{'fraction_non_alphanumeric': 0.028290766208251474, 'fraction_numerical': 0.005893909626719057, 'mean_word_length': 5.209756097560976, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
An unexpected finding in a child with myelomeningocele (Discussion and Diagnosis)

The Case Presentation can be found on page 1288. DISCUSSION On MRI, in addition to bilateral ventricular enlargement and Chiari-II malformation with kinking of the brain stem, a ruptured frontoethmoidal encephalocele (Fig. 1 white arrows) was noted with demonstration of cerebrospinal fluid engulfing the endotracheal tube (Fig. 1 black arrows; fluid isointense with cerebrospinal fluid). The encephalocele was confirmed on cranial computed tomography (Fig. 2A,B). After visualising the exact localisation and dimension of the encephalocele, operative closure was performed on day 10 of life. Initially, a periostal flap was prepared and scissored in half from a bifrontal skin flap. Then, a unilateral medial, fronto-basal bone flap was performed. This approach allowed the exploration of the fronto-medial herniated dural sac. A bone graft (part of the frontal bone flap) and periost was used for closure of the defect. The dura was then incised, and the other periostal flap was glued over the perforated dura. Thereafter, the dura was sutured watertight, and the remaining bone flap reinserted and fixed with absorbable sutures. Also, a ventriculoperitoneal shunt was inserted on the same occasion. This case report demonstrates the unusual simultaneous occurrence of a spinal and cerebral dysraphism, and supports the multiple-site closure of the neural tube theory as suggested by VanAllen (1). Van Allen proposed that there are five sites of closure and NTDs can result from defective closure at any of these sites (initial site of closure starts at the rhombencephalic segment, and the caudal end is the last to close) (1). Encephalomeningocele is a congenital malformation characterized by protrusion of meninges and ⁄ or brain tissue due to a defect in the skull. Encephaloceles are seen with a higher frequency in Southeast Asian populations (Thailand) (2). More commonly, myelomeningoceles are associated with occipital encephaloceles (3), and some of these infants would represent the Chiari III malformation. In general, a one-stage repair of encephaloceles is warranted (4). Albeit rare the treating physician should be aware that neonates with myelomeninocele may have other NTDs that may initially go unnoticed, and may present in a peculiar way. Progressive hydrocephalus may have led to increased intracranial pressure, rendering the frontoethmoidal encephalocele more susceptible to rupturing when the patient was bag-masked on day 4 of life.