PMC7468192_01
Computed tomography imaging of the head 6 years before presentation showing intraventricular pneumocephalus and the VP shunt catheter (white arrow).
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F1
At 6 years before presentation, she had undergone ligation of the shunt catheter after complaining of the right-sided tinnitus with evidence of intraventricular pneumocephalus [Figure 1].
Computed tomography imaging of the head showing enlargement of the inferior horn of the lateral ventricles (black dotted circles).
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F2
Computed tomography (CT) imaging of the head at admission showed enlargement of the lateral ventricles, a right mastoid fluid collection, and a defect of the superior wall of the right petrous bone [Figures 2-5].
Axial temporal bone computed tomography imaging showing a mastoid fluid collection (white dotted circle). (a), right side and (b), left side.
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F3
Computed tomography (CT) imaging of the head at admission showed enlargement of the lateral ventricles, a right mastoid fluid collection, and a defect of the superior wall of the right petrous bone [Figures 2-5].
Coronal temporal bone computed tomography imaging showing a mastoid fluid collection and a defect of the petrous bone (white arrow). (a), right side and (b), left side.
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F4
Computed tomography (CT) imaging of the head at admission showed enlargement of the lateral ventricles, a right mastoid fluid collection, and a defect of the superior wall of the right petrous bone [Figures 2-5].
Sagittal temporal bone computed tomography imaging showing a mastoid fluid collection and a defect of the petrous bone (white arrow). (a), right side and (b), left side.
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F5
Computed tomography (CT) imaging of the head at admission showed enlargement of the lateral ventricles, a right mastoid fluid collection, and a defect of the superior wall of the right petrous bone [Figures 2-5].
Intraoperative microscopic image showing a temporal lobe parenchymal herniation into the mastoid air cells through lacerated dura and a defect site of petrous bone (white arrow).
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F6
When the right temporal lobe was retracted, we identified the site of the leak, and it was noted that temporal lobe parenchyma herniated into the mastoid air cells through lacerated dura and a partially defective tegmen mastoideum [Figures 6 and 7].
Intraoperative microscopic image showing lacerated dura after herniated temporal lobe was interrupted (white arrow).
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F7
When the right temporal lobe was retracted, we identified the site of the leak, and it was noted that temporal lobe parenchyma herniated into the mastoid air cells through lacerated dura and a partially defective tegmen mastoideum [Figures 6 and 7].
Intraoperative microscopic image showing the defect site covered by the pericranial graft (white dotted circle). Figure 9: Intraoperative image showing the extradural space closure using an abdominal fat graft (white arrow).
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F8
We interrupted the herniated parenchyma using bipolar forceps and tacked the pericranial graft to the dura with 7-0 PRONOVA  Poly suture (Ethicon, Inc., Somerville, NJ) to cover the defect site [Figure 8].
Intraoperative image showing the extradural space closure using an abdominal fat graft (white arrow).
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F9
An abdominal fat graft was harvested to obliterate the defect site extradurally [Figure 9].
Intraoperative image showing a temporalis muscle flap sutured to the middle cranial fossa dura.
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F10
Furthermore, a temporalis muscle flap was sutured to the dura to close the extradural space [Figure 10].
Postoperative temporal bone CT imaging showing resolution of the mastoid fluid collection and disappearance of the defect site of the petrous bone. (a), axial, (b), coronal and (c), sagittal.
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F11
CSF otorrhea. CT imaging of the head performed at 2 months after the operation revealed resolution of the mastoid fluid collection and disappearance of the defect site of the petrous bone [Figure 11].