Board Certified Neurosurgeon Brain & Spine Care 860-889-9035
Mark Hornyak, MDBoard Certified Neurosurgeon
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Brain Case

Middle Skull Base Defect

67 year old man with history of cancer in his neck Routine CT of neck shows air inside his cranium (pneumocephalus).

Description

67 year old man with history of cancer in his neck
Routine CT of neck shows air inside his cranium (pneumocephalus).
Further work up is initiated with dedicated CT
CT shows severe degeneration of the temporomandibular joint with an associated defect in the floor of the skull.
There is air in the joint space and within the skull.

Gallery

Images

Figure 1CT scan. Top left axial tissue window. Top right axial bone window. Bottom left coronal bone window. Bottom right sagittal bone window. Blue arrows demonstrate areas of pneumocephalus. Beige areas demonstrate area of dehiscence in the middle fossa skull base.
Figure 2Photo taken in the operating room showing incision marked out in front of the right ear extending up into the frontal region.
Figure 3Intraoperative image captured through the surgical microscope. Shows the exposed middle fossa floor. Use figure 1 for orientation: Top of the screen is inferior, left is anterior. Blue arrow points to defect in the skull base.
Figure 4The bone flap, removed from the side of the skull to gain access to the middle fossa floor, has been contoured and is now being placed over the middle fossa floor defect. The left image shows the middle fossa floor and the calvarial graft within the field. On the right, the graft has been placed over the middle fossa floor defect.
Figure 5Intraoperative image showing additional steps in the skull base repair. On the left, the temporal lobe has been allowed to return to its normal position over the middle fossa floor including the calvarial graft. On the left synthetic dural graft has been placed between the dura and the repair. The right image shows the synthetic dura has been folded to entirely cover the repair and a thin layer of blue sealant has been applied. Application of the titanium mesh would be the next step in the procedure, not shown.
Figure 6Postoperative CT, compare to figure 1. Beige arrows show the placement of the calvarial graft. Blue arrows show titanium mesh cranioplasty covering the craniotomy/craniectomy/graft donor site.

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