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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">MRI and 3D CT scan&#44; most of the right hemisphere is herniated through the bone defect&#46; The bone defect involves frontal bone&#44; cribrosa laminae and ethmoidal bone&#46; Orbits are intact&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Encephaloceles represent a group of disorders in which a skull defect allows for extracranial herniation of leptomeninges&#44; brain&#44; and CSF&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> They can be classified as primary if they are present at birth or secondary if they are acquired following trauma or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> The occipital bone is the most common location<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> and frontoethmoidal encephaloceles are less frequent&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A case of fronto-ethmoidal encephalocele is presented as well as the surgical technique performed and a review of the literature up to the present date&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The case is presented of an Arabic female premature newborn &#40;gestational age of 30 weeks&#41; with a large frontal mass&#46; The mass was bulging between the two orbits and occupying the lowest part of the frontal area and the superior part of the nasal area&#46; Skin was intact &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; though thin and presented some degree of exudation&#46; Neurologically there were no motor deficits and the baby moved spontaneously the four limbs&#46; She was active and taking orally without any problem&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">MRI showed a large encephalocele through a frontoethmoidal bone defect&#44; consisting of most of the right cerebral hemisphere herniated through the defect&#46; CT scan showed a bone defect in the zone of frontal bone&#44; lamina cribrosa and anterior part of ethmoidal bone &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The weight of the baby at birth was 1&#46;500<span class="elsevierStyleHsp" style=""></span>g and there was no CSF leak so a elective surgery was decided&#46; A ventriculoperitoneal shunt was needed after 1 month due to the development of hydrocephalus&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was performed when the patient was 7 months old and reached 3000<span class="elsevierStyleHsp" style=""></span>g&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 3D model of the skull from a CT scan was made to identify clearly the bone defect and to plan the surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The CT scan was exported as a DICOM file and processed with virtual planning software &#40;ProPlan CMF&#41;&#46;The morphology of the defect was established and measured&#44; and the relation with the soft tissue coverage was identified using a virtual superposition of the soft tissues&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A 3D stereolithographic model of the skull was printed and sterilized&#44; and taken to the operative room in order to help as an anatomical reference during the surgery&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The surgery was performed by a multidisciplinary team&#46; Steps of the surgery can be seen in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A coronal skin incision was performed exposing the frontal bone&#44; upper orbital edges and the frontal part of the encephalocele&#46; A bifrontal craniotomy was done from the edge of the bone defect to expose the floor of the anterior cranial fossa surrounding the sac &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; After that&#44; the Maxillofacial surgeon made lateral rhinotomy incision over the encephalocele and a circumferential dissection of the encephalocele&#39;s sac was performed&#44; freeing it from the surrounding tissue&#44; including the nasal bones and the left orbital rim&#44; preserving the lacrimal sac and the medial cantal ligament attachment&#46; Once the sac was completely dissected and isolated from the surrounding tissues&#44; and the intracranial and facial edges of the sac were connected&#44; removal of the functionless brain tissue and suture of the dural sac in a watertight fashion were performed&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Tachosil<span class="elsevierStyleSup">&#174;</span> and a pericranial flap were used to reinforce the closure and fill the dead space&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Two full thickness cortical block bone grafts were harvested from the posterior border of the craniotomy&#44; in the parietal bone&#44; according to the size and shape recommend by the virtual planning software in order to reconstruct the glabella and the nasal bone&#46; The grafts were wired with absorbable sutures &#40;PDS 3&#8211;0&#41; to the remaining nasal bones&#46; Reposition of the craniotomized frontal bone was performed and stabilized again with reservable sutures&#46; Skin flap over the nasal area was remodeled to achieve a cosmetic closure&#46; The patient was transferred to the Pediatric ICU under mechanical ventilation&#44; and delayed extubation was performed without complication after 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Result</span><p id="par0065" class="elsevierStylePara elsevierViewall">No intraoperative complications were suffered&#44; surgical site was intact&#44; and the evolution of the patient was satisfactory from the cosmetic and functional point of view&#46; There was no CSF leak&#46; The patient developed a shunt infection that required external ventricular drainage and antibiotic treatment&#46; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a> shows the cosmetic result and postoperative CT scan where the reconstruction of frontal and nasal bone can be seen&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Encephaloceles are one of the so called neural tube defects&#46; There is an herniation of the meninges and brain matter through a structural defect in the skull&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Encephaloceles are classified based on the location and type of skull defect in three main types&#58; frontoethmoidal&#44; occipital&#44; cranial vault and basal type &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The most frequent location is the occipital cranial vault &#40;80&#37; of the cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Frontoethmoidal encephaloceles&#44; collectively known as nasal encephaloceles&#44; have three subtypes according to the bone associated with the defect&#58; nasofrontal&#44; nasoethmoidal&#44; and naso-orbital&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;5</span></a> The nasoethmoidal subtype is most frequently reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;6&#8211;8</span></a> and the naso-orbital subtype is the least common&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Estimated incidence in North America and Western countries is 1&#8211;3 per 10&#44;000 live births and the most common location is occipital&#46; Most cases of nasal encephaloceles have been found in Southeast Asian countries with very rare cases reported in Europe&#44; North America&#44; and the Middle Eas&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;10&#8211;12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Etiology of encephalocele is not well known&#46; Many have defined it as a multifactorial condition&#44; with a combination of genetic and environmental factors&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Most of the cases are present at birth as masses over the nose&#44; glabella and&#47;or forehead&#44; usually covered by skin&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Sometimes encephaloceles are hidden and may present with symptoms as snoring&#44; nasal obstruction&#44; CSF leak or recurrent meningitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;6</span></a> This is the main reason why the age at diagnosis has been reported to range from 0 to 40 years old&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;10&#44;13&#44;14</span></a> The presence of hydrocephalus is a main factor in the management of encephaloceles&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">8&#44;13</span></a> Untreated or late treated cases present a high risk of postoperative CSF leak&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;15&#44;16</span></a> Associated hydrocephalus should be treated and solved before surgical treatment&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">MRI and CT scan are necessary to plan the surgery&#46; MRI is essential to understand the anatomy of the herniated brain and its relations with the surrounding structures&#46; AngioMRI is also useful to evaluate the position of the anterior cerebral arteries&#44; because sometimes they are herniated in the sac&#46; CT scan with 3D reconstruction helps to define accurately the bone defect and to plan the surgery&#46; In the case presented the 3D model made for the planning helped to understand the anatomy of the cranial defect and to plan the surgical reconstruction&#46; Angiography is only recommended when presence of significant vessels is suspected inside the encephalocele&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Surgery is the only treatment of frontoethmoidal encephaloceles&#46; Skin is usually intact so elective surgery is indicated&#46; Planning of surgery and timing of operation is crucial in management of anterior encephaloceles&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;17&#8211;20</span></a> Surgery is usually long and blood loss and hypothermia are frequent&#44; which remain the two most important intraoperative complications&#46; If there is no active CSK leak or infection&#44; delayed surgery is preferred and some authors recommend surgery at 8&#8211;10 months of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">8&#44;13&#44;16</span></a> On the other hand&#44; frontoethmoidal encephaloceles should be treated at an early age to avoid further facial distortion during growth&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Due to the nature of the illness&#44; a multidisciplinary approach is strongly recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;6&#44;21</span></a> Endoscopic transnasal approaches<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">6&#44;7</span></a> have been successful in many cases of nasal encephaloceles but most authors recommend the &#8220;combined procedure&#8221; which combines a bicoronal and a nasofrontal flap approach with facial reconstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;11</span></a> This approach provides three main advantages to surgeons and patients&#58; a more successful closure of the meningoencephalocele&#44; with lower risk of CSF leak&#44; the possibility of telecanthus correction if necessary&#44; and in some cases the reduction of facial scars&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> In many studies&#44; the surgical procedure includes frontal coronal scalp flap incision to gain exposure to the craniofacial bones combined with the transfacial incision&#46; Some authors prefer to limit the repair of the encephalocele through the transfacial approach&#44; without the need of a coronal approach and bifrontal craniotomy&#44; making the procedure less agressive&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> This is possible if the sac and the bone defect are of a moderate size&#46; If the orbits are involved in the deformity causing hypertelorism&#44; a correction technique is necessary&#46; Usually there is no need to perform a full orbital mobilization&#44; and an hemiorbital advancement is usually enough&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Any neural or meningeal herniations are cut out and the dura is subsequently closed and repaired&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">7&#44;10&#44;12</span></a> The herniated brain does not contain any significant structures<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> so removal of this functionless tissue is possible&#46; Postoperative follow-up is essential because of the risk of CSF rhinorrhea and infection&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> CSF leaks are the most common postoperative complication&#46; There is an overall low mortality rate associated with encephaloceles&#44; with a 3&#37; surgery-related mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Some patients may need secondary cosmetic surgery&#44; like rhinoplasty or eyelid repair&#44; at a later stage&#44; depending on the involvement of soft tissues&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The case presented is a big frontoethmoidal encephalocele&#46; Surgical planning using a 3D model was extremely useful to prepare the surgery and to achieve a good reconstruction&#46; A multidisciplinary approach was planned to approach the case&#46; The cosmetic result and the closure were very good and no CSF leak was found after the surgery&#46; The shunt infection presented after surgery was undoubtedly related to it and required shunt removal and external ventricular drainage&#46; The age and the weight at surgery were maybe in the limit and it could contribute to the development of this complication&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Encephaloceles are a rare type of neural tube defect caused by herniation of brain matter through areas of arrested bone development in the skull&#46; Frontoethmoidal encephaloceles are rare and repair of the defect is mandatory&#46; Approach and timing of surgery have to be carefully planned and cases should be individualized&#46; Decision making has to take into account the age and weight of the patient&#44; the status of the skin and the anatomy of the herniation&#46; MRI and 3D reconstruction of skull CT are necessary to plan the surgery&#46; A multidisciplinary approach is strongly recommended and surgical plan must be tailored in each patient&#46; Complications&#44; especially infections&#44; are quite common&#46;</p></span></span>"
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          "titulo" => "Result"
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          "titulo" => "References"
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    "fechaRecibido" => "2017-11-14"
    "fechaAceptado" => "2018-02-18"
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            0 => "Encephalocele"
            1 => "Congenital malformation"
            2 => "Frontoethmoidal encephalocele"
            3 => "Nasal encephalocele"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Encefaloceles"
            1 => "Malformaci&#243;n cong&#233;nita"
            2 => "Encefalocele frontoetmoidal"
            3 => "Encefalocele nasal"
          ]
        ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Encephaloceles are uncommon in western countries and most cases are located in the occipital bone&#46; Frontal encephaloceles may involve the ethmoid bone&#44; nasal bones and&#47;or the orbits&#46; Surgical repair is complex and usually requires a multidisciplinary approach&#46; The goal of the surgery is to reconstruct the normal anatomy&#44; to achieve a good cosmetic repair and to avoid a cerebrospinal fluid leak&#46; We present a case of a patient with a large congenital frontoethmoidal encephalocele&#46; Autologous calvarian bone grafts were used to repair of encephalocele defect and for the reconstruction of the frontonasal area&#46; The defect closure and the cosmetic result were satisfactory&#44; and the only complication detected was the infection of a previously performed ventriculoperitoneal shunt&#46; A description of the technique and a review of the literature are presented&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los encefaloceles son infrecuentes en los pa&#237;ses occidentales y su localizaci&#243;n m&#225;s frecuente es occipital&#46; Los encefaloceles frontales pueden afectar hueso etmoidal&#44; frontal y&#47;o &#243;rbitas&#46; La reparaci&#243;n quir&#250;rgica es compleja y habitualmente precisa de un abordaje multidisciplinar&#46; El objetivo de la cirug&#237;a es reconstruir la anatom&#237;a del paciente con un buen resultado est&#233;tico&#44; y evitar la f&#237;stula de l&#237;quido cefalorraqu&#237;deo&#46; Se presenta un caso de un gran encefalocele frontoetmoidal&#46; El encefalocele fue reparado y la reconstrucci&#243;n &#243;sea se realiz&#243; con hueso aut&#243;logo de la capota craneal&#46; El cierre y el resultado cosm&#233;tico fueron buenos y la &#250;nica complicaci&#243;n fue una infecci&#243;n posquir&#250;rgica&#46; Se describe la t&#233;cnica y se revisa la literatura publicada al respecto&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Preoperative images of the frontoethmoidal encephalocele&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Surgical technique&#46; 1&#58; bicoronal incision and craneotomy&#46; 2&#8211;3&#58; dissection of the dural sac from the surrounding structures in the nasoorbital area&#46; 4&#58; resection of the encephalocele&#46; 5&#58; dissection of the duramater from brain and suture&#46; 6&#58; pericranial flap for covering duramater and filling dead space&#46; 7&#58; replacement of frontal bone adding a piece of autologous bone to reconstruct the glabella&#46; 8&#58; use of another piece of autologous bone from the skull to reconstruct the nasal bone&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Frontoethmoidal</td><td class="td" title="table-entry  " align="left" valign="top">Nasofrontal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nasoethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Naso-orbital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Basal</td><td class="td" title="table-entry  " align="left" valign="top">Transethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transsphenoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenoethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenomaxillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frontosphenoidal&#47;spheno-orbital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Encephalocele of the cranial vault</td><td class="td" title="table-entry  " align="left" valign="top">Interfrontal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anterior fontanelle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interparietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Posterior fontanelle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temporal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of encephaloceles&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative management of children with encephalocele&#58; an institutional experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46; Mahajan"
                            1 => "G&#46;P&#46; Rath"
                            2 => "H&#46;H&#46; Dash"
                            3 => "P&#46;K&#46; Bithal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ANA.0b013e31821f93dc"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg Anesthesiol"
                        "fecha" => "2011"
                        "volumen" => "23"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21633311"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nasal encephaloceles&#58; a review of etiology&#44; pathophysiology&#44; clinical presentations&#44; diagnosis&#44; treatment&#44; and complications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Tirumandas"
                            1 => "A&#46; Sharma"
                            2 => "I&#46; Gbenimacho"
                            3 => "M&#46;M&#46; Shoja"
                            4 => "R&#46;S&#46; Tubbs"
                            5 => "W&#46;J&#46; Oakes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00381-012-1998-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Childs Nerv Syst"
                        "fecha" => "2013"
                        "volumen" => "29"
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                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23247827"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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            ]
            2 => array:3 [
              "identificador" => "bib0125"
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                            0 => "L&#46; Barnes"
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                      ]
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                  ]
                  "host" => array:1 [
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              "identificador" => "bib0130"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "The teaching files&#58; brain and spine imaging"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "G&#46;M&#46; Fatterpekar"
                            1 => "T&#46;P&#46; Naidich"
                            2 => "P&#46;M&#46; Som"
                          ]
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                  ]
                  "host" => array:1 [
                    0 => array:1 [
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              ]
            ]
            4 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endocrine abnormalities in patients with frontoethmoidal encephalomeningocele&#46; A preliminary study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Wacharasindhu"
                            1 => "U&#46; Asawutmangkul"
                            2 => "S&#46; Srivuthana"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000087691"
                      "Revista" => array:6 [
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                        "fecha" => "2005"
                        "volumen" => "64"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nasal encephalocele&#58; endoscopic excision with anesthetic consideration"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Abdel-Aziz"
                            1 => "H&#46; El-Bosraty"
                            2 => "M&#46; Qotb"
                            3 => "M&#46; El-Hamamsy"
                            4 => "M&#46; El-Sonbaty"
                            5 => "H&#46; Abdel-Badie"
                          ]
                        ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijporl.2010.04.015"
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                        "tituloSerie" => "Int J Pediatr Otorhinolaryngol"
                        "fecha" => "2010"
                        "volumen" => "74"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20554034"
                            "web" => "Medline"
                          ]
                        ]
                      ]
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Case Report
Frontoethmoidal encephalocele. Report of a case
Encefalocele frontoetmoidal. A propósito de un caso
Angel Horcajadasa,
Autor para correspondencia
angel.horcajadas@gmail.com

Corresponding author.
, Antonio Palmab, Babar M. Khalona
a Neurosurgery, King Saud Medical City, Riyadh, Saudi Arabia
b Maxillofacial, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">MRI and 3D CT scan&#44; most of the right hemisphere is herniated through the bone defect&#46; The bone defect involves frontal bone&#44; cribrosa laminae and ethmoidal bone&#46; Orbits are intact&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Encephaloceles represent a group of disorders in which a skull defect allows for extracranial herniation of leptomeninges&#44; brain&#44; and CSF&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> They can be classified as primary if they are present at birth or secondary if they are acquired following trauma or surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a> The occipital bone is the most common location<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> and frontoethmoidal encephaloceles are less frequent&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">A case of fronto-ethmoidal encephalocele is presented as well as the surgical technique performed and a review of the literature up to the present date&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">The case is presented of an Arabic female premature newborn &#40;gestational age of 30 weeks&#41; with a large frontal mass&#46; The mass was bulging between the two orbits and occupying the lowest part of the frontal area and the superior part of the nasal area&#46; Skin was intact &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; though thin and presented some degree of exudation&#46; Neurologically there were no motor deficits and the baby moved spontaneously the four limbs&#46; She was active and taking orally without any problem&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">MRI showed a large encephalocele through a frontoethmoidal bone defect&#44; consisting of most of the right cerebral hemisphere herniated through the defect&#46; CT scan showed a bone defect in the zone of frontal bone&#44; lamina cribrosa and anterior part of ethmoidal bone &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The weight of the baby at birth was 1&#46;500<span class="elsevierStyleHsp" style=""></span>g and there was no CSF leak so a elective surgery was decided&#46; A ventriculoperitoneal shunt was needed after 1 month due to the development of hydrocephalus&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Surgery was performed when the patient was 7 months old and reached 3000<span class="elsevierStyleHsp" style=""></span>g&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Surgical technique</span><p id="par0035" class="elsevierStylePara elsevierViewall">A 3D model of the skull from a CT scan was made to identify clearly the bone defect and to plan the surgery &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The CT scan was exported as a DICOM file and processed with virtual planning software &#40;ProPlan CMF&#41;&#46;The morphology of the defect was established and measured&#44; and the relation with the soft tissue coverage was identified using a virtual superposition of the soft tissues&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">A 3D stereolithographic model of the skull was printed and sterilized&#44; and taken to the operative room in order to help as an anatomical reference during the surgery&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The surgery was performed by a multidisciplinary team&#46; Steps of the surgery can be seen in <a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A coronal skin incision was performed exposing the frontal bone&#44; upper orbital edges and the frontal part of the encephalocele&#46; A bifrontal craniotomy was done from the edge of the bone defect to expose the floor of the anterior cranial fossa surrounding the sac &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; After that&#44; the Maxillofacial surgeon made lateral rhinotomy incision over the encephalocele and a circumferential dissection of the encephalocele&#39;s sac was performed&#44; freeing it from the surrounding tissue&#44; including the nasal bones and the left orbital rim&#44; preserving the lacrimal sac and the medial cantal ligament attachment&#46; Once the sac was completely dissected and isolated from the surrounding tissues&#44; and the intracranial and facial edges of the sac were connected&#44; removal of the functionless brain tissue and suture of the dural sac in a watertight fashion were performed&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Tachosil<span class="elsevierStyleSup">&#174;</span> and a pericranial flap were used to reinforce the closure and fill the dead space&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Two full thickness cortical block bone grafts were harvested from the posterior border of the craniotomy&#44; in the parietal bone&#44; according to the size and shape recommend by the virtual planning software in order to reconstruct the glabella and the nasal bone&#46; The grafts were wired with absorbable sutures &#40;PDS 3&#8211;0&#41; to the remaining nasal bones&#46; Reposition of the craniotomized frontal bone was performed and stabilized again with reservable sutures&#46; Skin flap over the nasal area was remodeled to achieve a cosmetic closure&#46; The patient was transferred to the Pediatric ICU under mechanical ventilation&#44; and delayed extubation was performed without complication after 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Result</span><p id="par0065" class="elsevierStylePara elsevierViewall">No intraoperative complications were suffered&#44; surgical site was intact&#44; and the evolution of the patient was satisfactory from the cosmetic and functional point of view&#46; There was no CSF leak&#46; The patient developed a shunt infection that required external ventricular drainage and antibiotic treatment&#46; <a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a> shows the cosmetic result and postoperative CT scan where the reconstruction of frontal and nasal bone can be seen&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Encephaloceles are one of the so called neural tube defects&#46; There is an herniation of the meninges and brain matter through a structural defect in the skull&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">1</span></a> Encephaloceles are classified based on the location and type of skull defect in three main types&#58; frontoethmoidal&#44; occipital&#44; cranial vault and basal type &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The most frequent location is the occipital cranial vault &#40;80&#37; of the cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Frontoethmoidal encephaloceles&#44; collectively known as nasal encephaloceles&#44; have three subtypes according to the bone associated with the defect&#58; nasofrontal&#44; nasoethmoidal&#44; and naso-orbital&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;5</span></a> The nasoethmoidal subtype is most frequently reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;6&#8211;8</span></a> and the naso-orbital subtype is the least common&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Estimated incidence in North America and Western countries is 1&#8211;3 per 10&#44;000 live births and the most common location is occipital&#46; Most cases of nasal encephaloceles have been found in Southeast Asian countries with very rare cases reported in Europe&#44; North America&#44; and the Middle Eas&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;10&#8211;12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Etiology of encephalocele is not well known&#46; Many have defined it as a multifactorial condition&#44; with a combination of genetic and environmental factors&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">2</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Most of the cases are present at birth as masses over the nose&#44; glabella and&#47;or forehead&#44; usually covered by skin&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">3</span></a> Sometimes encephaloceles are hidden and may present with symptoms as snoring&#44; nasal obstruction&#44; CSF leak or recurrent meningitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">4&#44;6</span></a> This is the main reason why the age at diagnosis has been reported to range from 0 to 40 years old&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">1&#44;10&#44;13&#44;14</span></a> The presence of hydrocephalus is a main factor in the management of encephaloceles&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">8&#44;13</span></a> Untreated or late treated cases present a high risk of postoperative CSF leak&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;15&#44;16</span></a> Associated hydrocephalus should be treated and solved before surgical treatment&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">MRI and CT scan are necessary to plan the surgery&#46; MRI is essential to understand the anatomy of the herniated brain and its relations with the surrounding structures&#46; AngioMRI is also useful to evaluate the position of the anterior cerebral arteries&#44; because sometimes they are herniated in the sac&#46; CT scan with 3D reconstruction helps to define accurately the bone defect and to plan the surgery&#46; In the case presented the 3D model made for the planning helped to understand the anatomy of the cranial defect and to plan the surgical reconstruction&#46; Angiography is only recommended when presence of significant vessels is suspected inside the encephalocele&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Surgery is the only treatment of frontoethmoidal encephaloceles&#46; Skin is usually intact so elective surgery is indicated&#46; Planning of surgery and timing of operation is crucial in management of anterior encephaloceles&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">13&#44;17&#8211;20</span></a> Surgery is usually long and blood loss and hypothermia are frequent&#44; which remain the two most important intraoperative complications&#46; If there is no active CSK leak or infection&#44; delayed surgery is preferred and some authors recommend surgery at 8&#8211;10 months of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">8&#44;13&#44;16</span></a> On the other hand&#44; frontoethmoidal encephaloceles should be treated at an early age to avoid further facial distortion during growth&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Due to the nature of the illness&#44; a multidisciplinary approach is strongly recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;6&#44;21</span></a> Endoscopic transnasal approaches<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">6&#44;7</span></a> have been successful in many cases of nasal encephaloceles but most authors recommend the &#8220;combined procedure&#8221; which combines a bicoronal and a nasofrontal flap approach with facial reconstruction&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">2&#44;11</span></a> This approach provides three main advantages to surgeons and patients&#58; a more successful closure of the meningoencephalocele&#44; with lower risk of CSF leak&#44; the possibility of telecanthus correction if necessary&#44; and in some cases the reduction of facial scars&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">11</span></a> In many studies&#44; the surgical procedure includes frontal coronal scalp flap incision to gain exposure to the craniofacial bones combined with the transfacial incision&#46; Some authors prefer to limit the repair of the encephalocele through the transfacial approach&#44; without the need of a coronal approach and bifrontal craniotomy&#44; making the procedure less agressive&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">20</span></a> This is possible if the sac and the bone defect are of a moderate size&#46; If the orbits are involved in the deformity causing hypertelorism&#44; a correction technique is necessary&#46; Usually there is no need to perform a full orbital mobilization&#44; and an hemiorbital advancement is usually enough&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">21</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Any neural or meningeal herniations are cut out and the dura is subsequently closed and repaired&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">7&#44;10&#44;12</span></a> The herniated brain does not contain any significant structures<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">13</span></a> so removal of this functionless tissue is possible&#46; Postoperative follow-up is essential because of the risk of CSF rhinorrhea and infection&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">22</span></a> CSF leaks are the most common postoperative complication&#46; There is an overall low mortality rate associated with encephaloceles&#44; with a 3&#37; surgery-related mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">12</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Some patients may need secondary cosmetic surgery&#44; like rhinoplasty or eyelid repair&#44; at a later stage&#44; depending on the involvement of soft tissues&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The case presented is a big frontoethmoidal encephalocele&#46; Surgical planning using a 3D model was extremely useful to prepare the surgery and to achieve a good reconstruction&#46; A multidisciplinary approach was planned to approach the case&#46; The cosmetic result and the closure were very good and no CSF leak was found after the surgery&#46; The shunt infection presented after surgery was undoubtedly related to it and required shunt removal and external ventricular drainage&#46; The age and the weight at surgery were maybe in the limit and it could contribute to the development of this complication&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">Encephaloceles are a rare type of neural tube defect caused by herniation of brain matter through areas of arrested bone development in the skull&#46; Frontoethmoidal encephaloceles are rare and repair of the defect is mandatory&#46; Approach and timing of surgery have to be carefully planned and cases should be individualized&#46; Decision making has to take into account the age and weight of the patient&#44; the status of the skin and the anatomy of the herniation&#46; MRI and 3D reconstruction of skull CT are necessary to plan the surgery&#46; A multidisciplinary approach is strongly recommended and surgical plan must be tailored in each patient&#46; Complications&#44; especially infections&#44; are quite common&#46;</p></span></span>"
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            0 => "Encefaloceles"
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            2 => "Encefalocele frontoetmoidal"
            3 => "Encefalocele nasal"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Encephaloceles are uncommon in western countries and most cases are located in the occipital bone&#46; Frontal encephaloceles may involve the ethmoid bone&#44; nasal bones and&#47;or the orbits&#46; Surgical repair is complex and usually requires a multidisciplinary approach&#46; The goal of the surgery is to reconstruct the normal anatomy&#44; to achieve a good cosmetic repair and to avoid a cerebrospinal fluid leak&#46; We present a case of a patient with a large congenital frontoethmoidal encephalocele&#46; Autologous calvarian bone grafts were used to repair of encephalocele defect and for the reconstruction of the frontonasal area&#46; The defect closure and the cosmetic result were satisfactory&#44; and the only complication detected was the infection of a previously performed ventriculoperitoneal shunt&#46; A description of the technique and a review of the literature are presented&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los encefaloceles son infrecuentes en los pa&#237;ses occidentales y su localizaci&#243;n m&#225;s frecuente es occipital&#46; Los encefaloceles frontales pueden afectar hueso etmoidal&#44; frontal y&#47;o &#243;rbitas&#46; La reparaci&#243;n quir&#250;rgica es compleja y habitualmente precisa de un abordaje multidisciplinar&#46; El objetivo de la cirug&#237;a es reconstruir la anatom&#237;a del paciente con un buen resultado est&#233;tico&#44; y evitar la f&#237;stula de l&#237;quido cefalorraqu&#237;deo&#46; Se presenta un caso de un gran encefalocele frontoetmoidal&#46; El encefalocele fue reparado y la reconstrucci&#243;n &#243;sea se realiz&#243; con hueso aut&#243;logo de la capota craneal&#46; El cierre y el resultado cosm&#233;tico fueron buenos y la &#250;nica complicaci&#243;n fue una infecci&#243;n posquir&#250;rgica&#46; Se describe la t&#233;cnica y se revisa la literatura publicada al respecto&#46;</p></span>"
      ]
    ]
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        "etiqueta" => "Fig&#46; 1"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Preoperative images of the frontoethmoidal encephalocele&#46;</p>"
        ]
      ]
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        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">MRI and 3D CT scan&#44; most of the right hemisphere is herniated through the bone defect&#46; The bone defect involves frontal bone&#44; cribrosa laminae and ethmoidal bone&#46; Orbits are intact&#46;</p>"
        ]
      ]
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        "etiqueta" => "Fig&#46; 3"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">3D model built from 3D CT scan&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Line of craniotomy&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "fig0025"
        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Surgical technique&#46; 1&#58; bicoronal incision and craneotomy&#46; 2&#8211;3&#58; dissection of the dural sac from the surrounding structures in the nasoorbital area&#46; 4&#58; resection of the encephalocele&#46; 5&#58; dissection of the duramater from brain and suture&#46; 6&#58; pericranial flap for covering duramater and filling dead space&#46; 7&#58; replacement of frontal bone adding a piece of autologous bone to reconstruct the glabella&#46; 8&#58; use of another piece of autologous bone from the skull to reconstruct the nasal bone&#46;</p>"
        ]
      ]
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        "etiqueta" => "Fig&#46; 6"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Postoperative&#46; In the right side 3D CT reconstruction showing the two pieces of bone used for reconstruction &#40;yellow arrows&#41; and the places of skull where they were taken out &#40;green arrows&#41;&#46;</p>"
        ]
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="top">Frontoethmoidal</td><td class="td" title="table-entry  " align="left" valign="top">Nasofrontal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nasoethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Naso-orbital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Basal</td><td class="td" title="table-entry  " align="left" valign="top">Transethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transsphenoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenoethmoidal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sphenomaxillary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Frontosphenoidal&#47;spheno-orbital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="6" align="left" valign="top">Encephalocele of the cranial vault</td><td class="td" title="table-entry  " align="left" valign="top">Interfrontal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Anterior fontanelle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interparietal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Posterior fontanelle&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Temporal&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Occipital&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab1972409.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Classification of encephaloceles&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:22 [
            0 => array:3 [
              "identificador" => "bib0115"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perioperative management of children with encephalocele&#58; an institutional experience"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46; Mahajan"
                            1 => "G&#46;P&#46; Rath"
                            2 => "H&#46;H&#46; Dash"
                            3 => "P&#46;K&#46; Bithal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/ANA.0b013e31821f93dc"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg Anesthesiol"
                        "fecha" => "2011"
                        "volumen" => "23"
                        "paginaInicial" => "352"
                        "paginaFinal" => "356"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21633311"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nasal encephaloceles&#58; a review of etiology&#44; pathophysiology&#44; clinical presentations&#44; diagnosis&#44; treatment&#44; and complications"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Tirumandas"
                            1 => "A&#46; Sharma"
                            2 => "I&#46; Gbenimacho"
                            3 => "M&#46;M&#46; Shoja"
                            4 => "R&#46;S&#46; Tubbs"
                            5 => "W&#46;J&#46; Oakes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00381-012-1998-z"
                      "Revista" => array:6 [
                        "tituloSerie" => "Childs Nerv Syst"
                        "fecha" => "2013"
                        "volumen" => "29"
                        "paginaInicial" => "739"
                        "paginaFinal" => "744"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23247827"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "L&#46; Barnes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2001"
                        "editorial" => "Marcel Dekker"
                        "editorialLocalizacion" => "New York"
                      ]
                    ]
                  ]
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            ]
            3 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The teaching files&#58; brain and spine imaging"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "G&#46;M&#46; Fatterpekar"
                            1 => "T&#46;P&#46; Naidich"
                            2 => "P&#46;M&#46; Som"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2012"
                        "editorial" => "Elsevier&#47;Saunders"
                        "editorialLocalizacion" => "Philadelphia"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0135"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Endocrine abnormalities in patients with frontoethmoidal encephalomeningocele&#46; A preliminary study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46; Wacharasindhu"
                            1 => "U&#46; Asawutmangkul"
                            2 => "S&#46; Srivuthana"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000087691"
                      "Revista" => array:6 [
                        "tituloSerie" => "Horm Res"
                        "fecha" => "2005"
                        "volumen" => "64"
                        "paginaInicial" => "64"
                        "paginaFinal" => "67"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16113580"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Nasal encephalocele&#58; endoscopic excision with anesthetic consideration"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Abdel-Aziz"
                            1 => "H&#46; El-Bosraty"
                            2 => "M&#46; Qotb"
                            3 => "M&#46; El-Hamamsy"
                            4 => "M&#46; El-Sonbaty"
                            5 => "H&#46; Abdel-Badie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ijporl.2010.04.015"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Pediatr Otorhinolaryngol"
                        "fecha" => "2010"
                        "volumen" => "74"
                        "paginaInicial" => "869"
                        "paginaFinal" => "8733"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20554034"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cephalocele&#58; report of 55 cases over 8 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "N&#46; Baradaran"
                            1 => "F&#46; Nejat"
                            2 => "N&#46; Baradaran"
                            3 => "M&#46; El Khashab"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000277622"
                      "Revista" => array:6 [
                        "tituloSerie" => "Pediatr Neurosurg"
                        "fecha" => "2009"
                        "volumen" => "45"
                        "paginaInicial" => "461"
                        "paginaFinal" => "466"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20110760"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Anterior encephaloceles&#58; a series of 103 cases over 23 years"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "A&#46;K&#46; Mahapatra"
                            1 => "D&#46; Agrawal"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jocn.2005.05.016"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Neurosci"
                        "fecha" => "2006"
                        "volumen" => "13"
                        "paginaInicial" => "536"
                        "paginaFinal" => "539"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16679016"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Morning glory syndrome&#58; unusual congenital optic disc anomaly"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Kindler"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Ophthalmol"
                        "fecha" => "1970"
                        "volumen" => "69"
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                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of anterior encephaloceles over 24 years in Kosova"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "A&#46; Morina"
                            1 => "F&#46; Kelmendi"
                            2 => "Q&#46; Morina"
                            3 => "S&#46; Dragusha"
                            4 => "F&#46; Ahmeti"
                            5 => "D&#46; Morina"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
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                        "fecha" => "2011"
                        "volumen" => "65"
                        "paginaInicial" => "122"
                        "paginaFinal" => "124"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21585191"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Frontoethmoidal meningoencephalocele&#58; appraisal of 200 operated cases"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "N&#46; Oucheng"
                            1 => "F&#46; Lauwers"
                            2 => "J&#46; Gollogly"
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ISSN: 11301473
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