RNF213 vasculopathy manifested in various forms within a family: A case report.

RATIONALE: The ring finger protein 213 (RNF213) p.R4810K variant has been identified as being associated with Moyamoya disease (MMD), a condition that is more prevalent in East Asians. This association extends beyond cerebral vessels and has been implicated in coronary artery disease. PATIENT CONCERNS: A 36-year-old female was admitted to the emergency room with chest pain. Although the patient had no known underlying conditions or risk factors for atherosclerosis, she was diagnosed with unstable angina and underwent percutaneous coronary intervention. Given her older sister's ongoing treatment for MMD, it was suspected that the patient's coronary artery disease might be linked to the MMD-associated gene mutation. DIAGNOSES: Coronary angiography revealed 80% narrowing of the proximal left anterior descending artery. Based on clinical symptoms and coronary angiography, we diagnosed it as unstable angina. INTERVENTION: Due to the family history of MMD and detection of the RNF213 p.R4810K heterozygous variant in the patient's older sister, genetic counseling was recommended. Next-generation sequencing for vascular diseases was performed. OUTCOMES: Genetic testing confirmed the presence of an RNF213 p.R4810K heterozygous variant in the patient, mirroring that in her sister. An RNF213 p.C4397R heterozygous variant was identified concomitantly, although it was categorized as a variant of uncertain significance. Coronary artery disease has been attributed to the RNF213 p.R4810K variant. LESSONS: Although MMD is rare in Western populations, it is more common in East Asian populations. Traditionally, MMD diagnoses have focused solely on the cerebral vessels without guidelines for the assessment of other vascular involvements. This familial case underscores the fact that a single genetic mutation can manifest in diverse ways in different diseases. Hence, the need and regularity of systemic vessel screening should be thoughtfully considered in such a context.

Analysis of sagittal parameters for easier and more accurate determination of cervical spine alignment.

Cross-sectional comparative study. This study aimed to analyze the role of cervical parameters, in terms of the perception process, when evaluating cervical sagittal balance on an X-ray image. Reports on the role of cervical parameters in the perception of cervical sagittal balance have not been made. The study included 4 board-certified neurosurgeons and 6 residents of a neurosurgical department. They were instructed to answer a total of 40 questions. The parameter that was the most helpful in deriving the answer was checked. The correct answer rate, dependency on the parameter, and correct answer contribution of the parameter were analyzed. Among the various parameters, 5 parameters [C2-7 angle (C2-7A), T1 slope minus cervical lordosis (T1s-CL), C2 slope (C2s), C7 slope (C7s), and C2-7 sagittal vertical axis) were selected. The simple parameter (C2s, C7s) has a higher dependency and correct answer contribution than the complex parameter (C2-7A, T1s-CL). The angular (C2-7A, T1s-CL, C2s, C7s) parameters have a higher dependency; however, both the length and angular parameters correct answer contribution were similar. The cervical parameters that have simpler properties were highly preferred and had a lower perception error.

The safety and effectiveness of lumbar drainage for cerebrospinal fluid leakage after spinal surgery.

PURPOSE: Cerebrospinal fluid (CSF) leakage is a frequent complication after spinal surgery. The lumbar drainage procedure (LDP) is the preferred method for early closure of a dural tear. This study was conducted to assess the safety and effectiveness of LDP after spinal surgery. MATERIALS AND METHODS: We retrospectively reviewed 122 patients (55 male and 67 female) who underwent LDP after spinal surgery between January 2010 and June 2021. LDP was performed on patients with suspected CSF leakage due to a dural tear during spinal surgery or in whom mixed-color CSF was observed in the hemo-drain after surgery. LDP was performed aseptically by a resident according to our institution's protocol, and the amount drained was from 200cc to 300cc per day. Absolute bed rest was maintained during the lumbar drainage period. The hemo-drain was opened to confirm that CSF was no longer mixed or oozing, at which time the lumbar drain was removed. Culture was performed at the drain tip when the lumbar drain was removed. RESULTS: The spinal surgery level was cervical in 23 patients, thoracic in 27 patients, and lumbar in 72 patients. The mean duration of the indwelling lumbar drain was 7.2 days (2 days-18 days), and the mean amount of drainage was 1198.2cc (100cc-2542cc). Among the 122 patients, the CSF leakage in 101 patients was resolved with the initial procedure, but 21 patients required re-insertion. Of those 21 patients, improper insertion due to a technical problem occurred in 15 patients, poor line fixation occurred in 2 patients, and CSF leakage was again observed after removal of the lumbar drain in 4 patients. In only 1 case was open surgery done after LDP because follow-up magnetic resonance imaging showed a suspected infection. During lumbar drainage, 76 patients used antibiotics, and 46 patients did not. Four patients showed bacterial growth in the tip culture, and 3 of them had been using antibiotics. All 4 of those patients were treated without complications and discharged. Among the 122 patients, 1 patient was discharged with left hemiparesis due to cerebral venous infarction (CVI) and hemorrhage after LDP, and 1 patient underwent re-operation because the CSF collection was not resolved. CONCLUSIONS: No major complications such as systemic infection, deep vein thrombosis, or aspiration pneumonia occurred during the lumbar drainage, except for 1 patient (0.8%) with CVI caused by over-drainage. One patient (0.8%) required open surgery after LDP, but no cases of systemic infection occurred while maintaining lumbar drainage, irrespective of antibiotic use. In conclusion, LDP is a safe and effective treatment for CSF leakage after spinal surgery.

Failure to Obtain Baseline Signals of Transcranial Motor-Evoked Potentials in Spine Surgery: Analysis of the Reasons.

OBJECTIVE: Among the various intraoperative neurophysiologic monitoring (IONM) techniques, transcranial motor-evoked potential (Tc-MEP) has recently become the most widely used method to monitor motor function. However, we often find that Tc-MEP is not sufficiently detected at the start of surgery. Therefore, we aimed to analyze the reasons and risk factors for not detecting sufficient baseline signal of Tc-MEP from the beginning of spinal surgery. METHODS: We categorized IONM data from 1058 patients who underwent spine surgeries at a single institution from 2014 to 2020 and categorized them into 2 groups: 1) "poor MEP" if Tc-MEP could not be sufficiently obtained and 2) "normal MEP" if Tc-MEP could be sufficiently obtained from the surgery. We analyzed the patient's age, gender, underlying disease, operation type, level numbers, baseline motor function, existence of pathologic reflex, myelopathy, and duration from the onset and clinical diagnosis. RESULTS: The rate of failure to obtain sufficient baseline Tc-MEP signals in spine surgery was 21.8% (231/1058). Multivariate analysis showed significant associations of existence of diabetes mellitus, myelopathy, thoracic spine surgery, baseline motor deficit and tumor, and trauma disease with loss of meaningful and interpretable signals in baseline Tc-MEP (P < 0.05). Only 15 of 231 patients (6.4%) showed a trend of signal recovery after decompression procedures. CONCLUSIONS: Various factors (myelopathy, diabetes mellitus, thoracic surgery, baseline motor deficit, tumor, and trauma) were closely related to not obtaining sufficient baseline signals for Tc-MEP. When operating on patients with these considerations, we need to consider the efficacy and usefulness of Tc- MEP.

Penetrating Head Injury Resulting From Wild Boar Attack in Republic of Korea: A Case Report.

Few cases of injuries caused by wild boars have been reported in the literature. Here, we present the case of a 64-year-old male patient who was attacked by a wild boar. The patient had a laceration to the right forehead and a penetrating wound in the area before the right auricle. Computed tomography scan revealed traumatic subarachnoid hemorrhage, subdural hemorrhage, right temporal lobe contusion hemorrhage, pneumocephalus, right zygomatic arch and temporal bone fracture, and right coronal process fracture of the mandible. Prophylactically, 2,000 mg of ceftriaxone and 400 mg of moxifloxacin were intravenously administered every 24 hours. An emergency craniectomy was performed because the skull fracture was an open fracture and control of the increased intracranial pressure was necessary. Inactivated Rabies Virus Vaccine was also administered postoperatively. We concluded that, unlike typical wounds from other traumatic causes, the risk of wound infection is higher. In order to reduce morbidity and mortality due to wild boar attacks, rapid stabilization of the patient's vital signs, prevention of infection with appropriate antibiotics, and surgical intervention at the appropriate time and method are necessary.

Screw Insertional Torque Measurement in Spine Surgery: Correlation With Bone Mineral Density and Hounsfield Unit.

OBJECTIVE: Achieving successful fusion during spine surgery is dependent on rigid pedicle screw fixation. To assess fixation strength, the insertional torque can be measured during intraoperative screw fixation. This study aimed to explore the technical feasibility of measuring the insertional torque of a pedicle screw, while investigating its relationship with bone density. METHODS: Thoraco-lumbar screw fixation fusion surgery was performed on 53 patients (mean age, 65.5 ± 9.8 years). The insertional torque of 284 screws was measured at the point passing through the pedicle using a calibrated torque wrench, with a specially designed connector to the spine screw system. The Hounsfield units (HU) value was determined by assessing the trabecular portion of the index vertebral body on sagittal computed tomography images. We analyzed the relationship between the measured insertional torque and the following bone strength parameters: bone mineral density (BMD) and HU of the vertebral body. RESULTS: The mean insertion torque was 105.55 ± 58.08 N∙cm and T-score value (BMD) was -1.14 ± 1.49. Mean HU value was 136.37 ± 57.59. Screw insertion torque was positively correlated with BMD and HU in whole patients. However, in cases of osteopenia, all variables showed very weak correlations with insertional torque. In patients with osteoporosis, there was no statistically significant correlation between BMD and torque strength; HU showed a significant correlation. CONCLUSION: The insertional torque of screw fixation significantly correlated with bone density (BMD and HU). HU measurements showed greater clinical significance than did BMD values in patients with osteoporosis.

Analysis of Parameters That Can Predict the Cervical Sagittal Vertical Axis in Cervical Fusion Surgery.

OBJECTIVE: The absolute value of the cervical sagittal parameters cannot be guaranteed with certainty on all follow-up cervical radiographs. With the assumption that neck posture changes can occur at any time at each follow-up radiographic session, we examined whether the sagittal parameters change meaningfully and identified the factors most closely related to the C2-C7 sagittal vertical axis (SVA). METHODS: We enrolled 200 patients who had undergone either anterior cervical fusion (n = 100) or posterior cervical fusion (n = 100). The craniovertebral angle (CVA), mandible angle (MA), occipital slope (Os), C2 slope (C2s), C7 slope (C7s), and C2-C7 SVA were measured on 2 different follow-up radiographs after surgery. The C2-C7 angle (C2-C7A) and changes (Δ) in the sagittal parameters between the 2 radiographs were then calculated. RESULTS: The ΔC2s and ΔCVA showed a very strong correlation with the ΔC2-C7 SVA (r = |0.70-0.93|). An independent t test showed a statistically significant difference for multiple sagittal parameters (i.e., ΔMA, ΔOs, ΔC2s, ΔC7s, and ΔCVA) between the large and small ΔC2-C7 SVA groups. In contrast, the change in the C2-C7A was without statistical significance. A stepwise multivariate regression analysis revealed a high adjusted R2 value (0.841) between the ΔC2-C7 SVA and 2 parameters (standardized coefficient: ΔCVA, -0.563; ΔC2s, -0.398). CONCLUSIONS: During cervical fusion surgery, the CVA was the most predictable parameter reflecting the C2-C7 SVA in various analyses. The upper cervical parameters (Os and C2s) provided more explanatory power regarding the C2-C7 SVA changes than did the lower cervical parameter (C7s) or the presence of cervical lordosis (C2-C7A).

Activation of CamKIIα expressing neurons on ventrolateral periaqueductal gray improves behavioral hypersensitivity and thalamic discharge in a trigeminal neuralgia rat model.

BACKGROUND: Preceding studies have reported the association of chronic neuropathic orofacial pain with altered ongoing function in the ventrolateral periaqueductal gray (vlPAG). However, its role in trigeminal neuralgia (TN) lacks attention. We here reported the aspect that vlPAG neurons play in TN nociceptive processing by employing excitatory neuron-specific optogenetic approaches. METHODS: TN was generated via unilateral infraorbital nerve chronic constriction in Sprague Dawley rats which induced mechanical and thermal pain sensitivity in air puff and acetone test, respectively. Channelrhodopsin conjugated virus with CamKIIα promoter was used to specifically activate the excitatory vlPAG neuronal population by optogenetic stimulation and in vivo microdialysis was done to determine its effect on the excitatory-inhibitory balance. In vivo extracellular recordings from ventral posteromedial (VPM) thalamus were assessed in response to vlPAG optogenetic stimulation. Depending on the experimental terms, unpaired student's t test and two-way analysis of variance (ANOVA) were used for statistical analysis. RESULTS: We observed that optogenetic activation of vlPAG subgroup neurons markedly improved pain hypersensitivity in reflexive behavior tests which was also evident on microdialysis analysis with increase glutamate concentration during stimulation period. Decreased mean firing and burst rates were evident in VPM thalamic electrophysiological recordings during the stimulation period. Overall, our results suggest the optogenetic activation of vlPAG excitatory neurons in a TN rat model has pain ameliorating effect. CONCLUSIONS: This article presents the prospect of pain modulation in trigeminal pain pathway via optogenetic activation of vlPAG excitatory neurons in rat model. This outlook could potentially assist vlPAG insight and its optogenetic approach in trigeminal neuropathic pain which aid clinicians endeavoring towards enhanced pain relief therapy in trigeminal neuralgia patients.

Vacuum-Assisted Closure with Temporalis Muscle Reconstruction for Recurrent Scalp Erosion Following Deep Brain Stimulation: A Case Report.

BACKGROUND: Scalp erosion is not an uncommon complication of deep brain stimulation (DBS) surgery. Although various methods have been proposed to prevent and manage complications, there are still challenges. We introduce a case of recurrent scalp erosion after DBS surgery treated with vacuum-assisted closure. CASE DESCRIPTION: This article reports the case of a patient who underwent DBS for advanced Parkinson's disease and suffered from recurrent scalp erosion with device extrusion through the skin. Scalp erosion occurred 2 years after DBS and repeated improvement and deterioration despite scalp reconstruction using a skin flap. We opened the wound and performed temporal muscle reconstruction to cover the burr hole site, and we changed the exposed cable and applied vacuum-assisted closure. During the follow-up period, no signs of erosion or infection occurred, and DBS efficacy was preserved. CONCLUSION: To date, the available management strategies for scalp erosion after DBS are revision with debridement and scalp reconstruction using skin flaps or skin grafts. However, if erosion occurs repeatedly despite the above management strategies, vacuum-assisted closure with temporalis muscle reconstruction could be a suitable option. We suggest that if the condition of the scalp is weakened, it is worth considering this approach preferentially.

Ventralis oralis anterior (Voa) deep brain stimulation plus Gamma Knife thalamotomy in an elderly patient with essential tremor: A case report.

RATIONALE: Deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim) provides a safe and effective therapy for medically refractory essential tremor (ET). However, DBS may be risky in elderly patients and those with ischemic brain lesions. Gamma Knife radiosurgery (GKS) is a minimally invasive procedure, but bilateral thalamotomy is dangerous. PATIENT CONCERNS: We report a case of ventralis oralis anterior nucleus (Voa) DBS for dominant hand tremor plus Voa GKS for nondominant hand tremor in a very elderly patient with medically intractable ET. DIAGNOSIS: An 83-year-old right-handed woman visited our hospital with a medically intractable ET. Because of the ischemic lesion in the right basal ganglia, we decided to perform left unilateral DBS instead of bilateral DBS. INTERVENTION: We chose Voa as the target for DBS because, clinically, her tremor was mainly confined to her hands, and Voa had better intraoperative microelectrode recording results than Vim. OUTCOMES: After 2 years, her right-hand tremor remained in an improved state, but she still had severe tremor in her left hand. Therefore, we performed GKS targeting the right Voa. One year after surgery, the patient's hand tremor successfully improved without any complications. LESSONS: Salvage Voa GKS after unilateral Voa DBS is a valuable option for very elderly patients and patients with ischemic brain lesions. We suggest that Voa GKS thalamotomy is as useful and safe a surgical technique as Vim GKS for dystonic hand tremor. To the best of our knowledge, this is the first case report using salvage Voa as the only target for ET.

Brain metastasis with subtype conversion in a patient with male breast cancer: A case report.

RATIONALE: Brain metastasis of male breast cancer is extremely rare, and the pathological changes between the primary tumor and the metastatic brain tumor have not been reported. Herein, we report for the first time a case of male breast cancer with metastasis to the parietal lobe with subtype conversion after metastasis. PATIENT CONCERNS: we describe a 45-year-old male patient admitted for an incidentally found brain tumor after a motorcycle accident. The patient had been treated for breast cancer 5 years previously. The primary tumor was an invasive ductal carcinoma classified as pT1N1M0 with hormone receptor positivity (estrogen receptor ++, progesterone receptor +++, human epidermal growth factor receptor-type2 (HER2) +) and was treated with surgery, adjuvant chemotherapy, radiation therapy and endocrine therapy (tamoxifen). DIAGNOSES: Magnetic resonance imaging revealed a well enhanced focal solid tumor in the right parietal lobe (5.0 × 4.2 cm in size), Immunohistochemical staining revealed cerebral metastases of breast cancer with HER2 subtype conversion (estrogen receptor +++, progesterone receptor +++, HER2 -). INTERVENTIONS: The patient was successfully treated with surgery and whole brain irradiation (3 Gy × 10 fractions). OUTCOMES: There was no additional complication after the surgery and the patient transferred to oncology department for chemotherapy. 2 years later, he had gamma knife radiosurgery due to the recurred brain lesion and after that he discontinued the treatment and opted for hospice care. LESSONS: Male breast cancer with metastasis to the brain is an extremely rare condition. Although a few similar cases have been reported, subtype conversion in similar cases has not been reported. Therefore, we report this case of a male patient with brain metastasis of invasive ductal carcinoma with HER2 status conversion after metastasis.

Pain modulation effect on motor cortex after optogenetic stimulation in shPKCγ knockdown dorsal root ganglion-compressed Sprague-Dawley rat model.

Neuropathic pain can be generated by chronic compression of dorsal root ganglion (CCD). Stimulation of primary motor cortex can disrupt the nociceptive sensory signal at dorsal root ganglion level and reduce pain behaviors. But the mechanism behind it is still implicit. Protein kinase C gamma is known as an essential enzyme for the development of neuropathic pain, and specific inhibitor of protein kinase C gamma can disrupt the sensory signal and reduce pain behaviors. Optogenetic stimulation has been emerged as a new and promising conducive method for refractory neuropathic pain. The aim of this study was to provide evidence whether optical stimulation of primary motor cortex can modulate chronic neuropathic pain in CCD rat model. Animals were randomly divided into CCD group, sham group, and control group. Dorsal root ganglion-compressed neuropathic pain model was established in animals, and knocking down of protein kinase C gamma was also accomplished. Pain behavioral scores were significantly improved in the short hairpin Protein Kinase C gamma knockdown CCD animals during optic stimulation. Ventral posterolateral thalamic firing inhibition was also observed during light stimulation on motor cortex in CCD animal. We assessed alteration of pain behaviors in pre-light off, stimulation-light on, and post-light off state. In vivo extracellular recording of the ventral posterolateral thalamus, viral expression in the primary motor cortex, and protein kinase C gamma expression in dorsal root ganglion were investigated. So, optical cortico-thalamic inhibition by motor cortex stimulation can improve neuropathic pain behaviors in CCD animal, and knocking down of protein kinase C gamma plays a conducive role in the process. This study provides feasibility for in vivo optogenetic stimulation on primary motor cortex of dorsal root ganglion-initiated neuropathic pain.

Optogenetic stimulation of the motor cortex alleviates neuropathic pain in rats of infraorbital nerve injury with/without CGRP knock-down.

BACKGROUND: Previous studies have reported that electrical stimulation of the motor cortex is effective in reducing trigeminal neuropathic pain; however, the effects of optical motor cortex stimulation remain unclear. OBJECTIVE: The present study aimed to investigate whether optical stimulation of the primary motor cortex can modulate chronic neuropathic pain in rats with infraorbital nerve constriction injury. METHODS: Animals were randomly divided into a trigeminal neuralgia group, a sham group, and a control group. Trigeminal neuropathic pain was generated via constriction of the infraorbital nerve and animals were treated via selective inhibition of calcitonin gene-related peptide in the trigeminal ganglion. We assessed alterations in behavioral responses in the pre-stimulation, stimulation, and post-stimulation conditions. In vivo extracellular recordings were obtained from the ventral posteromedial nucleus of the thalamus, and viral and α-CGRP expression were investigated in the primary motor cortex and trigeminal ganglion, respectively. RESULTS: We found that optogenetic stimulation significantly improved pain behaviors in the trigeminal neuralgia animals and it provided more significant improvement with inhibited α-CGRP state than active α-CGRP state. Electrophysiological recordings revealed decreases in abnormal thalamic firing during the stimulation-on condition. CONCLUSION: Our findings suggest that optical motor cortex stimulation can alleviate pain behaviors in a rat model of trigeminal neuropathic pain. Transmission of trigeminal pain signals can be modulated via knock-down of α-CGRP and optical motor cortex stimulation.

Percutaneously Inserted Unilateral Lead Migration Salvaged with a Paddle Electrode.

INTRODUCTION: Lead migration has been regarded as a frequent complication after percutaneous spinal cord stimulation (SCS). Thus far, repeated reinsertion of leads or replacement of paddle electrodes after removing percutaneous leads has been performed, but a salvage surgical technique using the remaining electrode has not been reported. Here, we describe a case in which unilateral lead migration was successfully treated with the insertion of a paddle electrode. CASE SUMMARY: A 44-year-old male paraplegic patient with chronic neuropathic pain in the right leg and low back for 7 years underwent a percutaneous spinal cord stimulation procedure 5 times over 2 years because of repeated unilateral lead migration. The left lead underwent repeated migration and was difficult to reinsert due to epidural adhesion. After confirming the position and stimulation area of the remaining lead, we decided to insert another paddle electrode beside the remaining lead. We performed a T10 laminotomy and inserted a paddle electrode on the right side, using it in combination with the previous left lead. After surgery, the patient was satisfied with a wide coverage area. DISCUSSION: We recommend salvage additional paddle electrode insertion rather than removing both leads during revision SCS. This surgical method increases the possibility of covering the dorsal column (DC) of the spinal cord, is cost effective, and decreases the possibility of failing to cover dorsal column using the paddle electrode during open surgery because the remaining lead's position and stimulation area guide the insertion of the additional paddle lead.

Comparison of 7T and 3T MRI in patients with moyamoya disease.

Magnetic resonance imaging and magnetic resonance angiography (MRI/MRA) are widely used for evaluating the moyamoya disease (MMD). This study compared the diagnostic accuracy of 7Tesla (T) and 3T MRI/MRA in MMD. In this case control study, 12 patients [median age: 34years; range (10-66years)] with MMD and 12 healthy controls [median age: 25years; range (22-59years)] underwent both 7T and 3T MRI/MRA. To evaluate the accuracy of MRI/MRA in MMD, five criteria were compared between imaging systems of 7T and 3T: Suzuki grading system, internal carotid artery (ICA) diameter, ivy sign, flow void of the basal ganglia on T2-weighted images, and high signal intensity areas of the basal ganglia on time-of-flight (TOF) source images. No difference was observed between 7T and 3T MRI/MRA in Suzuki stage, ICA diameter, and ivy sign score; while, 7T MRI/MRA showed a higher detection rate in the flow void on T2-weighted images and TOF source images (p<0.001). Receiver operating characteristic curves of both T2 and TOF criteria showed that 7T MRI/MRA had higher sensitivity and specificity than 3T MRI/MRA. Our findings indicate that 7T MRI/MRA is superior to 3T MRI/MRA for the diagnosis of MMD in point of detecting the flow void in basal ganglia by T2-weighted and TOF images.

Secondary adult encephalocele with abscess formation of calcified frontal sinus mucocele.

INTRODUCTION: Although encephalocele is a rare congenital abnormality, secondary encephalocele is extremely rare and can cause fatal complications. Here, we report a case of secondary encephalocele caused by frontal sinus wall defect due to chronic sinusitis, which was completely removed by cranialization with autologous bone graft. A 50-year-old man with a 10-year history of chronic sinusitis visited our hospital due to suddenly altered mentality characterized by stupor. Computerized tomography scanning and magnetic resonance imaging revealed an enlarged left frontal sinus with sinusitis. The frontal sinus cavity was calcified, and the left frontal lobe had herniated into the cavity accompanied by yellow pus. A large dural defect was also found around the frontal sinus area. After removal of the abscess and some of the frontal lobe, frontal skull base repair by cranialization was performed using autologous bone graft. Streptococcus pneumoniae was cultured from the cerebrospinal fluid (CSF), necessitating treatment with antibiotics. After the operation, the mental status of the patient improved and no CSF leakage was observed. DISCUSSION: In addition to correct diagnosis and early treatment including antibiotics, the surgical repair of defects is needed in patients with secondary encephalocele to prevent further episodes of meningitis. Surgical correction of frontal sinus encephalocele can be achieved through bifrontal craniotomy or endoscopic transnasal repair. If a patient has CSF leakage, open craniotomy may facilitate repair of the dural defect and allow for cranialization of the sinus. CONCLUSIONS: Removal of dysplastic herniated brain tissue and cranialization of the frontal sinus may be a good option for treating secondary encephalocele and its associated complications, including meningitis, abscess formation, and infarction of the herniated brain parenchyma.