Endoscopic Repair Of Cerebrospinal Fluid Leaks Research Articles

The efficacy of an endoscopic endonasal approach in the repair of cerebrospinal fluid fistula: a clinical analysis

<p class="abstract"><strong>Background:</strong> Cerebrospinal fluid (CSF) fistula is an abnormal CSF leakage due to bone and/or dural defect of the skull base and usually operated with endonasal endoscopic approach. The aim of this study was to determine the efficacy of an endonasal endoscopic approach in the repair of CSF leakage and to find the reasons of the recurrence of endoscopic procedure.</p><p class="abstract"><strong>Methods:</strong> The medical records of 24 patients that presented with the diagnosis of cerebrospinal fluid fistula and who had undergone endonasal endoscopic repair surgery were reviewed retrospectively. </p><p class="abstract"><strong>Results:</strong> 13 patients (54.2%) were found to have spontaneous CSF fistulas without any history of trauma, while 11 patients (45.8%) had posttraumatic CSF fistulas. The mean body mass index (BMI) of patients was 31. 3 kg/m² (20.1-49.6). Nasal septal cartilage was used as a graft material in 19 patients (79%) while only fascia was used in 5 patients (21%). The evaluation of long-term results revealed recurrence in 4 patients (16.6%). Two of these patients required a second surgical repair.</p><p class="abstract"><strong>Conclusions:</strong> An endoscopic endonasal approach is a safe method with less morbidity and a reliable outcome in the repair of CSF fistulas. The most important causative factors in the recurrence of endoscopic repair of CSF leak might be to have high BMI and not to use multilayered graft material for closure of fistula.</p><p class="abstract"> </p>

Surgical Approach To Manage Cerebrospinal Fluid Rhinorrhea Through Vault Or Through Nose

Objective: Background: Surgical management of cerebrospinal fluid (CSF) rhinorrhea can be done through a transcranial approach or endoscopically using a transnasal approach. The endoscopic technology is relatively fresh in developing countries. Keeping this in mind we conducted an audit of patients undergoing endoscopic repair of CSF leaks to review their outcome in terms of recurrence and complications and compare them with the patients had transcranial repair. The objective of the study is to review the management of patients who underwent repair of CSF rhinorrhea at Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital – 10 years experience. Study design: Cross-sectional observational study Place and duration of Study: Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital, from January 2005 to December 2014 Patients & methods: A review of patient charts having undergone surgical repair for CSF rhinorrhea in the last 10 years at our institution was conducted. Thirty eight patients meeting the inclusion criteria of having undergone a surgical procedure for the repair of CSF rhinorrhea with a minimum post operative follow up of 6 months were included in the study. Results: Skull base defects were repaired with the help of minimally invasive transnasal endoscopic approach with a success rate of 80% in comparison to transcranial repair success rate of 29%. Post-operative complications were seen in only 10% of endoscopic group and 53% of transcranial group. Conclusion: Although endoscopic management is associated with better outcomes there is room for improvement in the approach in developing countries and training programs and detailed internal audits need to be conducted to improve the situation to the level of developed countries.

Cost Effectiveness of Dural Sealants in Endoscopic Cerebrospinal Fluid Leak Repair

Cost Effectiveness of Dural Sealants in Endoscopic Cerebrospinal Fluid Leak Repair

Development of a Perfusion-Based Cadaveric Simulation Model Integrated into Neurosurgical Training: Feasibility Based On Reconstitution of Vascular and Cerebrospinal Fluid Systems.

Novel methodologies providing realistic simulation of the neurosurgical operating room environment are currently needed, particularly for highly subspecialized operations with steep learning curves, high-risk profiles, and demands for advanced psychomotor skills. To describe the development of a curriculum for using perfusion-based cadaveric simulation models in a "Mock Operating Room" for neurosurgical procedures. At the USC Keck School of Medicine Fresh Tissue Dissection Laboratory between 2012 and 2016, 43 cadaveric specimens underwent cannulation of the femoral or carotid artery and artificial perfusion of the arterial system, and/or cannulation of the intradural cervical spine for intrathecal reconstitution of the cerebrospinal fluid (CSF) system. Models were used to train neurosurgical residents in various procedures. Self-assessment of pre- and postprocedure trainee confidence (Likert) scores was compared for each module. The following novel procedural training methodologies were successfully established: management of an injury to the carotid artery during an endoscopic endonasal approach (n = 12), endoscopic endonasal CSF leak repair (n = 6) with fluorescein perfusion, carotid endarterectomy (n = 4), extracranial-to-intracranial bypass (n = 2), insertion of ventriculostomy catheter (n = 7), spinal laminectomy with durotomy repair (n = 9), and intraventricular neuro-endoscopy with septum pellucidotomy and third ventriculostomy (n = 12). In all instances, trainees reported improvement in their postprocedural confidence scores, with mean pre- and postprocedural Likert scores being 2.85 ± 1.09 and 4.14 ± 0.93 (P < .05). Augmentation of fresh cadaveric specimens via reconstitution of vascular and CSF pathways is a feasible methodology for complimenting surgical training in numerous neurosurgical procedures, and may hold implications in the future of neurosurgical resident education.

The use of polydioxanone plates for endoscopic skull base repair.

Many reconstructive techniques and materials have been reported for repair of skull base defects after sinonasal tumor excision, cerebrospinal fluid (CSF) leaks, and coverage of denuded bone. Synthetic materials have been developed for endoscopic skull base repair to avoid donor-site morbidity. Polydioxanone plate is a bioabsorbable implant designed for nasal septal reconstruction and has the ability to retain strength for at least 10 weeks and absorbs in 6 months. This study aimed to describe the use of polydioxanone plates in endoscopic skull base defect and CSF leak repair, and to describe our experience with the surgical technique and postoperative management. This was a retrospective case series of patients who, between May 2013 and December 2015, underwent endoscopic sinus surgery and skull base repair for CSF leak or after excision of a skull base tumor by using polydioxanone plates. Patients who presented with sinonasal inflammatory disease or skull base tumors underwent endoscopic skull base repair by using polydioxanone plates in an underlay fashion and mucosal membrane grafts with or without adjuvant materials in an overlay fashion. The patients were reviewed at 6 days, 6 weeks, and 3 months after surgery. Postoperative adverse events, including CSF leak, infection, bleeding, headache, and graft failure, were recorded. The cases of seven patients (five women, two men; mean age, 53.9 years) were reviewed. Five patients underwent sinonasal tumor resection and two underwent repair for CSF leak. The mean (standard deviation) defect size was 16.4 ± 11.4 mm. There was no evidence of postoperative CSF leak, and lumbar drains were not used. One patient reported transient headache and facial pressure at the 6-week follow-up visit. The surgeons' experience with polydioxanone plate placement, postoperative healing, and follow-up was satisfactory. Polydioxanone could be used to achieve rigid repair of endoscopic skull base defects. These early results, although promising, require validation in clinical trials.

Efficacy of Perioperative Lumbar Drainage following Endonasal Endoscopic Cerebrospinal Fluid Leak Repair.

Objective Perioperative lumbar drain (LD) use in the setting of endoscopic cerebrospinal fluid (CSF) leak repair is a well-established practice. However, recent data suggest that LDs may not provide significant benefit and may thus confer unnecessary risk. To examine this, we conducted a meta-analysis to investigate the effect of LDs on postoperative CSF leak recurrence following endoscopic repair of CSF rhinorrhea. Data Sources A comprehensive search was performed with the following databases: Ovid MEDLINE (1947 to November 2015), EMBASE (1974 to November 2015), Cochrane Review, and PubMed (1990 to November 2015). Review Method A meta-analysis was performed according to PRISMA guidelines. Results A total of 1314 nonduplicate studies were identified in our search. Twelve articles comprising 508 cases met inclusion criteria. Overall, use of LDs was not associated with significantly lower postoperative CSF leak recurrence rates following endoscopic repair of CSF rhinorrhea (odds ratio: 0.89, 95% confidence interval: 0.40-1.95) as compared with cases performed without LDs. Subgroup analysis of only CSF leaks associated with anterior skull base resections (6 studies, 153 cases) also demonstrated that lumbar drainage did not significantly affect rates of successful repair (odds ratio: 2.67, 95% confidence interval: 0.64-11.10). Conclusions There is insufficient evidence to support that adjunctive lumbar drainage significantly reduces postoperative CSF leak recurrence in patients undergoing endoscopic CSF leak repair. Subgroup analysis examining only those patients whose CSF leaks were associated with anterior skull base resections demonstrated similar results. More level 1 and 2 studies are needed to further investigate the efficacy of LDs, particularly in the setting of patients at high risk for CSF leak recurrence.

Endoscopic transnasal repair of cerebrospinal fluid leaks with and without an encephalocele in pediatric patients: from infants to children.

The diagnosis and management of pediatric cerebrospinal fluid (CSF) leak and encephalocele are challenging. The current study aimed to identify patient characteristics, review operative techniques, and evaluate the efficacy and safety of endoscopic endonasal repair in a pediatric population. We retrospectively reviewed the records of pediatric patients who underwent transnasal endoscopic repair of CSF leak with or without a meningocele or an encephalocele at Beijing Tongren Hospital, Capital Medical University, between July 2003 and May 2014. All patients had preoperative radiological evaluations and underwent endoscopic endonasal repair of their skull base defects. Altogether, 23 children (mean age 7.0 years) underwent the procedures. Sixteen cases were congenital, and 7 patients had trauma history. The herniations or defects included meningoencephaloceles in 15 cases, meningoceles in 4 cases, and CSF leak in 4 cases (2 patients had bilateral leaks). The leak or herniation sites were ethmoid roof in 10 patients (one was bilateral), cribriform plate in 5, lateral to the foramen cecum in 3, posterior wall of the frontal sinus in 1, sphenoid sinus in 2, lateral recess of the sphenoid sinus in 1, and sella turcica base in 2. All subjects had favorable clinical outcomes without recurrence during a follow-up of 6-123 months (mean 61.1 months). The endoscopic endonasal approach was the preferred method for repairing CSF leaks with or without an encephalocele in pediatric patients. Compared to traditional operations, this endoscopic procedure is minimally invasive, efficient, and safe.

Perioperative continuous cerebrospinal fluid pressure monitoring in patients with spontaneous cerebrospinal fluid leaks.

Elevated intracranial pressure (ICP) is an inciting factor for cerebrospinal fluid (CSF) leaks and can be measured by CSF pressure (CSFP) monitoring. Current CSFP literature is limited to the assessments of opening pressure. This study reinvestigates a previously discussed monitoring approach that evaluates continuous CSFP parameters, physiologic measurements, and treatment outcomes in patients undergoing endoscopic repair of spontaneous CSF leaks. Retrospective review of patients undergoing endoscopic endonasal repair of spontaneous CSF leaks. All participants had a lumbar catheter placed for 24-hour continuous preoperative pressure monitoring, and 24 hours of continuous monitoring starting 48 hours after repair. In addition to patient characteristics, mean and peak CSFP, pulse waveform amplitudes (PWAs), and related parameters were calculated. Twenty-five patients underwent monitoring between 2004 and 2013, with a mean follow-up of 526 days. The mean age was 49.2 years, the mean body mass index (BMI) 38.5, and 8 of 25 (32%) had obstructive sleep apnea. Although mean CSFP and PWA decreased after the repair, mean peak CSFP increased by 1.56 cmH2O (1.15 mmHg). Six patients (24%) had elevation in their CSFP >25 cmH2O (18.4 mmHg) for a minimum of 4% of the recording time. Based on their continuous pressure monitoring data, 9 patients (36%) underwent treatment for high ICP, either with acetazolamide or a ventricular shunt. There were no CSF leak recurrences. Continuous perioperative CSFP monitoring provides valuable insight into multiple physiologic parameters. Systematic continuous CSFP monitoring can identify individuals in need of ICP-lowering therapy, possibly improving the outcomes in CSF leak repair surgeries.

Association between Physiologic Parameters and Anatomic Location in Spontaneous Cerebrospinal Fluid Leaks

Objectives: Although a relationship between elevated cerebrospinal fluid (CSF) pressure and spontaneous CSF leaks has been reported, analyses by anatomic sub-site are lacking. This study seeks to elucidate the association between physiologic parameters and CSF leak location. Methods: Prospective case series of patients undergoing endoscopic endonasal repair of spontaneous CSF leak between 2004 and 2013. All participants had a lumbar drain placed for 24-hour continuous preoperative pressure monitoring, and 24 hours of continuous monitoring starting 48 hours after the repair. In addition to patient characteristics, mean and peak CSF pressures by anatomic location were calculated and compared. Results: Twenty-five patients underwent perioperative CSF pressure monitoring, with a mean follow-up of 526 days. Nine patients had CSF leaks along the cribiform plate, 4 in the ethmoid roof, 8 in the sphenoid, 2 in the posterior table of the frontal sinus, and 2 with multiple leaks. Patients with cribiform leaks had the lowest mean body mass index (BMI) and prevalence of obstructive sleep apnea (22.2%), while those with multiple sites of leak had the highest mean BMI and prevalence of obstructive sleep apnea (50%). Patients with frontal sinus leaks had the highest postoperative mean (14.47 mmHg) and peak (42.5 mmHg) CSF pressures, while ethmoid roof had the lowest mean (0.43 mmHg) and peak (16.45 mmHg) CSF pressures. Conclusions: CSF pressure and other physiologic characteristics differ among patients with spontaneous CSF leaks by anatomic location. Understanding these differences may enable treatment approaches tailored by leak site, thereby improving repair outcomes.

Increased Intracranial Pressure in Spontaneous CSF Leak Patients Is Not Associated with Papilledema

Objectives: Spontaneous cerebrospinal fluid (CSF) leaks typically present in patients with undiagnosed idiopathic intracranial hypertension (IIH) secondary to pressure erosion of the skull base. Despite elevated intracranial pressure (ICP) on lumbar puncture or ventriculostomy, patients with spontaneous CSF leaks rarely complain of visual disturbances. The objective of this study is to correlate the presence of preoperative papilledema with opening ICP in patients undergoing endoscopic repair of spontaneous CSF leaks. Methods: Prospective evaluation of patients with spontaneous CSF leaks was performed over a 1-year period (December 2012 to December 2013). Fundoscopic examination for papilledema was completed preoperatively and CSF pressure was measured by lumbar puncture or ventriculostomy intraoperatively. Data regarding demographics, nature of presentation, and body mass index (BMI) were also recorded and compared to a control cohort of IIH patients with papilledema. Results: Sixteen patients (avg. age 52 years) were evaluated. Obesity was present in 94% of individuals (avg. BMI 43.5; range, 27-65). Papilledema was absent preoperatively in all subjects. Opening pressures via lumbar puncture/ventriculostomy were 27 ± 7.7 cmH20. Following 6 hours of clamping, measurements significantly increased to 36 ± 9.7 cmH20 ( P &lt; .001). IIH controls (avg. age 33 years, avg. BMI 36.7, 22-52) exhibited average ICP (36 ± 10.5) identical to post-clamp measurements in the spontaneous CSF leak cohort. Conclusions: Subjects with spontaneous CSF leaks had post-clamping average ICP identical to controls with IIH and papilledema. Such evidence suggests that a CSF leak in this patient population provides sufficient pressure diversion to avoid the development of papilledema.

Endoscopic Transnasal Management of Cerebrospinal Fluid Rhinorrhea: Early Experience

Background: Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communication between the subarachnoid space and the nasal cavities. During the last two decades the surgical management of anterior skull base fistulae has evolved from intracranial craniotomy to endoscopic transnasal repair with a high success rate and decreased morbidity. We recently changed our policy and repair CSF rhinorrhea through an endoscopic endonasal approach. The purpose of this work is to describe the technique used for watertight closure of CSF leak along the anterior skull base and to evaluate our early results. Methods: A prospective acquired database of all patients having undergone endonasal endoscopic repair of CSF leaks over a 20-month period at Military Hospital of Tunis starting in March, 2012 was reviewed. Results: A total of 20 patients underwent endoscopic repair of CSF fistula. The etiology was traumatic in 7 cases, spontaneous in 11, and iatrogenic in 2 associated with previous transsphenoidal pituitary surgery. A total of 19 patients had successful primary endoscopic repair of the CSF leak. One patient required a revision surgery due to early failure of the repair and the leak was plugged successfully on the second attempt. We experienced a single case of meningitis during the postoperative course. Conclusion: The overall success rate (100%) and low morbidity in this short series support endoscopic approach as standard of care for CSF leak closure.

Impact of Chemoradiotherapy on CSF Leak Repair after Skull Base Surgery.

Background Transnasal endoscopic resection (TER) has become the treatment of choice for many skull base tumors. A major limitation of TER is the management of large dural defects and the need for repair of cerebrospinal fluid (CSF) leaks, particularly among patients who are treated with chemotherapy (CTX) or radiotherapy (RT). The objective of this study is to determine the impact of CTX and RT on the success of CSF leak repair after TER. Methods We performed a retrospective chart review of a single-institution experience of TER from 1992 to 2011. Results We identified 28 patients who had endoscopic CSF leak repair after resection of malignant skull base tumors. Preoperative RT was utilized in 18 patients, and 9 had undergone CTX. All patients required CSF leak repair with rotational flaps after cribriform and/or dural resection. CSF leak repair failed in three patients (11%). A history of RT or CTX was not associated with failed CSF leak repair. Conclusion Adjuvant or neoadjuvant CTX or RT is not associated with failed CSF leak repair. Successful CSF leak repair can be performed in patients with malignant skull base tumors with an acceptable risk profile.

Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks

ObjectiveSkull base cerebrospinal fluid (CSF) leaks of various etiologies are increasingly repaired through the natural corridor using an endoscopic endonasal approach. Characteristics of the skull base defect significantly correlate with etiology, which should be ascertained to guide surgical management. The objectives of this study were to assess the long-term outcomes of patients that underwent endoscopic endonasal repair of CSF leak using low-dose intrathecal fluorescein (ITF) and an etiology-based algorithm for multi-layer graft closure. MethodsPatients were divided into 4 groups: A – congenital, B – post-traumatic, C – post-endonasal surgery, D – post-craniotomy. Low-dose ITF was utilized in all case series. Long-term clinical follow-up data, including perioperative complications associated with the use of intrathecal fluorescein and leak closure rates, were obtained retrospectively. Endoscopic visualization of fluorescein-stained CSF as well as the method of skull base closure and graft material is detailed. ResultsWe identified a total of 41 patients (N=24 in Group A, N=4 in Group B, N=12 in Group C and N=1 in Group D) that underwent 50 CSF leak repairs using the endoscopic endonasal approach with an average follow-up of 31.6 months. Nine patients (21.9%) had undergone a previous attempt at CSF leak repair. Lumbar drain was used intraoperatively in 26 patients (63.4%) and kept in place for an average duration of 3.25 days. ITF successfully identified the site of leak in 80.5% of cases regardless of etiology. Leaks were successfully closed in 92% of patients. One patient (2.4%) experienced transient leg weakness following lumbar drain placement. Another patient (2.4%) developed hydrocephalus requiring a ventriculoperitoneal shunt. ConclusionLow-dose ITF is a safe and useful adjunct to endoscopic endonasal repair of CSF leaks with minimal complications and successful localization of the leak in approximately 80%. An etiology-based approach to graft choice and duration of lumbar drain placement in CSF leak repair may optimize closure rates.

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30% following head injury and 15% were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60%) followed in frequency by the cribriform plate and the sphenoid sinus (20% each). Follow-up period was 12-24 months. We have achieved a 95% success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100% success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.

Successful Endoscopic Repair of Persistent Cerebrospinal Fluid Leak Following Attempted Transcranial Repair

Endoscopic techniques have become the preferred approach to address cerebrospinal fluid (CSF) leaks in the skull base, as they offer a minimally invasive method to directly visualize and repair the defect. The alternative technique of open craniotomy can still be considered for cases refractory to endoscopic repair; however, few studies have investigated the potential benefits of endoscopic repair for cases of persistent leaks after attempted transcranial repair. We report two such cases of successful long-term endoscopic repair of a persistent CSF leak, and demonstrate that endoscopic repair is a viable option to salvage an unsuccessful intracranial repair.

Diagnostic and Surgical Approach to Anterior Skull Base CSF Leaks in a Rhinology Practice

Background: Cerebrospinal fluid (CSF) leaks result from an abnormal communication between the subarachnoid space and the extracranial space. Leaks that occur at the anterior skull base may manifest with postural headaches, clear rhinorrhea, and a salty metallic taste. They can occur (1) as a poor outcome of a prior sinus or nasal surgery, (2) as the result of trauma, or (3) spontaneously without known cause. The condition can become life-threatening if not evaluated expeditiously. The majority of leaks encountered at our institution were repaired with endoscopic sinus surgery (ESS). The aim of this presentation is to consider our experience over a 6-year period, to evaluate various diagnostic and radiographic modalities prior to repair, and to evaluate the outcomes in patients who underwent an endoscopic repair of CSF leaks of the anterior skull base.

DuraSeal™ in Endoscopic Repair of Cerebrospinal Fluid Leak

Objective: 1) Review use of DuraSeal (Confluent Surgical, Waltham, MA) as sealant in the primary repair of spontaneous cerebrospinal fluid (CSF) leaks and in secondary repair following transspehnoidal pituitary surgery for persistent leak. 2) Compare success and postoperative course of DuraSeal to fibrin glues in our patients and in the literature. Method: A database of endoscopic cerebrospinal fluid leak repairs was created by retrospective review of the operative log from 1999 to 2012 at a tertiary care hospital. Operative reports and postoperative hospital records were collected and analyzed for type of repair and CSF leak recurrence. Results: Nine cases were identified in which DuraSeal was used as a dural sealant during endoscopic CSF leak repair for spontaneous leak or in secondary repair of CSF leaks following previous transsphenoidal pituitary surgery. There was no recurrence of CSF leak in any patients in which DuraSeal was used in the repair. The average follow-up was 21 months (range 1 to 53 months). There were no complications from the use of DuraSeal. A similar group of 7 patients in whom fibrin glue was used noted 1 repair failure (14.3%) with a 32-month average follow-up. Conclusion: The use of DuraSeal to strengthen CSF leak repair and form a watertight seal was successful in 100% of reported cases and had no adverse events related to its use. This report of 9 patients would be the largest to date where DuraSeal was used in this manner.

Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

The advances in endoscopic skull base surgery have led to the resection of increasingly larger cranial base lesions and the creation of larger skull base defects with the potential for increased postoperative high-flow cerebrospinal fluid (CSF) leaks. These concerns led to the development of the vascularized pedicled nasoseptal flap (PNSF), which is now used as the mainstay for repair of large skull base defects in many academic centers. In this report, we review the incidence of postoperative CSF leaks in our institution in patients undergoing endoscopic skull base repair of high-flow CSF leaks with a vascularized PNSF without concurrent CSF diversion. We performed a retrospective analysis at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF without CSF diversion between July 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. Fifty-nine high-flow CSF leaks were repaired with a PNSF and other repair materials, without the use of lumbar catheter drainage. No postoperative CSF leak occurred in this cohort of patients. The overall postoperative CSF leak rate was 0%. Meticulous multilayer-closure of skull base defects is critical to prevent postoperative CSF leaks. Although lumbar drainage may be useful in select scenarios, it carries inherent risks of intracranial hypotension and pneumocephalus, and may not be necessary for routine management of high-flow CSF leaks in conjunction with a robust PNSF. Further prospective randomized controlled studies may be warranted to evaluate the efficacy of postoperative lumbar drainage.

Endoscopic Nasoseptal Flap Repair of Skull Base Defects

We compared the incidence of postoperative cerebrospinal fluid (CSF) leaks in patients undergoing endoscopic skull base repair with a pedicled nasoseptal flap (PNSF) with or without the addition of a dural sealant. Retrospective analysis at a tertiary care medical center. A retrospective analysis was performed at our tertiary care medical center on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF between December 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. Thirty-two high-flow CSF leaks were repaired with a PNSF alone without dural sealant (group A), and 42 were repaired with a PNSF with the addition of a dural sealant (group B). In group A, there were no postoperative CSF leaks (0%), whereas in group B, there was 1 delayed postoperative CSF leak, resulting in a 2.4% leak rate. The incidence of postoperative CSF leakage was not significantly different between the 2 groups (P = .38). The overall postoperative CSF leak rate was 1.4%. The use of dural sealants when performing endoscopic PNSF repair of high-flow CSF leaks is not supported by our data. In addition, this practice may significantly increase surgical cost. We encountered no postoperative CSF leaks in patients with high-flow CSF leaks treated with PNSF alone without dural sealants. Meticulous surgical technique and proper positioning of the PNSF seem to obviate the need for dural sealants during endoscopic skull base reconstruction of high-flow CSF leaks.

Endoscopic Nasoseptal Flap Repair of Skull Base Defects: Is Addition of a Dural Sealant Necessary?

Background: We compared the incidence of postoperative cerebrospinal fluid (CSF) leaks in patients undergoing endoscopic skull base repair with a pedicled nasoseptal flap (PNSF), with or without the addition of a dural sealant. Methods: A retrospective analysis of a prospective database was performed on patients who underwent endoscopic repair of high-flow CSF leaks using a PNSF between December 2008 and August 2011. Repair materials, incidence of postoperative CSF leaks, and demographic data were collected. Results: Thirty-two high-flow CSF leaks were repaired with a PNSF alone without dural sealant (Group I), and 42 were repaired with a PNSF with the addition of a dural sealant (Group II). In Group I, there were no postoperative CSF leaks (0%), whereas in Group II, there was one delayed postoperative CSF leak, resulting in a 2.4% leak rate. The incidence of postoperative CSF leakage was not significantly different between the two groups (P > 0.05). The overall postoperative CSF leak rate was 1.4% in this cohort. Conclusions: The use of dural sealants when performing endoscopic PNSF repair of high-flow CSF leaks is not supported by our data. In addition, this practice may significantly increase surgical cost. We encountered no postoperative CSF leaks in patients with high-flow CSF leaks treated with PNSF alone without dural sealants. Meticulous surgical technique and proper positioning of the PNSF seem to obviate the need for dural sealants during endoscopic skull base reconstruction of high-flow CSF leaks.