Recurrent Cerebrospinal Fluid Leak Research Articles

Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report

BackgroundWatertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report the trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect. MethodsTDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an “inside-to-outside” direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications and outcomes of patients who received TDUWD are reported. ResultsA total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. The other one patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed. ConclusionUse of TDUWD for traumatic ASB dural defect results in an immediate, one-stage and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deep located dural defects.

Spontaneous delayed CSF rhinorrhea associated with encephalocele following surgical resection of a giant frontoparietal meningioma, an extremely rare entity and overlook of English literature

Introduction and importance: Spontaneous cerebrospinal fluid (CSF) rhinorrhea without a history of head trauma is rare. The authors describe a scarce case of spontaneous, nontraumatic, delayed CSF rhinorrhea due to ethmoidal encephalocele associated with frontoparietal giant meningioma. Case presentation: A 49-year-old male complained of a slowly growing skull mass lasting 10 years since a blunt head trauma and progressive hemiparesis 3 months ago and was referred to our center. There was a heterogeneous extra-axial mass (77×77×70 mm) with calcified components at his right frontal lobe, demonstrating notable adjacent parenchymal edema and a midline shift to the left. There was a sizeable extra-axial mass (113×95×80 mm) in his right front-temporoparietal lobe associated with adjacent invasion to calvarium leading to the lytic and sclerotic appearance of the calvarial bone showing intense heterogeneous contrast enhancement and an adjacent enhancing dural tail. A considerable mass effect on the adjacent frontotemporal cortex is evident, with mild parenchymal edema leading to a notable midline shift to the left, right uncal herniation, and left ventriculomegaly. On postoperation day 5, the patient developed a recurrent CSF leak exacerbated by hydrocephalus. He was rescheduled to undergo endoscopic endonasal surgery and dural repair on postoperative day 7. The postoperative course was uneventful. Clinical discussion: Frontoparietal lobe encephaloceles represent the least common cause of spontaneous CSF rhinorrhea. Early diagnosis and surgical management remain crucial to minimize the subsequent complications. Conclusion: The ventricular anatomy and CSF fluid dynamics alteration following tumor surgical resection seem to contribute to an environment by which a herniated ethmoidal encephalocele developed a delayed nontraumatic CSF leak.

Subfascial drains are safe and effective in preventing postoperative cerebrospinal fluid leaks after intradural spine tumor surgery.

Delayed cerebrospinal fluid (CSF) leaks are a known complication following intradural spinal tumor surgery. The placement of subfascial drains in these patients undergoing requisite intradural surgery is controversial. Here, we demonstrated that placing a subfascial drain on partial suction for 48 h, with early ambulation, proved to be safe and effective in preventing early/delayed recurrent CSF fistulas. Medical records of 17 patients undergoing surgery for intradural spinal tumors over a 30-month were reviewed. All patients underwent intradural tumor resection followed by primary dural closure, placement of Gelfoam in a non-compressive fashion, application of fibrin sealant, and utilization of a subfascial drain placed on partial suction for 48 h postoperatively. Patients are mobilized the morning following surgery. We tracked the incidence of postoperative recurrent CSF leaks, over drainage, infection, wound dehiscence, pseudo meningocele formation, and the reoperation rate. For the 17 patients, our programmed average utilization of subfascial drains was 48 h. Moreover, the average drain output was 165 mL. Over the 1-year follow-up period, no patient developed a recurrent early/ delayed CSF leak, there were no wound complications, nor need for revision surgery. Utilizing subfascial drains on partial suction following the resection of intradural spinal tumors with primary dural closure proved to be safe and effective.

Short Postoperative Length of Stay After Lateral Cerebrospinal Fluid Leak Repair.

To characterize the short-term outcomes of patients undergoing surgical repair of lateral skull base cerebrospinal fluid (CSF) leaks followed by a shortened length of stay (LOS) protocol. Retrospective study. Tertiary medical center. Atotal of 156 adult patients from July 2016 to December 2022 who underwent repair of CSF leaks via transmastoid (TM), middle cranial fossa (MCF), or combined (TM/MCF) approaches were included. Data collected included: LOS, presentation to the emergency department (ED), need for readmission, major neurologic complications (stroke, seizure, and meningitis), and CSF leak recurrence. Approximately half of patients underwent a TM repair (49.4%), whereas the other half underwent either an MCF (3.8%) or combined TM/MCF repair (46.8%). No peri-/postoperative lumbar drains were used and only 2 (1.3%) patients were admitted to the intensive care unit after surgery. Mean LOS for the cohort was 1.1 ± 0.7 days and was longer for surgeries involving MCF (1.3 ± 0.6) compared to TM (0.8 ± 0.7). Ninety-two percent of TM cases were discharged within 24hours (32% on the same day) while for cases involving an MCF approach, 72.2% of patients were discharged within 24hours. Of the patients in the study, 6 (3.8%) presented to an ED for minor complications and no patient required readmission. Revision surgery was required for 3 (1.9%) patients for recurrent CSF leak. Our findings suggest that short LOS after surgical repair of lateral skull base defects in the treatment of CSF leak is safe and effective.

Factors Affecting Success Rates in Endoscopic Repair of CSF Rhinorrhea.

Our aim in this study is to assess the effect of factors such as age, etiology, defect size, application of lumbar drainage and surgical technique on Cerebrospinal Fluid (CSF) fistula repair success rates. The Electronic Medical Records (EMR) system of our clinic was retrospectively reviewed for cases that were operated between 2006 and 2020 for CSF fistula originating from anterior skull base with endoscopic transnasal technique. A total of 35 patients were included in the study. Patients were grouped according to the number of layers used in repair (two, three or four-layered reconstruction) and defect size (smaller than 5 mm, 5 to 10 mm and larger than 10mm), etiology, location of the defect and application of lumbar drainage as LD (+) and LD (-). Complications and CSF leak recurrence were compared between groups. Recurrence rates in patients who had 2 layered reconstructions were significantly higher compared to patients who had 3 or 4 layered reconstructions (p=0.049). The recurrence rate in LD (+) group (41.7%) was significantly lower compared to LD (-) group (4.3%) (p=0.012). There were no significant difference in recurrence rates between groups in terms of age, defect size, defect location and etiology. In endoscopic transnasal repair of anterior skull base-derived bos fistulas, planning the reconstruction at least 3 times and applying lumbar CSF drainage increases the success rates.

Idiopathic Intracranial Hypertension Is Associated with Recurrent CSF Leak and Reoperation for Spontaneous Temporal Encephalocele

Abstract Objective Spontaneous temporal encephaloceles (STEs) are increasingly recognized as sequelae of idiopathic intracranial hypertension (IIH), which in turn may further complicate their management. We endeavored to review the University of Pennsylvania institutional experience on operative management of STEs, with a focus on factors which may influence surgical outcomes, particularly IIH. Design Retrospective chart review over 9 years from 2013 to 2022. Setting Single-center, two-hospital, tertiary care, academic setting. Participants Patients undergoing middle cranial fossa (43.9%), transmastoid (44.9%), or combined (11.2%) approaches for repair of STEs during the study period (n = 107). Main Outcome Measures Postoperative complication rates, recurrence, and diagnosis of IIH. Results The majority of patients were female (64.5%), with a mean body mass index (BMI) of 37 kg/m2 and mean age of 57 years. Twelve patients (9%) represented reoperations after failed primary repairs. Fourteen percent of patients undergoing primary surgical repair of STE were diagnosed with IIH, compared with 42% of patients undergoing reoperations (p = 0.015). In addition, there was a significant difference in the average BMI of patients undergoing primary (36.4 kg/m2) versus revision surgery (40.9 kg/m2, p = 0.04). Half of those undergoing reoperation were placed on postoperative acetazolamide compared with 11% of patients undergoing primary operations. No patient experienced recurrent leak after reoperation. Conclusion Based on our institutional experience, elevated BMI and the presence of IIH are significant predictors of reoperation for STE. In our experience, acetazolamide is a common adjunct management strategy in addition to reoperation for patients with recurrent cerebrospinal fluid leak in the setting of STE.

Pediatric Spontaneous Cerebrospinal Fluid Leak Repair: An Endoscopic Endonasal Approach.

Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea in the pediatric population is an exceedingly rare condition that occurs when the dura mater is breached, resulting in CSF drainage from the subarachnoid space into surrounding sinonasal tissue. Objective: This work delineates a step-by-step surgical approach to visually demonstrate the feasibility of an uninarial endoscopic endonasal approach for pediatric spontaneous CSF leak repair. Postoperative Outcome: A 2-year-old male with a 6-month history of clear rhinorrhea, intermittent headaches, and a previous episode of bacterial meningitis was evaluated as an inpatient consultation. Computed tomography cisternography revealed active CSF extravasation at the right sphenoid sinus roof. An endoscopic endonasal approach was performed including a complete sphenoethmoidectomy plus middle turbinectomy to provide access to the skull base defect. Once identified, a middle turbinate free mucosal graft was placed for cranial base reconstruction given the child's young agre. Sinonasal debridement 3 weeks following surgery under anesthesia revealed an intact viable graft with no evidence of CSF leak. There was no evidence of CSF leak recurrence or complications 1 year following surgery. Conclusion: The uninarial endoscopic endonasal approach is a safe and effective option for the surgical management of spontaneous CSF leak rhinorrhea in the pediatric population.

Lumbar Drain Use during Middle Fossa Approaches for Nonneoplastic Pathology of the Skull Base.

Introduction The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use. Methods A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation. Results In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol ( n = 24, 31.6% vs. n = 16, 16.7%, p = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05-2.02, p = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25-2.29, p = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48-4.96, p = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant ( p = 0.07). Conclusion No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies.

Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review.

Management of recurrent cerebrospinal fluid leak, current practices and open challenges. A systematic literature review.

Fibrin Glue–Coated Collagen Complex Patch: A Novel Material for Surgical Repair of Spontaneous Temporal Bone Cerebrospinal Fluid Leak and Encephalocele

To compare outcomes of surgical repair of temporal bone encephalocele and cerebrospinal fluid (CSF) leak using fibrin glue-coated collagen (FGCC) complex patch versus other materials for repair of dura. Retrospective chart review. Tertiary care hospital. Fifty-two adult patients undergoing transmastoid (TM), middle fossa (MF) or combined approach repair of spontaneous MF CSF leak between 2016 and 2020. Exposure of bony defect via TM approach, MF craniotomy, or combined TM/MF, and repair of the associated dura defect with FGCC complex patch, or other materials (acellular collagen matrix, bovine collagen, autologous fascia, fibrin tissue sealant). Successful repair without recurrent CSF leak or encephalocele throughout follow-up. Cost of materials used in duraplasty. Sixty-four percent of patients were female. Mean (standard deviation) age at repair was 61.4 (12.1) years. Mean (standard deviation) body mass index was 35.0 (8.3) kg/m 2 . Forty-nine (94%) patients had successful repair without known recurrence of CSF leak or encephalocele over a median follow-up interval of 11.7 months. Average duraplasty material cost was significantly lower with FGCC in comparison with other nonautologous materials (FGCC+: $1259.94, FGCC-: $1652.58; p = 0.004). No significant differences in recurrence risk (FGCC+: 6.9%, FGCC-: 6.9%; p > 0.999) or operative time (FGCC+: 153.7 min, FGCC-: 155.4 min; p = 0.88) were detected based on material used for duraplasty. All materials studied demonstrate effective and sustained means of repair for MF CSF leak and encephalocele, including in the presence of multiple defects. Use of FGCC for duraplasty produces noninferior surgical results to other nonautologous materials in repair of spontaneous CSF leaks of the temporal bone and may be more cost-effective.

Surgical management of spontaneous middle cranial fossa defects: a systematic review and meta-analysis of available reconstructive techniques and materials.

Different materials and techniques have been proposed for surgical repair of spontaneous middle cranial fossa (MCF) defects. However, conclusive evidence supporting their selection and impact on clinical outcomes is lacking. The study aims to conduct a systematic review and meta-analysis on materials and techniques employed to repair MCF defects and evaluate complications and rates of recurrent cerebrospinal fluid (CSF) leaks. A PRISMA-guided systematic review and meta-analysis were performed using MESH terms and specific keywords including studies published before May 2022. Primary outcomes included recurrence of CSF leak and complication rates by type of reconstructive material and technique utilized. Meta-analyses of proportions were performed using random effects and confidence intervals for individual proportions were calculated using the Clopper-Pearson method. Twenty-nine studies were included (n = 471 cases). Materials employed for repair were categorized according to defect size: 65% of defects were of unknown size, 24% were small (< 1cm), and 11% were large (≥ 1cm). Rigid reconstruction (RR) was significantly favored over soft reconstruction (SR) for larger defects (94% of cases, p < 0.05). Complications and recurrent CSF leak rates of SR and RR techniques were comparable for defects of all sizes (p > 0.05). Complication rates reported for these procedures are low regardless of technique and material. RR was universally preferred for larger defects and analysis of complication and recurrence rates did not reveal differences regardless of defect size. While RR was more frequently reported in smaller defects, SR was used by several centers, particularly for smaller MCF floor defects.

Endoscopic Endonasal Transsphenoidal Approach to Repair Cerebrospinal Fluid Rhinorrhea After an Anterior Clinoidectomy for Aneurysm Clipping: Series of 4 Cases.

Cerebrospinal fluid (CSF) rhinorrhea through a pneumatized optic strut is a known potential complication after an anterior clinoidectomy that is used to microsurgically clip a proximal internal carotid artery aneurysm. The original craniotomy site can be reopened to repair the skull base defect, but this technique has disadvantages. To avoid a repeat craniotomy and address the limitations of a transcranial approach, a straightforward alternative was used for skull base repair-the binostril endoscopic endonasal transsphenoidal approach. This retrospective case series describes the use of endoscopic transsphenoidal repair and outcomes for patients with CSF leaks after anterior clinoidectomy for aneurysm repair between January 1, 2015, and December 31, 2019. Four adult patients (3 women and 1 man) with a mean age of 59.5 years were reviewed. Skull base repair occurred on average 24 days (range, 4-75 days) after the index operation. After demucosalization of the parasellar sphenoid sinus, the fistula in the pneumatized optic strut was reconstructed with a free nasal mucosal graft with or without an autologous muscle graft. None of the patients developed a recurrent CSF leak at a mean follow-up of 12.5 months (range, 8-22 months), and none experienced complications. The endoscopic endonasal transsphenoidal approach was safe and effective for skull base repair in 4 patients with CSF rhinorrhea after an anterior clinoidectomy for aneurysm clipping.

3. Assessment of in vitro dural repair techniques with a hydrostatic pressure device

<h3>BACKGROUND CONTEXT</h3> Incidental durotomies are a relatively infrequent occurrence during lumbar spine surgery and are generally benign, without significant adverse consequences. Treatment with direct repair, with or without augmentation, is generally very effective and further cerebrospinal fluid (CSF) leak is uncommon. The strength and stability of a dural repair is dependent on several factors, including patient age, quality of dural tissue, the size and location of the durotomy, and the manner in which the repair is performed. There is limited in vitro evidence comparing the strength of different dural repair techniques and the resulting likelihood of recurrent CSF leak. <h3>PURPOSE</h3> To compare the strength and stability of various dural repair techniques in an in vitro human cadaveric durotomy model. <h3>STUDY DESIGN/SETTING</h3> An in vitro testing device was created to apply controlled, hydrostatic pressure to evaluate the integrity of a surgically-created durotomy. <h3>PATIENT SAMPLE</h3> Sixteen human cadaveric specimens. <h3>OUTCOME MEASURES</h3> The hydrostatic pressure required to cause a leak at the site of the dural repair. <h3>METHODS</h3> Complete human cadavers were placed in the prone position and the dura in the thoracic and lumbar spines was exposed through a midline incision and subsequent laminectomies. The dura was clamped 8 cm proximal and distal to the level of the durotomy and clamped with reliable, water-tight plastic rings. A 16-gauge plastic catheter was introduced into the lateral aspect of the dura and sutured in a water-tight fashion to serve as the source for instilling saline into the dura. The catheter was attached to a hydrostatic pressure measuring column to assess the intradural pressure. Linear durotomies of either 1 cm or 6 cm in length were made with a 15 blade in both the thoracic and lumbar spines of each cadaver. A dural repair was performed with either a 6-0 prolene or 2-0 silk suture. Repair technique were either multiple, simple interrupted sutures or a simple running repair with knots at the respective margins of the durotomy. An analysis of variant analysis (ANOVA) was employed to assess differences in leak rates with respect to applied hydrostatic pressure. <h3>RESULTS</h3> Eight repair groups (thoracic vs lumbar / 6-0 prolene vs 2-0 silk / running vs multiple interrupted) were studied for each of the 1 cm and 6 cm durotomies. There were no significant differences noted in the frequency or extent of spinal fluid leak at different hydrostatic pressures with respect to either suture type employed or suture technique performed. There was a slight difference in the mean applied hydrostatic pressure applied to create a fluid leak in the 6 cm durotomy (16 cm H2O) compared to the 1 cm durotomy (12 cm H2O) but this did not reach statistical significance. <h3>CONCLUSIONS</h3> In this in vitro study of the integrity of the repair of experimentally created durotomies, no significant difference was noted with respect to different suture type or technique of repair. Larger durotomies had a slight, not significant trend for recurrent leak at lower applied hydrostatic pressures. In general, expansion of the repaired dura with controlled delivery of intrathecal fluid, simulating an in vivo, intraoperative Valsalva maneuver, did not reveal significant differences in varying repair types. While this in vitro study does not directly replicate an in vivo scenario, the results do reinforce the necessity of a meticulous water tight suture repair to adequately treat incidental durotomies and thus avoid the troublesome consequences of a recurrent CSF leak. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Clinical Implementation of Platelet- and Extracellular Vesicle-Rich Product Preparation Protocols.

Extracellular vesicles (EVs) are considered essential mediators of regenerative roles of autologous platelet- and extracellular vesicle-rich plasma (PVRP) and platelet- and extracellular vesicle-rich gel (PVRG). PVRP and PVRG are novel blood-derived products gaining attraction in regenerative medicine. However, despite their reported good efficacy, their preparation protocols are too time-consuming. Moreover, patient-tailored preparation protocols are desired to optimize platelet and EV count in PVRP and PVRG. This article presents the clinical implementation of one-step, patient-tailored erythrocyte sedimentation rate (ESR)-based, PVRP and PVRG preparation protocols through the presentation of three cases: (1) large chronic tympanic membrane (TM) perforation, (2) osteoradionecrosis of the lateral skull base, and (3) cerebrospinal fluid (CSF) leak in the sphenoid sinus. These were treated with PVRP and PVRG, prepared according to our preclinically constructed mathematical sedimentation model of cells and EVs based on the patient's ESR. (1) TM healed completely after the treatment with 3.6 mL of PVRP and PVRG (high platelet and EV protocol). The speech discrimination score and air conduction pure tone average improved from 75% to 95% and from 65 to 25 dB, respectively. (2) The osteoradionecrotic surface area decreased from 46 to 18 cm2, and infection was eradicated after six applications of 13-65 mL of PVRG ("half-volume" protocol). (3) No CSF leak recurrence was detected after surgical closure with 30 mL of PVRG postoperatively. Reproducible preparation protocols proved effective, safe, fast, and straightforward enough for the surgical staff to prepare PVRP and PVRG intraoperatively. To alleviate preparation, a calculator is provided. This pilot study presents a sound basis for further studies, which are needed to assess the therapeutic effect of PVRP and PVRG. Impact statement We introduce a clinical implementation of a patient-tailored, erythrocyte sedimentation rate-based platelet- and extracellular vesicle-rich plasma (PVRP) and gel (PVRG) preparation protocol based on a mathematical model. Products proved beneficial in wound healing and were, to our knowledge, used for the first time in the treatment of osteoradionecrosis of the lateral skull base. Furthermore, this reproducible preparation protocol is fast and straightforward to implement in clinical practice. A calculator is provided to alleviate PVRP and PVRG preparation for various clinical scenarios.

Comparison of Outcomes of Surgical Repair of Spontaneous Temporal Bone CSF Leaks and Encephaloceles Using Bone Cement and Autologous Material.

To compare outcomes transmastoid repair of spontaneous middle fossa cerebrospinal fluid (CSF) leak using only bone cement (BC) versus only autologous material (AM) or combined materials (CM) with both bone cement and autologous material. Retrospective Chart Review. Tertiary Care Hospital. Forty-three adult patients undergoing transmastoid repair of spontaneous middle fossa CSF leak between 2014 and 2020 (BC:12, AM:15, CR:16). Cortical mastoidectomy, identification of defect, and repair with BC (Cranios® hydroxyapatite), AM (local bone, fascia, fat, and/or cartilage), or CM (Cranios® combined with autologous materials). Successful repair without recurrent CSF leak or encephalocele throughout follow up. Fifty-one percent of subjects were female. Mean age at repair was 58.6 years (SD 10.9). Mean BMI was 35.4 (SD 7.6; BC:36.3, AM:36.5, CM:33.6). Forty (93%) patients had successful repair without known recurrent CSF leak or encephalocele since surgery (BC:11, 91.6%; AM:14, 93.3%; CM:15, 93.8%; p = 0.49) over a mean length of follow up of 49.6 months (BC: 37.9, AM: 59.2, CR: 49.5). The difference in mean operative time amongst the groups was faster for patients using bone cement (BC: 100.2 min, AM: 182.8, CM: 133.2; p < 0.00001). BC, AM, and CM techniques each demonstrate effective and sustained means of repair for middle fossa CSF leak and encephalocele, even in the presence of multiple defects. Use of isolated BC offers a significant decrease in operative time with a noninferior outcome. Active CSF leak at the time of surgery is associated with increased risk of recurrence.

Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide.

Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks. Multi-Institutional, Retrospective Case Series. Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated. Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months. The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus. 4 Laryngoscope, 131:2224-2230, 2021.

Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach

ObjectiveTo describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach. MethodsThis was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent. ResultsThirty-five patients were included in this series. The patients’ mean age was 33 years (range 11–71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3–65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus. ConclusionTraumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management

Introduction Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same. Materials and Methods In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management. Results A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak. Conclusion Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.

Risk Factors and Reconstruction Techniques for Persistent Cerebrospinal Fluid Leak in Patients Undergoing Endoscopic Endonasal Approach to the Posterior Fossa.

Background High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) ( p = 0.02). All patients with a persistent CSF leak developed meningitis ( p = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial-pericranial flaps, should be considered as an early rescue option in obese patients.

Endoscopic skull base reconstruction of large defects: retrospective analysis of 30 cases

Background. Endoscopic skull base reconstruction of large defects is a difficult issue in neurosurgery, as there are problems associated with a wide dural resection, intra-arachnoid dissection (due to removal of the meningocele or resection of an intracranially spreading tumor), and exposure to high-flow cerebrospinal fluid within the cisterns. But perhaps the most significant influence is the larger nonvascularized reconstructive bed – cerebrospinal fluid on one side and sinus cavity (air) on the other.The study objective is to analyze our own experience in treating patients with large defects of the skull base and, based on the results obtained, to optimize the method of reconstruction.Materials and methods. A retrospective analysis of 30 cases of reconstruction of large defects of skull base of various etiologies. The results of surgery in the early and late postoperative period were evaluated. Statistical analysis was carried out using the exact Fisher criterion and the analysis of arbitrary contingency tables using the chi-square criterion. A literature review was conducted to compare the data obtained with the results of other studies.Results. In the group of patients (n = 16) for whom reconstruction was performed only with free transplants the effectiveness of reconstruction was 75 %. In the group of patients (n = 14) who underwent the last stage of reconstruction using a vascularized pedicled nasoseptal flap, the plastic surgery efficiency was 100 %. According to statistical analysis, there is a relationship between the choice of transplant type and the multilayer technique (p &lt;0.05). The use of lumbar drainage did not affect the recurrence of cerebrospinal fluid leak in the postoperative period (p &gt;0.05).Conclusion. Endoscopic skull base reconstruction can be effectively used for defects of the skull base &gt;1.5 cm. When choosing the technique of reconstruction of large defects of the skull base, preference should be given to multilayer plastic using vascularized flaps. The use of lumbar drainage for reconstruction of large defects is a justified method in the case of a clear definition of indications for its use, based on a comparison of the possible benefits and risks associated with the invasiveness of the method.