Incidence Of CSF Leakage Research Articles

English

BACKGROUND Watertight dural closure is a vital and desirable step following all intracerebral operations to prevent CSF leakage, consequent infection and wound dehiscence and delayed wound healing which in turn increases patient morbidity and mortality. Various autologous and synthetic materials have been tried for duraplasty. This study was done to compare two types of synthetic materials used for duraplasty. METHODS This randomised prospective study was done at our institute on 56 patients who underwent decompressive craniectomy. Patients were randomly divided into two groups, one group underwent duraplasty with synthetic fabric patch graft and the other group underwent duraplasty with collagen matrix graft and results were compared between the two groups. RESULTS Patients who underwent duraplasty with collagen matrix graft were found to have a significantly reduced operating time of nearly 34 minutes as compared to the synthetic fabric patch and also there was no incidence of CSF leakage or wound infection in those patients in whom collagen matrix was used. CONCLUSIONS Collagen matrix graft is far superior to synthetic fabric graft for duraplasty as it saves valuable operating time and has fewer complications as compared to synthetic fabric grafts. KEY WORDS Duraplasty, Collagen Matrix Graft, Synthetic Fabric Patch Graft

Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects.

Endonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects. A retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap. Thirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery. Extended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.

Decision making in dissection range of temporal bone: refinements to enlarged translabyrinthine approach.

The aim of the study was to describe the refinements to the classic enlarged translabyrinthine approach (ETLA) by modifying the bony dissection range of temporal bone and to analyze the main outcomes achieved in a series of vestibular schwannoma (VS) cases submitted to microsurgery by ETLA. This was a retrospective study of 382 patients who underwent VS surgical removal via ETLA between January 2001 and December 2012. Among those cases, 332 were via classic ETLA, while 28 cases were via ETLA with blind sac technique and middle ear eradication and 22 via transotic approach. Total tumor removal was achieved in 368 cases, whereas near total removal in 11 patients and subtotal in 3 patients. In cases of large VS (>3 cm) via classic ETLA, good short-term and long-term facial nerve function (HB I-II) was gained in 27.8 % (32/115) and 42.6 % (49/115) cases, respectively, meanwhile in VS operated via blind sac technique, good short-term (p = 0.048) and long-term (p = 0.044) facial nerve function was reached in 44.0 % (22/50) and 60.0 % (30/50) cases, respectively. Postoperative facial nerve function was proved to be better in modified ETLA group. CSF leakage occurred in 16 (4.2 %) patients via classic ETLA. In 115 cases of large VS (>3 cm), postoperative CSF leakage occurred in 10 (8.7 %) patients. Whereas in 50 cases via blind sac technique, none developed CSF leakage (p = 0.03). The incidence of CSF leakage was lower in modified ETLA group. Our refinements to classic ETLA by changing the temporal bone resection range provide a wide surgical field, well prevention of CSF leakage and preservation of facial nerve function in large VS.

Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial.

Cerebrospinal fluid leakage is an immanent risk of cranial surgery with dural opening. Recognizing the risk factors for this complication and improving the technique of dural closure may reduce the associated morbidity and its surgical burden. The aim of this paper was to investigate whether the addition of TachoSil on top of the dural suture reduces postoperative CSF leakage compared with dural suturing alone and to assess the frequency and risk factors for dural leakage and potentially related complications after elective craniotomy. The authors conducted a prospective, randomized, double-blinded single-center trial in patients undergoing elective craniotomy with dural opening. They compared their standard dural closure by running suture alone (with the use of a dural patch if needed) to the same closure with the addition of TachoSil on top of the suture. The primary end point was the incidence of CSF leakage, defined as CSF collection or any open CSF fistula within 30 days. Secondary end points were the incidence of infection, surgical revision, and length of stay in the intensive care unit (ICU) or intermediate care (IMC) unit. The site of craniotomy, a history of diabetes mellitus, a diagnosis of meningioma, the intraoperative need of a suturable dural substitute, and blood parameters were assessed as potential risk factors for CSF leakage. The authors enrolled 241 patients, of whom 229 were included in the analysis. Cerebrospinal fluid leakage, mostly self-limiting subgaleal collections, occurred in 13.5% of patients. Invasive treatment was performed in 8 patients (3.5%) (subgaleal puncture in 6, lumbar drainage in 1, and surgical revision in 1 patient). Diabetes mellitus, a higher preoperative level of C-reactive protein (CRP), and the intraoperative need for a dural patch were positively associated with the occurrence of the primary end point (p = 0.014, 0.01, and 0.049, respectively). Cerebrospinal fluid leakage (9.7% vs 17.2%, OR 0.53 [95% CI 0.23-1.15], p = 0.108) and infection (OR 0.18 [95% CI 0.01-1.18], p = 0.077) occurred less frequently in the study group than in the control group. TachoSil significantly reduced the probability of staying in the IMC unit for 1 day or longer (OR 0.53 [95% CI 0.27-0.99], p = 0.048). Postoperative epidural hematoma and empyema occurred in the control group but not in the study group. Dural leakage after elective craniotomy/durotomy occurs more frequently in association with diabetes mellitus, elevated preoperative CRP levels, and the intraoperative need of a dural patch. This randomized controlled trial showed no statistically significant reduction of postoperative CSF leakage and surgical site infections upon addition of TachoSil on the dural suture, but there was a significant reduction in the length of stay in the IMC unit. Dural augmentation with TachoSil was safe and not related to adverse events. Clinical trial registration no. NCT00999999 ( http://www.ClinicalTrials.gov ).

Causal analysis and management strategies of cerebrospinal fluid leakage following translabyrinthine approach for acoustic neuromas

The purpose of the report was to investigate the causes of CSF leakage and discuss the methods for prevention and management of CSF leakage following translabyrinthine resection of acoustic neuromas. A retrospective review of cerebrospinal fluid leakage following translabyrinthine approach for 152 acoustic neuromas patients, from January 1983 to December 2013, was performed. The cases were divided into two groups, traditional and modified closure techniques. The incidence of CSF leakage was compared between the two groups. The incidence of postoperative CSF leakage by translabyrinthine approach was 5.9% (9/152), with four cases of rhinorrhea, two case of wound leakage, one case of rhinorrhea and otorrhea, one case of otorrhea, and one case of rhinorrhea and wound leakage. The CSF leakage incidence of traditional closure technique was 14.3% (5/35); the incidence of modified closure technique was 3.4% (4/117). After introducing a modified closure technique, the incidence of the CSF leakage significantly decreased. As a common complication of translabyrinthine approach, the incidence of CSF leakage is closely related to the closure technique. The incidence of the CSF leakage should decrease dramatically when adopting the modified closure technique.

Evaluation of complication rates of pediatric spinal procedures in which a polyethylene glycol sealant was used

Cerebrospinal fluid leakage following durotomy in spinal surgery can lead to significant patient morbidity and mortality, including meningitis and even death. Usage of a polyethylene glycol (PEG) sealant in combination with standard closure techniques has been shown to be effective in preventing CSF leaks in animal models and adult patients, but the results of its use have not been reported in the pediatric population. A retrospective analysis was performed of pediatric neurosurgery patients (0-18 years of age) treated at The Johns Hopkins Hospital from 2003 to 2010. There were 93 spinal surgery patients identified in whom PEG was applied. The incidence of CSF leakage, meningitis, and neurological injury was recorded. There were 54 males and 39 females in this study with an average age of 8.7 years. Of the identified patients, 16.1%, 28%, and 55.9% underwent surgery in the cervical region, thoracic region, and lumbar region, respectively. At 90-day follow-up, 5 patients (5.4%) had a CSF leak, 4 patients (4.3%) required a reoperation, and 1 patient (1.1%) had meningitis within this time period. No deaths or associated neurological deficits were observed. The use of a PEG sealant to augment dural closure in pediatric spine surgery appears to be a safe adjunct to standard dural closure in pediatric spine patients.

Endonasal endoscopic skull base multilayer reconstruction surgery with nasal pedicled mucosal flap to manage high flow csf leakage

Multilayer reconstruction of skull base using nasal pedicled mucosal flap has been widely accepted as a standard method for repairing high flow cerebrospinal fluid [CSF] leakage. In this study, we analyzed our outcome and summarized several valuable operation experiences from this technique. This study included 20 consecutive patients who underwent endoscopic endonasal multilayer reconstruction using a nasal pedicled mucosal flap to repair high flow CSF leakage and were available for follow-up. In this series, all cases encountered intraoperative high-flow CSF leakage, including 11 (55%) patients with opening of third ventricles (TV) and 9 (45%) patients with wide opening of cistern (CS). After endoscopic endonasal multilayer reconstruction with nasal pedicled mucosal flap, 3 patients (15.0%) encountered CSF leakage in the early postoperative period but were successfully repaired; 2 patients (10.0%) encountered late postoperative CSF leakage. In the TV group, the ratio of CSF leakage was 18.2% (2/11); while the incidence of CSF leakage was 11.1% (1/9) in the CS group. One patient developed meningitis due to CSF leakage four month after surgery, then gave up treatment and died. Multilayer reconstruction with nasal pedicled flap seems to be useful and reliable for the treatment of ventral skull base defects using endoscopic endonasal approach.

Non-watertight dural reconstruction in meningioma surgery: results in 439 consecutive patients and a review of the literature

There are various schools of thought when it comes to dural reconstruction following meningioma surgery, which are largely based on the personal experience of the individual surgeons. The authors' aim in this study was to review different dural reconstruction techniques, with an emphasis on their experience with the synthetic onlay dural graft technique. The medical records of 439 consecutive patients who were surgically treated for an intracranial meningioma over a period of 7 years, and for whom dural reconstruction was performed using the onlay dural graft DuraGen (Integra Neurosciences) were reviewed retrospectively. The most common tumor location was the convexity (27.6%), and 12% of the patients had undergone previous surgery. Complications related to the closure technique and/or closure material, such as CSF leakage from the incision, rhinorrhea, or infectious or chemical meningitis were reviewed. A CSF leak was encountered in 2 patients (0.4%), and 10 patients (2.3%) experienced graft-related complications in the form of chemical meningitis, cerebritis, and accumulation of extraaxial fluid. Infectious complications were seen in 4 patients (0.9%; bacterial meningitis, osteomyelitis, epidural abscess). None of the patients had pseudomeningocele that required a second intervention. In the authors' experience, the incidence of CSF leakage following non-watertight reconstruction of the dura mater in meningioma surgery performed using dural onlay graft was 0.4%. Graft-related complications occurred in 2.3%. These figures compare favorably to the majority of the series in which watertight dural closure is described and emphasized.