Incidence Of Postoperative Cerebrospinal Fluid Leak Research Articles

Nasoseptal Flap Reuse for Reconstruction in Revision Endoscopic Skull Base Surgery

Abstract Introduction The nasoseptal flap (NSF) is the “workhorse” for reconstruction in endoscopic skull base surgery. It creates a reliable, watertight closure to prevent cerebrospinal fluid (CSF) leaks. The flap's robust vascular pedicle allows for it to be taken down and reused in subsequent reconstructive surgeries if needed. Previous literature has demonstrated successful reuse of the flap up to 24 months after initial surgery. The present study analyzes a cohort of patients with NSFs that were reused up to 12 years following the initial surgery. Methods A retrospective analysis was performed on patients who underwent revision endoscopic skull base surgery for recurrent tumor at a tertiary academic skull base center. Patient demographics, tumor type, length of time between first and second surgery, and outcomes were evaluated. Results A total of 15 patients were identified between 2012 and 2022 who underwent revision endoscopic skull base surgery with previous NSFs that were reused for reconstruction. The time interval between surgeries ranged from 9 months to 12 years. There were 12 pituitary adenomas, 2 Rathke's cleft cysts, and 1 craniopharyngioma. One patient developed a CSF leak 5 days postoperatively, which was repaired with an abdominal fat graft, synthetic dural substitute, and a middle turbinate flap. The operative technique for the take-down and reuse of the NSF will be demonstrated. Conclusion The NSF can be taken down and reused in revision endoscopic skull base cases, even several years after the initial surgery, with excellent coverage of the defect and low incidence of postoperative CSF leak.

Endoscopic Suturing of Skull Base Dura and its Effectiveness in Preventing CSF Leak.

Proper skull base repair is essential in preventing postoperative cerebrospinal fluid (CSF) leak following endonasal endoscopic skull base surgery. Direct suturing of the skull base dura is desirable but difficult. Here, we discuss the effectiveness of endoscopic suturing of skull base dura in cases of skull base lesions with intraoperative CSF leak. A total of 36 cases (three arachnoid cyst, two Rathke's cleft cyst, two tuberculum sella meningioma, and 29 pituitary adenoma) where dura was sutured endoscopically after endonasal endoscopic excision of lesion were evaluated. Endoscopic suturing was categorized in to three types (type 1 - dura with tumor excised and single suture placed across the anterior tuberculum sella dura to clival dura, type 2 - dura excised partially and repaired with multiple interrupted sutures, type 3 - dura was completely intact at the end of surgery and closed with interrupted suture). Type 1 dura closure was performed in eight cases, type 2 in 16 cases, and type 3 in 12 cases. Two patients with type 1 closure had CSF leak in the postoperative period and managed with lumbar puncture. None of the other patients had CSF leak after surgery. Direct suturing of the skull base dura is effective in preventing postoperative CSF leak. Even a single suture is able to hold the fat graft in place and provides sufficient support against pulsatile CSF flow and thereby reduces the incidence of postoperative CSF leak.

Risk factors associated with postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery: Two-center retrospective cohort study.

Over the past two decades, endoscopic endonasal skull base surgery (EESBS) has revolutionized the treatment of skull base tumors by enabling minimal access to resect significant pathologies such as meningiomas, pituitary adenomas, and chordomas. Despite its efficacy, complications such as cerebrospinal fluid (CSF) leak pose significant challenges, with an average incidence of 8.9% following EESBS. Therefore, our study aims to investigate the risk factors associated with postoperative CSF leak after employing an endoscopic endonasal approach for skull base surgery, focusing on patients treated at King Abdul-Aziz Medical City in Jeddah and King Abdullah Medical City in Makkah, Saudi Arabia. A retrospective review of patients who underwent an endoscopic endonasal approach for the resection of intradural skull base pathology between January 2016 and December 2022 was performed with a total of 51 patients. Basic demographic data were collected, along with patient comorbidities, presenting symptoms, tumor pathology, tumor site, the extent of resection, and outcomes. 51 participants were analyzed, with a mean age of 43.41. Male participants comprised (58.8%), while headaches were the most common symptom (74.5%), followed by visual disturbances (51.0%). Nonsecretory tumors predominated, primarily located in the sellar and suprasellar regions (58.8%). Gross total resection was performed in the majority (56.9%), with a 9.8% incidence of postoperative CSF leak. Notably, all four patients with CSF leak experienced preoperative headaches. Hypertension was prevalent in Cases 1 and 4, with Case 4 having a history of neurological disease and radiation therapy. Anterior skull base tumors were most frequent in Cases 3 and 4. The incidence of CSF leakage after surgery in this study was similar to that previously reported. It is worth noting that repeated surgeries may increase the risk of postoperative CSF leakage. Therefore, it is important to carefully evaluate the surgical approach for tumor removal and skull base reconstruction, considering the tumor characteristics and the patient's overall condition.

Conventional clinical signs and symptoms are poor predictors of postoperative cerebrospinal fluid leak: A single-centre cohort perspective.

Postoperative cerebrospinal fluid (CSF) leak remains a concerning complication of the endoscopic endonasal approach (EEA) for skull base pathology. Signs and symptoms suggesting CSF leak often trigger additional workup during the postoperative course. We systematically evaluate associations between subjectively reported clinical signs/symptoms noted during the immediate postoperative period and incidence of postoperative CSF leaks. Retrospective chart review was conducted at a tertiary academic medical centre including 137 consecutive patients with intraoperative CSF leak during EEA with primary repair between July 2018 and August 2022. Postoperative CSF leak associations with clinical signs and symptoms were evaluated using positive (PPV) and negative predictive values (NPV), sensitivity, specificity and odds ratio (OR) via univariate logistic regression. Seventy-nine patients (57.7%) had high-flow leaks repaired and 5 (3.6%) developed CSF leaks postoperatively. Of reported symptoms, rhinorrhea was most common (n = 52, 38.0%; PPV [95% CI] = 7.6% [4.8%, 11.9%]), followed by severe headache (n = 47, 34.3%; 6.3% [3.1%, 12.5%]), dizziness (n = 43, 31.4%; 2.3% [0.4%, 12.1%]), salty or metallic taste (n = 20, 14.6%; 9.9% [3.3%, 25.8%]), and throat drainage (n = 10, 7.3%; 9.9% [1.7%, 41.4%]). Nausea or vomiting constituted the most reported sign concerning for CSF leak (n = 73, 53.3%; PPV [95% CI] = 4.1% [2.0%, 8.1%]). On univariate regression, no sign or symptom, including rhinorrhea (OR [95% CI] = 7.00 [0.76-64.44]), throat drainage (3.42 [0.35-33.86]), salty/metallic taste (4.22 [0.66-27.04]), severe headache (3.00 [0.48-18.62]), dizziness (0.54 [0.06-4.94]), fever (3.16 [0.50-19.99]), and nausea/vomiting (1.33 [0.22-8.21]), associated with postoperative CSF leak. A range of subjectively reported symptoms and signs failed to predict postoperative CSF leak. Further investigation is warranted to inform appropriate attention and response.

PEG hydrogel sealant versus fibrin glue in posterior fossa surgery: an economic comparison across five European countries.

Aim: Posterior cranial fossa (PCF) surgery is associated with complications, including cerebrospinal fluid (CSF) leakage. Dural sealants such as polyethylene glycol (PEG)-based hydrogels and fibrin glue can prevent CSF leaks, with evidence suggesting PEG hydrogels may outperform fibrin glue. However, the budget impact of using PEG hydrogels in PCF surgeries in Europe is unclear. Materials & methods: A decision tree was developed based on a previous US model, to assess the budget impact of switching from fibrin glue to PEG hydrogel in PCF surgery across five European countries. Input costs were derived from published sources for the financial year 2022/2023. Health outcomes, including CSF leaks, were considered. Results: The model predicted that using PEG hydrogel instead of fibrin glue in PCF surgery can lead to cost savings in five European countries. Cost savings per patient ranged from EUR 419 to EUR 1279, depending on the country. Sensitivity analysis showed that the incidence of CSF leaks and pseudomeningoceles had a substantial impact on the model's results. Conclusion: PEG hydrogels may be a cost-effective alternative to fibrin glue in PCF surgery. The model predicted that cost savings would be mainly driven by a reduction in the incidence of postoperative CSF leaks, resulting in reduced reliance on lumbar drains, reparative surgery and shortened hospital stays.

Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons

Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons.

Skull base reconstruction using in situ bone flap in patients with pituitary adenomas treated by endoscopic endonasal approach.

The objective of this study is to study the effect of in situ bone flap (ISBF) repositioning, a recently proposed rigid skull base reconstruction technique, on patients diagnosed with pituitary adenoma undergoing endoscopic endonasal approach (EEA). A retrospective analysis was conducted on 188 patients with pituitary adenomas who underwent EEA from February 2018 to September 2022. Patients were divided into the ISBF group and non-ISBF group, according to whether ISBF was used during skull base reconstruction. Of the 75 patients in the non-ISBF group, 6 had postoperative cerebrospinal fluid (CSF) leakage (8%), while only 1 of 113 patients in the ISBF group (0.8%) had postoperative CSF leakage, indicating that the incidence of postoperative CSF leakage in the ISBF group was significantly lower than that in the non-ISBF group (P = 0.033). In addition, we also found that the postoperative hospitalization days of patients in the ISBF group (5.34 ± 1.24) were significantly less than those in the non-ISBF group (6.83 ± 1.91, P = 0.015). ISBF repositioning is a safe, effective, and convenient rigid skull base reconstruction method for patients with pituitary adenoma treated by EEA, which can significantly reduce the rate of postoperative CSF leakage and shorten postoperative hospital stays.

Strategy of skull base reconstruction after endoscopic transnasal pituitary adenoma resection.

Endoscopic endonasal surgery (EES) is commonly performed for resection of lesions of the anterior/middle cranial fossa region. Cerebrospinal fluid (CSF) leakage is a major complication. Skull base reconstruction after EES is challenging. We describe our reconstruction strategy and technique and analyze its outcomes. We retrospectively analyzed 703 patients with pituitary adenoma who underwent EES in our center from January 2020 to August 2022. Clinical, imaging, operative, and pathologic data were recorded from the medical records and analyzed. Skull base reconstruction was performed to achieve the following three goals: seal the original leak, eliminate dead space, provide blood supply, and early ambulation. Reconstruction was tailored to individual patients based on grade of CSF leakage encountered during surgery. The number of patients with a grade 0, 1, 2, and 3 intraoperative CSF leak was 487, 101, 86, and 29, respectively. Overall incidence of postoperative CSF leakage was 0.14% (1/703). Fascia sutured and vascularized nasoseptal flap were selected for all grade 3 CSF leaks. One patient who experienced postoperative CSF leakage developed intracranial infection and were treated with lumbar CSF drainage that failed; eventually re-exploration surgery for repair was required. Other patients did not have complications such as CSF leak and infection. 29 patients with grade 3 CSF leakage did not complain of severe nasal complications after operation. No perioperative complications related to the strategy (overpacking, infections, or hematomas) occurred. Incidence of postoperative CSF leak according to intraoperative leak grade was as follows: grade 0, zero; grade 1, zero; grade 2, 1.16% (1/86); and grade 3, zero. The principles of sealing the original leak, eliminating dead space, providing blood supply, and early ambulation are key in skull base reconstruction after EES. Individualization of these principles can significantly reduce the incidence of postoperative CSF leakage and intracranial infection and reduce the use of lumbar CSF drainage. Skull base suture technique is safe and effective in patients with high-flow cerebrospinal fluid leaks.

Continuous Dural Suturing for the Closure of Grade 1 to 2 Cerebrospinal Fluid Leakage After Pituitary Adenoma Removal Using an Endoscopic Endonasal Approach.

In this study, we aim at evaluating continuous dural suturing in patients with grade 1 to 2 cerebrospinal fluid (CSF) leakage after pituitary adenoma removal using an endoscopic endonasal approach. The study population comprised 381 pituitary adenoma patients who underwent endoscopic endonasal removal of the tumor. The degree of intraoperative CSF leakage was graded based on Esposito method. Cranial base repair using continuous dural suturing was performed according to the grade of CSF leakage. Intraoperative grade 1 to 2 CSF leakage was identified in 143 patients (37.5%). Continuous dural suturing to repair the cranial base was accepted by 61 patients and refused by 82 patients. Among patients who accepted dural suturing, the incidence of postoperative CSF leakage was reduced and the length of hospital stay was shortened. Patients with low-flow leakage were treated using a reduced vascularized pedicled nasoseptal flap. In conclusion, our graded cranial base repair method using the dural suturing technique is simple and effective.

Clinical Impact of Hydroxyapatite on the Outcome of Skull Base Reconstruction for Intraoperative High-Flow CSF Leak: A Propensity Score Matching Analysis.

BackgroundDespite recent advances in skull base reconstructive techniques, including the multilayer technique during the last decade, complete reconstruction of grade 3 intraoperative high-flow cerebrospinal fluid (CSF) leak remains challenging. This study was designed to investigate the role of injectable hydroxyapatite (HXA) used in the multilayer technique on the clinical outcome of skull base reconstruction for intraoperative high-flow CSF leak.Materials and MethodsThis study enrolled 187 patients who experienced intraoperative high-flow CSF leak after endoscopic endonasal surgery for anterior skull base or suprasellar pathologies between January 2014 and July 2021. All skull base defects were reconstructed using the conventional multilayer technique including a vascularized naso-septal flap (NSF, n = 141) and the combined use of HXA with the conventional multilayer technique (HXA group, n = 46). We retrospectively evaluated the efficacy of the HXA group by 1:2 propensity score matching analysis.ResultsOverall, 17 of 187 patients (9.1%) showed postoperative CSF leaks, resulting in second reconstruction surgery. There were no statistical differences in patient age, sex, body mass index, tumor location, tumor type, and degree of resection, except for the follow-up period between the two groups. The HXA group showed a significantly lower incidence of postoperative CSF leak than the control group (0% vs. 12.1%, p < 0.05). Postoperative lumbar drain (LD) was performed in 8.7% of the HXA group compared to 46.1% of the control group (p < 0.01). CSF leak-related infection rates showed a decreasing tendency in the HXA group compared to the control group (0 vs. 7.1%, p = 0.06). A total of 46 patients in the HXA group were well matched with the control group (92 patients) at a 1:2 ratio. In the propensity score-matched control group, there were higher rates of postoperative CSF leaks than in the HXA group.ConclusionThe use of HXA combined with the conventional multilayer technique completely reduced postoperative CSF leaks in this study. This technique resulted in reduced CSF leakage, even without postoperative LD, and decreased infection rates. Further randomized comparative studies are required to confirm our findings.

Sellar Floor Reconstruction with and without Intrasellar Fat Packing after Endoscopic Resection of Large Pituitary Macroadenomas with Evident Intraoperative CSF Leak

Abstract Background Intraoperative cerebrospinal fluid (CSF) leak is not uncommon with endoscopic transsphenoidal surgical excision of pituitary macroadenomas. How to seal the defect and prevent postoperative leak is still a matter of debate. Objectives In patients with CSF leak, we tried to figure out which is more important in preventing postoperative leak, is it the sellar fat packing, is it tight repair of the sellar floor, or do we need to combine them both? Patients and Methods Over 5 years, in patients with evident intraoperative CSF leak, with growing experience supported by positive postoperative results, we shifted gradually from intrasellar packing using combined fat graft and bioabsorbable materials (SURGICEL FIBRILLAR/Gelfoam) (group A, n =15) to only bioabsorbable materials (group B, n = 18), either of which is followed by tight repair of the sellar floor. Results Postoperative clinical assessment did not differ significantly between both groups at early, midterm, and long-term follow-up intervals. We did not have any patients with delayed postoperative CSF leak or symptomatic empty sella syndrome (ESS). Conclusion There is no difference in the incidence of postoperative CSF leak and clinical ESS among both groups, indicating that tight sellar floor repair is more important than packing the sellar cavity with or without fat graft.

From Research to Clinical Practice: Long-Term Impact of Randomized Clinical Trial Examining the Effect of Lumbar Drains on Cerebrospinal Fluid Leak Rates Following Endonasal Skull Base Surgery.

Intraoperative cerebrospinal fluid (CSF) leaks are associated with increased risk of postoperative CSF leaks despite multilayered reconstruction with vascularized tissue. A recent randomized controlled trial (RCT) examining the use of perioperative lumbar drains (LD) in high-risk skull base defects identified a significant reduction in postoperative CSF leak incidence (21.2 vs. 8.2%; p = 0.017). This study was conducted to assess the efficacy of the selective use of CSF diversion, for patients with intraoperative CSF leaks involving endoscopic endonasal approaches (EEA) to the skull base. Method Consecutive endoscopic endonasal surgeries of the skull base from a pre-RCT cohort and post-RCT cohort were compared. The following case characteristics between the two cohorts were examined: patient age, body mass index (BMI), rate of revision surgery, tumor histology, use of CSF diversion, and vascularized reconstruction. The primary measured outcome was postoperative CSF leak. Results The pre-RCT cohort included 76 patients and the post-RCT cohort included 77 patients, with dural defects in either the anterior or posterior cranial fossa (pituitary and parasellar/suprasellar surgeries excluded). There was a significant reduction in the incidence of postoperative CSF leak in the post-RCT cohort (27.6 vs. 12.9%; p = 0.04). On subgroup analysis, there was a trend toward improvement in CSF leak rate of the anterior cranial fossa (19.2 vs. 10.5%; p = 0.27), whereas CSF leak rates of the posterior cranial fossa were significantly reduced compared with the pre-RCT cohort (41.4 vs. 12.8%; p = 0.02). Conclusion This study demonstrates that the integration of selective CSF diversion into the reconstructive algorithm improved postoperative CSF leak rates.

The incidence of postoperative cerebrospinal fluid leakage after elective cranial surgery: a systematic review.

Cerebrospinal fluid (CSF) leakage is a major complication after elective neurosurgical procedures. The aim of this systematic literature review is to summarize the incidence rates of postoperative cerebrospinal fluid leakage for neurosurgical procedures, classified by surgical approach. The Pubmed, Cochrane, Embase, and Web of Science databases were searched for studies reporting the outcome of patients undergoing elective neurosurgical procedures. The number of patients, surgical approach, and indication for surgery were recorded for each study. Outcomes related to CSF leakage such as clinical manifestation and treatment were reported as well. One hundred and thirteen studies were included, reporting 94,695 cases. Overall, CSF leaks were present in 3.8% of cases. Skull base surgery had the highest rate of CSF leakage with 6.2%. CSF leakage occurred in 5.9% of anterior skull base procedures, 6.4% of middle fossa, and 5.2% of transpetrosal surgeries. 5.8% of reported infratentorial procedures were complicated by CSF leakage versus 2.9% of supratentorial surgeries. CSF leakage remains a common serious adverse event after cranial surgery. There exists a need for standardized procedures to reduce the incidence of postoperative CSF leakage, as this serious adverse event may lead to increased health care costs.

Evaluating the Role of Pre-operative Cerebrospinal Fluid Diversion by Lumbar Drain in Transnasal Transsphenoidal Tumor Surgeries

Background and Aim: The major concerns related to the Endoscopic Endonasal Transsphenoidal (EET) surgery for sellar and suprasellar tumors include the risks of post-operative Cerebrospinal Fluid (CSF) leak, leading to morbidity and at times mortality, due to severe meningitis. Time is required to develop possible preventive measures that can reduce the risk of post-operative CSF rhinorrhea. The present study aimed to evaluate the effects of pre-operative CSF diversion by lumbar drainage in EET tumor surgeries on preventing post-operative CSF leak and its effect on the length of hospital stay. Methods and Materials/Patients: We conducted a prospective study on 20 patients with a pituitary tumor that underwent EET surgery between October 2018 and December 2019. Preoperative Lumbar Drain (LD) was inserted after induction in all explored patients. The tumor was excised with continuous intraoperative CSF drainage. Post-operatively, the LD was kept for 3 days and clamped for the next 24 hours. If no evidence of CSF rhinorrhea was present, it was removed. Complications related to CSF drainage, CSF leak, and hospital stays were evaluated. Results: Our study population consisted of 13(65%) men and 7(35%) women, with Mean±SD age of 39.8±10.71 years. The most commonly presented complaint was visual disturbance (60%) and the least common symptom was urinary disturbance (5%). The intra-operative leak was detected in 9(45%) patients, while the post-operative leak was present in only 1(5%) patient. LD blockage significantly contributed to post-operative CSF leak (P=0.001). The Mean±SD hospital stay in the post-operative period was 8.85±3.22 days with 65% of patients having a hospital stay of &lt;7 days. Other post-operative complications (e.g. diabetes insipidus, electrolyte imbalance, and hormonal disturbances) were mainly responsible for prolonged post-operative hospital stay (P=0.001). Conclusion: Pre-operative LD, apart from helping to reduce the incidence of post-operative CSF leak, is not associated with an overall increased post-operative hospital stay.

The relation between serum vitamin D deficiency and allergic rhinosinusitis

Introduction Endonasal endoscopic approaches gained acceptance in managing many benign skull base tumors. Cerebrospinal fluid (CSF) leak is a common and serious complication with high risk of morbidities or mortality. Identification and management of intraoperative CSF leak is a critical step in these approaches. Various methods and materials had been described for a skull base reconstruction. The size of arachnoid defect plays a crucial role in selecting the proper method of reconstruction. Patients and methods This is a prospective analytical study in which 67 patients with benign skull base lesions who were candidates for endoscopic transnasal transsphenoid surgery were included. All cases were subjected to detailed assessment protocol preoperatively and postoperatively. Intraoperative CSF leak was meticulously observed and graded according to the size of arachnoid defect, and then reconstruction was done according to grade of CSF leak by grafts or flaps or combination of them. Results This study included 67 patients with sellar–suprasellar tumors who were managed by endoscopic transsphenoid approach. Intraoperative CSF leak occurred in 23 (34.3%) cases. A total of nine (13.4%) cases had grade 1 CSF leak, and all cases were reconstructed with abdominal fat with success rate of 100%;six (8.9%) cases had grade 2 CSF leaks, and all cases were repaired with pedicled nasal flap with success rate (83%); and grade 3 CSF leak occurred in eight (11.9%) cases, and all were repaired with multilayer technique, with success rate of 75%. The incidence of postoperative CSF leak in this study was 4.5%, that is, three patients. Conclusion The strategy of skull base reconstruction depending on grade of intraoperative CSF leak according to size of arachnoid defect produces a promising result in decreasing the incidence of postoperative CSF leak and saving the need of unnecessary flaps. Keywords: arachnoid defect, reconstruction, sella, skull base.

Bone Cement Cranioplasty Reduces Cerebrospinal Fluid Leak Rate after Microvascular Decompression: A Single-Institutional Experience.

Background Microvascular decompression (MVD) is a common surgical treatment for cranial nerve compression, though cerebrospinal fluid (CSF) leak is a known complication of this procedure. Bone cement cranioplasty may reduce rates of CSF leak. Objective To compare rates of CSF leak before and after implementation of bone cement cranioplasty for the reconstruction of cranial defects after MVD. Methods Retrospective chart review was performed of patients who underwent MVD through retrosigmoid craniectomy for cranial nerve compression at a single institution from 1998 to 2017. Study variables included patient demographics, medical history, type of closure, and postoperative complications such as CSF leak, meningitis, lumbar drain placement, and ventriculoperitoneal shunt insertion. Cement and noncement closure groups were compared, and predictors of CSF leak were assessed using a multivariate logistic regression model. Results A total of 547 patients treated by 10 neurosurgeons were followed up for more than 20 years, of whom 288 (52.7%) received cement cranioplasty and 259 (47.3%) did not. Baseline comorbidities were not significantly different between groups. CSF leak rate was significantly lower in the cement group than in the noncement group (4.5 vs. 14.3%; p < 0.001). This was associated with significantly fewer patients developing postoperative meningitis (0.7 vs. 5.2%; p = 0.003). Multiple logistic regression model demonstrated noncement closure as the only independent predictor of CSF leak (odds ratio: 3.55; 95% CI: 1.78-7.06; p < 0.001). Conclusion CSF leak is a well-known complication after MVD. Bone cement cranioplasty significantly reduces the incidence of postoperative CSF leak and other complications. Modifiable risk factors such as body mass index were not associated with the development of CSF leak.

Reconstruction Following Endoscopic Endonasal Skull Base Surgery: Options and Technical Considerations

To provide a brief overview of the options available for reconstruction of the skull base and to discuss their technical considerations. To review the contemporary literature surrounding adjunctive measures such as acetazolamide and perioperative cerebrospinal fluid (CSF) diversion. A recent randomized, control trial examining perioperative lumbar drainage following endoscopic skull base surgery has demonstrated that perioperative lumbar drainage is significantly associated with decreased incidence of postoperative CSF leak in specific anatomical subsites. Many factors must be weighed when considering proper skull base reconstruction. For large defects, multilayered repair with vascularized tissue is the gold standard. Perioperative lumbar drainage is recommended for large anterior or posterior fossa defects. The effect of acetazolamide on postoperative CSF leak remains unclear. Indocyanine green angiography (ICG) is a promising innovation that can aid in assessment of vascularized flaps.

Postoperative CSF leakages after transsphenoidal surgery for pituitary adenomas: Analysis of a series of 302 surgical procedures.

Transsphenoidal surgical removal is the preferred treatment of most pituitary adenomas. Postoperative cerebrospinal fluid (CSF) leakage is the leading cause of morbidity after this procedure, with an incidence rate that varies from 0,5-15% in the main published series. The primary objective of this study was to establish the incidence of postoperative CSF leakage in a sample of surgeries performed at the University Hospital of La Ribera by the same surgical team. The secondary objectives were to: ascertain the distinctive features between patients with and without postoperative CSF leakage, identify risk factors for their development, evaluate the relationship between the surgical technique for closing the sella turcica and the onset of postoperative CSF leakage and evaluate different treatment regimens for this complication. The data of 302 consecutive transsphenoidal surgical procedures for pituitary adenoma removal which were performed between 1999 and 2017 were retrospectively reviewed. The incidence of postoperative CSF leakage in our series was 2,3% (in accordance with similar published studies). It was possible to correlate intraoperative CSF leakage with two variables: pituitary macroadenoma and tumors with suprasellar extension (P<.005). This correlation did not exist for postoperative CSF leakage. We found a statistically significant correlation between intraoperative and postoperative CSF leakage (P<.005). Due to the low incidence of postoperative CSF leakage in our series, it was not possible to identify risk factors for its development.

Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata "Button" Graft and Nasoseptal Flap: Surgical Technique and Case Series.

Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m 2 (median = 31 kg/m 2 ), with 18 patients meeting criteria for obesity (BMI > 30 kg/m 2 ) and 12 patients overweight (25 kg/m 2 < BMI < 29.9 kg/m 2 ). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Postoperative CSF leakages after transsphenoidal surgery for pituitary adenomas: Analysis of a series of 302 surgical procedures

IntroductionTranssphenoidal surgical removal is the preferred treatment of most pituitary adenomas. Postoperative cerebrospinal fluid (CSF) leakage is the leading cause of morbidity after this procedure, with an incidence rate that varies from 0.5 to 15% in the main published series. ObjectivesThe primary objective of this study was to establish the incidence of postoperative CSF leakage in a sample of surgeries performed at the University Hospital of La Ribera by the same surgical team. The secondary objectives were to: ascertain the distinctive features between patients with and without postoperative CSF leakage, identify risk factors for their development, evaluate the relationship between the surgical technique for closing the sella turcica and the onset of postoperative CSF leakage and evaluate different treatment regimens for this complication. MethodsThe data of 302 consecutive transsphenoidal surgical procedures for pituitary adenoma removal which were performed between 1999 and 2017 were retrospectively reviewed. Results and conclusionsThe incidence of postoperative CSF leakage in our series was 2.3% (in accordance with similar published studies). It was possible to correlate intraoperative CSF leakage with two variables: pituitary macroadenoma and tumours with suprasellar extension (p<0.005). This correlation did not exist for postoperative CSF leakage. We found a statistically significant correlation between intraoperative and postoperative CSF leakage (p<0.005). Due to the low incidence of postoperative CSF leakage in our series, it was not possible to identify risk factors for its development.