CSF Rhinorrhoea After Endonasal Intervention to the Skull Base (CRANIAL) - Part 1: Multicenter Pilot Study

Danyal Z Khan,Parag Sayal,Mohammad Saud Khan,Anuj Bahl,Duncan Henderson,Joan Grieve,Patrick Statham,Shumail Mahmood,Jonathan Pollock,Dimitris Paraskevopoulos,Bhaskar Ram,Mohammad Habibullah Khan,Syed Shumon,David Choi,Mohamed Youssef,Alexandros Boukas,Adithya Varma,Alex Paluzzi,Soham Bandyopadhyay,Raj Bhalla,David Bennett,Anastasios Giamouriadis,Jonathan Shapey,Ivan Cabrilo,James R Tysome,Kanna Gnanalingham,Brendan Hanna,Thomas Santarius,Sinan Al-Barazi,Rishi Sharma,Rafid Al-Mahfoudh,Philip Weir,Shahzada Ahmed,Georgios Tsermoulas,Wai Cheong Soon,Alice O’Donnell,Andrew Martin,Jonathan Hempenstall,Alireza Shoakazemi,Kismet Hossain-Ibrahim,Jane Halliday,Nick Thomas,Meriem Amarouche,Callum Allison,Saurabh Sinha,Showkat Mirza,Simon Shaw,Georgios Solomou,Nijaguna Mathad,Mahmoud Kamel,Peter Ross,Neil Donnelly,Andrew F Alalade,Simon Stapleton,Catherine Gilkes,Pragnesh Bhatt,Mohsen Javadpour,Sam Muquit,Eleni Maratos,Hugo Layard Horsfall,Caroline Hayhurst,Mark Hughes,Iain Robertson,Patrick Mcaleavey,Omar Pathmanaban,Graham Dow,Claire Nicholson,Nigel Mendoza,Hani J Marcus,Ramesh Nair,Adam Williams,Alistair Jenkins,Vikesh Patel,Nick Phillips,Benjamin Stew,Richard Mannion ,Paresh Naik ,Christopher P Millward ,Neil Dorward ,Ahmad M Ali ,Angelina Chadwick ,Elena Román ,Rory J Piper ,Benjamin E Schroeder ,Daniel D Murray ,Theodore C Hirst ,Peter D Lacy ,Simon Cudlip ,Daniel M Fountain ,Angelos Kolias ,Yasir A Chowdhury

doi:10.1016/j.wneu.2020.12.171

Abstract

BackgroundCRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data.MethodsA prospective observational cohort study was piloted at 12 tertiary neurosurgical units in the United Kingdom. Feedback regarding project positives and challenges were qualitatively analyzed.ResultsA total of 187 cases were included: 159 TSA (85%) and 28 EEA (15%). The most common diseases included pituitary adenomas (n = 142/187), craniopharyngiomas (n = 13/187). and skull base meningiomas (n = 4/187). The most common skull base repair techniques used were tissue glues (n = 132/187, most commonly Tisseel), grafts (n = 94/187, most commonly fat autograft or Spongostan) and vascularized flaps (n = 51/187, most commonly nasoseptal). These repairs were most frequently supported by nasal packs (n = 125/187) and lumbar drains (n = 20/187). Biochemically confirmed CSF rhinorrhea occurred in 6/159 patients undergoing TSA (3.8%) and 2/28 patients undergoing EEA (7.1%). Four patients undergoing TSA (2.5%) and 2 patients undergoing EEA (7.1%) required operative management for CSF rhinorrhea (CSF diversion or direct repair). Qualitative feedback was largely positive (themes included user-friendly and efficient data collection and strong support from senior team members), demonstrating acceptability.ConclusionsOur pilot experience highlights the acceptability and feasibility of CRANIAL. There is a precedent for multicenter dissemination of this project, to establish a benchmark of contemporary practice in skull base neurosurgery, particularly with respect to patients undergoing EEA.

Highlights

The expanded endonasal approach (EEA) has bolstered endoscopic access to the skull base, allowing resection of many diseases extending beyond the sella alone, including large pituitary adenomas, craniopharyngiomas, Rathke cleft cysts, meningiomas, and clival chordomas.[3,4]
We present preliminary data collected and outline our experience, the successes, and the challenges in establishing a scalable version of the CRANIAL study
Body mass index CRANIAL (BMI) was recorded in 182 patients (n 1⁄4 182/187, 97%)

Summary

Introduction

The endonasal transsphenoidal approach (TSA) has developed into the approach of choice for resecting pituitary adenoma and most sellar masses.[1,2] More recently, the expanded endonasal approach (EEA) has bolstered endoscopic access to the skull base, allowing resection of many diseases extending beyond the sella alone, including large pituitary adenomas, craniopharyngiomas, Rathke cleft cysts, meningiomas, and clival chordomas.[3,4] Despite the benefits that these minimally invasive approaches afford, cerebrospinal fluid (CSF) rhinorrhea remains a frequent complication,[5,6,7] with potentially serious consequences, including meningitis, pneumocephalus, low-pressure headaches, and prolonged admission.[6,8,9]Key words - Cerebrospinal fluid leak - Cerebrospinal fluid rhinorrhea - CSF - EEA - Endoscopic endonasal - Skull base surgeryAbbreviations and Acronyms BMI: Body mass index CRANIAL: CSF Rhinorrhoea After Endonasal Intervention to the Skull Base CSF: Cerebrospinal fluidEEA: Expanded endonasal approach TSA: Transsphenoidal approachWORLD NEUROSURGERY -: e1-e13, - 2021 www.journals.elsevier.com/world-neurosurgery e1DANYAL Z. Abbreviations and Acronyms BMI: Body mass index CRANIAL: CSF Rhinorrhoea After Endonasal Intervention to the Skull Base CSF: Cerebrospinal fluid. EEA: Expanded endonasal approach TSA: Transsphenoidal approach. CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) is a prospective multicenter observational study seeking to determine 1) the scope of skull base repair methods used and 2) corresponding rates of postoperative cerebrospinal fluid (CSF) rhinorrhea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull base tumors. We sought to pilot the project, assessing the feasibility and acceptability by gathering preliminary data

Methods

Results

Discussion

Conclusion