Case Report
Transcranial cerebellar herniation following craniotomy: Case report and literature review
Herniación cerebelosa transcraneal tras una craneotomía: reporte de un caso y revisión de la literatura
Irene Panero Pérez
, Carla Eiriz Fernández, Daniel García Pérez, Alfonso Lagares, Luis Jiménez Roldán, Jose-Antonio Fernández Alen, Ana-M. Castaño León, Igor Paredes
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Department of Neurosurgery, 12 de Octubre University Hospital, Av. De Córdoba s/n, 28041 Madrid, Spain
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Castaño León, Igor Paredes" "autores" => array:8 [ 0 => array:4 [ "nombre" => "Irene" "apellidos" => "Panero Pérez" "email" => array:1 [ 0 => "ipanero903@hotmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Carla" "apellidos" => "Eiriz Fernández" ] 2 => array:2 [ "nombre" => "Daniel" "apellidos" => "García Pérez" ] 3 => array:2 [ "nombre" => "Alfonso" "apellidos" => "Lagares" ] 4 => array:2 [ "nombre" => "Luis" "apellidos" => "Jiménez Roldán" ] 5 => array:2 [ "nombre" => "Jose-Antonio" "apellidos" => "Fernández Alen" ] 6 => array:2 [ "nombre" => "Ana-M." "apellidos" => "Castaño León" ] 7 => array:2 [ "nombre" => "Igor" "apellidos" => "Paredes" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Neurosurgery, 12 de Octubre University Hospital, Av. De Córdoba s/n, 28041 Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herniación cerebelosa transcraneal tras una craneotomía: reporte de un caso y revisión de la literatura" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1299 "Ancho" => 1300 "Tamanyo" => 199733 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Post-operative cranial magnetic resonance imaging (MRI). Cranial MRI shows post-surgical changes and absence of tumor lesion. (A) On T2-weighted MRI image, shows bilateral herniation of the cerebellar hemispheres through the burr holes of the craniotomy; (B) T1-weighted sagital and (C) T1-weighted coronal images after gadolinium shows cerebellar herniation; (D) 3D reconstruction of the bone flap, which presents a bone defect in the region that corresponds to the two inferior burr holes of the craniotomy on each side.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Encephalocele is a condition characterized by the protrusion of the intracranial contents through a bone defect of the skull, this defect may have a congenital origin or follow a skull fracture or may be of iatrogenic origin.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the unusual case of post-surgical encephalocele through craniotomy following excision of a posterior fossa meningioma. Transcranial herniation is a dangerous and infrequent post-operative complication.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Case report</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 49-year-old female with no relevant medical history except obesity, consulted in the emergency department referring headache that had lasted three months. We performed an urgent CT scan that showed an extradural posterior fossa lesion. In the magnetic resonance imaging (MRI) the lesion size was 5<span class="elsevierStyleHsp" style=""></span>cm, it was homogeneous and isointense in T1 and T2 weighted images. It enhanced homogeneously after gadolinium was administered. Therefore a tentative diagnosis of meningioma was made (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Surgery was performed after one week. We made a midline occipital incision, two burr holes and a suboccipital craniotomy. The meninges were intact and we could see a bulge were the lesion was located. The lesion was intimately attached to the transverse sinuses, debulking was performed and the rest of the lesion was subsequently separated from the surrounding parenchyma and resected.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Haemostasia was performed. The dura was closed in a non water-tight fashion with interrupted single sutures, and a subdural non-suturable dural substitute (bovine collagen matrix, Integra® DuraGen®); followed by bone flap replacement with mini-screws and plates. <span class="elsevierStyleItalic">A small gap</span> on the bone defect was left unrepaired at the lower edge of the craniotomy, as usually performed.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The postoperative course was uneventful. At discharge the patient recovered fully and the wound healed adequately.</p><p id="par0035" class="elsevierStylePara elsevierViewall">One month later the patient was readmitted to our hospital due to cephalea, recurrent vomiting, dizziness and gait instability. The physical examination revealed cerebellar signs (ataxia and nystagmus). A MRI demonstrated trans-cranial herniation of the posterior aspect of both cerebellar hemispheres through the small gap at the lower edge of the occipital craniotomy consistent with an encephalocele (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">There were no clinical signs or symptoms of raised intracranial pressure (ICP) and no hydrocephalus or other indirect sings of high ICP were observed in the radiological studies.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to these findings, an urgent surgical intervention was carried out. The surgical wound was opened and we observed that cerebellum was herniated through the two inferior burr holes of the craniotomy on each side. The bone flap was removed and an attempt to return the herniated cerebellum to its original position was done, but it was incarcerated so the herniated cerebellum was resected. An attempt to perform a watertight closure of the dura was done, but the scarcity of dural borders precluded it. Therefore the same procedure for surgical closure as in the first intervention was performed: dural repair with non-suturable substitute and craneoplasty closing burr holes defects with mini-plates, but in this occasion without leaving defects uncovered with titanium plates (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">The symptoms of the patient resolved rapidly and at discharge, the patient was asymptomatic. Magnetic resonance imaging performed post-operatively demonstrated a complete resolution of the encephalocele. After six months the patient continues asymptomatic and the imaging tests show no complications (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">Encephalocele is defined as an extension of intracranial structures outside the normal confines of the skull. Other than cases of congenital bone defects, skull fractures, infections or neoplasia; encephalocele may occur postoperatively<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">2</span></a> due to osseus-dural defects after performing a craniotomy. Dural closure and bone reconstruction following a craniotomy for brain tumor removal prevent the development of post-surgical encephalocele. The cerebellar herniation is a rare finding and even more so when the tumor causing the tightening of the posterior fossa has been removed, and there are no other causes associated with this situation, such as high ICP or hydrocephalus.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Trans-cranial brain herniation is a rare disease. There are numerous cases reported in the literature of congenital encephaloceles, spontaneous or following a skull fracture, infection or a neoplasm.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">3</span></a> Nevertheless, there are very few reported cases of encephaloceles following craniotomy and no reported cases of cerebellar herniation after a posterior fossa cranioplasty. We are aware of a similar report following posterior fossa surgery. <span class="elsevierStyleItalic">Craig Timms</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">4</span></a> described a case of a patient with a cerebellar encephalocele after excision of a cerebellar metastasis, one month after surgery the patient complained of dizziness, unsteadiness and vomiting and the MRI showed a cerebellar encephalocele. Clinical and radiological characteristics are similar to our case; nevertheless, in this paper the bone flap was not replaced and cranioplasty was not performed. In our case, the bone flap was replaced, but it should be noted that the dural defect was not closed in a water-tight fashion in either of the two operations, due to the dural cuff being insufficient and with poor quality, not allowing the suture of a dural substitute.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In the literature, two cases of frontal brain herniation through anterior skull base defect after expanded endoscopic resection have been described. <span class="elsevierStyleItalic">Paolo Bataglia</span><a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a> collects these two cases in an article and analyzes the possible causes of this event. They reported the hypothesis that frontal lobe herniation into the sinonasal cavities is not attributable to the size of defect of the anterior skull base, to surgical technique or materials used for reconstruction. They believe that the factor that could be involved in the pathogenesis of this complication may be the presence of high ICP. The patients described in this article presented the “Modified Dandy criteria” (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) on the MRI. These alterations were related with idiopathic raised ICP.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> It is believed that obesity and sleep apnea syndrome may play a role in the pathogenesis of the idiopathic high ICP and therefore the consecutive risk of brain herniation. In our case, the patient presented a high BMI and did not have sleep apnea. But, due to the patient's emergent condition, a full study to rule out raised ICP was not performed. Nonetheless, the patient did not show pre-surgical symptoms or signs of high ICP (neither visual alterations, nor ventricular dilatation or indirect sings in the MRI). The fact that the patient did not present any symptoms or signs of high ICP after the surgery supports the suspicion that the patient did not suffer from high ICP. The author of this report suggested weight loss, sodium restriction, and even acetazolamide treatment, in high-risk patients, to reduce the risk of frontal lobe herniation.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0070" class="elsevierStylePara elsevierViewall">There is another paper that describes transclival pontine encephalocele following transclival endoscopic endonasal surgery, this article also concludes that being overweight is a factor that increases the risk of this complication.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">7</span></a> Two cases in the literature described trans-cranial brain herniation through burr holes. <span class="elsevierStyleItalic">Hater</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a> reported an asymptomatic encephalocele in a child three months after performing a burr hole for a ventriculostomy. The defect was repaired with a cranioplasty and dural closure. The author proposes as pathophysiology of the lesion of that case, a bone defect associated to pulsatile forces generated during cardiac cycle. <span class="elsevierStyleItalic">Doglietto</span><a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> exposed a similar case of trans-cranial cerebral herniation 10 days after the accomplishment of a burr hole in an adult patient, to evacuate a chronic subdural hematoma. The patient presented with sudden right arm monoparesis and dysarthria, associated with local scalp swelling. In our case an urgent duroplasty and craneoplasty were performed.</p><p id="par0075" class="elsevierStylePara elsevierViewall">There have been six recorded cases in the literature of herniation of brain tissues through a defect in the inner membrane after partial membranectomy to resolve an organized chronic subdural hematoma.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">10,11</span></a> Two of these cases were in adults<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9,11</span></a> and the other four cases were in children.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3,12</span></a> But the difference with our case is in the fact that in these reports the physiopathology of the encephaloceles was brain herniation through an internal subdural membrane, but there was not an herniation through the bony defect.</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ceccherini</span>, suggested that the cerebral pulsation appears to play a key role in the extrusion of cerebral tissue into the subdural space.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleItalic">Yoshikazu Kusano</span> proposed as pathophysiology of the lesion that when an increased intracranial pressure is accompanied by a defect in the subdural membrane, herniation of brain tissue might occur in the adult.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Cerebellar ptosis after posterior fossa decompressive craniectomy in a traumatic brain injury setting has been documented to cause similar symptoms cephalea, vomiting, dizziness and gait instability. Castaño-Leon reported the disappearance of the symptoms after repairing the bone and dural defect, as it happens in our case.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">14</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">To conclude, transcranial cerebellar encephaloceles have not been previously described. The uncommon problem described in this paper is serious and potentially life-threatening. If herniation occurs, an urgent surgical intervention is required to avoid permanent neurological damage. Therefore, it is recommended adequate dural and bony closure for all intracranial surgery, particularly in the posterior fossa surgeries and in high-risk patients. Since the late 1960s, authors have also demonstrated a correlation between obesity and increases in intracranial pressure. Increased intra-abdominal pressure creates a cascade of events that decreases venous return from the brain, leading to a non pathological increase of the intracranial pressure. In high-risk patients this situation may result in a herniation if there are post-surgical dural or bone defects.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> From a clinical viewpoint, in high-risk patients, some authors recommends weight loss, sodium restriction often with the addition of acetazolamide, to minimize this complication.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conclusions</span><p id="par0095" class="elsevierStylePara elsevierViewall">To the best of our knowledge, no similar cases of postoperatively encephalocele have been reported after performance of a posterior fossa craniotomy. To avoid this potentially lethal complication a careful dural closure must be done followed by the bone flap replacement. Special care must be taken with patients with or suspected raised ICP, or predisposing factors like obesity.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1384886" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1270986" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xpalclavsec1270988" "titulo" => "Abbreviations" ] 3 => array:3 [ "identificador" => "xres1384887" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1270987" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 7 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-09-03" "fechaAceptado" => "2018-12-06" "PalabrasClave" => array:2 [ "en" => array:2 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1270986" "palabras" => array:5 [ 0 => "Postoperatively encephalocele" 1 => "Post-surgical encephalocele" 2 => "Trans-cranial herniation" 3 => "Craniotomy" 4 => "Cranioplasty" ] ] 1 => array:4 [ "clase" => "abr" "titulo" => "Abbreviations" "identificador" => "xpalclavsec1270988" "palabras" => array:3 [ 0 => "MRI" 1 => "SFC" 2 => "ICP" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1270987" "palabras" => array:5 [ 0 => "Encefalocele postoperatorio" 1 => "Encefalocele posquirúrgico" 2 => "Herniación transcraneal" 3 => "Craneotomía" 4 => "Craneoplastia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To report a case of post-surgical encephalocele through craniotomy burr holes following the resection of a meningioma of the posterior fossa. A 49-year-old female presented in the emergency room with cephalea. The MRI showed a meningioma of the convexity of the posterior fossa. A resection was performed and the bone flap replaced. The patient recovered uneventfully and was discharged. After 30 days the patient consulted referring cephalea, vomiting and imbalance. Brain MRI revealed a trans-cranial cerebellar herniation through the craniotomy burr holes. An urgent surgery was performed to repair the encephalocele. Post-surgical brain MRI was performed and did not show complications.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Post-surgical encephalocele is an uncommon complication after the resection of a posterior fossa lesion. To avoid this complication, it is recommended thorough dural and bony closure, particularly in the posterior fossa surgeries and in high-risk patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Reportamos un caso de un encefalocele posquirúrgico tras la realización de una craneotomía para la resección de un meningioma de fosa posterior. Se trata de una mujer de 49 años que acude al servicio de urgencias por cefalea. Se realizó una resonancia magnética (RM) cerebral que mostró un meningioma de la convexidad en fosa posterior. Se realizó su resección quirúrgica y reposición del colgajo óseo. La paciente se recuperó sin incidencias y fue dada de alta. Treinta días más tarde consultó por cefalea, vómitos e inestabilidad. Se realizó una RM que mostró una herniación cerebelosa a través de los orificios de trépano de la craneotomía, por lo que se llevó a cabo una reparación quirúrgica urgente del encefalocele. Se realizó una RM posquirúrgica, la cual no mostró complicaciones.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El encefalocele posquirúrgico es una complicación poco frecuente tras la resección de un meningioma de fosa posterior. Para evitar esta complicación se recomienda realizar un cierre dural y una reposición ósea cuidadosos, particularmente en las cirugías de fosa posterior y en pacientes con alto riesgo.</p></span>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1299 "Ancho" => 1300 "Tamanyo" => 178491 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Preoperative cranial magnetic resonance imaging (MRI). Cranial MRI shows an extensive tumor in the central region of the posterior fossa, extraaxial, with maximum diameters of 5<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>4<span class="elsevierStyleHsp" style=""></span>cm. (A) On T1-weighted MRI, the lesion is homogeneus, isointense with hypointense foci inside, in relation to calcifications and flow voids, it is well-defined; (B) shows homogeneus strong enhacement after gadolinium administration on T1-weighted axial image; (C) T1-weigthed sagital image post-gadolinium which shows the lesion compressing the fourth ventricle and descent of the cerebellar tonsils; (D) T1-weigthed coronal image post-gadolinium that shows a lesion that seems to be attached to the cerebellar tentorium.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1299 "Ancho" => 1300 "Tamanyo" => 199733 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Post-operative cranial magnetic resonance imaging (MRI). Cranial MRI shows post-surgical changes and absence of tumor lesion. (A) On T2-weighted MRI image, shows bilateral herniation of the cerebellar hemispheres through the burr holes of the craniotomy; (B) T1-weighted sagital and (C) T1-weighted coronal images after gadolinium shows cerebellar herniation; (D) 3D reconstruction of the bone flap, which presents a bone defect in the region that corresponds to the two inferior burr holes of the craniotomy on each side.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 906 "Ancho" => 1300 "Tamanyo" => 277326 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Intraoperative images. (A) The image shows the cerebellum herniated through the two inferior burr holes of the craniotomy on each side. (B) The bone flap was removed and shows the surgical bed after complete resection of the herniated cerebellum.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1302 "Ancho" => 1300 "Tamanyo" => 215788 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Post second surgery cranial magnetic resonance imaging (MRI). (A) On T2-weighted axial MRI image and (B) T2-weighted sagital and coronal images which shows post-surgical changes and absence of herniated cerebellum; (B) T1-weighted sagital and (C) T1-weighted coronal images after gadolinium shows two hypointense regions that correspond to the resection of the herniated cerebellar parenchyma without complications; (D) 3D reconstruction of the bone flap, in which no bone defects are observed in the caudal region.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 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-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. Neurologic manifestations attributable to generalized increased intracranial pressure (headaches, nausea, vomiting, papilledema). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. No localizing neurologic signs otherwise with the single exception being unilateral or bilateral VI nerve paresis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. Cerebroespinal fluid which can show increased pressure but with no cytologic or chemical abnormalities otherwise. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4. Normal to small symmetrical ventricles demonstrated by neuroimaging). \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2377244.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">“Modified Dandy criteria”: diagnosis of idiopatic intracranial hypertension.<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0085" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary occipital encephalocele in an elderly patient" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "F.C. Barros" 1 => "H.A. Barros" 2 => "H.M. Junior" 3 => "P.F. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2023 Marzo | 5 | 2 | 7 |
| 2021 Septiembre | 1 | 0 | 1 |
| 2021 Abril | 1 | 0 | 1 |
| 2020 Mayo | 1 | 0 | 1 |
| 2020 Abril | 2 | 0 | 2 |
| 2020 Marzo | 2 | 2 | 4 |
| 2020 Enero | 2 | 2 | 4 |
| 2019 Diciembre | 1 | 0 | 1 |
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| 2019 Mayo | 1 | 2 | 3 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Enero | 1 | 0 | 1 |
