Cerebrospinal Fluid Leak Repair Research Articles

Minimally Invasive Approaches to Spinal Cerebrospinal Fluid Leak Repair: Current Strategies and a Novel Technique

Spinal cerebrospinal fluid (CSF) leaks can be caused by tears in the dura and are challenging to treat. Traditional methods of treating spinal CSF leakage include nonsurgical management, epidural blood patches (EBP), and direct surgical repair. Minimally invasive surgery (MIS) is rapidly progressing within neurosurgery due to its advantages for patient safety and comfort. Existing MIS techniques to spine surgery utilize a rigid endoscope, which has limitations when reaching smaller areas requiring greater degrees of visualization. The simultaneous use of a flexible endoscope and wearable heads-up display (wHUD) improves access and visualization in these small areas while allowing the surgeon to maintain optimal ergonomics. In this article, we review minimally invasive approaches to spine surgery and the management of spinal CSF leaks. We also demonstrate a novel minimally invasive technique utilizing flexible endoscopy and a wHUD to treat a case of recurrent CSF leak. We describe the successful utilization of this technology and provide the groundwork for future practitioners to incorporate this approach into their practice.

Intradural Repair of Temporal Bone Encephalocele and Cerebrospinal Fluid Leak: Results from a Single Institution

Abstract Background Lateral temporal bone encephaloceles incidence is increasing with obesity rates. Middle fossa (MF) craniotomy, transmastoid (TM), or combined MF + TM access can be used for repair. Methods Retrospective review of MF or MF + TM repair with an intradural graft. Sex, age, and body mass index (BMI) were collected. Pre/postoperative audiometric results were included. Postoperative complications were reported. Results A total of 49 patients (50 repairs) were included. In addition, 74% were women (p < 0.05). Ten patients had a history of chronic otitis media and surgery. Average BMI was 35.8, and average age was 59. Furthermore, 54% had multiple skull base defects; 18 (36%) patients had a MF approach. In total, 32 (64%) patients had a MF + TM approach for repair; 13 (40.1%) of these patients had a concurrent tympanoplasty. Hearing improved for 74%. Air conduction pure-tone average improved by an average of 5 dB (p 0.27). No differences in hearing outcomes were observed between the MF and MF + TM groups. Two patients (6%) had hearing decline. Eight complications were reported (1 (2%) skin infection, 4 (8%) recurrent/persistent cerebrospinal fluid [CSF] leaks requiring lumbar drain or shunt, and 3 (6%) episodes of aphasia or mental status change). Age >65 years was not associated with risk of postoperative complication. Conclusion Intradural repair of encephalocele and CSF leak is a safe and effective surgical approach. Intradural reinforcement along the entire MF floor is beneficial for multiple areas of dehiscence and thin dura. Complication rates including recurrent/persistent CSF leak and aphasia related to temporal lobe retraction were similar to previously published reports and not associated with older patient age. Hearing was stable or improved in 94% with no difference noted between MF and MF + TM repair.

Ventral Thoracic Cerebrospinal Fluid Leak Repair in Spontaneous Intracranial Hypotension Complicated by Superficial Siderosis: 2-Dimensional Operative Video.

Ventral Thoracic Cerebrospinal Fluid Leak Repair in Spontaneous Intracranial Hypotension Complicated by Superficial Siderosis: 2-Dimensional Operative Video.

Treatment of Acute Iatrogenic Cerebrovascular Injury Using Flow Diverter Stents

BACKGROUND AND OBJECTIVES: Iatrogenic cerebrovascular injury can cause intracranial hemorrhage and pseudoaneurysm formation, putting patients at high risk for postoperative bleeding. No consensus for management exists. This study describes endovascular treatment of these acute injuries with flow diverter stents. METHODS: Electronic medical records were retrospectively reviewed for injury type and etiology, timing of diagnosis, and endovascular management, including antiplatelet regimens, embolization results, and clinical outcome. RESULTS: Six patients were included. Three suffered an injury to the internal carotid artery, 1 suffered an injury to the left anterior cerebral artery, 1 suffered an injury to the right posterior cerebral artery, and 1 suffered an injury to the basilar artery. Four of the 6 injuries occurred during attempted tumor resection, 1 occurred during cerebrospinal fluid leak repair, and 1 occurred during an ophthalmic artery aneurysm clipping. All injuries resulted in pseudoaneurysm formation. Four were immediately detected on angiography; 2 were initially negative on imaging. Five were treated with a pipeline embolization device, and 1 was treated with a Silk Vista Baby. Two were treated with 2 pipeline embolization devices telescopically overlapped across the pseudoaneurysm. All devices deployed successfully. No pseudoaneurysm recurrence or rebleeding occurred. No parent artery occlusion or stenosis was observed, and complete pseudoaneurysm occlusion was observed in 4 patients (in 2 patients, follow-up imaging could not be obtained). CONCLUSION: With proper antiplatelet regimens, flow diverter stents can be used safely to successfully treat complex acute iatrogenic injuries. Early repeat angiogram is needed when immediate postinjury imaging does not discover the point of vessel injury.

Endoscopic Repair of Cerebrospinal Fluid Leak

BACKGROUND AND IMPORTANCE: The evolution of endoscopic techniques in spine has allowed novel approaches to various pathologies. We describe the use of endoscopy for repair of refractory cerebrospinal fluid (CSF) leak after lumbar puncture (LP). CLINICAL PRESENTATION: A 31-year-old female presented with refractory postural headaches after undergoing LP. The patient underwent 4 total epidural blood patches (EBPs) with minimal symptomatic relief. The LP opening pressure was found to be 18 cm of water, inconsistent with underlying pseudotumor cerebri. A myelogram demonstrated persistent CSF leak and contrast accumulation within the dorsal epidural space at L2-3. Endoscopic exploration was ultimately performed, which demonstrated well-placed EBPs; however, continuous CSF egressed from a pinhole site. This was repaired with coagulation using a radiofrequency probe, DuraSeal (Integra LifeSciences) and DuraGen (Integra LifeSciences). Postoperatively, the patient noted resolution of debilitating intracranial hypotension symptoms and was able to return to work. CONCLUSION: Postdural puncture headaches occur in about 1/3 of patients after LP. Symptoms are often debilitating and can include nausea, neck pain, dizziness, tinnitus, visual changes, and hearing loss. Multiple pharmacological and invasive treatments, such as EBP, have been used historically with success, but Postdural puncture headaches refractory to these interventions can put patients at risk for serious complications including seizures and subdural hematomas. We present the first reported case of an endoscopic approach to repair refractory CSF leak in the lumbar spine. Our approach highlights the potential of minimally invasive endoscopic techniques in the repair of refractory CSF leak from the puncture site after LP.

Microsurgical Repair of Ventral Cerebrospinal Fluid Leaks in Spontaneous Intracranial Hypotension: Efficacy and Safety of Patch-Sealing Versus Suturing.

In patients with spontaneous intracranial hypotension (SIH), microsurgical repair is recommended in Type 1 (ventral) dural leaks, when conservative measures fail. However, there is lacking consensus on the optimal surgical technique for permanent and safe closure of ventral leaks. We performed a retrospective analysis of surgically treated SIH patients with Type 1 leaks at our institution between 2013 and 2023. Patients were analyzed according to the type of surgical technique: (1) Microsurgical suture vs (2) extradural and intradural patching (sealing technique). End points were resolution of spinal longitudinal epidural cerebrospinal fluid collection (SLEC), change in brain SIH-Score (Bern-Score), headache resolution after 3 months, surgery time, complications, and reoperation rates. In total, 85 (66% women) patients with consecutive SIH (mean age 47 ± 11 years) underwent transdural microsurgical repair. The leak was sutured in 53 (62%) patients (suture group) and patch-sealed in 32 (38%) patients (sealing group). We found no significant difference in the rates of residual SLEC and resolution of headache between suture and sealing groups (13% vs 22%, P = .238 and 89% vs 94%, P = .508). No changes were found in the postoperative Bern-Score between suture and sealing groups (1.4 [±1.6] vs 1.7 [±2.1] P = 1). Mean surgery time was significantly shorter in the sealing group than in the suture group (139 ± 48 vs 169 ± 51 minutes; P = .007). Ten patients of the suture and 3 of the sealing group had a complication (23% vs 9%, P = .212), whereas 6 patients of the suture and 2 patients of the sealing group required reoperation (11% vs 6%, P = .438). Microsurgical suturing and patch-sealing of ventral dural leaks in patients with SIH are equally effective. Sealing alone is a significantly faster technique, requiring less spinal cord manipulation and may therefore minimize the risk of surgical complications.

Morphology, pneumatization, septation, and protrusion of nearby structures into the sphenoid sinus: A retrospective radiological study

The morphology of the sphenoid sinus is critical in planning endoscopic sinus surgery, pituitary gland surgery, cerebrospinal fluid leak repair, the management of chronic sphenoid sinusitis, and the evaluation of skull base tumours. The objective of this study was to evaluate the morphology of the sphenoid sinus, with an emphasis on classification, septation, protrusion of structures, and dehiscence of the bony covering. In this retrospective radiological study, the morphology of the sphenoid sinus was analysed using 400 computed tomography scans. According to Hamberger’s classification, the sphenoid sinus was classified into postsellar and presellar varieties. Additionally, the extent of pneumatization of the pterygoid process, anterior clinoid process, and greater wing of the sphenoid was noted. The anteroposterior, transverse, and vertical diameters of the sphenoid sinus were also measured. The relative positions of the genu of the internal carotid artery, vidian canal, and intracanalicular optic nerve were also recorded. The mean anteroposterior length, transverse length, and vertical length of the sphenoid sinus were found to be 29.3 (±2.8), 31.9 (±2.7), and 22.8 (±1.9) mm, respectively. The sellar type was found in 90% of subjects, while the remaining 10% had the presellar type. Only two subjects had the concha type of sinus. A single septum was noted in 32% of cases.Pneumatization of the pterygoid process was found in 22.5%, the anterior clinoid process in 27%, and the greater wing of the sphenoid in 21.25%. Optic nerve protrusion occurred in 24.5% of cases, and 23% of optic canals were dehiscent. The findings of this study hold significant relevance for neurosurgery, particularly in procedures involving the skull base, such as transsphenoidal surgery and optic nerve decompression

Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey.

Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.

Endoscopic Endonasal Anterior Skull Base Meningoencephalocele and Cerebrospinal Fluid Leak Repair: Our Intraoperative and Postoperative Protocol and Long-term Outcomes

Abstract Objective We evaluated the long-term outcomes from a single neurosurgeon and otolaryngologist team using a specific operative protocol for repair and postoperative evaluation. Design The charts of patients undergoing endoscopic endonasal repair of meningoencephaloceles (MECs) and cerebrospinal fluid (CSF) leaks were retrospectively reviewed from 2015 to 2023. Intraoperative steps of the repair and reconstruction were analyzed. Patients' postoperative assessments and complications were analyzed. Setting Loyola University Medical Center's electronic medical record database. Participants Forty-three patients (32 female) aged between 11 and 81 years. Main Outcome Measures Long-term outcomes of patients who underwent endoscopic endonasal repair of MECs and CSF leaks by a single team and protocol. We hypothesized that there would be minimal complications and no recurrences, requiring secondary operation. Results The most common site for MECs was the cribriform plate. Lumbar drain opening pressures ranged from 10 to 35 cm H2O with 18 out of 34 patients having the lumbar drain removed immediately postoperatively. The median hospital stay was 3 days. The average length of follow-up was 3.8 years. No recurrences or secondary operations were noted in all patients. One patient had a sinonasal infection that was successfully treated. Eight patients were noted to have venous stenosis and underwent further evaluation. Conclusion This study represents one of the largest long-term analyses of outcomes by a single team. Our specific protocol for the endoscopic endonasal repair of anterior skull base MECs and CSF leaks is safe and effective. These patients should be evaluated and treated for elevated intracranial pressure following the repair.

Systematic Review: Success Rate of Endoscopic Endonasal versus Combined Endonasal and Transorbital Neuroendoscopic Approach for Nontraumatic Cerebrospinal Fluid Leak Repairs in the Lateral Recess of Sphenoid Sinus

Abstract Background Cerebrospinal fluid (CSF) leaks from the lateral recess of the sphenoid sinus (LRS) occur due to a skull base defect and are important to treat due to the associated morbidity, e.g., life-threatening meningitis. Nontraumatic CSF leaks have a predilection toward obesity which is a rising phenomenon. LRS is notoriously difficult to access because of its lateral location and its associated neurovascular complications. An alternative surgical corridor has been explored which is the transorbital neuroendoscopic (TONES) approach. Objective To compare the success rate of the endoscopic endonasal with the TONES approaches. Rationale This is the first systematic review on the endoscopic endonasal and combined transorbital approaches to treat CSF leaks from the LRS. Method A PRISMA-concordant systematic review. PubMed, MEDLINE, EMBASE, Web of Science, and SCOPUS were searched. The studies underwent abstract and full-text screening by two reviewers. The data collected included patient demographic, surgical approach, reconstruction method, layers and materials, follow-up period, ROBINS-I bias, complications, and success rate. Results In total, 26 of 4,385 studies were included for further synthesis. Of these studies, a total of 336 patients were identified from a cohort of 910 patients. The endoscopic endonasal approach showed a repair success rate of 95.24% and the combined TONES and endonasal approach showed a success rate of 100%. Conclusion Both the endoscopic endonasal and transorbital approach provide a good success rate. However, due to the small TONES sample, large, randomized control trials are needed.

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients.

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair. Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission. A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05). Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population. IV Laryngoscope, 134:2713-2717, 2024.

Opioid Prescribing Patterns Following Lateral Skull Base Spontaneous Cerebrospinal Fluid Leak Repair.

To characterize the opioid prescribing patterns for and requirements of patients undergoing repair of spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base. Retrospective chart review. Tertiary referral center. Adults with lateral skull base sCSF leaks who underwent repairs between September 1, 2014, and December 31, 2020. Mean morphine milligram equivalents (MMEs) of opioids dispensed to inpatients and prescribed at discharge, additional pain control medications dispensed, and outpatient additional opioid requests were compared between groups. Of 78 patients included, 46 (59%) underwent repair via a transmastoid (TM), 6 (7.7%) via a middle cranial fossa (MCF), and 26 (33.3%) via a combined TM-MCF approach. Inpatients received a mean of 21.3, 31.4, and 37.6 MMEs per day during admission for the TM, MCF, and combined TM-MCF approaches, respectively ( p = 0.019, ηp 2 = 0.101). Upon discharge, nearly all patients (n = 74, 94.9%) received opioids; 27.3, 32.5, and 37.6 MMEs per day were prescribed after the TM, MCF, and TM-MCF approaches, respectively ( p = 0.015, ηp 2 = 0.093). Five (6.4%) patients requested additional outpatient pain medication, after which three were prescribed 36.7 MMEs per day. Patients with idiopathic intracranial hypertension required significantly more inpatient MMEs than those without (41.5 versus 25.2, p = 0.02, d = 0.689), as did patients with a history of headaches (39.6 versus 23.6, p = 0.042, d = 0.684). Patients undergoing sCSF leak repair via the MCF or TM-MCF approaches are prescribed more opioids postoperatively than patients undergoing the TM approach. Patients with a history of headaches or idiopathic intracranial hypertension might require more opioids postoperatively.

The Role of Lumbar Drains in the Perioperative Management of Primary Spontaneous Temporal Lobe Encephaloceles and Cerebrospinal Fluid Leaks.

To examine the role of lumbar drains (LDs) in the success of spontaneous temporal cerebrospinal fluid (CSF) leak and encephalocele repair. Retrospective cohort study. Tertiary academic health system. Patients undergoing repair of spontaneous temporal lobe encephaloceles or middle fossa CSF leaks during years 2017 to 2023. Transmastoid, middle fossa craniotomy, or combination approaches to CSF leak repair. Failure rate, complication rate, length of stay (LOS), readmission. Sixty-nine patients were included, with a combination approach performed in 78.3%, transmastoid in 17.4%, and isolated middle fossa craniotomy in 4.3%. Mean body mass index was 33.2, mean bony defect size width was 6.51 mm, and defect locations included the epitympanum, antrum, mastoid, and petrous apex. Multilayer closure with three or more layers was performed in 87.0%. LD was used in 73.9% of cases for a mean duration 2.27 days and was associated with longer LOS (3.27 vs. 1.56 d, p = 0.006) but not with failure rate, complications, discharge destination, or readmission. Only one major complication occurred as a result of the drain, but low-pressure headache was anecdotally common. Use of LD in the repair of spontaneous CSF leaks and temporal lobe encephaloceles is associated with longer LOS but not failure rates or other admission-level outcomes.

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.

Cerebrospinal fluid leakage due to dural thinning after endoscopic pituitary tumor resection.

Sellar reconstruction is important for preventing cerebrospinal fluid (CSF) leakage after transsphenoidal pituitary surgery. This report describes how, despite standard sellar reconstruction, CSF exudation resulted from dural thinning at the anterior skull base, outside the intrasellar area manipulated during pituitary tumor resection. A 76-year-old man underwent endoscopic transsphenoidal surgery for a pituitary tumor extending toward the anterior skull base. After opening the sellar floor, intractable bleeding from the anterior intercavernous sinus occurred during bone removal at the anterior skull base. Pseudocapsule-based extracapsular resection was completed after stopping the bleeding. On the 10th postoperative day, the patient developed CSF rhinorrhea complicated by marked pneumocephalus, and emergency endoscopic repair of the CSF leak was performed. CSF leakage originated from the thinned dura at the anterior skull base located outside the intrasellar area manipulated during tumor resection. The thinned dural area at the anterior skull base coincided with the site of intractable bleeding of the anterior intercavernous sinus during bone removal in tumor resection. The thinned anterior skull base dura was covered with fascia, overlaid with fat, and closed with the nasoseptal flap. Endoscopic CSF leak repair was successful. Severe damage to the anterior intercavernous sinus can cause extensive exposure of the single-layered inner meningeal dura, where thinning might result in CSF exudation. Therefore, use of autologous tissues to cover and reinforce the severely damaged area of the anterior intercavernous sinus might help prevent postoperative CSF exudation.

Delayed diagnosis and management of a congenital intranasal meningoencephalocele in a 24-year-old male

Background: Intranasal meningoencephalocele is a rare congenital malformation. It is defined by protrusion of cerebral tissue and meninges through a defect in the skull base. Serious complications usually occur in early childhood, however, symptoms occasionally can wait until adulthood. Case Presentation: We report a case of a 24-year-old male who had a congenital intranasal meningoencephalocele with recurrent episodes of bacterial meningitis. After a delayed diagnosis, he eventually underwent Endoscopic Endonasal Repair of Meningoencephalocele via 'Bath-plug' technique. Conclusions: To prevent improper management, it is crucial that ENT colleagues, to whom these cases are primarily present, are well informed about this unusual condition. For the purpose of preventing further neurological problems, thorough neuroimaging evaluations and successful surgical repair are important. The 'Bath-plug' technique for anterior skull base cerebrospinal fluid leak repair is effective for a wide range of situations.

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case.

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

Outcomes of Spontaneous Cerebrospinal Fluid Leak Repair With Concurrent Eustachian Tube Dysfunction.

To compare the presentation and outcomes of patients with and without obstructive eustachian tube dysfunction (oETD) undergoing repair of lateral skull base spontaneous cerebrospinal fluid (sCSF) leaks. Retrospective chart review. Tertiary referral center. Adults with lateral skull base sCSF leaks who underwent repairs from January 1, 2011, to December 31, 2020, were collected. Comparative statistics and effect sizes were used to compare clinical features, operative findings, and outcomes between groups. Of 92 ears from 89 patients included, 51.1% (n = 47) had oETD. There were no differences in demographics between patients with and without oETD. Mean age was 60.7 ± 13.1 versus 58.5 ± 12.8 years (d = -0.17 [-0.58 to 0.24]), mean body mass index was 33.8 ± 8.5 versus 36.0 ± 8.0 kg/m2 (d = 0.27 [-0.14 to 0.68]), and female sex preponderance was 59.6% (n = 28) versus 68.8% (n = 31; Φ = -0.09), respectively. There were no differences in the radiologic number, size, and locations of defects. Patients with oETD had less pneumatized mastoids than those without oETD (p = 0.001; Φ = 0.43). Mean change from preoperative to postoperative air pure-tone average for those with and without oETD was -1.1 ± 12.6 versus 0.1 ± 17.2 dB (d = 0.09 [-0.04 to 0.58]), respectively. Six ears (6.5%; three with and three without oETD) underwent revisions for rhinorrhea/otorrhea between 5 and 28 months postoperatively, during which four leaks were found, the two patients without leaks had oETD. The presentation of sCSF leaks and outcomes of repairs in patients with oETD do not differ from those without oETD. Although postoperative otorrhea might represent an inflammatory or infectious process in patients with oETD, reexploration is warranted if patients do not improve with conservative treatment.

Hydroxyapatite Use in Repair of Lateral Skull Base CSF Leaks Via Transmastoid Approach: When Does It Work?

The objective of this study is to evaluate the efficacy and outcomes of using a transmastoid approach with hydroxyapatite cement to repair lateral skull base cerebrospinal fluid (CSF) leaks. Retrospective cohort study. Tertiary-level care hospital. Surgical patients 18 years or older between 2013 and 2022 with spontaneous CSF leak. Trans-mastoid approach for skull base repair using hydroxyapatite cement. Failure rate of repair; location and size of defect, patient demographic factors. Of the 60 total defects (55 patients, 5 bilateral repairs) that underwent CSF leak repair using hydroxyapatite cement, the success rate was 91.66% (55 successful repairs). The average defect size in unsuccessful repairs was 1.15 cm compared with 0.71 cm for successful repairs. In addition, 80% (4/5) of the failed repairs were in the tegmen tympani region. Higher failure rate was noted in women (3/5) and in former smokers (4/5). Average time to recurrent symptoms was 1.75 years in the failed repair cohort. Of the patients with failed repairs, 4/5 were prescribed acetazolamide before their second procedure with successful second repair. In addition, five patients experienced postoperative headaches, three (5.4%) of whom required placement of VP shunts to relieve increased intracranial pressure. Two patients (3.6%) had complications of either infection or hearing loss. Transmastoid approach utilizing hydroxyapatite is a successful approach for CSF leak repair, with a low complication and failure rate. Women, prior smoking history, and larger defects in the tegmen tympani region may need alternative materials or approach for repair. Long follow-up is warranted as recurrence of symptoms might be delayed. In cases of benign intracranial hypertension, adjuvant treatment with either acetazolamide or VP shunt placement may prevent failures.

The Etiology, Diagnosis, and Management of Cerebrospinal Fluid Rhinorrhea: A Tertiary Center Experience.

Introduction The aim of the present study was to describe our institution's nine years of experience in the endoscopic endonasal management of cerebrospinal fluid (CSF) rhinorrhea and to discuss the causes, sites, and outcomes. Methodology The medical records of patients diagnosed with CSF rhinorrhea in King Abdulaziz Medical City-Jeddah (KAMC-J) between 2014 and 2023 were retrospectively reviewed, and all relevant information including body mass index, medical and surgical history, and postoperative outcomes were obtained. Results A total of 20 cases were included in the present study, sixteen (80%) of which were females and four (20%) were males. The mean age of participants was 42.59±13.9 years. Nine cases (45%) were spontaneous CSF rhinorrhea and 11 (55%) were traumatic; within the traumatic group, six cases (54%) were iatrogenic either following previous neurosurgery or functional endoscopic sinus surgery, while the remaining five cases were related to motor vehicle accidents. The mean body mass index for the spontaneous CSF leak was 32 Kg/m2, and 33 Kg/m2 for the traumatic leaks, no statistically significant difference was noted. The cribriform plate was the most common site of leakage (65%). A multilayer surgical technique using facia lata graft with nasoseptal flap was the most common choice for reconstruction with a first-attempt success rate approximating 90%. A recurrence was observed in two patients only. No major complications were reported. The average length of stay was nine days. Conclusion The endoscopic endonasal repair of CSF leak is a safe and reliable procedure and is associated with high success rates and low risk of complications. Therefore, it should be preferred as a first-line treatment for CSF rhinorrhea.