Encephalocele, Parietal

H&P

• HPI:
  • Presented to clinic
  • Born with a 2-3 cm slightly right biased parietal skull/scalp mass
  • Expands when cries
  • No drainage
• PE:
  • Alert, appears stated age and cooperative
  • 2-3 cm right biased parietal scalp/skull mass, with thinned area of alopecia overlying
  • No palpable bony defect
  • No pulsatility
  • Anterior fontanelle soft and flat
  • Normal strength and tone, symmetric reflexes
  • Cranial nerves II-XII grossly intact
• Workup: CT head without contrast

Imaging

CT Head without Contrast - Axial, Coronal, and Sagittal

CT Head with Contrast - Axial, Coronal, and Sagittal

• A vertically oriented primitive falcine sinus extends from the posterior internal cerebral veins to the site of the calvarial defect.
• The straight sinus is relatively hypoplastic.

CT Head (Bone Window) - Axial, Coronal, and Sagittal

Diagnosis

• Parietal encephalocele

Surgical Repair

• Prone
• Fish-mouth style incision from just to the left of midline to the right
• Dissection down to skull
• Identification of bony defect and the stalk
• Skeletonization of the stalk
• Occlusion with a 2-0 silk tie
• Resection of the cutaneous portion
• Circumferential dissection of the bony defect
• Coverage of defect using the bone harvested lateral to the defect (secured with 3-0 Vicryl)
• Surgicel coverage
• Closure
• Pathology: skin tissue with no significant pathological findings, consistent with clinical diagnosis of encephalocele.

Post-Op Recovery

• ICU with hourly neuro-checks overnight
• No deficits
• TTF on POD1
• Discharged home

Discussion

• The lesion is at the proximity of the superior sagittal sinus and seems to have connection with the falcine sinus, posing a high risk of intraoperative vascular injury.
• Falcine sinus