case_images: PMC4033760_01
case_images: High-resolution computed tomography (CT) reveals enlargement of the sella turcica (c) and the broadly attenuated bony wall of both the sphenoid sinus (c, arrowhead) and ethmoid sinus (a,b, arrowheads). No apparent bony defect can be found.
case_images: SNI-5-54-g001.jpg
case_images: PMC4033760_01_SNI-5-54-g001.jpg
case_images: F1
case_images: High-resolution CT revealed enlargement of the sella turcica and broad thinning of the bony wall of both the sphenoid sinus and ethmoid sinus, including the cribriform plate [Figure 1].
case_images: Magnetic resonance cisternography (MRC) reveals an extracranial extension of cerebrospinal fluid (CSF) space as a small pouch protruding into the left olfactory cleft (a,b). Arachnoid herniation is indicated by soft tissue isointense strands of tissue intermingled with CSF signal intensity probably through the osteodural defect at the olfactory cleft (b, arrowhead). Note that the empty sella is depicted (c, arrow). MRC taken one week after surgery reveals the arachnoid herniation diminishing with a solid mass (abdominal fat) (d,e, blue arrowhead)
case_images: SNI-5-54-g002.jpg
case_images: PMC4033760_01_SNI-5-54-g002.jpg
case_images: F2
case_images: Coronal T2-weighted 3D drive equilibrium magnetic resonance imaging (MRI; T2-3D DRIVE), a kind of MRC, revealed an extracranial extension of CSF space as a small pouch protruding into the left olfactory cleft [Figure 2a-c]. In addition, enlargement of the subarachnoid space and dilated optic nerve sheaths and empty sella were depicted [Figures 2c and 3], suggesting a chronic state of increased ICP. At the time of writing, 14 months after surgery, there has been no recurrence of CSF rhinorrhea [Figure 2d and e].
case_images: Preoperative magnetic resonance imaging depicts enlargement of the subarachnoid space (a, arrowheads) and dilated optic nerve sheaths (b, arrow). This most likely indicates a chronic state of increased intracranial pressure
case_images: SNI-5-54-g003.jpg
case_images: PMC4033760_01_SNI-5-54-g003.jpg
case_images: F3
case_images: In addition, enlargement of the subarachnoid space and dilated optic nerve sheaths and empty sella were depicted [Figures 2c and 3], suggesting a chronic state of increased ICP.
case_images: Intraoperative photography shows the arachnoid herniation at the olfactory cleft (a). After removing the mucosa surrounding the bony defect, the arrow heads indicate the edge of the osteodural defect (b)
case_images: SNI-5-54-g004.jpg
case_images: PMC4033760_01_SNI-5-54-g004.jpg
case_images: F4
case_images: During the surgery, arachnoid herniation was observed at the olfactory cleft, precisely as demonstrated by the preoperative MRC [Figure 4a]. After detecting the leak point, the mucosa surrounding the bony defect was thoroughly removed in a range of several square millimeters [Figure 4b].