Case Of Cerebrospinal Fluid Leak Research Articles

An unusual case of cerebrospinal fluid leak and pneumocephalus following a lumbar stab injury

An unusual case of cerebrospinal fluid leak and pneumocephalus following a lumbar stab injury

Cerebrospinal Fluid Leaks Complicating Orbital or Oculoplastic Surgery

To report cerebrospinal fluid (CSF) leakage as an unusual complication following orbital or oculoplastic procedures and to describe its diagnosis and management. Retrospective case review. Three cases of CSF leaks are described in patients following orbital or oculoplastic procedures. Two patients developed CSF leaks after orbital decompression surgery for compressive optic neuropathy and 1 patient had a CSF leak following endonasal dacryocystorhinostomy. In the first case, high-resolution computed tomography confirmed the site of the leak that required surgical repair. In the second case, a beta(2)-transferrin test result confirmed the presence of CSF in the nasal drip, and coronal computed tomography identified a small fracture near the fovea ethmoidalis, but the leak resolved within 2 days of bed rest. In the third case, the patient reported several days of nasal dripping, but the problem had already resolved at the first follow-up appointment. A CSF leak following certain orbital and oculoplastic procedures is a rare but well-recognized complication. This case report reviews the mechanisms, diagnostic techniques, and staged management of CSF leaks.

Cerebrospinal Fluid Otorrhea Presenting in Complicated Chronic Suppurative Otitis Media

Since the introduction of antibiotics, the simultaneous occurrence of multiple intra- and extracranial complications in chronic suppurative otitis media (CSOM) has been uncommon. Such a combination is associated with high mortality and morbidity, especially in the pediatric age group. Cerebrospinal fluid (CSF) otorrhea presenting in CSOM is unusual and rare. To the best of our knowledge, only 19 cases of CSF otorrhea in complicated CSOM have been previously reported in the literature. Identifying the site of leak might require a high index of suspicion. Management of such a case could be challenging in terms of leak closure, disease clearance, and restoration of function. We report a new case of CSF leak in CSOM, and we describe our line of management. Even though CSOM is an uncommon indication for radical mastoidectomy today, such surgery might be necessary for these cases.

Effectiveness and handling characteristics of a three-layer polymer dura substitute: a prospective multicenter clinical study

The goal of this study was to assess the effectiveness and handling characteristics of a dura substitute composed of two outer layers of expanded polytetrafluoroethylene (PTFE) and a middle layer consisting of an elastomeric fluoropolymer. In a prospective multicenter study, the dura substitute was implanted using a standard technique in 119 patients undergoing cranial or spinal surgery requiring duraplasty. Intraoperative assessments of the dura patch consisted of testing for cerebrospinal fluid (CSF) leakage employing the Valsalva maneuver and a surgeon's standard evaluation of the handling characteristics of the device. Postoperative assessments conducted during a mean follow-up time of 15.7 months (range 0.3-45.6 months) consisted of physical examinations, routine computed tomography (CT) or magnetic resonance (MR) imaging studies, and histological studies of any removed dura patches. The mean age of the 119 patients was 40 years (range < 1-81 years). The dura substitute was implanted cranially in 102 patients and spinally in 17. Intraoperative assessment including the Valsalva maneuver led to application of additional sutures in 17 patients. Handling features were rated very good to excellent. Postoperative clinical evaluation resulted in 79 excellent and 18 good results. Imaging studies (MR imaging studies in 69 patients and CT studies in 34 patients) showed no adhesions in 87 patients and minimal adhesions in seven patients (the dura was not visualized in nine patients). Postoperative complications occurred in 12 patients. There were six cases of CSF leakage, three cases of extradural hematoma, one case of arachnoid fibrosis after decompression of a Chiari malformation Type I, and two cases of infection. Eight (7%) of these complications were potentially related to the dura patch. In a large, multicenter clinical study of the use of an expanded-PTFE-containing dura substitute, the device was found to be easy to handle and implant. No serious dura patch-related intraoperative adverse events were observed. Postoperatively, there were no major sealing problems or long-term complications. In two cases the patch had to be removed due to fibrosis and infection. The three-layer polymer dura substitute appears to be safe and effective in minimizing CSF leakage and adhesion formation, and its use avoids any risk of prion disease transmission.

Leakage of cerebro-spinal fluid after removal of a pedicular screw

A case of cerebro-spinal fluid leakage occurring after the removal of a pedicular screw is reported. It allowed emphasizing the frequency of the dural tears in spinal surgery, particularly when pedicular screws are used. Moreover, the removal of screws having involved neurological complications can induce other lesions, such in the reported case. This removal procedure is not benign and requires precautions and a monitoring identical to the other spinal procedures.

Clinical Application of Artificial Dura Mater to Avoid Cerebrospinal Fluid Leaks after Microvascular Decompression Surgery

Although technological advances combined with many surgical innovations have helped to minimize its occurrence, cerebrospinal fluid (CSF) leak still remains to be one of the most common postoperative complications following microvascular decompression (MVD) surgeries. The objectives of this study are 1) to detail our experience with the clinical application of artificial dura mater for the avoidance of CSF leaks in a group of 103 patients who underwent MVD surgeries and 2) to compare the results of CSF leak and deep wound infection between the group with and one without using artificial dura mater. From July, 2002 to June, 2004 217 consecutive patients who underwent MVD surgeries for hemifacial spasm or trigeminal neuralgia in our center were enrolled into this study. Among them, 103 patients underwent the application of artificial dura mater (Neuro-patch) in the surgical closure procedure to prevent postoperative CSF leak. The handling techniques were detailed and the postoperative results were evaluated. The follow-up period was at least 6 months. No postoperative CSF leak occurred in the group of patients receiving artificial dura mater whereas 6 cases of CSF leak (2 otorrhea, 2 rhinorrea and 2 CSF wound leak) were found in the group not receiving artificial dura mater. There was no statistical difference of wound infection rates found between these two groups, 1.9 % vs. 2.6 %. The use of the artificial dura mater in the closure procedure of MVD surgery seems to be a safe and effective way to prevent CSF leaks. However, further investigations on a larger number of cases still need to be done to substantiate its validity.

Endoscopie et traitement chirurgical des macroadénomes hypophysaires endo- et suprasellaires invasifs: Une série consécutive rétrospective de 13 patients

Surgery of invasive endo- and suprasellar pituitary macroadenomas remains difficult. The records of 13 consecutive patients who underwent transsphenoidal surgery were analyzed in order to evaluate advantages and limitations of endoscopy for surgery of invasive pituitary macroadenomas.A transseptal transsphenoidal intersepto-columellar approach was performed with a nasal 0-degree endoscope. Removal of the macroadenoma was performed under the control of a microscope. When the tumor seemed to be completely removed with microscope, a rigid 30-degree endoscope was inserted in the intrasellar and suprasellar regions in order to detect residual adenoma tissue. These residues were removed when technically possible.No rhinologic complication was noted. In 7 patients, the intra- and suprasellar endoscopic view detected a tumor residue which could be removed in each case. Two cases of cerebrospinal fluid leakage occurred during the complementary tumor resection. Two cases of diabetes insipidus and two of rhinorrhea were reported postoperatively. The analysis of the postoperative MRIs showed a complete removal in 23% of the patients (3/13), 75 to 100% removal in 54% of the patients (7/13), 50 to 75% removal in 8% of the patients (1/13) and 50% removal in 15% of the patients (2/13). More than 75% removal was thus achieved in 77% of the patients (10/13). The mean follow-up was 27.2 months.Rhinologic morbidity was reduced with the endoscopic endonasal approach. Endoscopy complemented with a microscope offered an optimal view of the intra- and suprasellar regions. Endoscopy also improved tumor resection of the invasive endo- and suprasellar pituitary macroadenomas by visualizing hidden suprasellar tumor residues. However, endoscopy was associated with a higher rate of postoperative rhinorrhea.

Cerebrospinal Fluid Leakage during Dacryocystorhinostomy in a Patient with Meningoencephalocele

To report a rare case of cerebrospinal fluid leakage during dacryocystorhinostomy in a patient with Mobius syndrome and meningoencephalocele and to explain our experience in the management of this complication. A 9-year-old girl with a history of surgically repaired fronto-ethmoidal meningoencephalocele and bilateral canthopexy was diagnosed with Mobius syndrome and underwent sequential bilateral dacryocystorhinostomy and silicone intubation because of dysgenesis of the lacrimal drainage pathway. Both dacryocystorhinostomies resulted in cerebrospinal fluid leakage, which spontaneously ceased with conservative management. Dacryocystorhinostomy surgery in patients with a history of trauma or surgery or congenital defects around the base of the nose or lacrimal system may rarely result in cerebrospinal fluid leakage; thus an ophthalmologist should be familiar with its management.

Long-term neurological, visual, and endocrine outcomes following transnasal resection of craniopharyngioma

The authors report on a cohort of patients with craniopharyngioma treated principally through transnasal (TN) resection and followed up for a minimum of 5 years. More specifically, they evaluate the role of the TN approach in the management of craniopharyngioma. Between 1984 and 1994, 68 patients underwent TN resection of craniopharyngiomas at the University of Southern California. The tumor was at least partially cystic in 88% of cases. Four tumors were purely intrasellar, 53 had intra- and suprasellar components, and 11 were exclusively suprasellar. During the same period, 18 patients underwent transcranial (TC) resection of purely suprasellar craniopharyngiomas. Long-term neurological, visual, and endocrine outcomes were reviewed for all patients. In 61 (90%) of 68 patients in the TN group, total resection was achieved, according to 3-month postoperative magnetic resonance images, although four patients suffered a recurrence. Three (43%) of the seven tumors that had been partially resected were enlarged on serial imaging. Fifty-four (87%) of 62 patients with preoperative visual loss experienced improvement in one or both eyes, but two patients (3%) with exclusively suprasellar tumors experienced postoperative visual worsening in one or both eyes. New instances of postoperative endocrinopathy (that is, not present preoperatively) occurred as follows: hypogonadism (eight of 22 cases), growth hormone (GH) deficiency (four of 18 cases), hypothyroidism (11 of 49 cases), hypocortisolemia (nine of 52 cases), and diabetes insipidus (DI; four of 61 cases). One case each of hypocortisolemia and hypothyroidism resolved after surgery. Hyperphagia occurred in 27 (40%) of 68 patients. One patient had short-term memory loss. Postoperative complications included one case of cerebrospinal fluid leak. Among the 18 patients in the TC group, 11 had complete resections. In one case (9%) the tumors recurred. Three (43%) of the seven subtotally resected tumors grew during the follow-up interval. Vision improved in 11 (61%) of 18 cases and worsened in three (17%) as a result of surgery. New instances of postoperative endocrinopathy occurred as follows: hypogonadism (one of six cases), GH deficiency (four of seven cases), hypothyroidism (11 of 14 cases), hypocortisolemia (eight of 15 cases), and DI (nine of 16 cases). No instance of preoperative endocrinopathy was corrected through TC surgery. Four patients (22%) exhibited short-term memory loss and 11 (61%) had hyperphagia after surgery. When compared with those in the TC group, patients in the TN group had shorter hospital stays. Use of the TN approach can render good outcomes in properly selected patients with craniopharyngioma, particularly when the tumor is cystic. Even in mostly suprasellar cases, an extended TN approach can afford complete resection. Note that endocrine function often worsens after surgery and that postoperative obesity can be a significant problem.

Cerebrospinal Fluid Leak in a Premature Neonate

Cerebrospinal fluid (CSF) cranial leaks in neonates are rare, and only four case reports have been published previously. Two of the previous cases were also in preterm newborns delivered at 30 weeks gestation. We present a case of CSF leak in a premature neonate delivered at 30 weeks gestation. Our approach to treatment was different from that previously described. After the initial treatment with local packing bandage failed to stop CSF leakage, local exploration with wound suturing was done, with resultant ceasing of leakage within 12 hours of birth. This case presents a rare complication of CSF leakage caused by internal scalp monitoring. This complication seems to be more frequent in premature babies, thus special consideration should be taken in premature infants before applying such monitoring.

Radial forearm free tissue transfer reduces complications in salvage skull base surgery

Patients who undergo skull base resection after prior surgery or radiation may be at high risk for complications when local flaps alone are used for reconstruction. To determine whether the complication rate could be reduced, fasciocutaneous free tissue transfer was used to reinforce the dural closure in patients who had prior skull base surgery or radiation. This study is a case series of 20 patients (14 males, 6 females, aged 8-79 years of age with a mean of 47.7 years) from 1997 to 2001 who had prior skull base surgery or radiation, and underwent salvage skull base resection without large volume defects. All patients had a radial forearm free tissue transfer to reinforce the dural closure. Six patients had an osseous component to the forearm flap to provide vascularized bone to the orbital rim. The overall local complication rate was 35%. Three patients (15%) had major complications including 1 case of meningitis, 1 case of cerebrospinal fluid leak, and 1 case of a flap requiring venous salvage. There were no flap failures, 1 idiopathic median nerve palsy, and no pathologic radius bone fractures. Reconstruction with fasciocutaneous free tissue transfer for high-risk patients with low-volume dural defects following skull base resection can minimize the risk of major postoperative complications. C.

Endoscopic endonasal surgery for resection of benign sinunasal tumors

Objectives: The use of endoscopic surgery for nasal and sinus pathologies has revolutionized our approaches to the disease of the areas. In this retrospective study we would like to summarize our experience with endoscopic surgery in benign tumors and tumor-like condition of nose and paranasal sinuses. Methods: The medical records of 107 patients with benign sinonasal tumors that underwent endoscopic surgery for removal of their neoplasm between 1997 to 2003 were analyzed. These include 32 patients with juvenile nasopharyngeal angiofibroma, 24 with inverted papilloma, 23 of benign fibroosseous lesions, 18 with pyogenic granuloma, 6 with intranasal hemangioma, 2 with pleomorphic adenoma, and benign fibrohistiocytoma and orbital pseudolymphoma each in 1 case. Results: The period of follow-up ranges from 9 to 73 months (medium, 41 month). In this time period and with close observation (serial endoscopy and yearly CT scan), we had 8 cases of recurrent tumor (2 angiofibroma, 4 inverted papilloma, 1 fibrous dysplasia, and 1 osteoma) that were managed endoscopically or with combined (endoscopic and Caldwell-Luc) approach in 4 recurrent inverted papilloma patients. The major complications that we encountered were 2 cases of cerebrospinal fluid leakage that were sealed intraoperatively with local tissue flaps without further squeals. Conclusion: Endoscopic surgery can be valuable for removal of benign tumors of nose and paranasal sinuses in the hands of an experienced surgeon.

Pericranial flap fixation using titanium miniplates and screws

Opening the frontal sinuses is a common occurrence during neurosurgical procedures involving the anterior cranial base. Obliteration of the exposed sinuses is usually accomplished packing them with various materials and/or covering them with an anteriorly-based pericranial flap. In the absence of more extensive cranial base defects, the flap only needs to be wrapped around the sinus and secured against its posterior wall. We describe the technique for and the results of using titanium miniplates and screws to secure the pericranial flap to the inner surface of the frontal bone. In 10 patients treated with this alternative technique, the pericranial flap provided an excellent separation between the sinuses and the intradural compartment. No cases of cerebrospinal fluid leakage or infections were observed.

Pericranial flap fixation using titanium miniplates and screws

Opening the frontal sinuses is a common occurrence during neurosurgical procedures involving the anterior cranial base. Obliteration of the exposed sinuses is usually accomplished packing them with various materials and/or covering them with an anteriorly-based pericranial flap. In the absence of more extensive cranial base defects, the flap only needs to be wrapped around the sinus and secured against its posterior wall. We describe the technique for and the results of using titanium miniplates and screws to secure the pericranial flap to the inner surface of the frontal bone. In 10 patients treated with this alternative technique, the pericranial flap provided an excellent separation between the sinuses and the intradural compartment. No cases of cerebrospinal fluid leakage or infections were observed.

A case of meningoencephalic herniation of the temporal bone

A case of cerebrospinal fluid leakage from a meningoencephalic herniation of the temporal bone is presented. Computed tomography and magnetic resonance imaging were useful for a diagnosis of meningoencephalic herniation. After surgical treatment, no recurrence was observed during a 6-month follow-up period.

Complications of endoscopic third ventriculostomy.

The purpose of this prospective investigation was to determine the rate of complications associated with endoscopic third ventriculostomy (ETV). Between March 1993 and October 2001, 193 ETVs were performed in 188 patients at a single institution. The age of the patients ranged from 1 month to 85 years (mean age 39 years). One procedure had to be abandoned because a severe venous hemorrhage blurred the surgeon's view; however, third ventriculostomy was successfully accomplished in that patient 14 days later. In addition, there were two cases in which significant venous hemorrhages could be controlled endoscopically by using irrigation. Postoperative imaging revealed three subdural collections, one tiny thalamic contusion, one cortical hemorrhage at the puncture site, and one severe subarachnoid hemorrhage (SAH). There were two deaths (1% mortality rate) related to the endoscopic procedure; causes of death were one SAH from a torn basilar perforating artery and one wound infection leading to meningitis and septic multiorgan failure. Three permanent deficits occurred (confusion, oculomotor palsy, and diabetes insipidus [1.6% permanent morbidity rate]). Transient deficits included four cases of meningitis, three cases of cerebrospinal fluid leak, two cases of herniation syndrome, two cases of confusion, one case in which there was a decrease of consciousness, two cases of oculomotor palsy, and one case in which there was loss of thirst (7.8% transient morbidity rate). Misplacement of the fenestration was the main reason for severe complications. During the course of the study, the complication rate dropped significantly (no incidences of mortality or permanent morbidity occurred during the last 100 procedures). All permanent and fatal complications occurred during the authors' very early experience, indicating that a steep learning curve was associated with the procedure. Endoscopic third ventriculostomy, if performed correctly, is a safe, simple, and effective treatment option for various forms of noncommunicating hydrocephalus.

Combined chest wall resection with vertebrectomy and spinal reconstruction for the treatment of Pancoast tumors.

Traditionally, superior sulcus tumors of the lung that involve the chest wall and spinal column have been considered to be unresectable, and historically, patients harboring these tumors have been treated with local radiation therapy with, at best, modest results. The value of gross-total resection remains unclear in this patient population; however, with the recent advances in surgical technique and spinal instrumentation, procedures involving more radical removal of such tumors are now possible. At The University of Texas M. D. Anderson Cancer Center, the authors have developed a new technique for resecting superior sulcus tumors that invade the chest wall and spinal column. They present a technical description of this procedure and results in nine patients in whom stage IIIb superior sulcus tumors extensively invaded the vertebral column. These patients underwent gross-total tumor resection via a combined approach that included posterolateral thoracotomy, apical lobectomy, chest wall resection, laminectomy, vertebrectomy, anterior spinal column reconstruction with methylmethacrylate, and placement of spinal instrumentation. There were six men and three women, with a mean age of 55 years (range 36-72 years). Histological examination revealed squamous cell carcinoma (three patients), adenocarcinoma (four patients), and large cell carcinoma (two patients). The mean postoperative follow-up period was 16 months. All patients are currently ambulatory or remained ambulatory until they died. Pain related to tumor invasion improved in four patients and remained unchanged in five. In three patients instrumentation failed and required revision. There was one case of cerebrospinal fluid leakage that was treated with lumbar drainage and one case of wound breakdown that required revision. Two patients experienced local tumor recurrence, and one patient developed a second primary lung tumor. The authors conclude that in selected patients, combined radical resection of superior sulcus tumors of the lung that involve the chest wall and spinal column may represent an acceptable treatment modality that can offer a potential cure while preserving neurological function and providing pain control.

Cerebrospinal fluid leak associated with proplast implant removal from the temporomandibular joint

Severe bone erosion within the temporomandibular joint reconstructed with polytetrafluoroethylene implants is a well-recognized phenomenon. Although erosion into the middle cranial fossa has been reported, we know of no report of dural disruption with cerebrospinal fluid leakage. We report a case of cerebrospinal fluid leak noted at the time of PTFE implant removal and its subsequent management. Perforation of the contralateral glenoid fossa and its reconstruction is also reported.

Nasal Endoscopy In The Outpatient Clinic

The introduction of the nasal endoscope has greatly advanced the diagnostic and therapeutic capability of otolaryngologists in the office setting. With continued technologic developments in endoscopic equipment and topical intranasal anesthesia, further advances are expected that undoubtedly will expand endoscopic diagnosis treatment in the office setting. Presently otolaryngologists are beginning to use endoscopes in the evaluation and treatment of nasolacrimal duct obstruction, and we are aware of one case of cerebrospinal fluid leak that has been repaired in the office setting with nasal endoscopic technique. (Lanza D: personal communication, 1991).

Results of transsphenoidal microsurgery for growth hormone-secreting pituitary adenoma in a series of 214 patients.

Of 214 patients with acromegaly who underwent transsphenoidal microsurgical resection of a pituitary adenoma, 54% had growth hormone (GH) levels below 5 ng/ml and 74% had levels less than 10 ng/ml immediately after surgery. Among the 174 patients who could be contacted for long-term follow-up review (average duration 76 months), most recent GH determinations were available for 165. Of these 165 patients, 131 (79.4%) have a GH level less than 5 ng/ml and 153 (92.7%) have a level below 10 ng/ml; these represent 75.3% and 87.9%, respectively, of the total 174 patients reviewed. Fifty-two patients received postoperative radiation therapy. Nine patients underwent reoperation. There were five cases of tumor recurrence following an apparent surgical cure (4.3%), nine new instances of anterior pituitary hypofunction (5%), and five failures of multimodality therapy (2.3%). There were no perioperative deaths, five cases of cerebrospinal fluid leak requiring surgical repair (2.2%), and four cases of postoperative meningitis (1.8%). Permanent diabetes insipidus did not occur. Two of 52 patients who were irradiated postoperatively had severe complications; 23 (54.8%) of 42 patients who were available for follow-up evaluation had developed panhypopituitarism; and eight (19%) of 42 had normal pituitary function an average of 44 months postirradiation.