Endoscopic Repair Of CSF Leaks Research Articles

FRI321 Aggressive Prolactinoma Empirically Treated With Cabergoline Leading To Rapid CSF Leak

Abstract Disclosure: A. Yau: None. T. Reisman: None. Over two-thirds of pituitary tumors are prolactinomas. These are discovered as a result of symptoms of hypogonadism, menstrual irregularities, infertility or galactorrhea, as well as symptoms of mass effects including visual field deficit or acute severe headaches.1 A more rare subgroup, aggressive prolactinomas, in which the tumors are radiographically invasive and show resistance to dopamine agonist treatment as well as surgery, account for 10% of all hypophyseal neoplasia. 2 During medical treatment of prolactinomas, there is a known rare complication of CSF rhinorrhea; recorded time of onset of leak following treatment ranges from 14 days to 5 years.3 We present a case in which a patient with an aggressive prolactinoma rapidly developed a CSF leak within 48 hours of starting cabergoline treatment. Case: A 36-year-old male with type 2 diabetes, erectile dysfunction and infertility presents to Endocrine clinic after initial evaluation by Urology revealed elevated prolactin. He reported headaches, gynecomastia associated with liquid discharge from nipples, and minor issues with peripheral vision. He was started empirically on cabergoline for probable prolactinoma and within 48 hours developed worsening frontal headache, cough and clear fluid leakage from his right nostril. Labs revealed prolactin over 2600 ng/ml. MRI pituitary showed evidence of pituitary adenoma as well as likely CSF leak. Cabergoline was stopped and the patient was sent to the emergency room. The patient was underwent urgent neurosurgical transsphenoidal endoscopic surgery and CSF leak repair with resolution of rhinorrhea and cough. Post-operative MRI was consistent with minimal residual tumor. He was monitored in the NICU with no obvious post-operative pituitary hormone imbalance, diabetes insipidus, adrenal insufficiency or syndrome of inappropriate ADH. Months after discharge, the patient’s prolactin remained elevated to the 600’s ng/ml and repeat MRI showed a mass occupying the entire sella and suprasellar cistern, compressing the optic chiasm. Conclusion: In this case of a patient with the subtype of aggressive prolactinoma, there seems to be a more rapid presentation of complications. When treating these rare subtypes, physicians need to stay vigilant of developing complications or even consider nonstandard therapies as first-line management. 1. Molitch ME, Drummond J, Korbonits M. Prolactinoma Management. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc.; January 6, 2022.2. Lasolle H, Ilie MD, Raverot G. Aggressive prolactinomas: how to manage?. Pituitary. 2020;23(1):70-77. doi:10.1007/s11102-019-01000-73. Arimappamagan A, Sadashiva N, Kandregula S, Shukla D, Somanna S. CSF Rhinorrhea Following Medical Treatment for Prolactinoma: Management and Challenges. J Neurol Surg B Skull Base. 2019;80(6):620-625. doi:10.1055/s-0039-1677686 Presentation: Friday, June 16, 2023

ODP334 Must we Wait for the Development of Metastasis to be Able to Distinguish Dopamine Resistant Aggressive Prolactinoma from Prolactin Producing Pituitary Carcinomas? Case Report and Literature Review

Abstract Background Prolactinomas, the most prevalent type of neuroendocrine disease, account for approximately 40% of all pituitary adenomas. In the vast majority of cases, these are benign tumors with excellent clinical response to medical therapy with dopamine agonist agents such as bromocriptine and cabergoline. Rarely medical treatment fails to normalize prolactin levels and/or decrease the size of the tumor, posing a challenge to the clinician. Case presentation 40-year-old man who underwent resection of a 7.4 cm pituitary prolactinoma via frontal craniotomy followed by radiotherapy. He developed panhypopituitarism and was placed on chronic hormonal replacement therapy plus high dose cabergoline. Two years later he presented with recurrence of his disease and was diagnosed with an unresectable 4.9 cm pituitary adenoma showing cortical breakthrough of the sellar floor, invasion into the optic chiasm, erosion of the posterior sphenoid walls, extension into the sphenoid sinuses and posteriorly into the pons, midbrain and third ventricle, as well as complete encasement of the distal, superior cerebellar and posterior cerebral arteries. The patient underwent endoscopic trans sphenoidal partial tumor resection and CSF leak repair. Pathology revealed a pituitary prolactinoma with Ki-67 of up to 8% and positive p53 immunostaining. His cabergoline dose was adjusted to 0.5 mg PO daily and he was also started on Sandostatin 20 mg IM monthly as well as appropriate hormonal replacement of the other deficient pituitary hormonal axes. Follow up imaging revealed stability of the lesion. The patient continues to do clinically well and actively follows with endocrinology and neurosurgery with serial brain MRIs and laboratory workup. Discussion The histological and biochemical characteristics of aggressive prolactin secreting tumors has been reported to be of minimal utility in distinguishing benign from malignant lesions. Tumors can only be diagnosed as carcinomas after they have metastasized and they can only be classified as aggressive after treatment failure or unusual growth, which creates a disadvantage for the prognosis and management of these patients. Clinicians are in need of better guidelines that can help them identify the rare cases that might warrant more aggressive clinical interventions beyond dopamine agonists such as surgery, radiation, temozolomide, somatostatin receptor agonists and others, with the hope of delaying or preventing the development of metastasis. Case reports of atypical presentations of aggressive prolactinomas such as the one here presented, can help broaden our understanding of the predictable signs of poor prognosis. Presentation: No date and time listed

A Rare Case of Tension Pneumocephalus with Spontaneous CSF Rhinorrhea Managed by Endoscopic Trans-Sphenoidal CSF Leak Repair.

Tension Pneumocephalus and spontaneous CSF rhinorrhea are very rare associations in clinical practice. We report a case of 65years old male with clear rhinorrhea, severe frontal headache, vomiting and lethargy for a week. MR Cisternography and CT Paranasal sinuses showed significant Tension Pneumocephalus with defect in the posterior wall of sphenoid sinus and CSF pooling in the sphenoid sinus. Endoscopic trans-sphenoidal CSF leak repair was done without any delay followed by complete resolution of Tension Pneumocephalus with in 4 post op days. Prompt precise diagnosis and early intervention of Tension Pneumocephalus is vital to avoid neurological complications.

In Reply to the Letter to the Editor Regarding: “The ‘Parachute’ Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks”

In Reply to the Letter to the Editor Regarding: “The ‘Parachute’ Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks”

Letter to the Editor Regarding “The ‘Parachute’ Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks”

Letter to the Editor Regarding “The ‘Parachute’ Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks”

Anaesthetic Management of a Patient with Endotracheal Tuberculosis Posted for Endoscopic CSF Leak Repair

Introduction: Patient with tracheal tuberculosis with active lung infection requiring Intubation using Double lumen Endotracheal tube pose a challenge to anesthesiologist to prevent contamination of healthy lung. Case Report: 55 year female presented with complaints of nasal discharge for 2 weeks, cough with expectoration for one week. A diagnosis of CSF Rhinorrhoea was made. HRCT chest report showed tree in bud opacities suggestive of TB. General anaesthesia was planned. Preoperatively nebulized with Lignocaine with adrenaline; Patient was Pre medicated, Preoxygenation done with 100% oxygen. Induced with Inj Propofol. 35F Left Double lumen tube was inserted under fibreoptic guidance and was confirmed by chest rise and ETCO2 and Tube fixed in place. A portable ventilator was used with Tidal volume of 5ml per kg for the right lung and regular ventilator with same tidal volume to left lung. Intra operative vitals were stable throughout the procedure. The patient was extubated after adequate spontaneous efforts. After extubation the patient started desaturating, saturation went upto 70% on room air, immediately the patient was reintubated and shifted to ICU with ET tube insitu. The patient was extubated in ICU after 2 days and shifted to postoperative ward. Conclusion: In patients with active lung infection a plan for Double lumen ET tube may help in avoiding the infection spreading to healthy lung, intubation period is crucial to avoid most common problems such as malposition, airway trauma and tension pneumothorax caused by high ventilating pressure or large tidal volumes in patients.

The surgical treatment of cerebrospinal fistula: Qualitative and quantitative analysis of indications and results

Cerebrospinal fistula might occur in different ways. CSF closure techniques have undergone significant evolution that has led to the consolidation of the transnasal endoscopic approach. Despite the existence of multiple publications, meaningful information is still lacking in clinical practice and the literature about the ideal method, material, and timing for repair of CSF. The purpose of this review was to summarize the success rate of endoscopic CSF leak repair as well as whether specific techniques or materials influence the primary success rate through a review of the latest advancements in endoscopic CSF management published in the past 10 years. The principles of multilayer reconstructions and the routine use of vascularized flaps in expanded endonasal surgery have reduced postoperative CSF leaks' failure rates between 5% and 10% (4% in this meta-analysis). Effective endoscopic anterior skull base (ASB) closure may be achieved by multiple reconstructive techniques, which should be tailored case by case according to the patient and defect conditions.

Contrasting Surgical Management of CSF Leak from Lateral Recess of Sphenoid Sinus and Its Surgical Outcomes: Our Experience.

CSF leak from Lateral Recess of Sphenoid (LRS) sinus accounts for 35% of all CSF rhinorrhoea cases. There are various surgical techniques described for repair of LRS CSF leak. This study describes the experience of LRS leak repair in a tertiary care center with three different surgical techniques. Study comprises of 3 cases of LRS CSF leak that presented to J.S.S. Hospital, during the time period of July 2018-January 2019, who underwent endoscopic CSF leak repair. All three cases underwent endoscopic endonasal transpterygoid approach to the leak site. The closure technique opted for all three cases were different. For the first case free mucosal flap from ipsilateral middle turbinate was used, for the second ipsilateral nasoseptal flap (NSF) was used and contralateral NSF was used for the third. All the cases were followed up for a minimum of 3months. In all the 3 cases the CSF leak site was located in the lateral recess of Sphenoid sinus. Encephalocele was noted in two cases, which were cauterised and closure was done as planned. Crusting was more in cases that underwent closure using free mucosal flap. Healing and take up was similar for both the ipsilateral NSF and contralateral NSF. The endoscope has revolutionized the management of CSF leak from the lateral recess of sphenoid sinus. These defects can be managed efficiently using multilayer closure of defect. For large defects, the Posterior nasoseptal flaps can be used. In addition, contralateral PNSF has lower chances of being devascularized due to injury to pedicle while drilling the pterygoid plates.

Outcome of Endoscopic Cerebrospinal Fluid Rhinorrhoea Repair: An Institutional Study.

Cerebrospinal fluid Rhinorrhoea is caused by an abnormal open communication between the subarachnoid space and the nasal cavity. The most common anatomic sites of such abnormal communication are found in the anterior skull base, namely, ethmoid roof, olfactory groove, roof of the sphenoid sinus and the posterior wall of the frontal sinus. It can be classified into traumatic or spontaneous. Spontaneous leaks are associated with highest recurrence rates following surgical repair. The repair of CSF Rhinorrhoea has rapidly evolved over the past 30years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs which carried a variable success rate and morbidity. The purpose of our study was to ascertain the outcome after Transnasal Endoscopic Repair of spontaneous CSF leaks. This was a prospective study conducted at the Department of ENT at Safdarjung Hospital, New Delhi between January 2015 and June 2016. The study comprised of eleven patients who presented with the complaint of watery nasal discharge and were diagnosed to have spontaneous CSF Rhinorrhoea. Proper clinical examination, nasal endoscopy and biochemical and cytological analysis of nasal secretions of the patient was done. High Resolution Computed Tomography and MRI scans of the nose and paranasal sinuses were done to identify precise location of CSF leak and the size of fistula. CT cisternography was done wherever required. Fistula was repaired via Transnasal endoscopic approach in a multi layered underlay fashion. Out of all eleven patients with spontaneous CSF leaks, most common site of leak was from left cribriform area. Four patients (36.36%) were found to have meningoencephalocele. No associated intracranial lesion was found and all patients did not have any benign intracranial hypertension. Our success rate of endoscopic repair on first attempt was 100% with recurrence in 1 patient after 4months of repair. Endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques. Accurate localization of leak site followed by multilayered closure of dural defect appear to be essential for successful endoscopic repair.

Leukocyte- and platelet-rich fibrin: a new graft material in endoscopic repair of spontaneous CSF leaks.

Spontaneous CSF leak is a challenging condition, with frequent recurrences following attempted surgical closure. The selection of graft materials depends on the experience of the operating surgeon. Leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation platelet concentrate that has currently invaded every surgical specialty. To our knowledge, no previous reports about the use of L-PRF in repair of CSF leak were published. The study was conducted to assess the potential role of L-PRF in spontaneous CSF leaks repair. This prospective controlled study was conducted on 40 patients who were randomly divided into 2 groups: In group A, L-PRF was used in addition to another layer, while patients in group B underwent multilayer repair using traditional graft materials. Preoperative HRCT scan showed bony dehiscence (n = 30) and opacity in a nearby sinus (n = 9). MRI findings varied between empty sella in 28 patients, and meningocele in 19 patients. Mean preoperatively measured CSF pressure was 26.6cm H2O. Cribriform plate was identified as the commonest site of leaks. Multiple skull defects were detected in 2 cases. Failure of repair was found in 3 patients (15%) of group B and 1 patient (5%) of group A, this difference was statistically insignificant (P value = 0.28). Significance correlation between recurrence of CSF leak and elevated intracranial pressure was observed (P value; 0.04). L-PRF was found to be a good adjunct material in endoscopic spontaneous CSF leaks repair. It helps in decreasing the number of layers needed for defect closure.

Multilayered Endonasal endoscopic repair of CSF leaks of sphenoid sinus

Cerebrospinal fluid rhinorrhea of the sphenoid sinus is a serious clinical condition. Endoscopic management has become the gold standard treatment. Use of multilayer closure to occlude the anatomical defect was suggested by some reports. The current study aims to evaluate endoscopic repair of sphenoid sinus CSF leak using multilayer closure. The present study included 17 patients. Their CSF leak was caused by accidental trauma in 9 patients (52.9 %), iatrogenic trauma in 1 patient (5.9 %) and in 7 patients (41.1 %), the leak occurred spontaneously. After localization of the leak, multilayer closure was used for anatomical defect repair. All patients achieved successful operative repair form the first attempt. The reported complications included meningitis in only 1 patient (5.9 %).Endoscopic repair of the sphenoid sinus CSF leaks using multilayer closure is a safe and effective approach. The Hadad–Bassagasteguy flap is the corner stone for sealing skull base defects in sphenoid sinus.

A systematic review of secondary cerebrospinal fluid leaks.

Secondary cerebrospinal leaks (CSF) are leaks that recur after an initial endoscopic repair of CSF leaks. Identification of characteristics that could predict secondary leaks may allow surgeons to plan repairs with the knowledge that these defects are more likely to fail. To identify characteristics that could predict secondary CSF leaks. A search of all studies that reported outcomes after endoscopic repair of CSF leaks was conducted by using medical literature data bases. Studies with the following criteria were included: written in the English language, secondary CSF leaks after primary repair, and assessment of success of fistula repair. Data extracted included the etiology of the leak, site of the leak, reconstructive materials used, and success of the repair. Ninety-four studies, from 1988 to 2015, with a total of 3149 primary CSF leaks were included. Sixty-three studies (67%) had a success rate of ≥80%; 77 studies (82%) had secondary leak rates of <40%. For 88 of the 94 studies (94%), the success rate after secondary repair improved to 81.0-100%. Of 48 studies that included leaks of more than one site, the sphenoid was the most common site of leak in 26 studies (55%), the ethmoid was the most common site in 16 studies (34%), and the cribriform was the most common site in 11 studies (23%). The rate of secondary CSF leaks was low due to advances in endoscopic repair techniques. Spontaneous and iatrogenic CSF leaks were more likely to recur, especially without adequate control of underlying factors, such as increased intracranial pressure and obesity. Further studies with consistent reporting are required for more definitive conclusions about secondary CSF leaks.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

What is the evidence for postoperative lumbar drains in endoscopic repair of CSF leaks?

What is the evidence for postoperative lumbar drains in endoscopic repair of CSF leaks?

Surgical challenge: endoscopic repair of cerebrospinal fluid leak

BackgroundCerebrospinal fluid leaks (CSF) result from an abnormal communication between the subarachnoid space and the extracranial space. Approximately 90% of CSF leak at the anterior skull base manifests as rhinorrhea and can become life-threatening condition. Endoscopic sinus surgery (ESS) has become a common otolaryngologist procedure. The aim of this article is to consider our experience and to evaluate the outcomes in patients who underwent a purely endoscopic repair of CSF leaks of the anterior skull base.FindingsRetrospective chart review was performed of all patients surgically treated for CSF leaks presenting to the Section of Nasal and Sinus Disorders at the Service of ENT–Head and Neck Surgery, University Hospital Complex of Santiago de Compostela (CHUS), between 2004 and 2010. A total of 30 patients who underwent repair CSF leak by ESS. The success rate was 93.4% at the first attempt; only two patients (6.6%) required a second surgical procedure, and none of it was necessary to use a craniotomy for closure. Follow-up periods ranged from 4 months to 6 years.ConclusionIdentifying the size, site, and etiology of the CSF leak remains the most important factor in the surgical success. It is generally accepted that the ESS have made procedures minimally invasive, and CSF leak is now one of its well-established indications with low morbidity and high success rate, with one restriction for fistulas of the posterior wall of the frontal sinus should be repaired in conjunction with open techniques.

A Systematic Review of the Endoscopic Repair of Cerebrospinal Fluid Leaks

To provide an up-to-date review of the literature on the safety and efficacy of the endoscopic technique for cerebrospinal (CSF) leak repairs. PubMed, Medline/Old Medline, and Cochrane Central databases. Using the above outlined data sources, studies involving the endoscopic repair of CSF leaks were reviewed independently by 2 researchers. Studies included met the following criteria: full-text article written in the English language, at least 5 human patients undergoing purely endoscopic surgical repair of a CSF leak, and documented follow-up. Data extracted included leak etiology, presentation and location, the use of imaging, intrathecal fluorescein, and adjunctive measures as well as the success rate of the repair. Fifty-five studies, involving 1778 fistulae repairs, were included for analysis. Spontaneous leaks were most prevalent, with the ethmoid roof and sphenoid the most common sites involved. The overall success rate of repair was high at 90% for primary and 97% for secondary repairs. A low complication rate of less than 0.03% was reported. The endoscopic repair of CSF fistula is both safe and effective and should be considered the standard of care for most cases. Evidence supporting adjunctive measures such as lumbar drains and antibiotics remains limited despite their common use.

Endoscopic Transnasal Repair of CSF Leaks: Our Practice and Review of the Literature

Objective: Endoscopic repair of CSF leaks of the anterior skull base have been well described since the early 1980s. We describe our variation on the septal mucoperichondrial flap and stepwise approach to investigation and management of the patient and compare it to the current literature.

Endoscopic repair of anterior or middle skull base cerebrospinal fluid leaks after tumour resection

This study analysed the factors influencing the risk of recurrence following endoscopic repair of CSF leaks of the anterior and middle skull base after endonasal skull base tumour resection. A retrospective review was conducted on 17 patients operated between May 2007 and December 2010 by endonasal endoscopic resection of anterior or middle skull base tumour who presented an intraoperative CSF leak. Epidemiological data (body mass index [BMI], age, gender) and type of leak (site, size) were studied. CSF leaks involved the roof of the ethmoid sinus (one patient), cribriform plate (three), posterolateral wall of the sphenoid sinus (six) or the sella turcica (seven). The CSF leak recurrence rate after the first endoscopic procedure was 29.4% (5/17). Failures were not influenced by gender, age, BMI or size of the leak. All recurrences involved the sella turcica or the lateral wall of the sphenoid sinus. The success rate after a second endoscopic procedure was 88.2%. Endonasal endoscopic repair of anterior and middle skull base meningeal injuries after tumour resection is a minimally invasive and effective technique. The main challenge of this method consists of ensuring effective control of the postoperative defect after tumour resection in the sphenoidal region, as this region was the only potential risk factor for recurrence identified in this study.

Endoscopic Laser Welding (ELW) for Spontaneous Cerebrospinal Fluid Leak (CSF) Repair: A Preliminary Report

Background: Endoscopic repair of spontaneous CSF leaks represents a technical challenge given the increased incidence of comorbid elevations in intracranial pressure (ICP). Endoscopic Laser Welding (ELW) offers a method of creating instantaneous wound repairs using a lased albumin-based soldering gel. These welds have burst strengths far exceeding normal ICP and may therefore be useful in skull base reconstruction. The goal of this study is to examine the behavior of the soldering gel in human mucosa and to report on the technical feasibility and efficacy of ELW in the closure of spontaneous CSF leaks.

Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles

The endoscopic endonasal approach has become the preferred technique for CSF leak and encephalocele repair of the anterior skull base. The purpose of this study is to identify patient characteristics; review adjunctive perioperative treatments, reconstruction techniques, and outcomes; and identify risk factors for failure in patients undergoing endoscopic endonasal repair of anterior skull base CSF leaks and encephaloceles. This is a prospective observational study of patients undergoing endoscopic endonasal repair of a CSF leak between October 2004 and May 2009. Twenty-eight consecutive patients underwent 32 procedures. Twenty-two of the patients were women, which represents a statistically significant trend toward the female sex (p < 0.05). The average body mass index (33.9) was significant for obesity. The origin of the skull base defect included the cribriform plate (in 9 cases), fovea ethmoidalis (in 7), combined fovea ethmoidalis/cribriform plate (in 2), lateral sphenoid sinus (in 6), sella (in 4), clivus (in 3), and frontal sinus (in 1). The overall endonasal closure rate was 93.8% (30 of 32 procedures). One failure occurred due to overaggressive postoperative debridement, while the other recurred along the posterior wall of the frontal sinus, and endoscopic repair would have occluded the recess. The endoscopic endonasal approach for the treatment of CSF leaks and encephaloceles of the anterior skull base is the preferred method of repair in the vast majority of cases. The authors' 93.8% closure rate in a variety of anatomical locations compares favorably with the transcranial approach and echoes the results of other endoscopic series.