Cerebrospinal Fluid Leak Repair Research Articles

Association between Physiologic Parameters and Anatomic Location in Spontaneous Cerebrospinal Fluid Leaks

Objectives: Although a relationship between elevated cerebrospinal fluid (CSF) pressure and spontaneous CSF leaks has been reported, analyses by anatomic sub-site are lacking. This study seeks to elucidate the association between physiologic parameters and CSF leak location. Methods: Prospective case series of patients undergoing endoscopic endonasal repair of spontaneous CSF leak between 2004 and 2013. All participants had a lumbar drain placed for 24-hour continuous preoperative pressure monitoring, and 24 hours of continuous monitoring starting 48 hours after the repair. In addition to patient characteristics, mean and peak CSF pressures by anatomic location were calculated and compared. Results: Twenty-five patients underwent perioperative CSF pressure monitoring, with a mean follow-up of 526 days. Nine patients had CSF leaks along the cribiform plate, 4 in the ethmoid roof, 8 in the sphenoid, 2 in the posterior table of the frontal sinus, and 2 with multiple leaks. Patients with cribiform leaks had the lowest mean body mass index (BMI) and prevalence of obstructive sleep apnea (22.2%), while those with multiple sites of leak had the highest mean BMI and prevalence of obstructive sleep apnea (50%). Patients with frontal sinus leaks had the highest postoperative mean (14.47 mmHg) and peak (42.5 mmHg) CSF pressures, while ethmoid roof had the lowest mean (0.43 mmHg) and peak (16.45 mmHg) CSF pressures. Conclusions: CSF pressure and other physiologic characteristics differ among patients with spontaneous CSF leaks by anatomic location. Understanding these differences may enable treatment approaches tailored by leak site, thereby improving repair outcomes.

Increased Intracranial Pressure in Spontaneous CSF Leak Patients Is Not Associated with Papilledema

Objectives: Spontaneous cerebrospinal fluid (CSF) leaks typically present in patients with undiagnosed idiopathic intracranial hypertension (IIH) secondary to pressure erosion of the skull base. Despite elevated intracranial pressure (ICP) on lumbar puncture or ventriculostomy, patients with spontaneous CSF leaks rarely complain of visual disturbances. The objective of this study is to correlate the presence of preoperative papilledema with opening ICP in patients undergoing endoscopic repair of spontaneous CSF leaks. Methods: Prospective evaluation of patients with spontaneous CSF leaks was performed over a 1-year period (December 2012 to December 2013). Fundoscopic examination for papilledema was completed preoperatively and CSF pressure was measured by lumbar puncture or ventriculostomy intraoperatively. Data regarding demographics, nature of presentation, and body mass index (BMI) were also recorded and compared to a control cohort of IIH patients with papilledema. Results: Sixteen patients (avg. age 52 years) were evaluated. Obesity was present in 94% of individuals (avg. BMI 43.5; range, 27-65). Papilledema was absent preoperatively in all subjects. Opening pressures via lumbar puncture/ventriculostomy were 27 ± 7.7 cmH20. Following 6 hours of clamping, measurements significantly increased to 36 ± 9.7 cmH20 ( P < .001). IIH controls (avg. age 33 years, avg. BMI 36.7, 22-52) exhibited average ICP (36 ± 10.5) identical to post-clamp measurements in the spontaneous CSF leak cohort. Conclusions: Subjects with spontaneous CSF leaks had post-clamping average ICP identical to controls with IIH and papilledema. Such evidence suggests that a CSF leak in this patient population provides sufficient pressure diversion to avoid the development of papilledema.

Endoscopic repair of cerebrospinal fluid leak in paediatric patients

BackgroundIn scientific literature exist fewer case series regarding endoscopic treatment of paediatric cerebrospinal fluid fistulas. Compared to craniotomy endoscopic repair does not reach wider consent even if craniotomy carries higher complications rate. ObjectiveThe aim of the present study was to report our institutional experience on paediatric cerebrospinal fluid leak to demonstrate the safety and efficacy of the endoscopic approach in a variety of cases. MethodsClinical records of all paediatric patients who underwent endoscopic repair of anterior and middle fossa skull base defects are reviewed for several parameters. Results10 patients were enrolled, 6 males and 4 females with a mean age of 10 years. The aetiology of the leak was congenital in 2 cases, trauma-induced in 6 cases and iatrogenic in 2 cases. In all the cases the defect was localized by computed tomography. Remedial was obtained using multiple grafts technique with autologous materials during a single procedure in all but one case, this one case requiring a second operation for delayed recurrence. The mean follow-up duration is 36 months. ConclusionCSF fistulas can be approached in paediatrics of any age with high success and low complications rate using the endonasal technique.

Passive smoke exposure in chronic rhinosinusitis as assessed by hair nicotine.

Prevalence of passive smoke exposure is relatively unknown in chronic rhinosinusitis (CRS). Previous studies have attempted to establish this relationship using subjective, questionnaire-based methodologies to assess smoke exposure, thus introducing the potential for error bias. The purpose of this study was to accurately determine the prevalence of passive smoke exposure in CRS and control patients using hair nicotine levels as a quantitative measure of cigarette smoke exposure. Hair samples were obtained at time of surgery from 569 patients: 404 undergoing surgery for CRS and 165 controls undergoing surgery for repair of cerebrospinal fluid leak, removal of pituitary tumors, or adenoidectomy from 2007 to 2013. Patient charts were reviewed for reported smoking status. Hair nicotine was quantified using reversed-phase high-performance liquid chromatography. Nonsmoking patients were classified as passive smoke exposed or smoke naïve according to the hair nicotine results. Statistical analysis was performed to test for differences in demographic information and smoke exposure prevalence between CRS, CRS subtypes, and controls. The prevalence of passive smoke exposure in CRS as documented by hair nicotine was lower than previously reported subjective estimates. Passive smoke exposure rates were equivalent between those with CRS versus controls and significantly higher in children. Severity of passive smoke exposure was also equivalent between CRS subsets and controls. Annual passive smoke exposure prevalence did not change over time. There is no clear evidence of avoidance of passive smoke exposure in the CRS population compared with controls. Passive smoke exposure also remained stable over time despite recent regional implementation of smoking bans. Given the constancy of exposure, it is critical that the impact of passive smoke on CRS exacerbation, outcomes, and pathophysiology be evaluated in large-scale clinical studies.

Endoscopic Transnasal Management of Cerebrospinal Fluid Rhinorrhea: Early Experience

Background: Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communication between the subarachnoid space and the nasal cavities. During the last two decades the surgical management of anterior skull base fistulae has evolved from intracranial craniotomy to endoscopic transnasal repair with a high success rate and decreased morbidity. We recently changed our policy and repair CSF rhinorrhea through an endoscopic endonasal approach. The purpose of this work is to describe the technique used for watertight closure of CSF leak along the anterior skull base and to evaluate our early results. Methods: A prospective acquired database of all patients having undergone endonasal endoscopic repair of CSF leaks over a 20-month period at Military Hospital of Tunis starting in March, 2012 was reviewed. Results: A total of 20 patients underwent endoscopic repair of CSF fistula. The etiology was traumatic in 7 cases, spontaneous in 11, and iatrogenic in 2 associated with previous transsphenoidal pituitary surgery. A total of 19 patients had successful primary endoscopic repair of the CSF leak. One patient required a revision surgery due to early failure of the repair and the leak was plugged successfully on the second attempt. We experienced a single case of meningitis during the postoperative course. Conclusion: The overall success rate (100%) and low morbidity in this short series support endoscopic approach as standard of care for CSF leak closure.

Preservation of Functioning Sinus in Frontal Sinus Posterior Table Fractures

Objective: Sinus preservation after posterior table frontal fractures (PTFF) may be preferable to obliteration/cranialization for minimizing risk of mucocele. This study assessed functional outcomes and complications after open reduction and internal fixation (ORIF) with sinus preservation for PTFF. Study Design: Consecutive case series. Patients and Methods: Patients with PTFF undergoing ORIF with sinus preservation from July 2012 to December 2013 were assessed. Fracture type/extent, presence/extent of dural injury, and cerebrospinal fluid (CSF) leak were recorded. Type of frontal sinusotomy, use of frontal stents, and lumbar drain were recorded. Outcomes evaluated were CSF leak closure, incidence of perioperative meningitis and frontal patency. Results: For two patients with intact dura and no CSF leak, displaced fragments were removed without dural repair. For one patient with CSF leak, a 1 cm dural defect was associated with comminuted PTFF; two-layered closure with underlay Duragen sheet and pericranial flap (PF) was performed. Lumbar drainage was not used. In two patients, Draf 2a frontal sinusotomy was performed with silastic stenting for 3 weeks. Frontal sinuses were aerated with widely patent frontal recess in all cases with no postoperative CSF leak, meningitis or cranial prolapse at mean 14.0 ± 5.0 months. Conclusion: Preservation of frontal sinus is an option for selected PTFF cases. Dural graft plus vascularized PF without a rigid layer may be used for frontal sinus CSF leak repair.

Impact of Chemoradiotherapy on CSF Leak Repair after Skull Base Surgery.

Background Transnasal endoscopic resection (TER) has become the treatment of choice for many skull base tumors. A major limitation of TER is the management of large dural defects and the need for repair of cerebrospinal fluid (CSF) leaks, particularly among patients who are treated with chemotherapy (CTX) or radiotherapy (RT). The objective of this study is to determine the impact of CTX and RT on the success of CSF leak repair after TER. Methods We performed a retrospective chart review of a single-institution experience of TER from 1992 to 2011. Results We identified 28 patients who had endoscopic CSF leak repair after resection of malignant skull base tumors. Preoperative RT was utilized in 18 patients, and 9 had undergone CTX. All patients required CSF leak repair with rotational flaps after cribriform and/or dural resection. CSF leak repair failed in three patients (11%). A history of RT or CTX was not associated with failed CSF leak repair. Conclusion Adjuvant or neoadjuvant CTX or RT is not associated with failed CSF leak repair. Successful CSF leak repair can be performed in patients with malignant skull base tumors with an acceptable risk profile.

Structural pedicled mucochondral‐osteal nasoseptal flap: a novel method for orbital floor reconstruction after sinonasal and skull base tumor resection

Unrepaired orbital floor defects after sinonasal and skull-base tumor resection can lead to herniation of orbital contents into the maxillary or ethmoidal sinuses, possibly resulting in infection and significant cosmetic and functional deficits. Orbital floor defects are usually repaired using prosthetic implants or autogenous material. Nasal septal cartilage has been used previously as a free graft for reconstruction. However, its reliance on local vascular supply can result in ischemia and necrosis in the postoperative period. The vascularized pedicled nasoseptal flap, consisting of mucoperichondrium and mucoperiosteum, is routinely used as an effective reconstruction method for endoscopic repair of cerebrospinal fluid leaks arising from skull base dural defects. However, this flap does not provide rigid structural reconstruction when used alone. We report a case of an orbital floor defect repaired using a pedicled mucochondral-osteal nasoseptal flap. This technique incorporates the structural component of the nasal septal cartilage and bone with the vascularized pedicled nasoseptal flap. This repair technique may be useful in patients requiring postoperative radiotherapy.

Transmastoid Approach to Spontaneous Temporal Bone Cerebrospinal Fluid Leaks: Hearing Improvement and Success of Repair

To determine whether the transmastoid approach to repair of spontaneous temporal bone cerebrospinal fluid (CSF) leak is safe and effective and if improvement in conductive hearing loss is an achievable goal with this approach. Case series with chart review. Tertiary academic medical center. Fifteen consecutive patients (16 ears) presented with spontaneous temporal bone CSF leaks over a 6-year period. Clinical data, imaging, audiometry, operative reports, and postoperative course were reviewed. Median age was 59.5 years. Mean body mass index was 40.7 kg/m2. All presented with chronic otorrhea after tympanostomy tube placement and conductive/mixed hearing loss. The mean preoperative air-bone gap was 19 dB. A transmastoid approach alone was used in 15 cases; 1 underwent middle fossa craniotomy. Most defects were located in the tegmen mastoideum and tympani. All repairs were multilayered, typically using autologous mastoid bone, temporalis fascia, and tissue sealant. Primary repair was successful in 15 cases; 1 patient with persistent postoperative otorrhea subsequently underwent middle fossa craniotomy, but no frank leakage was found. No serious complications were encountered. Following transmastoid repair, postoperative audiograms were available for 14 patients. The mean improvement in air-bone gap was 12 dB. Closure of the air-bone gap to ≤12 dB occurred in 100% of cases. The transmastoid approach to repair of spontaneous temporal bone CSF leak is highly successful. Furthermore, patients in this series had excellent hearing results with closure of their air-bone gap to ≤12 dB, which has not been previously described.

Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases

ABSTRACTCerebrospinal fluid rhinorrhea results from a breakdown of barriers between the subarachnoid space and aerodigestive tract. Because of the risk of potential intracranial complications, all persistent cerebrospinal fluid (CSF) leaks should be repaired. Over the past few decades, with the advances in endoscopic techniques, the surgical management of CSF rhinorrhea has changed significantly. CSF leak repair has advanced from the conventional open intracranial approaches by neurosurgeons to the transnasal endoscopic ones by otorhinolaryngologists. In this study, 35 patients with CSF leaks underwent endoscopic repair with a 94.3% first attempt success rate, and 100% overall success rate. There were no major intraoperative or postoperative complications. To conclude, the endoscopic approach has a high success rate with minimal morbidity and has therefore, become the preferred method.How to cite this articleJain A, Singhal P, Sharma MP, Singh SN, Grover M. Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases. Clin Rhinol An Int J 2014;7(2):47-51.

Practice patterns in endoscopic skull base surgery: survey of the American Rhinologic Society

The introduction of advanced endoscopic techniques has facilitated significant growth in the field of endoscopic skull base surgery (SBS). The purpose of this study is to evaluate the impact of endoscopic SBS on the clinical practice patterns of the American Rhinologic Society (ARS) membership. A 23-item survey vetted by the ARS Board of Directors was electronically disseminated to the ARS membership from February 5, 2013, to March 31, 2013. The target group encompassed 982 ARS members. A total of 152 physicians (15.5%) completed the survey. Open and endoscopic skull base procedures were performed by 41% and 94% of the respondents, respectively. During a typical year, the number of endoscopic skull base cases ranged from 0 to 20 in 56%, 21 to 50 in 26%, 51 to 100 in 9%, and >100 in 8%. Endoscopic cerebrospinal fluid (CSF) leak repair (96%) and transsphenoidal pituitary surgery (81%) were the most commonly performed procedures, followed by transcribriform (68.4%), transplanum (54.4%), and transclival (49.6%) approaches. Overall, 69.6% used endoscopy for resections of malignant sinus/skull base lesions. Considerable variation in Current Procedural Terminology (CPT) coding philosophy was observed, with open skull base (32%), unlisted endoscopic (29%), sinus surgery (24%), and unlisted neurosurgical (15%) codes employed by surgeons. Only 29% of physicians reported adequate reimbursement in ≥75% of cases. Eighty-five percent of respondents supported creation of dedicated endoscopic SBS codes. This study illustrates the widespread integration of endoscopic SBS procedures into rhinologic clinical practice among survey respondents. However, current variability in coding strategies and inadequate reimbursement may warrant development of specific guidelines to standardize coding and billing processes in the future.

Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks

ObjectiveSkull base cerebrospinal fluid (CSF) leaks of various etiologies are increasingly repaired through the natural corridor using an endoscopic endonasal approach. Characteristics of the skull base defect significantly correlate with etiology, which should be ascertained to guide surgical management. The objectives of this study were to assess the long-term outcomes of patients that underwent endoscopic endonasal repair of CSF leak using low-dose intrathecal fluorescein (ITF) and an etiology-based algorithm for multi-layer graft closure. MethodsPatients were divided into 4 groups: A – congenital, B – post-traumatic, C – post-endonasal surgery, D – post-craniotomy. Low-dose ITF was utilized in all case series. Long-term clinical follow-up data, including perioperative complications associated with the use of intrathecal fluorescein and leak closure rates, were obtained retrospectively. Endoscopic visualization of fluorescein-stained CSF as well as the method of skull base closure and graft material is detailed. ResultsWe identified a total of 41 patients (N=24 in Group A, N=4 in Group B, N=12 in Group C and N=1 in Group D) that underwent 50 CSF leak repairs using the endoscopic endonasal approach with an average follow-up of 31.6 months. Nine patients (21.9%) had undergone a previous attempt at CSF leak repair. Lumbar drain was used intraoperatively in 26 patients (63.4%) and kept in place for an average duration of 3.25 days. ITF successfully identified the site of leak in 80.5% of cases regardless of etiology. Leaks were successfully closed in 92% of patients. One patient (2.4%) experienced transient leg weakness following lumbar drain placement. Another patient (2.4%) developed hydrocephalus requiring a ventriculoperitoneal shunt. ConclusionLow-dose ITF is a safe and useful adjunct to endoscopic endonasal repair of CSF leaks with minimal complications and successful localization of the leak in approximately 80%. An etiology-based approach to graft choice and duration of lumbar drain placement in CSF leak repair may optimize closure rates.

Spontaneous Intracranial Hypotension with Magnetic Resonance Localisation of Spinal Cerebrospinal Fluid Leak

To increase the awareness of spontaneous intracranial hypotension (SIH), we report in this paper a middle-aged woman who presented with an intractable headache that worsened in sitting and standing positions (a postural headache). Magnetic resonance imaging (MRI) of the spine demonstrated a cerebrospinal fluid (CSF) leak at the level of the cervical spine, in addition to typical features in a brain MRI, including symmetrical subdural collections, circumferential dural enhancement and features of midbrain sagging. The patient underwent a surgical repair of the cervical CSF leak which resulted in a dramatic symptomatic improvement that was confirmed by follow-up imaging.

Effectiveness of Lumbar Drains on Recurrence Rates in Endoscopic Surgery of Cerebrospinal Fluid Leaks

In cerebrospinal fluid (CSF) leakage endoscopic repair, lumbar drains (LDs) were used in an attempt to increase success rates. To critically assess the relationship between use of LDs and recurrent leaks, we embarked on this randomized prospective study. Patients undergoing CSF leak repair between 2000 and 2012 were randomized into two groups: 75 patients were managed without LDs and in the other group of 75 patients an LD was always placed. Different parameters were analyzed to identify their relationship with failures: occurrence of increased intracranial pressure (ICP), body mass index, smoking habits, existence of diabetes, chronic corticosteroid use, previous sinus surgery, etiology (traumatic, iatrogenic, or spontaneous leak), site, and size of the CSF leak. Success rate was 93% for the whole group. Patients managed with LDs attained 95% success rate and those without LD attained 92%; the difference is not significant (p = 0.2). The only factor predictive of recurrence is increased ICP: 77% success rate versus 97% for traumatic leaks and 96% for iatrogenic leaks. Recurrence rates were identical in the two groups with increased ICP, regardless of the use of a LD (23%). In this study, success rates of CSF repair were not associated with the use of LDs. However, the small number of cases with high success rates precludes appropriate statistical analysis.

Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components

Simulated Spinal Cerebrospinal Fluid Leak Repair: An Educational Model With Didactic and Technical Components

Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea

The surgical management of cerebrospinal fluid (CSF) rhinorrhoea has changed significantly after the introduction of functional endoscopic sinus surgery. The clear anatomical exposure of the roof of the nasal and paranasal sinus cavities by the endoscope offers the surgeon a golden chance to identify the area of CSF leak, and thus enables one to adequately plan the management. The aim of this work is to evaluate the use of facia lata sandwich graft technique for endoscopic endonasal repair of CSF rhinorrhoea. Forty patients with CSF rhinorrhoea were treated endoscopically using 2 layers of facia lata (underlay and onlay) interposed with a layer of septal cartilage or conchal bone in-between (sandwich technique) for repair. Fifty-five percent of cases were regarded as spontaneous CSF leaks with no obvious cause, 30% following head injury and 15% were iatrogenic. The ethmoidal roof was the commonest location of CSF leak (60%) followed in frequency by the cribriform plate and the sphenoid sinus (20% each). Follow-up period was 12-24 months. We have achieved a 95% success rate in managing CSF leaks in our 40 patients in the first attempt repair and 100% success rate after second attempt repair. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high success rate and avoid the morbidity associated with craniotomy. Using the three-layer, sandwich-grafting technique of facia lata further adds more security to the sealing of CSF and augments the results of repair.

Spontaneous cerebrospinal fluid leak repair: A five‐year prospective evaluation

Mounting evidence indicates the majority of spontaneous cerebrospinal fluid (CSF) leaks are associated with intracranial hypertension. The objectives of the current study were to assess outcomes regarding spontaneous CSF leaks focusing on premorbid factors, surgical technique, and management of intracranial pressure. Prospective cohort. Prospective evaluation of patients with spontaneous CSF leaks was performed. Data regarding demographics, nature of presentation, body mass index (BMI), location and size of defect, intracranial pressure, clinical follow-up, and complications were collected. Over 5 years, 46 patients (average age, 51 years) with 56 spontaneous CSF leaks were treated by a single otolaryngologist. Twenty-one subjects presented with recurrence of their CSF leak following previous endoscopic and/or open approaches by other physicians. Obesity was present in 78% of individuals (average BMI, 35.6). Fifty-two CSF leaks (93%) were successfully repaired at first attempt. With secondary repair, all CSF leaks were closed at last clinical follow-up (average, 93 weeks). Three patients developed late failures (>2 months), with one recurrence at a distinct location from the primary site at 8 months postprocedure (associated with ventriculoperitoneal shunt failure). Opening pressures via lumbar puncture averaged 24.3 ± 8.3 cm H2 0, which increased significantly to 32.3 ± 9.0 cm H2 0 (P < .0001) following closure of the skull base defect(s). Management of intracranial hypertension included acetazolamide (n = 23) or permanent CSF diversion (n = 19, including five revisions of failed preexisting shunts). Although spontaneous CSF leaks have the highest recurrence rate of any etiology, prospective evaluation demonstrates high success rates with control of intracranial hypertension.

Training Cerebrospinal Fluid Leak Repair with Nasoseptal Flap on the Lamb's Head

Background: One of the major challenges of cranial base surgery is reconstruction of dural defects and cerebrospinal fluid leak closure. Various grafting methods have been used for smaller skull base defects with great success. The indications for endoscopic reconstruction have recently evolved to encompass much larger breeches in the skull base following tumor removal, thus emphasizing the need for vascularized tissue flaps for reconstruction. Methods: Some authors proposed a pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium, which is very vascularized and has quite a large surface. It is also long enough to easily cover even larger defects of the skull base. The elevation of a nasoseptal flap is based on a particularly advanced surgical technique and thus requires proper training before being performed in a real patient. Results: Anatomical differences between human and lamb heads were observed and explained although they do not affect the procedure of the elevation of the nasoseptal flap. Conclusions: The lamb's head has been shown to be an ideal model for the adequate training of the surgical skills required for this demanding procedure.

Successful Endoscopic Repair of Persistent Cerebrospinal Fluid Leak Following Attempted Transcranial Repair

Endoscopic techniques have become the preferred approach to address cerebrospinal fluid (CSF) leaks in the skull base, as they offer a minimally invasive method to directly visualize and repair the defect. The alternative technique of open craniotomy can still be considered for cases refractory to endoscopic repair; however, few studies have investigated the potential benefits of endoscopic repair for cases of persistent leaks after attempted transcranial repair. We report two such cases of successful long-term endoscopic repair of a persistent CSF leak, and demonstrate that endoscopic repair is a viable option to salvage an unsuccessful intracranial repair.

Diagnostic and Surgical Approach to Anterior Skull Base CSF Leaks in a Rhinology Practice

Background: Cerebrospinal fluid (CSF) leaks result from an abnormal communication between the subarachnoid space and the extracranial space. Leaks that occur at the anterior skull base may manifest with postural headaches, clear rhinorrhea, and a salty metallic taste. They can occur (1) as a poor outcome of a prior sinus or nasal surgery, (2) as the result of trauma, or (3) spontaneously without known cause. The condition can become life-threatening if not evaluated expeditiously. The majority of leaks encountered at our institution were repaired with endoscopic sinus surgery (ESS). The aim of this presentation is to consider our experience over a 6-year period, to evaluate various diagnostic and radiographic modalities prior to repair, and to evaluate the outcomes in patients who underwent an endoscopic repair of CSF leaks of the anterior skull base.