilization or improvement in ventriculomegaly following CMD. The authors retrospectively reviewed the records of pediatric patients at Cedars-Sinai Medical Center with achondroplasia and signs of progressive ventriculomegaly who underwent CMD for symptomatic foramen magnum stenosis between the years 2000 and 2018. Clinical outcomes included changes in fontanelle characteristics, head circumference (HC) percentile, and incidence of ventriculoperitoneal (VP) shunting. Radiographic outcomes measured included changes in Evans ratio. We excluded individuals who were shunted before CMD from our study. Sixteen children presented with symptomatic foramen magnum stenosis and full anterior fontanelle or jump in the HC percentiles. Two children underwent placement of a VP shunt before decompressive surgery and were excluded from further analysis. Of the remaining 14 children who underwent CMD, 13 (93%) showed softening or flattening of their fontanelles post-operatively. Ten of these 14 children had both pre- and post-operative HC percentile records available, with 8 showing increasing HC percentiles before surgery. Seven of those eight children (88%) showed a deceleration or stabilization of HC growth velocity following decompression of the foramen magnum. Among 10 children with available pre- and post-operative brain imaging, ventricular size improved in 5 (50%), stabilized in 2 (20%), and slightly increased in 3 (30%) children after decompression. Two children (14%) required a shunt despite decompression of the foramen magnum. A significant proportion of children with concomitant signs of raised intracranial pressure or findings of progressive ventriculomegaly and foramen magnum stenosis may have improvement or stabilization of these findings following CMD. CMD may decrease the need for VP shunting and its associated complications in the select group of hydrocephalic children with achondroplasia presenting with symptomatic foramen magnum stenosis.

Accessory maxillary ostium repair using middle turbinate flap: a case series of 116 patients with chronic rhinosinusitis.

BACKGROUND: The ostiomeatal complex (OMC), comprising a small natural maxillary sinus ostium and narrow infundibulum, transmits the air diffusion into the antrum and mucociliary transport from the antrum, and is considered a key area in chronic rhinosinusitis (CRS). Thin membranous anterior and posterior fontanelle areas below the OMC can rupture forming a perforation, accessory maxillary ostium (AMO), that increases antral airflow changing the anatomy and function of the sinus. The purpose of this study was to report the first case series of CRS patients who had undergone repair of fontanelle defects aiming to reconstruct normal structures. METHODS: Between 2011 and 2017, a total of 157 perforations were diagnosed and repaired in 121 of 525 consecutive endoscopic sinus operations performed by the author. Defects were 3 mm to 4 mm in size (range, 1 mm to 7 mm). A flap cut from the undersurface of the middle turbinate was used. In total, 101 patients received concurrent balloon catheter dilation (BCD), while 15 patients had only an AMO repair. The mean endoscopic follow-up time was 16 weeks (range, 1 to 188 weeks). RESULTS: Overall, 101 perforations were closed, 21 open, and 17 partially open. A history of earlier endoscopic sinus surgery (ESS) or BCD surgery, presence of nasal polyposis or whether the repair was made without simultaneous BCD did not influence the closure rate. Postoperative febrile sinusitis occurred in 26 patients. CONCLUSION: Repair of AMO is in theory a beneficial and technically feasible office procedure with only transient side effects. Three out of 4 perforations were closed after repair.

Extent of surgery in endoscopic transsphenoidal skull base approaches and the effects on sinonasal morbidity.

BACKGROUND: Endoscopic transsphenoidal skull base surgery (ETSS) is now considered the criterion standard approach for resection of pituitary adenomas and other midline anterior skull base lesions. Normal sinonasal structures are resected during ETSS, which raises concerns for nasal morbidity and patient-based outcome. OBJECTIVE: To perform a surgical outcome assessment by examining whether the extent of ETSS approaches affected patient-specific sinonasal quality of life as measured by the 22-item Sino-Nasal Outcome Test (SNOT-22). METHODS: A single-center prospective cohort study of patients operated on by the same skull base team between 2012 and 2016. Patients with completed pre- and postoperative SNOT-22 were included. The primary outcome was SNOT-22 scores at preoperative, 0-1 month, 2-4 months, >5 months follow-up. Age, sex, tumor pathology, surgical procedure, and intraoperative cerebral spinal fluid leak repair were also obtained. RESULTS: Of the 249 ETSS performed, 148 patients (59%) had at least one completed SNOT-22; 45 (18%) met the inclusion criteria. Sinonasal quality of life based on SNOT-22 at the 0-1-month follow-up was significantly worse than the presurgical levels (p < 0.05). However, there was a return of SNOT-22 scores to preoperative levels at 2-4 months (p > 0.05), which was sustained at >5 months (p > 0.05). Factors such as the extent of ETSS, a previous nasal surgery, repair of an intraoperative cerebral spinal fluid leak, and the tumor pathology did not affect SNOT-22 scores at any follow-up intervals (p > 0.05). CONCLUSION: Sinonasal quality of life worsened after ETSS at 0-1 month follow-up but returned to preoperative levels at 2-4 months and remained at postoperative levels >5 months. Analysis of these data will allow us to educate our patients that the anticipated nasal morbidity after ETSS is usually only transient and should be expected to recover to preoperative levels.

Introduction of percutaneous-tunneled transfontanellar external ventricular drainage in the management of hydrocephalus in extremely low-birth-weight infants.

OBJECTIVE Hydrocephalus treatment in extremely low-birth-weight (ELBW) infants still represents a challenge for the pediatric neurosurgeon, particularly when the patient weighs far less than 1000 g. In such cases, the benefits in terms of neurological outcome following early treatment do not always outweigh the surgical risks, especially considering the great difference in the surgical risk before patient weight increases. To assess the efficacy and reliability of a percutaneous-tunneled, transfontanellar external ventricular drain (PTTEVD) in ELBW infants, the authors started a new protocol for the early surgical treatment of hydrocephalus. METHODS Ten cases of posthemorrhagic hydrocephalus (PHH) in ELBW infants (5 cases < 700 g, range for all cases 550-1000 g) were treated with a PTTEVD that was implanted at bedside as the first measure in a stepwise approach. RESULTS The average duration of the procedure was 7 minutes, and there was no blood loss. The drain remained in place for an average of 24 days (range 8-45 days). In all cases early control of the hydrocephalus was achieved. One patient had a single episode of CSF leakage (due to insufficient CSF removal). In another patient Enterococcus in the CSF sample was detected the day after abdominal surgery with ileostomy (infection resolved with intrathecal vancomycin). One patient died of Streptococcus sepsis, a systemic infection existing prior to drain placement that never resolved. One patient had Pseudomonas aeruginosa sepsis prior to drain insertion; a PTTEVD was implanted, the infection resolved, and the hydrocephalus was treated in the same way as with a traditional EVD, while the advantages of a quick, minimally invasive, bedside procedure were maintained. Once a patient reached 1 kg in weight, when necessary, a ventriculoperitoneal shunt was implanted and the PTTEVD was removed. CONCLUSIONS The introduction of PTTEVD placement in our standard protocol for the management of PHH has proved to be a wise option for small patients.

Cystic Congenital Scalp Inclusion Dermoid: A Case Report.

Dermoid cysts are developmental tumours that develop from germ cells displaced between the 3rd and 5th week of embryogenesis. Although dermoid cysts are known to be the most common scalp swellings; cystic congenital inclusion dermoid of the anterior fontanelle is a very rare scalp swelling. It is a benign, slow-growing, non-tender, soft swelling which is covered with intact skin. Ruling out intracranial extension is necessary. Computed Tomography is the investigation of choice for its diagnosis. We describe such a rare case of cystic congenital inclusion dermoid of the anterior fontanelle where the cyst was completely excised.

Congenital dermoid cyst at the anterior fontanelle: neuroimaging before and after fontanelle closure.

We report on a 2-month-old boy with a dermoid cyst arising at the anterior fontanelle, with observation during both the open and closed stages of the fontanelle. The etiology of this benign, curable tumor is discussed.

Uncinectomy through the anterior nasal fontanelle in endoscopic sinus surgery.

In functional endoscopic sinus surgery, the resection of the uncinate process is an important step. The traditional method of performing uncinectomy is associated with the risk of penetrating the lamina papyracea and orbital fat exposure. Without timely detection and appropriate treatment, uncinectomy may lead to serious consequences such as blindness. In our study, we used the novel approach of performing uncinectomy through the anterior nasal fontanelle. Orbital complications were observed in 4 of the 112 patients who underwent the traditional method; however, no complication was observed in patients who underwent surgeries with the new approach (P < 0.01). No nasolacrimal duct injury or eye movement disorder was observed in the 2 groups. The percentage of opening of the maxillary sinus ostia by using the new method was significantly greater than that achieved by using the traditional method (97.93% and 70.53%, respectively). The mean score in the visual analog scale, which is used to measure the efficacy of the procedure, for the new method was lower than that for the traditional method, and the difference was statically significant (t = 4.17, P < 0.01). Six and 12 months after the operations, the Lund-Kennedy endoscopy scores obtained when the new method was used were lower than those obtained when the traditional method was used (t = 3.27 and t = 4.40, respectively; P < 0.05). Therefore, uncinectomy through the anterior nasal fontanelle was a convenient and safe procedure and ensured good exposure of the maxillary sinus ostia. This procedure effectively improved the efficacy of endoscopic sinus surgery.

Combined fontanelle puncture and surgical operation in treatment of desmoplastic infantile astrocytoma: case report and a review of the literature.

Desmoplastic infantile astrocytoma is a rare low-grade malignant brain tumor found in infants. Its pathological diagnosis can be made on the basis of its histological characteristics and immunohistochemical staining. A case of desmoplastic infantile astrocytoma, including its clinical manifestations, pathological characteristics, differential diagnosis, treatment, and prognosis, is reported. Presurgical percutaneous decompression and subsequent resection resulted in a satisfactory therapeutic outcome.

Correction of depressed forehead with BoneSource in cleidocranial dysplasia.

Cleidocranial dysplasia is a well-documented rare congenital disorder of the bone characterized by abnormalities of the skull, clavicle, and dentition. Despite numerous observations, there are still comparatively few reports regarding patients with cleidocranial dysplasia that focus on the impact of reconstruction of these defects on facial aesthetics. We report a 19-year-old woman with opened metopic and sagittal sutures and delayed closure of the anterior fontanelle. Through bicoronal incision and pericranial elevation, the defect was fully exposed. BoneSource was used to fill the cranial defect and was contoured to the desired cosmetic outcome. During a 24-month follow-up period, no absorption or recurrence was seen, and the patient was satisfied.