Skull Base Repair Research Articles

The Effect of lumbar drains on spontaneous cerebrospinal fluid leak repair.

Objectives:To address the factors affecting recurrence after endoscopic surgical repairs of spontaneous cerebrospinal fluid leak, specifically the influence of using lumbar drains.Methods:This study involved a retrospective data analysis, including a chart review of all spontaneous cerebrospinal fluid (CSF) leak cases who underwent endoscopic anterior skull base repair from 2012-2017 in King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia.Results:Thirteen patients with spontaneous CSF leaks were identified and evaluated. The majority were females (92.3%) with an average body mass index of 34.9. All patients underwent endoscopic repair with intra-operative lumbar drain placement. Patients continued having post-operative lumbar drain for an average of 6.4 days. Four patients (30.8%) developed recurrence; however, only one of those had a documented high opening pressure.Conclusion:Spontaneous CSF leak repairs are at a higher failure risk and may have an underlying pathology involving CSF circulation. The use of lumbar drains and intracranial pressure lowering agents are controversial and seems to be reserved only for high risk patients; however, the higher risk of recurrence in this group may be better managed by proper pre-operative evaluation and selective, patient-specific management protocols.

Repair of bony lateral skull base defects equal to or larger than 10\xa0mm by extracorporeally sewed unit-sandwich graft

ObjectiveTo see effectiveness of the senior author’s repair technique for repair of large (equal to or larger than 10 mm) bony lateral skull base defects.Study designRetrospective.SettingsSecondary/tertiary care center.MethodsWe performed retrospective review of 9 surgeries done in our institution between January 2010 and December 2013 for repair of large lateral bony skull base defects. We defined skull base defects extra-cranially and repaired them intra-cranially. We made an extracorporeal sandwich of autologous fascia-bone-fascia (fascia lata and nasal septal bone) and sewed it together to make it into a unit-sandwich graft. This extracorporeally sewed unit-sandwich graft was then inserted to close the large skull base defects either via (1) a cranial slit-window, or (2) the skull base defect itself. Since skull base is bony, bony repair is preferred. Bone plates that are easily available for skull base repair are calvarial and nasal septal bone. Occasionally, harvest of split calvarial bone carries risk of major complications. We preferred nasal septal bone. Harvesting of septal bone even in children using a posterior incision should not disturb the cartilage growth centers.ResultsAll nine patients were operated by this technique. We had four patients with cerebrospinal fluid leak, and five patients with brain herniation. All these patients had complete reversal of herniation of cranial contents and cessation of cerebrospinal fluid leak. On imaging, in 6 cases the bone graft remained in original intended position after 12 months of surgery. The bone graft was not identifiable in 3 cases.ConclusionThe senior author’s technique using autologous multi-layered graft is simple to master, repeatable and very effective.

A low cost and stepwise training model for skull base repair using a suturing and knotting technique during endoscopic endonasal surgery.

Cerebrospinal fluid leakage is always the primary complication during the endoscopic endonasal skull base surgery. Dural suturing technique may supply a rescue method. However, suturing and knotting in such a deep and narrow space are difficult. Training in the model can improve skills and setting a stepwise curriculum can increase trainers' interest and confidence. We constructed an easy model using silicone and acrylic as sphenoid sinus and using the egg-shell membrane as skull base dura. The training is divided into three steps: Step 1: extracorporeal knot-tying suture on the silicone of sphenoid sinus, Step 2: intra-nasal knot-tying suture on the same silicone, and Step 3: intra-nasal egg-shell membrane knot-tying suture. Fifteen experienced microneurosurgical neurosurgeons (Group A) and ten inexperienced PGY residents (Group B) were recruited to perform the tasks. Performance measures were time, suturing and knotting errors, and needle and thread manipulations. The third step was assessed through the injection of full water into the other side of the egg to verify the watertight suture. The results were compared between two groups. Group A finishes the first and second tasks in significantly less time (total time, 125.1 ± 10.8 vs 195.8 ± 15.9min) and fewer error points (2.4 ± 1.3 vs 5.3 ± 1.0) than group B. There are five trainers in group A who passed the third step, this number in group B was only one. This low cost and stepwise training model improved the suture and knot skills for skull base repair during endoscopic endonasal surgery. Experienced microneurosurgical neurosurgeons perform this technique more competent.

Endoscopic repair of the anterior skull base -is there a learning curve?

Introduction: Endoscopic anterior skull base surgery is now established practice. For skull base teams to manage complex pathology a variety of good dural repair techniques are required. However repairing certain skull base defects can be challenging. We look to see if a learning curve is associated with different types of CSF leaks in the anterior skull baseMethods: Analysis of a prospectively collected database, contain 383 cases, on all endoscopic anterior skull base operations at one UK institution looking at CSF repair. Chi squared statistical analysis was undertaken comparing results from 2009 to 2013 with the 2014 to 2017 results. CSF leaks were categorised as either low flow with defects less than 2cm in diameter or high flow with defects greater than 2cm in diameter associated with a CSF void.Results:137 cases requiring repair were identified. Overall 96% of cases underwent successful primary repair with low flow CSF defects. The primary repair rate was similar in the early and later years.Successful repair of large anterior skull base defects was statistically more likely in the 2014-2017 group 96% compare to the 2009–2013 group 65%.Conclusions: A learning curve for small defects was not seen.However a learning curve does exist in relation to large defects with high flow over the first 20 cases.

Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients.

The authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base reconstruction in the endoscopic era. A retrospective review of a single-institution endonasal endoscopic patient database (April 2010–April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 [no leak], 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared. In total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke’s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0–2 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI ≥ 30 (7/9), lack of buttress (4/9), grade 3 leak (4/9), and postoperative vomiting (4/9). Comparison of the epochs showed that grade 1–3 repair failures decreased from 6/143 (4.1%) to 3/141 (2.1%) and grade 1–3 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1–3 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001). A graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor surgery.

Use of Autologous Fat Grafts for the Endoscopic Reconstruction of Skull Base Defects: Indications, Outcomes, and Complications.

Background The use of abdominal free fat is a traditional surgical method for the repair and reconstruction of the anterior skull base. Our objective is to assess the outcomes associated with the autologous fat graft to endoscopically repair anterior skull base defects at a single tertiary care center. Methods All patients, who underwent endoscopic skull base repair utilizing abdominal free fat from September 2009 to June 2016, were included for retrospective chart review. Evaluated outcome measurements included (1) the successful closure of preoperative and intraoperative cerebrospinal fluid (CSF) leaks and (2) complications at both donor and recipient graft sites during the postoperative periods. Four representative clinical cases have additionally been selected to highlight the common indications for which the fat graft may be effective in skull base reconstruction. Results Of the 27 patients who were identified for inclusion in this review, 25 (92.6%) demonstrated successful repair of preoperative or intraoperative CSF leaks following primary skull base repair. Two patients developed recurrent CSF leaks occurring about 1 week after their primary closures, and a secondary closure rate of 96.3% was achieved with use of fat grafts. Other complications included seroma and hematoma formation at the abdominal donor sites, each occurring in 1 patient. Conclusions The use of autologous fat remains a viable option for grafting material during endoscopic skull base reconstruction. Despite the wide variety of closure techniques in skull base surgery, autologous fat provides safe and easily accessible material to repair CSF leaks.

Endoscopic Transcranial Duraplasty for Rhinoliquorrhea: A Cadaveric Study.

Repair of the anterior skull base for cerebrospinal fluid leak requires either endoscopic endonasal approach or open transcranial approach. To present a less invasive surgical procedure for sealing of the entire anterior fossa floor for traumatic rhinoliquorrhea. Cadaver study in 3 head specimens. Endoscopic placement of a furled bovine pericardial patch bilaterally along the sphenoid ridge and planum in guidewire technique. Unfurling and spreading of the patch under endoscope assistance. Patch placement was feasible in all 3 specimens without visible injuries to the frontal lobes. Dissection and preservation of the olfactory tracts was only possible for 50% of olfactory tracts. Endoscopic transcranial keyhole duraplasty is a promising concept for traumatic rhinoliquorrhea.

Less Is More in Select Pediatric Patients: Conservative Management of Skull Base Repair in the Case of a Complex Clival Chordoma

Less Is More in Select Pediatric Patients: Conservative Management of Skull Base Repair in the Case of a Complex Clival Chordoma

Expanded Endoscopic Endonasal Resection of Retrochiasmatic Craniopharyngioma.

This video abstract demonstrates the use of the expanded endoscopic endonasal approach for the resection of a retrochiasmatic craniopharyngioma. These tumors are notoriously difficult to treat, and many approaches have been tried to facilitate safe and effective resection. The endoscopic endonasal approach has been increasingly utilized for selected sellar/suprasellar pathology. We present the case of a 39-year-old man who was found to have a cystic, partially calcified suprasellar mass consistent with a craniopharyngioma. To facilitate robust skull base repair, a vascularized nasoseptal flap was harvested. A wide sphenoidotomy was performed and the sella and tuberculum were exposed. After the dural opening and arachnoid dissection, the stalk was identified, merging seamlessly with the tumor capsule. The lesion was then internally debulked with the use of an ultrasonic aspirator. The capsule was then dissected off of the optic chiasm, thalamus, and hypothalamus. The cavity was inspected with an angled endoscope to ensure complete resection. A multilayered reconstruction was performed using autologous fascia lata, the previously harvested nasoseptal flap, and dural sealant. Postoperatively, the patient did have expected panhypopituitarism but remained neurologically intact and had improvement in his vision. In conclusion, this video demonstrates how an expanded endonasal approach can be used to safely resect a craniopharyngioma, even when in close proximity to delicate structures such as the optic chiasm. The link to the video can be found at: https://youtu.be/tahjHmrXhc4 .

Multicenter assessment of exclusive endoscopic endonasal approach for the treatment of 53 olfactory neuroblastomas.

Given the particularities of olfactory neuroblastoma (ONB) and the lack of studies on the subject, a multicenter collaborative study was conducted to assess treatment strategy. Fifty-three patients with ONB were included from the French Rare Head and Neck Cancer Expert Network (REFCOR) database: 16T1, 8T2, 19T3, and 10T4. All cases were treated endoscopically with skull base removal and repair in 26 cases (49%) and without external craniotomy. The overall survival (OS) and disease-free survival (DFS) rates at 5 years were 87% and 71%, respectively, with mean follow-up of 45.4 ± 26.5 months. The complication rate was 18.8% with 4 cases of meningitis. Pathological analysis showed positive margins in 26.8%, notably on the dura-mater and periorbita, without impairment of OS or DFS. Forty-eight patients received adjuvant radiotherapy on T ± N. Ten patients had a recurrence (18.9%). Six patients died of their disease. Prophylactic neck irradiation seemed to reduce the recurrence rate. Exclusively endoscopic treatment proved efficient and reliable in a large controlled series.

The use of polydioxanone plates for endoscopic skull base repair.

Many reconstructive techniques and materials have been reported for repair of skull base defects after sinonasal tumor excision, cerebrospinal fluid (CSF) leaks, and coverage of denuded bone. Synthetic materials have been developed for endoscopic skull base repair to avoid donor-site morbidity. Polydioxanone plate is a bioabsorbable implant designed for nasal septal reconstruction and has the ability to retain strength for at least 10 weeks and absorbs in 6 months. This study aimed to describe the use of polydioxanone plates in endoscopic skull base defect and CSF leak repair, and to describe our experience with the surgical technique and postoperative management. This was a retrospective case series of patients who, between May 2013 and December 2015, underwent endoscopic sinus surgery and skull base repair for CSF leak or after excision of a skull base tumor by using polydioxanone plates. Patients who presented with sinonasal inflammatory disease or skull base tumors underwent endoscopic skull base repair by using polydioxanone plates in an underlay fashion and mucosal membrane grafts with or without adjuvant materials in an overlay fashion. The patients were reviewed at 6 days, 6 weeks, and 3 months after surgery. Postoperative adverse events, including CSF leak, infection, bleeding, headache, and graft failure, were recorded. The cases of seven patients (five women, two men; mean age, 53.9 years) were reviewed. Five patients underwent sinonasal tumor resection and two underwent repair for CSF leak. The mean (standard deviation) defect size was 16.4 ± 11.4 mm. There was no evidence of postoperative CSF leak, and lumbar drains were not used. One patient reported transient headache and facial pressure at the 6-week follow-up visit. The surgeons' experience with polydioxanone plate placement, postoperative healing, and follow-up was satisfactory. Polydioxanone could be used to achieve rigid repair of endoscopic skull base defects. These early results, although promising, require validation in clinical trials.

Middle cranial fossa approach to repair tegmen defects assisted by three-dimensionally printed temporal bone models.

To explore the perioperative utility of three-dimensionally (3D)-printed temporal bone models of patients undergoing repair of lateral skull base defects and spontaneous cerebrospinal fluid leaks with the middle cranial fossa approach. Case series. 3D-printed temporal bone models-based on patient-specific, high-resolution computed tomographic imaging-were constructed using inexpensive polymer materials. Preoperatively, the models demonstrated the extent of temporal lobe retraction necessary to visualize the proposed defects in the lateral skull base. Also preoperatively, Silastic sheeting was arranged across the modeled tegmen, marked, and cut to cover all of the proposed defect sites. The Silastic sheeting was then sterilized and subsequently served as a precise intraoperative template for a synthetic dural replacement graft. Of note, these grafts were customized without needing to retract the temporal lobe. Five patients underwent the middle cranial fossa approach assisted by 3D-printed temporal bone models to repair tegmen defects and spontaneous cerebrospinal fluid leaks. No complications were encountered. The prefabricated dural repair grafts were easily placed and fit precisely onto the middle fossa floor without any additional modifications. All defects were covered as predicted by the 3D temporal bone models. At their postoperative visits, all five patients maintained resolution of their spontaneous cerebrospinal fluid leaks. Inexpensive 3D-printed temporal bone models of tegmen defects can serve as beneficial adjuncts during lateral skull base repair. The models provide a panoramic preoperative view of all tegmen defects and allow for custom templating of dural grafts without temporal lobe retraction. 4 Laryngoscope, 127:2347-2351, 2017.

Single Layer Repair of Large Anterior Skull Base Defects without Vascularized Mucosal Flap.

Objectives Bilateral anterior skull base (ASB) defects following endoscopic endonasal tumor resection are most commonly repaired utilizing multilayered reconstruction with a vascularized mucosal flap. Single-layer closure of large ASB defects has been described in the literature but this technique has yet to gain a widespread use. We report our experience with a series of patients who underwent reconstruction of large ASB defects using a single-layer intradural graft, without nasoseptal flaps. We also compared the use of acellular dermal matrix (AlloDerm, LifeCell, Branchburg, New Jersey, United States) or collagen matrix xenograft (Duramatrix, Stryker, Kalamazoo, Michigan, United States) as the graft biomaterial. Design A retrospective case series. Setting Tertiary academic medical center. Main Outcome Measures Postoperative cerebrospinal fluid leak, the number of postoperative debridements, the number of postoperative infections, and time to remucosalization. Results Two patients were reconstructed with AlloDerm and three with Duramatrix, with all patients receiving postoperative external beam radiation. There were no postoperative cerebrospinal fluid leaks identified in these patients during follow-up. The AlloDerm group showed increased postsurgical crusting, the number of clinically apparent postoperative infections, and an increased time to remucosalization. Conclusions Single-layer repair without a vascularized mucosal flap is a viable method of skull base repair for large ASB defects. We found repair with Duramatrix was superior, with less graft crusting and infection, requiring fewer debridements.

The turbinal flap: an additional option for anterior skull base reconstruction. Cadaveric feasibility study and case report

Over the past decade, the treatment of complex intradural and extradural pathologies via expanded endonasal approaches has been made possible by progresses and refinements in skull base reconstruction techniques. The aim of this anatomic study is to describe a novel endonasal flap, the turbinal flap (TF), based on the middle and superior turbinate mucosa and pedicled on the ethmoidal arteries system. Three fresh-frozen (6 sides) cadaver heads previously injected with colored silicone were dissected. A step-by-step description of the surgical technique is provided. Vascularization of the TF and its range of possibilities to cover anterior skull base defects were studied. Flap dimensions and area were measured. A case report where the TF was successfully used is also described. The TF was adequate to repair defects along the entire ethmoid roof. Its pedicle along the skull base was 3.0 cm in length and sagittally oriented. Mean measures of the TF were 3.4 cm (anterior height), 5.5 cm (posterior height), and 4.8 cm (inferior length). Its mean area was 8.6 cm2 . The flap was supplied by rich network of vessels. A demonstrative case of anterior skull base repair after the endoscopic resection of meningocephalocele of the ethmoid roof is reported. The main indication for the TF is the repair of anterior skull base defects involving the ethmoid roof. Its advantages include the double pedicle, rich vascularization, autonomy from the maxillary artery system, and preservation of the olfactory mucosa.

Layered sellar reconstruction with avascular free grafts: Acceptable alternative to the nasoseptal flap for repair of low-volume intraoperative cerebrospinal fluid leak.

Although the nasoseptal flap has become the method of choice for reconstruction of intraoperative cerebrospinal fluid (CSF) leak in endoscopic minimally invasive surgery of the skull base, layered avascular graft techniques, including allografts and middle turbinate mucosal autografts, may provide comparable reconstructive success with decreased nasal morbidity. To describe a method of reconstruction of intraoperative CSF leak in endoscopic surgery of the sella turcica and analyze its postoperative success rate and associated comorbidities. A retrospective review of expanded endonasal sellar tumor resections from 2008-2014 was performed, and cases of layered intraoperative skull base reconstruction with avascular free grafts were identified. Demographic factors and comorbidities that predisposed to reconstruction failure (obstructive sleep apnea, obesity) were determined. Reconstruction-related nasal complications were also identified. Postoperative CSF leak rate was determined, and statistical analysis was performed to identify predictive factors for reconstructive failure. Seventy-three cases were identified. Layered closure with avascular free grafts was performed. There were five cases of postoperative CSF leak (6.85%). The mean follow-up was 19 months (range, 1-76 months). Intraoperative high-flow CSF leak was a significant predictor of reconstruction failure on univariate (odds ratio 22 [95% confidence interval, 2.26-214]; p = 0.008) and multivariate analysis (odds ratio 33.6 [95% confidence interval, 2.30-492]; p = 0.010). There were no significant differences in postoperative leak rates among bony overlay graft types. There were five patients (7.9%) who experienced persistent crusting after surgery. There were no significant differences in crusting rates between allografts and mucosal grafts. There were no postoperative mucoceles. In cases of low-volume intraoperative CSF leak, layered skull base repair with avascular free grafts was an acceptable alternative to the nasoseptal flap, which may reduce prolonged sinonasal healing and donor-site morbidities.

Pattern of head injuries in the recent megaearthquakes in Nepal: an audit to prepare for future!

Introduction and Objective: Nepal falls in very high risk zone for earthquakes. Recently in April 2015, we witnessed the worst human casualty of this century. We present an audit of the head injuries we received at KMCTH during the Mega-earthquake.Materials and Methods: We did an audit of the activities of the department of neurological surgery at KMCTH, during the megaearthquake to identify the pattern of head injuries and make disaster plan for future.Results: We served more than 150 patients in the emergency who approached with head injuries. Majority were concussion with scalp lacerations and after few hours of observations were discharged. However 34 required surgical intervention with 22 being craniotomies for skull base repair and contusions. Strokes also presented during this period possibly due to emotional stress of the happenings. We suffered a double whammy of internal and external disaster as the staff were also threatened and repeated tremors make it difficult to boost the morale and confidence of the service providers. We drafted a disaster protocol for our department in liaison with the hospital and did table top rehearsals for the same.Conclusion: A change in pattern of neurotrauma was seen during the Mega-earthquake. The health facility suffered both internal and external disaster. Better preparedness and protocol based approach with coordination at national level would help us to prepare for future.

Minimal invasive endoscopic neurosurgery

Introduction and Objective: If microscope heralded a new era in delicate and precise neurosurgical procedures, endoscope introduced an element of minimal invasiveness and supplemented microscope where they could not reach. We introduced and have been improving this art in brain and spine surgery and here present our experiences.Materials and Methods: We retrospectively studied patients who underwent endoscopic neurosurgery since July 2014 till January 2016 for brain and spine diseases. Endpoints for the audit were feasibility, reliability, cost effectiveness, extra time taken and morbidity.Results: We used endoscope in 42 cases. Ventriculoscopy was done for endoscopic third ventriculostomy, septoplasty, cyst aspiration and excision and biopsy. Nasal endoscopy was used to excise pituitary tumor and repair skull base CSF leaks. Spinal endoscopy was performed to remove herniated discs and canal stenosis. Endoscope helped in microscopic excision of acoustic schwannoma as well as craniopharyngioma. We did not have any mortality however CSF leaks were seen which was successfully managed. Since endoscopic procedures involve minimal incision and retraction, patients could be discharged early and mobilised. We discuss our learning phase and limitations of the endoscope with videos and case scenarios.Conclusion: A continuous phase of learning and problem solving is required to master the art of minimal invasive neurosurgery. Use of endoscope not only supplemented microscope but in cases of ventricular surgery is beyond comparison. It has minimised morbidity as well as hospital stay and is cosmetically acceptable to patients.

Inferior Frontal Lobe Position after Endoscopic Anterior Skull Base Resection and Repair with Acellular Allograft

Background: Reconstruction methods for large anterior skull base defects vary without consensus on the optimal reconstruction to achieve a water-tight seal and anatomic frontal lobe position. Many have described the use of multilayer closure utilizing a septal flap with excellent results. Unfortunately, a septal flap may not always be available in extensive resections. High success has been reported with single layer reconstruction using acellular allograft. However, it is unclear if there is sufficient support with a single layer reconstruction to achieve anatomic frontal lobe positioning.

Delayed Tension Pneumocephalus Secondary to a Missile Injury Requiring Skull Base Repair

Delayed Tension Pneumocephalus Secondary to a Missile Injury Requiring Skull Base Repair

Endoscopic repair technique for traumatic penetrating injuries of the clivus

Unlike basilar skull fractures, penetrating traumatic injuries to the clivus are uncommon. We present two novel and interesting cases of traumatic crossbow arrow injury and penetrating screwdriver injury to the clivus. A review of the literature describing methods to repair these injuries was performed. A careful, systematic approach is required when working up and treating these injuries, as airway preservation is critical. An adaptation to the previously described “gasket-seal” method for skull base repair was utilized to repair the traumatic cerebrospinal fluid (CSF) fistulas. This repair technique is unique in that it is tailored to a much smaller defect than typical post-surgical defects. Two patients are presented, one with a post-traumatic CSF fistula after penetrating crossbow injury to the clivus and one with a penetrating screwdriver injury to the clivus. The patients were treated successfully with transnasal endoscopic repair with fascia lata graft and a nasoseptal flap, a novel adaptation to the previously described “gasket-seal” technique of skull base repair.