Cerebrospinal Fluid Leak Research Articles

Outcomes of Endoscopic Endonasal Surgery for Tuberculum Sellae and Planum Sphenoidale Meningiomas: A Retrospective Study.

To evaluate clinical outcomes and volumetric changes following endoscopic endonasal approach (EEA) for tuberculum sellae (TS) and planum sphenoidale (PS) meningiomas. Key objectives included evaluating pre- and postoperative tumor volumes, visual assessments and EEA-related complications. A single-center retrospective study was conducted at Foothills Medical Centre, University of Calgary, Canada, from 2009 to 2022 including 24 patients meeting inclusion criteria for midline skull base tumors, confirmed as WHO Grade I or II meningiomas with optic canal extension. EEA achieved gross total resection in 87.5% of cases, with a mean tumor volume reduction of 92.24%. Postoperatively, 91.67% exhibited visual improvement or stability. Cerebrospinal fluid leaks occurred in 12.5% of cases, necessitating revision surgery in one case. Persistent postoperative endocrine dysfunction affected 4.17%. Preoperative tumor volume did not demonstrate a correlation with complications. This study delivers reproducible data for pre- and postoperative tumor volume following the EEA after TS or PS meningiomas. The EEA demonstrated favorable radiographic and clinical outcomes in TS and PS meningiomas, achieving gross total resection with minimal morbidity.

Transnasal Endoscopic Approach for Excision of Intracranial Nasal Dermoid Sinus Cysts.

Nasal dermoid sinus cysts (NDSCs) with intracranial extension in the form of dermal sinus tracts require careful and complete resection to prevent recurrence. Resection techniques necessitate adequate intracranial exposure, but morbidity associated with historical resection approaches has presented unique multidisciplinary challenges for surgeons treating cysts with intracranial extension. The authors primarily employed a transnasal approach through a midline nasal incision, utilizing endoscopic or microscopic access between the lateral cartilages for resection of NDSCs with intracranial extension. A retrospective review was completed for patients treated for NDSCs at the authors' pediatric quaternary referral center from 2017 to 2023. Data collection included demographics, comorbidities, perioperative data, pre and postoperative imaging, surgical outcomes, and complications. Eighteen patients with NDSCs with possible or confirmed intracranial extension were surgically treated from 2017 to 2023. Fifteen were treated with resection performed through a midline transnasal approach with endoscopic assistance, achieving successful total resection while avoiding nasal osteotomy or frontal craniotomy. One patient had a slow cerebrospinal fluid leak from an operative durotomy, successfully treated with a lumbar drain. No other complications occurred. No patients required transfusion. Incision length and postoperative scar burden were less than approaches that used osteotomies or craniotomies and demonstrated excellent cosmetic results. No patients have had cyst recurrence or required reoperation. A transnasal approach through a midline incision with endoscopic assistance is an effective approach for resection of NDSC with intracranial extension, but utility may vary with cyst size and complexity. This approach leverages appropriate exposure for resection with decreased morbidity and decreased incision length through avoidance of osteotomies.

ThP7.14 - CSF Leak or Ear Wax? Logical Thinking in Emergency Management of a Collapsed Patient With Heat stroke

Abstract A man in his 60s presented to RESUS by ambulance on the hottest day of the year with suspected STEMI and collapse at home. The patient was intubated and unresponsive (GCS 5), with global rigors. Hospital ECG showed sinus tachycardia. Body temperature was in excess of 41°C, confirmed on central temperature monitoring. Bilateral clear fluid was noted to be discharging from both ear canals. Query CSF leak was indication for CT head, which was unremarkable. Considering this, efforts were focused on optimising body temperature. This was done with the use of ice packs and fans as well as continuous misting of cool water over the exposed patient. Improvement was shown with temperatures decreasing to 38°C. In questioning the cause of the “clear fluid,” a swab of it placed on an icepack swiftly returned the fluid to its natural consistency of ear wax. As a result of the extraordinarily high body temperatures, ear wax had melted in both ear canals and started to leak out, giving the impression of a CSF leak. This was simply identified at the bedside to refute the idea of a CSF leak. As CSF leak was the indication for a CT head, this could have been avoided with rapid cooling initiated earlier. Unfortunately, this patient later died due to heat stroke. Whilst avoiding the delay of a CT head most likely would not have changed the prognosis for this patient, it is useful to note the importance of logical thinking in an emergency setting.

Clinical Observation of Zero-P System Interbody Fusion Combined with Traditional Chinese Medicine-Directed Drug Delivery Technology for Treating Cervical Spondylotic Myelopathy

Objective: To investigate the clinical efficacy of the Zero-profile fusion cage (Zero-P) combined with Traditional Chinese Medicine-directed drug delivery technique in the treatment of cervical spondylotic myelopathy, and to assess its impact on potential postoperative complications. Methods: 13 patients with cervical spondylotic myelopathy were selected from January 2022 to October 2023. The intraoperative bleeding volume, operation duration, and hospitalization days were recorded, the incidence and improvement of postoperative complications were observed, and the pain index and cervical function index were analyzed, including Visual Analogue Scale (VAS) score, Japanese Orthopedic Association (JOA) score, Neck Disability Index (NDI) index, etc. Results: The operation duration of patients was 65–110 (81.92 ± 13.47) min; mean intraoperative blood loss was 12.30 ± 7.80 ml, and mean postoperative hospital days were 9.62 ± 3.52 days. All patients in this group were followed up over 3 months after surgery, and the study found that the VAS, JOA, and NDI scores improved significantly compared with the preoperative difference (P < 0.01); and the VAS, JOA, and NDI scores 1 month postoperative improved significantly compared with 1 week postoperative (P < 0.01). In addition, the incidence of postoperative complications of the Zero-P system was low, with no incision infection, implant rejection, fracture, displacement, cerebrospinal fluid leakage, recurrent laryngeal nerve injury, and laryngeal edema; one patient had mild dysphagia (7.69%) and nine patients had throat dryness and discomfort (69.23%), which completely disappeared after 1 week of TCM-directed drug treatment and symptomatic treatment. Conclusion: Zero-P system interbody fusion has a significant effect on cervical spondylotic myelopathy, with a low incidence of postoperative complications and fast improvement speed, which can effectively enhance the impact of surgery on cervical spondylotic myelopathy patients, thus it is worthy of application and promotion.

Traumatic encephalocele in the nasal cavity after 6 years of trauma: a case report

BackgroundEncephalocele refers to protrusion of the meninges and brain tissue through a skull bone defect. It results from congenital, traumatic, neoplastic, or spontaneous reasons. Traumatic encephalocele occurs because of the posttraumatic fracture of the skull bone or iatrogenic causes. The manifestations vary a lot, such as rhinorrhea, seizures, headaches, and focal neurological deficits.Case presentationA 20-year-old Syrian male presented to our department with the complaint of clear cerebrospinal fluid drainage from his right nostril, which started 6 years ago after a head trauma, moderate headache, and episodes of tonic–clonic seizures without any response to medical treatment. Then, 2 months ago, the patient had meningoencephalitis, so he was admitted to the intensive care unit and treated for a month until he was cured. The patient underwent radiological investigations, which showed that he had a base fracture with an encephalocele in the nasal cavity. The brain tissues with the meninges herniated through the skull base fracture with a significant expansion of the subarachnoid spaces in the right hemisphere. He was advised to undergo surgical repair at that time, but he refused the surgery. During this visit, surgery was indicated. The surgery was done by a specialist who returned the herniated brain tissues to their normal location, repaired the meninges, and reconstructed the skull base with bone cement and bio-glue. The patient’s recovery after the surgery was uneventful.ConclusionTraumatic encephalocele is a rare and unexpected complication of trauma, but we should keep it in mind when the patient comes with head trauma because of its life-threatening consequences. This complication can happen after years of trauma if the patient refuses treatment, therefore, we must educate patients about the dangerous results of neglecting cerebrospinal fluid leakage and skull fractures.

Transsphenoidal Approach for Sellar Region Tumor : A Case Series

Introduction: Transsphenoidal approaches to the sellar region, with endoscopic or microscopic techniques, are regularly used to treat a diverse collection of pathologies. Case Description: Three patients with presenting symptoms visual disturbance and headache were evaluated with MRI that showes sellar region masses. All patients were undergo transphenoid tumor removal. Post operation evaluation show improvement in visual disturbance and headache with no adverse event after procedure. Discussion : Transsphenoidal endoscopic surgery (TSS) for functional pituitary adenomas yields better endocrinologic results for noninvasive macroadenomas. However, the rate of postoperative CSF leakage was greater with the endoscopic method. In patients with pituitary adenomas, younger age, dense visual field defect, and the preoperative absence of central or bilateral visual field abnormalities were predictive factors of visual field recovery following transsphenoidal approach-tumor excision. Overall survival rates are generally high, ranging from 91% to 98%. Conclusion: Transphenoid approach was a good surgical method for sellar region masses and show good outcomes after operation. Keyword : Sellar region masses; Surgical; Transsphenoid approach

Spinal Dural Ectasia Spectrum: Management of Two Cases and Systematic Review of the Therapeutic Options.

To describe 2 cases with pathologic expansion of lumbosacral dura mater exerting compression on lumbosacral nerves treated with placement of lumboperitoneal shunt (LPS). Although dural ectasia (DE) is asymptomatic in most cases, a systematic review of the literature was performed focusing on the management when it causes symptoms. Pubmed/Medline and Embase databases were searched for the surgical management of DE. Both pediatric and adult patients were included. The presence of a cerebrospinal fluid leak was considered an exclusion criterion. An additional search was performed to provide a more complete picture of the DE spectrum considering meningoceles as a severe form of dural expansion. Differentiating DE from meningocele, only 20 patients were treated for symptomatic DE. Surgical management varied according to presentation and etiopathogenesis: blood patch or fibrin glue were attempted in case of intracranial hypotension, followed eventually by LPS or marsupialization or dura reduction in cases of failure, whereas LPS or spinal decompression were proposed in cases of radiculopathy or cauda equina syndrome. DE is a rare condition mostly associated with connective tissue disorders. The different etiopathogenesis may explain how it causes symptoms in specific conditions. Treatments should be chosen according to this and may be proposed at the appearance of symptoms since dural expansion is a self-sustained mechanism.

Rathke's cleft cysts: from pathophysiology to management.

Rathke's cleft cysts (RCCs) are benign, non-neoplastic lesions located in the sellar and suprasellar regions of the brain, originating from remnants of Rathke's pouch, an embryonic precursor to the anterior pituitary gland. Although RCCs are frequently asymptomatic and discovered incidentally during imaging studies, they can present with a variety of symptoms, including headaches, visual disturbances, and endocrine dysfunction due to the compression of adjacent neural structures. The management of RCCs is particularly challenging, as the decision to pursue conservative monitoring or surgical intervention depends heavily on the cyst's size, growth potential, and the severity of symptoms. Transsphenoidal surgery is the primary treatment for symptomatic RCCs, offering effective relief from symptoms through decompression of the cyst. However, recurrence remains a significant issue, with rates reported up to 33%, prompting debates about the extent of cyst wall removal during surgery. Recent advancements in minimally invasive endoscopic techniques have improved surgical outcomes, yet the risk of postoperative complications such as hypopituitarism and cerebrospinal fluid leaks persists. Additionally, stereotactic radiosurgery has emerged as a potential alternative for patients with recurrent RCCs or those who are not suitable candidates for repeat surgery. Despite its promise, the long-term safety and efficacy of radiotherapy in RCC management require further investigation. This narrative review aims to provide a comprehensive overview of RCCs, integrating the latest research and clinical guidelines to discuss pathophysiology, clinical presentation, and management strategies, emphasizing the need for a personalized approach to treating this complex condition.

Assessing the effects of spontaneous intracranial hypotension on quality of life, work ability and disability.

Spontaneous intracranial hypotension (SIH), characterized by headaches due to cerebrospinal fluid leaks or low pressure, is achallenging condition to diagnose and treat and affects the quality of life. An 8‑week online survey was conducted to assess the impact of SIH on symptoms, sociodemographics and quality of life. The cohort was comprised of patients who had a self-reported diagnosis of SIH and were divided into two groups: those with radiological evidence of SIH and those with clinical suspicion but no radiological evidence. Mental health and disability were evaluated using the Depression, Anxiety and Stress Scale-21 (DASS-21) and the Henry Ford Hospital Headache Disability Inventory (HDI). A total of 86 participants were included in the study, 59with radiological evidence and 27without. Most participants were female (84.9%) with amean age of 44.8 years. Orthostatic headache was more common in participants without radiological evidence (74.1% vs. 42.4%). The severity in those with radiological evidence was 27.1% mild, 27.1% moderate, 30.5% severe and 15.3% extremely severe, while those without had 7.4% mild, 18.5% moderate, 63.0% severe and 11.1% extremely severe headaches. Mental health assessment using the DASS-21 scale showed that 77.9% of all participants reported signs of depression, 96.5% reported anxiety and 89.5% reported stress. The HDI showed 2.3% total disability, 40.7% severe, 19.8% moderate and 37.2% mild. The impact on employment was significant: 15.1% were able to work full-time, 48.8% part-time, 30.2% were unable to work and 5.8% retired early due to SIH. The study demonstrates the broad impact of SIH affecting physical health, mental well-being, and socioeconomic status, and calls for multifaceted and robust management approaches to address its complex effects on patients.

Spontaneous intracranial hypotension mimicking iatrogenic spinal cerebrospinal fluid leaks.

To raise awareness that patients with persistent post-dural puncture headache should be considered for evaluation of spontaneous cerebrospinal fluid (CSF) leak. Spontaneous intracranial hypotension (SIH) due to a spinal CSF leak may occur following more-or-less trivial traumatic events. We report our experience with spontaneous spinal CSF leaks that occur following percutaneous or open spine procedures, a potential source of diagnostic confusion. In a retrospective cohort study, using a prospectively maintained database of patients with SIH, we identified all new patients evaluated between January 1, 2022, and June 30, 2023, who were referred for evaluation of an iatrogenic spinal CSF leak but were found to have a spontaneous spinal CSF leak. Nine (4%) of the 248 patients with SIH were originally referred for evaluation of an iatrogenic spinal CSF leak. The spinal procedures included epidural steroid injections, laminectomies, epidural anesthesia, and lumbar puncture. Brain magnetic resonance imaging (MRI) showed changes in intracranial hypotension in seven of the nine patients (78%). The spontaneous CSF leak was found to be at least five levels removed from the spinal procedure in all patients. A spontaneous spinal CSF leak should be suspected in patients with recalcitrant orthostatic headaches following a spinal procedure, even if symptoms of the leak occur within hours of the spinal procedure and especially if brain MRI is abnormal.

Duropathy as a rare motor neuron disease mimic: from bibrachial amyotrophy to infratentorial superficial siderosis

BackgroundBibrachial amyotrophy associated with an extradural CSF collection and infratentorial superficial siderosis (SS) are rare conditions that may occasionally mimic ALS. Both disorders are assumed to be due to dural tears.Case presentationA 53-year-old man presented with a 7-year history of slowly progressive asymmetric bibrachial amyotrophy. Initially, a diagnosis of atypical motor neuron disease (MND) was made. At re-evaluation 11 years later, upper limb wasting and weakness had further progressed and were accompanied by sensorineural hearing loss. MRI of the brain and spine demonstrated extensive supra- and infratentorial SS (including the surface of the whole spinal cord) as well as a ventral longitudinal intraspinal fluid collection (VLISFC) extending along almost the entire thoracic spine. Osteodegenerative changes were observed at C5-C7 level, with osteophytes protruding posteriorly. The bony spurs at C6-C7 level were hypothesized to have lesioned the dura, causing a CSF leak and thus a VLISFC. Review of the MRI acquired at first evaluation showed that the VLISFC was already present at that time (actually beginning at C7 level), whereas the SS was not. 19 years after the onset of upper limb weakness, the patient additionally developed parkinsonism. Response to levodopa, brain scintigraphy with 123I-ioflupane and brain MRI with nigrosome 1 evaluation were consistent with idiopathic Parkinson’s disease (PD). On the latest follow-up 21 years after symptom onset, the VLISFC was unchanged, as were upper arm weakness and wasting.ConclusionsBased on the long-term follow-up, we could establish that, while the evidence of the VLISFC was concomitant with the clinical presentation of upper limb amyotrophy and weakness, the radiological signs of SS appeared later. This suggests that SS was not per se the cause of the ALS-like clinical picture, but rather a long-term sequela of a dural leak. The latter was instead the causative lesion, giving rise to a VLISFC which compressed the cervical motor roots. Dural tears can actually cause several symptoms, and further studies are needed to elucidate the pathophysiological correlates of “duropathies”. Finally, as iron metabolism has been implicated in PD, the co-occurrence of PD with SS deserves further investigation.

Upright CT-based evaluation of the effects of posture on skull-base reconstruction after endoscopic endonasal surgery

Cerebrospinal fluid (CSF) leakage is a common complication associated with endoscopic endonasal skull-base surgery (EESBS). Postoperative mobilization-associated postural changes are considered to cause CSF leakage. However, no study has demonstrated a robust relationship between postural changes and CSF leakage. We used upright computed tomography (CT) to clarify the effects of postural changes on the reconstructed skull base (RSB) after EESBS. Thirty patients who underwent EESBS at our institution were prospectively included, and their upright and supine CTs were compared to measure morphological changes in the RSB. Patient clinical data were also collected from medical charts and surgical videos, and their relationships with morphological changes were assessed. In upright CTs, the RSB shifted intracranially by 0.94 (0.0–2.9) mm on average. This shift was larger in cases with lesions extending to the sphenoid sinus, dural defects, intraoperative pulsation of the RSB, and large bone windows. The direction of the change was opposite to intuitive movement driven by gravity because of reduced intracranial pressure in the sitting position. Thus, these shifts can be directly associated with postoperative CSF leakage caused by reconstruction material displacement. Skull-base reconstruction and postoperative postural management accounting for these morphological changes may be necessary for preventing CSF leakage.

The Use of Synthetic, Nonabsorbable Graft for Middle Fossa Repair in Patients With Spontaneous Cerebrospinal Fluid Leak: A Pilot, Prospective Study.

To evaluate the efficacy of a nonabsorbable, synthetic graft for the reconstruction of spontaneous middle fossa (sMF) cerebrospinal fluid (CSF) leaks. Six adult patients (age ≥16 yr) who had sMF CSF leaks surgically repaired within an 18-month period at a single university hospital using synthetic, nonbiological, nonabsorbable graft (Neuro-Patch) and a retrospective control group of five patients undergoing multilayer MF repair with autologous grafts. MF repair through a combined transmastoid/MF approach using Neuro-Patch or multilayer autologous grafts. The incidence of postoperative leak within 6 months postoperatively was the main outcome measure; we also recorded the need for lumbar drain, additional hearing loss, length of inpatient stay, body mass index, previous meningitis, preoperative increased intracranial pressure, and age. In the Neuro-Patch group, there was no postoperative CSF leak without the need for lumbar drain. We observed no additional hearing loss; patients were monitored for 2 days without any readmissions. Increased intracranial pressure (four of six), previous episodes of meningitis (two of six) or obesity (five of six) did not affect patient outcomes. Demographic and prognostic factors were the same for the control group. However, one patient needed lumbar drain postoperatively because of residual leak; lumbar drain was used in one more case (two of five cases), whereas three of five patients had to stay for longer than 2 days (5 d). Our pilot study suggests the use of Neuro-Patch via combined transmastoid/MF approach as an effective technique with minimum, if any morbidity; it could be of particular benefit for patients with larger MF dura defects. A larger number of patients are required to strengthen the evidence.

Clinical utility of CT myelography renal collecting system density in the evaluation of spinal CSF leak or CSF-venous connection in patients with spontaneous intracranial hypotension.

Identifying spontaneous CSF leaks can be difficult on CT myelography (CTM) in patients with suspected spontaneous intracranial hypotension (SIH). The current study compared renal collecting system (RCS) density during CTM in patients with suspected SIH relative to non-SIH controls and evaluated the overall utility as an indirect sign of spontaneous CSF leak in patients with SIH. All CTM performed over an 8-year period (n = 392) were retrospectively reviewed and included cases (n = 295) were divided into groups consisting of SIH patients with (n = 35) or without (n = 77) confirmed CSF leak on CTM and non-SIH controls (n = 183). Average and relative average (relative to systemic contrast density) RCS densities were compared with multivariate analysis adjusting for patient characteristics and CTM technical differences. Average RCS densities were greater for confirmed versus non-confirmed SIH groups and greater for both SIH groups relative to non-SIH controls. Correlations between RCS density and time from injection to CTM were higher within SIH patient groups compared to controls. Measured RCS density had a higher negative predictive value for excluding CSF leak both within the SIH patient groups as well as the overall cohort (84% and 96%, respectively), with optimized thresholds yielding 80% sensitivity and 70% specificity for the presence of leak in the overall cohort. Accounting for RCS density may provide reliable additional indirect diagnostic value about the suspicion of a CSF leak in patients undergoing CTM for evaluation of SIH symptoms.

Predictors of length of postoperative stay following endoscopic skull base surgery with intraoperative CSF leak.

Establishing benchmarks for length of stay (LOS) may inform strategies to improve resource efficiency, decrease costs, and advance care quality. In this study, the authors characterize postoperative LOS in endoscopic skull base surgery (ESBS) and elucidate prolonging factors. A retrospective chart review was conducted at a tertiary academic center including consecutive adult patients who underwent intradural ESBS with intraoperative CSF leak during primary repair between July 2018 and March 2024. LOS, calculated as the time between the end of anesthesia until discharge from the hospital, comprised the primary outcome. Categorical and continuous independent study variables were assessed for univariate LOS association via the Mann-Whitney U-test and Kendall's tau-b correlation, respectively, and those with significant associations were included as multiple linear regression inputs. One hundred sixty-three patients were included, with a median LOS of 4.0 (interquartile range [IQR] 2.8-5.8) days. LOS was significantly prolonged in high-flow (n = 82) compared with low-flow (n = 81) CSF leak cohorts (median 4.5 [IQR 3.9-6.5] vs 2.9 [IQR 2.1-4.7] days, p = 0.002). Defects involving the anterior cranial fossa (n = 16, median 4.6 [IQR 3.3-7.5)] days), suprasellar region (n = 94, median 4.4 [IQR 3.2-6.4] days), sella (n = 138, median 3.9 [IQR 2.8-5.8] days), or posterior cranial fossa (n = 17, median 4.5 [IQR 3.9-6.5] days) had variable LOSs. On multiple linear regression, after controlling for numerous patient, surgical, and postoperative factors, lesion diameter (B = 0.16, 95% CI 0.048-0.26), bone defect area (B = 0.008, 95% CI 0.001-0.014), anesthesia time (B = 0.015, 95% CI 0.004-0.026), bed rest length (B = 2.34, 95% CI 1.12-3.56), postoperative CSF leak (B = 11.06, 95% CI 4.11-18.01), postoperative meningitis (B = 11.79, 95% CI 4.83-18.74), postoperative stroke/hemorrhage (B = 25.25, 95% CI 18.43-32.06), and postoperative pneumonia (B = 5.59, 95% CI 0.79-10.38) independently predicted overall prolonged LOS. With healthcare utilization receiving increased attention, mitigating factors that extend LOS are important. Extent of surgery and certain postoperative complications may constitute key factors prolonging LOS following intradural ESBS with intraoperative CSF leak.

Posterior cranial vault distraction osteogenesis: a literature review

Introduction:Craniosynostosis is a congenital condition where one or more cranial sutures close prematurely, limiting skull growth and causing cranial deformities. Posterior cranial vault distraction (PCVD) is used to relieve intracranial pressure and improve cranial aesthetics. Its incidence is about 1 in 2000–2500 live births. Methods:This systematic review followed PRISMA guidelines. We searched PubMed, Scielo, and Lilacs for studies on PCVD in craniosynostosis, focusing on success, morbidity, and mortality. Six articles were included in the final review. Data were extracted and risk of bias was assessed using the ROBINS-I tool. Results:The included studies reported significant increases in intracranial volume (144 mL to 281 mL) post-PCVD. Most patients showed stable results without recurrence. Complications included wound infection (29%) and cerebrospinal fluid leaks, though few required re-operations. PCVD improved intracranial pressure symptoms in most cases. Conclusion:PCVD is an effective technique for treating craniosynostosis, increasing intracranial volume and improving symptoms of intracranial hypertension. Despite some complications, it remains a reliable and stable alternative for cranial expansion.

Individualized surgical management of acute intracranial infection-associated hydrocephalus

Objective: This study aims to discuss and summarize surgical treatments for acute intracranial infections with hydrocephalus as a supplement to antibiotic treatment. Methods: A total of 29 patients diagnosed with acute intracranial infection associated with hydrocephalus were divided into three groups for comparison and analysis of surgical interventions and outcomes. Results: In this study, 29 patients in one group underwent surgical treatment, while 28 received various forms of external cerebrospinal fluid (CSF) drainage, with a maximum of 5 drainage procedures. Additionally, 6 patients had Ommaya reservoir implantation, 6 had debridement, and 11 had a hydrocephalus shunt. Among the five patients in Group 1, all underwent shunt device extubation. The statistical analysis revealed no significant difference in surgical modes between the groups, but the outcomes did show a statistically significant difference (χ2 = 6.433, P = 0.040). Conclusion: Individualized and multiple surgeries are needed for acute intracranial infection associated with hydrocephalus. In cases where the infection is secondary to a shunt, the primary surgical approach involves removing the shunt device. In situations where the infection is linked to hydrocephalus following different craniotomies, addressing scalp infection, cerebrospinal fluid leakage, and skull defects is essential. In instances of community-acquired intracranial infection associated with hydrocephalus, continuing drainage of cerebrospinal fluid is imperative.

Surgical Complications and Management Strategies in Endoscopic Endonasal Transsphenoidal Surgery for Pediatric Craniopharyngiomas

Endoscopic endonasal transsphenoidal surgery (EETS) has emerged as an effective method for the resection of craniopharyngiomas in pediatric patients, offering minimally invasive access and enhanced visualization. This literature review examines the surgical complications and management strategies associated with EETS for pediatric craniopharyngiomas. Common complications include cerebrospinal fluid (CSF) leaks, intraoperative hemorrhage, hypopituitarism, and visual disturbances. The incidence of these complications is influenced by factors such as tumor size and location, patient age, comorbidities, and surgeon experience. Effective management strategies involve meticulous preoperative planning, advanced imaging techniques, intraoperative monitoring, and comprehensive postoperative care. Detailed preoperative imaging is crucial for surgical planning, while intraoperative neuronavigation and neurophysiological monitoring help mitigate risks. Postoperative care, including endocrine evaluation and rehabilitation, is essential for addressing complications and improving patient outcomes. This review underscores the critical aspects of managing surgical complications to enhance the safety and efficacy of EETS in treating pediatric craniopharyngiomas.

A management algorithm for idiopathic intracranial hypertension in skull base meningoencephaloceles.

In this study, the authors assessed an algorithm for the diagnosis and management of idiopathic intracranial hypertension (IIH) in patients who had undergone surgical repair of skull base meningoencephaloceles presenting with spontaneous cerebrospinal fluid (sCSF) leakage. The authors conducted an institutional retrospective review of patients surgically treated for skull base sCSF leaks between 2014 and 2021. Opening pressure (OP) measurements were taken intraoperatively. The algorithm recommended a ventriculoperitoneal shunt (VPS) for high-risk patients (OP ≥ 30 cm H2O), 4 weeks of acetazolamide plus a 2-week washout and repeat lumbar puncture (LP) at 6 weeks for intermediate-risk patients (OP = 20-29 cm H2O), and repeat LP at 4-6 weeks for low-risk patients (OP < 20 cm H2O). Demographics, radiographic characteristics, management adherence, and outcomes were analyzed. Eighty patients with sCSF leakage were identified. The mean age was 51.9 years, and the mean body mass index was 36.3 kg/m2. The median follow-up was 8.3 months (IQR 3.3-19.7 months). The overall VPS rate was 15.0%. Three patients (3.8%) experienced acute recurrent leakage, and 3 (3.8%) developed remote recurrent leaks (mean time of 48.1 months). For the 50 patients with both intra- and postoperative OPs, the mean OPs were not significantly different (23.3 vs 23.0 cm H2O, respectively, p = 0.82). The mean variability between the two measurements was an absolute difference of 6.6 cm H2O. While 13 patients (26.0%) moved to a higher-risk category based on postoperative OP, 18 patients (36.0%) moved to a lower-risk category. Utilizing an algorithm of direct meningoencephalocele repair and selective shunting, acute and remote CSF leak recurrence rates were each 3.8%, and the VPS rate was 15.0%. These data provide further insight into CSF dynamics in this population and argue against the theoretical concern that CSF pressure will increase postrepair. Significant intraindividual variability suggests multiple LPs may be necessary before committing to invasive IIH treatment. Further work is necessary to determine the optimal IIH management strategy.

Headache Due to Spontaneous Intracranial Hypotension Treated with Cervical Epidural Blood Patch

Abstract Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid and it is characterized by an orthostatic headache without a history of trauma or dural puncture. Epidural blood patches have been regarded as the mainstay of therapy for SIH, often providing instantaneous relief of symptoms in 90% of cases regardless of the site of the leak. We present a rare case report of an epidural leak treated with a cervical epidural blood patch.