title: Pseudomeningocele With Orbital Extension as a Complication of Fronto-Orbital Advancement and Remodeling in Craniosynostosis.
abstract: OBJECTIVE
  The authors present a series of patients who developed a pseudomeningocele following fronto-orbital advancement and remodeling (FOAR), describing clinical presentation, investigations, and management. Risk factors are identified and preventative strategies suggested.
  
  
  METHODS
  From 2002 to 2012, all patients who underwent FOAR at our unit were identified. Those who developed a pseudomeningocele were selected and case notes, scan imaging and photographs were reviewed.
  
  
  RESULTS
  Two hundred thirty-six FOAR operations were carried out over 12 consecutive years. Sixty-one of these patients were syndromic. A pseudomeningocele occurred in 6 patients. All affected cases were syndromic. Clinical features of presentation with orbital pseudomeningocele included orbital swelling, ptosis, proptosis, and/or hypoglobus. Raised intracranial pressure (ICP) was managed before pseudomeningocele repair in 2 patients, at the time of pseudomeningocele repair using an extra-ventricular drain (EVD) or lumbar drain in 4 patients. Decompression of the pseudomeningocele with excision and duraplsty was carried out in 5 patients, 1 patient required excision of gliotic brain and obliteration of dead space. Four patients had a calvarial graft to manage the bony defect and a further 2 had a titanium mesh. None of the patients had a recurrence of the pseudomeningocele or any long-term ocular or aesthetic complications.
  
  
  CONCLUSIONS
  Pseudomeningocele has not previously been described in FOAR, but in a large series of consecutive patients, we have identified a 2.5% incidence. This incidence increases to 10% in the syndromic population of patients undergoing FOAR. The risk factors include a diagnosis of syndromic craniosynostosis, dural tear, hydrocephalus or raised ICP, infection, persistent cerebrospinal fluid (CSF) leak, or presence of dead space. Preventative strategies include CSF management before or post-FOAR. The ultimate treatment of the pseudomeningocele and growing fracture involves surgical decompression of the collection, a duraplasty, reconstruction of the orbital roof, and temporary CSF diversion.
authors.affiliation: *Department of Craniofacial, Alder Hey Children's Hospital, Liverpool, Merseyside †Maxillofacial Unit, University Aintree Hospital, Lower Lane, Liverpool, Merseyside, UK.
authors.forename: David
authors.initials: D
authors.lastname: Richardson
authors.forename: Christian
authors.initials: C
authors.lastname: Duncan
authors.forename: Ajay
authors.initials: A
authors.lastname: Sinha
authors.forename: Anusha Adeline
authors.initials: AA
authors.lastname: Hennedige
mesh_terms: D016080:Arachnoid Cysts / Q000209:etiology* / Q000601:surgery; D001672:Biocompatible Materials / Q000737:chemistry; D001763:Blepharoptosis / Q000209:etiology; D016025:Bone Transplantation / Q000379:methods; D065634:Cerebrospinal Fluid Leak / Q000209:etiology; D002675:Child, Preschool; D003398:Craniosynostoses / Q000601:surgery*; D003399:Craniotomy / Q000009:adverse effects; D019299:Decompression, Surgical / Q000379:methods; D004322:Drainage / Q000295:instrumentation / Q000379:methods; D004388:Dura Mater / Q000293:injuries / Q000601:surgery; D005094:Exophthalmos / Q000209:etiology; D005500:Follow-Up Studies; D005624:Frontal Bone / Q000601:surgery*; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology; D007223:Infant; D019586:Intracranial Hypertension / Q000209:etiology; D007431:Intraoperative Complications; D009915:Orbit / Q000601:surgery*; D011183:Postoperative Complications; D019651:Plastic Surgery Procedures / Q000009:adverse effects*; D012307:Risk Factors; D013526:Surgical Mesh; D014025:Titanium / Q000737:chemistry
chemical_list: D001672:Biocompatible Materials; D014025:Titanium