Endoscopic endonasal repair of temporal lobe meningoencephalocele in the lateral recess of the sphenoid sinus, complicated by intracerebral hematoma: illustrative case

Rasim Agaev Department of Neurooncology, FSBI Federal Neurosurgical Center, Novosibirsk, Russia

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Ekaterina Gormolysova Department of Neurooncology, FSBI Federal Neurosurgical Center, Novosibirsk, Russia

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Anton Kalinovskiy Department of Neurooncology, FSBI Federal Neurosurgical Center, Novosibirsk, Russia

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Jamil Rzaev Department of Neurooncology, FSBI Federal Neurosurgical Center, Novosibirsk, Russia

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BACKGROUND

Anomalies in the anatomical structure of the nasal cavity and paranasal sinuses often serve as a potential cause of spontaneous cerebrospinal fluid (CSF) leakage and may result in the development of a meningoencephalocele. In this report, the authors present a case of surgically treated intrasphenoidal meningoencephalocele attributed to the persistence of the lateral craniopharyngeal canal, which was further complicated by the occurrence of an intracerebral hematoma.

OBSERVATIONS

A temporal lobe meningoencephalocele located in the lateral recess of the sphenoid sinus was successfully managed using endoscopic endonasal transpterygoid repair (EETR). However, an intracerebral hematoma developed after resection of the meningoencephalocele, necessitating additional surgical interventions. Despite this complication, the patient exhibited a favorable clinical outcome after the surgical interventions.

LESSONS

This case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. A thorough examination of magnetic resonance imaging scans, especially identifying vascular structures, is crucial during surgical planning. This knowledge can help to prevent the occurrence of complications, including intracerebral hematoma.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; EEA = endonasal approach; EETR = endoscopic endonasal transpterygoid repair; MCA = middle cerebral artery; MRI = magnetic resonance imaging; SAH = subarachnoid hemorrhage; SS = sphenoid sinus; TCD = transcranial Doppler; TPA = temporopolar artery

BACKGROUND

Anomalies in the anatomical structure of the nasal cavity and paranasal sinuses often serve as a potential cause of spontaneous cerebrospinal fluid (CSF) leakage and may result in the development of a meningoencephalocele. In this report, the authors present a case of surgically treated intrasphenoidal meningoencephalocele attributed to the persistence of the lateral craniopharyngeal canal, which was further complicated by the occurrence of an intracerebral hematoma.

OBSERVATIONS

A temporal lobe meningoencephalocele located in the lateral recess of the sphenoid sinus was successfully managed using endoscopic endonasal transpterygoid repair (EETR). However, an intracerebral hematoma developed after resection of the meningoencephalocele, necessitating additional surgical interventions. Despite this complication, the patient exhibited a favorable clinical outcome after the surgical interventions.

LESSONS

This case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. A thorough examination of magnetic resonance imaging scans, especially identifying vascular structures, is crucial during surgical planning. This knowledge can help to prevent the occurrence of complications, including intracerebral hematoma.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; EEA = endonasal approach; EETR = endoscopic endonasal transpterygoid repair; MCA = middle cerebral artery; MRI = magnetic resonance imaging; SAH = subarachnoid hemorrhage; SS = sphenoid sinus; TCD = transcranial Doppler; TPA = temporopolar artery

Cerebrospinal fluid (CSF) leakage is an uncommon yet potentially life-threatening condition, primarily because of the elevated risk of infectious complications, including meningitis. The medical literature even recounts a case in which a patient with meningoencephalocele developed pneumocephalus.1 CSF leakage can arise from various pathologies, such as congenital defects in the skull base, persistent Sternberg’s canal, tumors, or traumatic lesions. Patients often experience significant delays in seeking medical attention, either due to prolonged misdiagnosis and treatment for rhinitis or because only active fluid leakage from the nose prompts healthcare professionals to investigate the skull base.2,3 In 1888, Maximilian Sternberg documented the lateral craniopharyngeal canal as a congenital bone defect located in the lateral wall of the sphenoid sinus. This defect arises from incomplete fusion of the greater wings of the sphenoid bone with its posterior and anterior sections during development of the sphenoid sinus.4–6 The presence of this defect creates a vulnerable area in the skull base, which can result in the formation of a temporal lobe meningoencephalocele that protrudes into the lateral recess of the sphenoid sinus (SS).7 The most common signs of meningoencephaloceles include nasal obstruction, CSF rhinorrhea, recurrent meningitis, and seizures. Less common symptoms include facial pain, numbness, and headache.8,9 Here, we present the case of a surgically managed intrasphenoidal meningoencephalocele caused by persistence of the lateral recess of the SS, which was further complicated by the development of an intracerebral hematoma.

Illustrative Case

History and Examination

A 34-year-old female presented with a chronic 8-year history of rhinorrhea. There was no reported history of previous head trauma or surgical intervention. The patient sought medical attention because of a noticeable increase in the amount of fluid being secreted from her nose. Additional clinically relevant information included morbid obesity (body mass index of 55 kg/m2) and untreated hypertension. Clinically, the rhinorrhea was consistent with CSF leakage, which was confirmed by both an otolaryngologist and a positive glucose test.

Imaging Findings

Initial head computed tomography (CT) scanning upon admission revealed a 5-mm bony defect on the posterior aspect of the sphenoid sinus, through which a mass of soft tissue density (meningoencephalocele) was observed (Fig. 1). Subsequent magnetic resonance imaging (MRI) displayed gliotic changes in the temporal brain parenchyma and an encompassing meningeal sac, without any evidence of contrast enhancement. This structure was found to herniate through the previously identified defect in the sphenoid bone (Fig. 2). Given clear visualization of the defect on both the MRI and CT scanning, CT cisternography was deemed unnecessary.

FIG. 1
FIG. 1

On preoperative CT, the bone defect was clearly visualized on the coronal (A) and sagittal sections (B). On the three-dimensional reconstruction (C), a bone defect of the sphenoid sinus was visualized. Red arrows indicate the defect.

FIG. 2
FIG. 2

Preoperative MRI scans with contrast enhancement visualized the gliotic temporal brain parenchyma and a surrounding meningeal sac without contrast enhancement herniating through the sphenoid sinus bony defect on coronal (A), sagittal (B), and axial (C) sections. Red arrows indicate brain tissue.

Treatment and Outcomes

Surgical repair of the defect was performed using an endoscopic endonasal transpterygoid repair (EETR). A 0°-angled endoscope was used, providing clear visualization of the herniated tissue protruding through a circular bony defect, accompanied by liquorrhea. The protruding tissue was carefully removed until the bone margins were reached. Subsequently, the defect was sealed using TachoComb, an autologous fat graft, and free mucosal tissue harvested from the nasal septum. Hemostasis was achieved using Surgicel, Spongostan, and electrocoagulation techniques. No evidence of bleeding or liquorrhea was observed during the procedure. To conclude the operation, a balloon catheter was used. After surgery, the patient was extubated and regained consciousness, albeit with decreased functional levels (Glasgow Outcome Scale score 12). No other neurological deficits were detected. A CT scan was obtained, revealing the presence of an intracerebral hematoma in the left temporal lobe measuring up to 40 mL and accompanied by indications of subarachnoid hemorrhage (SAH; Fig. 3A). Given these findings, an immediate decision was made to proceed with microsurgical removal of the intracerebral hematoma in the left temporal lobe. In the postoperative period, the patient’s overall condition remained stable, and extubation was successfully performed. There was no disorder of consciousness (Glasgow Outcome Scale score 15), but an additional neurological deficit in the form of motor aphasia was noted. Subsequent CT scans obtained after the surgery revealed the absence of the hematoma, with only residual SAH visible (Fig. 3B).

FIG. 3
FIG. 3

Postoperative axial CT imaging revealed intracerebral hematoma (red arrow, A) of the left temporal lobe. Axial CT scan after the second surgery with SAH (red arrows, B) without any signs of hematoma.

In light of the presence of SAH, the patient was prescribed nimodipine as a preventive measure against future vasospasm. MRI performed on the following day demonstrated the presence of a perifocal ischemic area in the temporal lobe, along with indications of SAH (Fig. 4A). By the 7th day, mild vasospasm was observed during a transcranial Doppler (TCD) ultrasound examination, whereas no new neurological deficits were identified. Continuing the therapeutic regimen, on the 13th day, an increase in aphasic symptoms was observed. Follow-up MRI of the brain revealed the presence of new small areas of ischemia in the left frontal lobe (Fig. 4B). Consequently, the decision was made to maintain the ongoing nimodipine therapy. During the course of ongoing conservative therapy, a notable regression of aphasic symptoms was observed, without the presence of any other neurological deficits. TCD examinations indicated a regression of vasospasm. At the time of discharge, the patient’s condition remained stable, with no signs of liquorrhea. However, mild residual motor aphasia persisted, albeit with a tendency to improvement. The patient was discharged in a satisfactory condition under the supervision of a neurologist. Continuing the administration of nimodipine was recommended for a duration of 15 days. Follow-up MRI, accompanied by consultation with a neurosurgeon, was scheduled after 6 months. At the 6-month follow-up, the patient exhibited a complete recovery with no signs of neurological deficit or CSF rhinorrhea.

FIG. 4
FIG. 4

Control diffusion-weighted MRI with a perifocal ischemic area (red arrows, A) in the temporal lobe. Control diffusion-weighted MRI of the brain after 13 days with an ischemic area (red arrow, B) in the left frontal lobe.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Intracerebral hematoma is an exceedingly rare and uncommon complication of endoscopic transnasal repair of lateral sphenoid sinus meningoencephalocele defects. Currently, various surgical treatment options are available for skull base defects, including both conventional approaches and the endoscopic endonasal approach (EEA). The EEA offers advantages such as minimal invasiveness, reduced trauma, and lower complication rates. Although endoscopic surgery is generally the preferred choice, repairing the defect in the sphenoid sinus region endoscopically can present challenges compared to transcranial approaches.10 According to a literature review, the most frequently encountered complications of EEA include CSF leaks, infectious complications, neural injury, vascular injury, permanent visual loss, and instances of permanent morbidity and death. The two primary sources of morbidity in skull base surgery are damage to vascular structures and to cranial nerves. Comprehensive knowledge of the surgical relations among the internal carotid artery, vertebral arteries, and circle of Willis can help to mitigate complications associated with cerebrovascular issues.11–17 However, it is important to consider the possibility of anatomical anomalies in the vascular system’s normal development, as encountered in our case.

Observations

Upon reviewing the MRI scans, we noted that the meningoencephalocele was composed of a branch of the middle cerebral artery (MCA) known as the temporopolar artery (TPA). This arterial branch was believed to be the underlying cause of the hemorrhage (Fig. 5). The first major branch of the MCA is a substantial arterial trunk that supplies the entire temporal lobe by giving rise to the TPA, anterior temporal artery, middle temporal artery, and posterior temporal artery.18 The TPA specifically serves as one of the 12 named cortical branches of the MCA, supplying the most anterior regions of the superior, middle, and inferior temporal gyri.19 During the final hemostasis stage of the intraoperative procedure, no signs of bleeding from the skull base defect into the nasal cavity were observed. Consequently, no complications were initially suspected intraoperatively. It is plausible that during resection of the dural sac, the artery retracted into the cranial cavity, leading to the occurrence of this complication. Our review of the literature revealed that there has been only one reported case like ours involving a lateral sphenoid sinus meningoencephalocele. In that case, the meningoencephalocele was resected up to the level of the bone defect. Complications included asymptomatic hemorrhagic imbibition of the temporal lobe pole, without any associated neurological deficits. Regrettably, the authors opted not to investigate this complication further due to the lack of clinical manifestations.20

FIG. 5
FIG. 5

Preoperative MRI with a branch of the MCA, the TPA (red arrows), which was visualized on coronal (A), sagittal (B), and axial (C) sections.

Lessons

Our case highlights the potential risk of intracerebral hematoma associated with EETR of a lateral sphenoid sinus meningoencephalocele. The presence of this vascular anatomy is unexpected and poses challenges in terms of its clinical identification. Therefore, meticulous examination of MRI scans to identify vascular structures is crucial in the surgical planning process. This knowledge plays a vital role in preventing the occurrence of complications, such as intracerebral hematoma.

Author Contributions

Conception and design: Agaev, Gormolysova. Acquisition of data: Agaev, Gormolysova. Analysis and interpretation of data: Agaev. Drafting the article: Agaev. Critically revising the article: Gormolysova, Kalinovskiy, Rzaev. Reviewed submitted version of manuscript: Gormolysova, Kalinovskiy. Approved the final version of the manuscript on behalf of all authors: Agaev. Statistical analysis: Agaev. Administrative/technical/material support: Rzaev. Study supervision: Kalinovskiy, Rzaev.

Supplemental Information

Previous Presentations

The abstract presented as e-poster at the 3rd International Rhoton Society Meeting, in Istanbul, Turkey, August 22–24, 2023.

References

  • 1

    Ohkawa T, Nakao N, Uematsu Y, Itakura T. Temporal lobe encephalocele in the lateral recess of the sphenoid sinus presenting with intraventricular tension pneumocephalus. Skull Base. 2010;20(6):481486.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Cruz e Silva V, Luís A, Mora Féria R, et al. Transsphenoidal meningoencephalocele protruding into the nasal cavity. BJR Case Rep. 2016;3(2):20160082.

  • 3

    Hanwate R, Thorawade V, Jagade M, et al. CSF rhinorrhoea with encephalocele through Sternberg’s canal: our experience. Int J Otolaryngol Head Neck Surg. 2015;04:5054.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Schick B, Brors D, Prescher A. Sternberg’s canal—cause of congenital sphenoidal meningocele. Eur Arch Otorhinolaryngol. 2000;257(8):430432.

  • 5

    Khattar VS, Hathiram BT, Sharma H. Sternberg’s canal and the controversies surrounding it. Int J Otorhinolaryngol Clin. 2011;3(3):184187.

  • 6

    Tomazic PV, Stammberger H. Spontaneous CSF-leaks and meningoencephaloceles in sphenoid sinus by persisting Sternberg’s canal. Rhinology. 2009;47(4):369374.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Zoli M, Farneti P, Ghirelli M, et al. Meningocele and meningoencephalocele of the lateral wall of sphenoidal sinus: the role of the endoscopic endonasal surgery. World Neurosurg. 2016;87:9197.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Alokby G, Albathi A, Alshurafa Z, AlQahtani A. Endoscopic endonasal repair of a temporal lobe meningoencephalocele in the pterygoid fossa: A case report and literature review. Int J Surg Case Rep. 2021;83:105963.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Deniz M, Kabar F, Besnek A. Frontoethmoidal encephalocele as a cause of recurrent meningitis. Rev Soc Bras Med Trop. 2023;56:e02362023.

  • 10

    Bozkurt G, Turri-Zanoni M, Coden E, et al. Endoscopic endonasal transpterygoid approach to sphenoid sinus lateral recess defects. J Neurol Surg B Skull Base. 2020;81(5):553561.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kassam AB, Prevedello DM, Carrau RL, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011;114(6):15441568.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Borg A, Kirkman MA, Choi D. Endoscopic Endonasal anterior skull base surgery: a systematic review of complications during the past 65 years. World Neurosurg. 2016;95:383391.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Rojas HP, José PH, Herrera RR, Ledesma JL, Rubín E, Stieben LAR. Transnasal endoscopic skull base surgery: analysis of complications in the first 120 procedures. Article in Spanish. Surg Neurol Int. 2022;13:523.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Hardesty DA, Montaser A, Kreatsoulas D, et al. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg. 2021;136(2):393404.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Tirumandas M, Sharma A, Gbenimacho I, et al. Nasal encephaloceles: a review of etiology, pathophysiology, clinical presentations, diagnosis, treatment, and complications. Childs Nerv Syst. 2013;29(5):739744.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Tabaee A, Anand VK, Cappabianca P, Stamm A, Esposito F, Schwartz TH. Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg. 2010;112(5):10701077.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Schmidt RF, Choudhry OJ, Raviv J, et al. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus. 2012;32(6):E5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    De Long WB. Anatomy of the middle cerebral artery: the temporal branches. Stroke. 1973;4(3):412418.

  • 19

    Tayebi Meybodi A, Benet A, Griswold D, Dones F, Preul MC, Lawton MT. Anatomical assessment of the temporopolar artery for revascularization of deep recipients. Oper Neurosurg (Hagerstown). 2019;16(3):335344.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Sharipov OI, Kutin MA, Polev GA, Kalinin PL. Lateral extended transsphenoidal endoscopic approach through the pterygopalatine fossa in surgery for meningoencephalocele of the lateral sphenoid recess. Article in Russian. Vopr Neirokhir. 2018;82(5):96103.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1

    On preoperative CT, the bone defect was clearly visualized on the coronal (A) and sagittal sections (B). On the three-dimensional reconstruction (C), a bone defect of the sphenoid sinus was visualized. Red arrows indicate the defect.

  • FIG. 2

    Preoperative MRI scans with contrast enhancement visualized the gliotic temporal brain parenchyma and a surrounding meningeal sac without contrast enhancement herniating through the sphenoid sinus bony defect on coronal (A), sagittal (B), and axial (C) sections. Red arrows indicate brain tissue.

  • FIG. 3

    Postoperative axial CT imaging revealed intracerebral hematoma (red arrow, A) of the left temporal lobe. Axial CT scan after the second surgery with SAH (red arrows, B) without any signs of hematoma.

  • FIG. 4

    Control diffusion-weighted MRI with a perifocal ischemic area (red arrows, A) in the temporal lobe. Control diffusion-weighted MRI of the brain after 13 days with an ischemic area (red arrow, B) in the left frontal lobe.

  • FIG. 5

    Preoperative MRI with a branch of the MCA, the TPA (red arrows), which was visualized on coronal (A), sagittal (B), and axial (C) sections.

  • 1

    Ohkawa T, Nakao N, Uematsu Y, Itakura T. Temporal lobe encephalocele in the lateral recess of the sphenoid sinus presenting with intraventricular tension pneumocephalus. Skull Base. 2010;20(6):481486.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Cruz e Silva V, Luís A, Mora Féria R, et al. Transsphenoidal meningoencephalocele protruding into the nasal cavity. BJR Case Rep. 2016;3(2):20160082.

  • 3

    Hanwate R, Thorawade V, Jagade M, et al. CSF rhinorrhoea with encephalocele through Sternberg’s canal: our experience. Int J Otolaryngol Head Neck Surg. 2015;04:5054.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Schick B, Brors D, Prescher A. Sternberg’s canal—cause of congenital sphenoidal meningocele. Eur Arch Otorhinolaryngol. 2000;257(8):430432.

  • 5

    Khattar VS, Hathiram BT, Sharma H. Sternberg’s canal and the controversies surrounding it. Int J Otorhinolaryngol Clin. 2011;3(3):184187.

  • 6

    Tomazic PV, Stammberger H. Spontaneous CSF-leaks and meningoencephaloceles in sphenoid sinus by persisting Sternberg’s canal. Rhinology. 2009;47(4):369374.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Zoli M, Farneti P, Ghirelli M, et al. Meningocele and meningoencephalocele of the lateral wall of sphenoidal sinus: the role of the endoscopic endonasal surgery. World Neurosurg. 2016;87:9197.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Alokby G, Albathi A, Alshurafa Z, AlQahtani A. Endoscopic endonasal repair of a temporal lobe meningoencephalocele in the pterygoid fossa: A case report and literature review. Int J Surg Case Rep. 2021;83:105963.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Deniz M, Kabar F, Besnek A. Frontoethmoidal encephalocele as a cause of recurrent meningitis. Rev Soc Bras Med Trop. 2023;56:e02362023.

  • 10

    Bozkurt G, Turri-Zanoni M, Coden E, et al. Endoscopic endonasal transpterygoid approach to sphenoid sinus lateral recess defects. J Neurol Surg B Skull Base. 2020;81(5):553561.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Kassam AB, Prevedello DM, Carrau RL, et al. Endoscopic endonasal skull base surgery: analysis of complications in the authors’ initial 800 patients. J Neurosurg. 2011;114(6):15441568.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Borg A, Kirkman MA, Choi D. Endoscopic Endonasal anterior skull base surgery: a systematic review of complications during the past 65 years. World Neurosurg. 2016;95:383391.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Rojas HP, José PH, Herrera RR, Ledesma JL, Rubín E, Stieben LAR. Transnasal endoscopic skull base surgery: analysis of complications in the first 120 procedures. Article in Spanish. Surg Neurol Int. 2022;13:523.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Hardesty DA, Montaser A, Kreatsoulas D, et al. Complications after 1002 endoscopic endonasal approach procedures at a single center: lessons learned, 2010-2018. J Neurosurg. 2021;136(2):393404.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Tirumandas M, Sharma A, Gbenimacho I, et al. Nasal encephaloceles: a review of etiology, pathophysiology, clinical presentations, diagnosis, treatment, and complications. Childs Nerv Syst. 2013;29(5):739744.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Tabaee A, Anand VK, Cappabianca P, Stamm A, Esposito F, Schwartz TH. Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg. 2010;112(5):10701077.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Schmidt RF, Choudhry OJ, Raviv J, et al. Surgical nuances for the endoscopic endonasal transpterygoid approach to lateral sphenoid sinus encephaloceles. Neurosurg Focus. 2012;32(6):E5.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    De Long WB. Anatomy of the middle cerebral artery: the temporal branches. Stroke. 1973;4(3):412418.

  • 19

    Tayebi Meybodi A, Benet A, Griswold D, Dones F, Preul MC, Lawton MT. Anatomical assessment of the temporopolar artery for revascularization of deep recipients. Oper Neurosurg (Hagerstown). 2019;16(3):335344.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Sharipov OI, Kutin MA, Polev GA, Kalinin PL. Lateral extended transsphenoidal endoscopic approach through the pterygopalatine fossa in surgery for meningoencephalocele of the lateral sphenoid recess. Article in Russian. Vopr Neirokhir. 2018;82(5):96103.

    • PubMed
    • Search Google Scholar
    • Export Citation

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