Cerebrospinal fluid rhinorrhea with meningoencephalocele related to Sternberg’s canal: A report of two cases
- Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan
- Department of Neurosurgery, Juntendo University Urayasu Hospital, Urayasu, Japan.
Satoshi Adachi, Department of Neurosurgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan.
DOI:10.25259/SNI_260_2023Copyright: © 2023 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, transform, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Satoshi Adachi1, Hideaki Ueno2, Shunsuke Magami1, Naohide Fujita1, Shintaro Nakajima1, Ryogo Ikemura1, Yasuhito Ueki1, Yuki Takaki1, Keisuke Murofushi1, Yasuaki Nakao1, Takuji Yamamoto1. Cerebrospinal fluid rhinorrhea with meningoencephalocele related to Sternberg’s canal: A report of two cases. 30-Jun-2023;14:228
How to cite this URL: Satoshi Adachi1, Hideaki Ueno2, Shunsuke Magami1, Naohide Fujita1, Shintaro Nakajima1, Ryogo Ikemura1, Yasuhito Ueki1, Yuki Takaki1, Keisuke Murofushi1, Yasuaki Nakao1, Takuji Yamamoto1. Cerebrospinal fluid rhinorrhea with meningoencephalocele related to Sternberg’s canal: A report of two cases. 30-Jun-2023;14:228. Available from: https://surgicalneurologyint.com/surgicalint-articles/12384/
Background: Cerebrospinal fluid (CSF) rhinorrhea with meningoencephalocele (MEC) associated with Sternberg’s canal is rare. We treated two such cases.
Case Description: A 41-year-old man and a 35-year-old woman presented with CSF rhinorrhea and mild headache worsening with standing posture. Head computed tomography showed a defect close to the foramen rotundum in the lateral wall of the left sphenoid sinus in both cases. Head magnetic resonance (MR) imaging and MR cisternography revealed that brain parenchyma had herniated into the lateral sphenoid sinus through the defect of the middle cranial fossa. The intradural and extradural spaces and bone defect were sealed with fascia and fat through both intradural and extradural approaches. The MEC was cut away to prevent infection. CSF rhinorrhea completely stopped after the surgery.
Conclusion: Our cases were characterized by empty sella, thinning of the dorsum sellae, and large arteriovenous malformations that suggest chronic intracranial hypertension. The possibility of Sternberg’s canal in patients with CSF rhinorrhea with chronic intracranial hypertension should be considered. The cranial approach has the advantages of lower infection risk and the ability to close the defect with multilayer plasty under direct vision. The transcranial approach is still safe if performed by a skillful neurosurgeon.
Keywords: Arteriovenous malformation, Cerebrospinal fluid rhinorrhea, Lateral craniopharyngeal canal, Meningoencephalocele, Surgical repair
Sternberg’s canal (lateral craniopharyngeal canal) was first described by Maximilian Sternberg in 1888,[
A 41-year-old man became aware of left-sided intermittent nasal discharge which gradually worsened and mild headache worsening with standing posture. He had no previous history of head trauma, medical disorders, or seizures. Clinical examination revealed left-sided CSF rhinorrhea, and biochemical tests showed protein 46 mg/ dL and glucose 75 mg/dL in the nasal discharge. The rhinorrhea worsened with cervical anteflexion. Head computed tomography (CT) showed a defect lateral to the foramen rotundum in the lateral wall of the left sphenoid sinus and erosion of the dorsum sellae [
Case 1 - (a and b) Computed tomography scans showed a defect (white arrow, black arrow) in the lateral wall of the left sphenoid sinus lateral to the foramen rotundum (black arrowhead) and erosion of the dorsum sellae (asterisk). (c and d) Head T2-weighted magnetic resonance (MR) image (c) and MR cisternogram (d) revealed brain parenchyma had herniated into the lateral sphenoid sinus through the defect of the middle cranial fossa (white arrow). (e) Schema of meningoencephalocele and cerebrospinal fluid rhinorrhea associated with Sternberg’s canal.
Case 1 - Intraoperative photographs showing the left frontotemporal craniotomy with temporal extension. (a) The intradural approach exposing middle cranial dura and brain tissue protruding into the defect in the middle skull base leading to the sphenoid sinus (arrow). (b) Herniated dura (arrow). (c) Dural defect was sutured through the extradural approach (arrow). (d) Defect in the lateral sphenoid sinus was 5 mm in size (arrow). (e-g) Intradural (e) and extradural spaces (f) and bone defect (g) were sealed with abdominal external oblique fascia containing fat, fibrin glue, and biological tissue reinforcement material.
A 35-year-old woman suffered intermittent nasal discharge without seizures. She had a history of large arteriovenous malformations (AVMs) in the right frontal lobe. CT showed a defect in the floor of the sella turcica and AVMs in the right frontal lobe, with nidus of 5 cm [
Case 2 - (a and b) Sagittal (a) and coronal computed tomography scans (b) showed a defect in the floor of the sella turcica (arrow). (c) Arteriovenous malformations in the right frontal lobe, with nidus of 5 cm (arrow). (d) Magnetic resonance cisternogram revealed abnormal fluid collection in the sphenoid sinus and the empty sella.
Case 2 - (a and b) Computed tomography scans showed severe pneumocephalus and a defect in the lateral wall of the left sphenoid sinus between the foramen rotundum and foramen ovale (black arrow). (c and d) Axial (c) and coronal (d) magnetic resonance cisternogram showed that brain parenchyma had herniated into the lateral sphenoid sinus through the defect of the middle cranial fossa (white arrow).
Case 2 - Intraoperative photographs of the second surgery. (a and b) Intradural (a) and extradural approaches (b) to the Stenberg’s canal. The cranial dura involved multiple holes and protruded with brain parenchyma (black arrow) into the skull base defect between the foramen rotundum and foramen ovale in the middle skull base leading to the sphenoid sinus. (c) Herniated dura and meningoencephalocele were cut away and the nasal mucosa (black arrow) exposed. (d) Bone defect was reconstructed with a titanium plate. (e-h) Intradural (e and f) and extradural spaces (g and h) including the bone defect were sealed with temporal fascia, abdominal fat, fibrin glue, and biological tissue reinforcement material.
Various classifications of CSF rhinorrhea have been reported. CSF rhinorrhea was divided into three categories as follows: (1) traumatic, (2) postsurgical, and (3) spontaneous.[
Sternberg’s canal (lateral craniopharyngeal canal) has been considered to be an underlying factor related to sphenoid sinus spontaneous CSF rhinorrhea.[
Rhinorrhea and MEC associated with Sternberg’s canal are rare.[
Treatment of MEC and CSF rhinorrhea consists of reconstruction through the transcranial or endoscopic approach. Herniated dura mater and brain parenchyma should be excised because these tissues are considered contaminated and functionless.[
Our cases were characterized by empty sella and thinning of the dorsum sellae which suggest chronic intracranial hypertension. Furthermore, our Case 2 had a long history of large AVMs and previous CSF rhinorrhea due to a defect in the floor of the sella turcica. The possibility of Sternberg’s canal in patients with spontaneous CSF rhinorrhea with chronic intracranial hypertension should be considered. The transcranial closure technique which requires multi-layered reconstruction might be safe and effective if performed by a skillful neurosurgeon. Intracranial pressure management and prolonged clinical follow-up are essential in patients with chronic intracranial hypertension.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Journal or its management. The information contained in this article should not be considered to be medical advice; patients should consult their own physicians for advice as to their specific medical needs.
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