Effect of using bone cement (Methyl methacrylate) and lumbar drain in the managing of refractory Cerebrospinal fluid (CSF) leak in the anterior skull base defect, case report

Abstract OBJECTIVE The anterior skull base, in front of the sphenoid sinus, can be approached using a variety of techniques including extended subfrontal, transfacial, and craniofacial approaches. These methods include risks of brain retraction, contusion, cerebrospinal fluid leak, meningitis, and cosmetic deformity. An alternate and more direct approach is the endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach. METHODS An endoscopic, endonasal approach was used to treat a variety of conditions of the anterior skull base arising in front of the sphenoid sinus and between the orbits in a series of 44 patients. A prospective database was used to detail the corridor of approach, closure technique, use of intraoperative lumbar drainage, operative time, and postoperative complications. Extent of resection was determined by a radiologist using volumetric analysis. RESULTS Pathology included meningo/encephaloceles (19), benign tumors (14), malignant tumors (9), and infectious lesions (2). Lumbar drains were placed intraoperatively in 20 patients. The CSF leak rate was 6.8% for the whole series and 9% for intradural cases. Leaks were effectively managed with lumbar drainage. Early reoperation for cerebrospinal fluid (CSF) leak occurred in 1 patient (2.2%). There were no intracranial infections. Greater than 98% resection was achieved in 12 of 14 benign and 5 of 9 malignant tumors. CONCLUSION The endoscopic, endonasal, transethmoidal, transcribriform, transfovea ethmoidalis approach is versatile and suitable for managing a variety of pathological entities. This minimal access surgery is a feasible alternative to transcranial, transfacial, or combined craniofacial approaches to the anterior skull base and anterior cranial fossa in front of the sphenoid sinus. The risk of CSF leak and infection are reasonably low and decrease with experience. Longer follow-up and larger series of patients will be required to validate the long-term efficacy of this minimally invasive approach.

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The Surgical Treatment of Posttraumatic Skull Base Defects with Cerebrospinal Fluid Leak

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0037-1606555 ◽

2017 ◽

Vol 79 (02) ◽

pp. 205-216 ◽

Cited By ~ 1

Author(s):

Ashish Thapa ◽

Bing-Xi Lei ◽

Mei-Guang Zheng ◽

Zhong-Jun Li ◽

Zheng-Hao Liu ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Treatment ◽

Skull Base ◽

Surgical Approach ◽

Common Factors ◽

Csf Leak ◽

Surgical Approaches ◽

Skull Base Defect ◽

The Common ◽

Skull Base Defects

Objectives The objective was to explore further the surgical treatment of posttraumatic skull base defects with cerebrospinal fluid (CSF) leak and to identify the most common factors affecting the surgical treatment of posttraumatic skull base defect with CSF leak retrospectively. Materials and Methods This study included 144 patients with head trauma having skull base defect with CSF leak who had been surgically treated at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from 1998 to June 2016. There were 113 (78.5%) males and 31 (21.5%) females, with age ranging from 1 to 78 years and mean age of 26.58 ± 14.95 years. We explored the surgical approaches for the treatment of the skull base defect and the graft materials used and also measured the association among surgical approaches; location, size, and type of skull base defects; presence or absence of associated intracranial pathologies; postoperative complications; outcome; age; Glasgow outcome score (GOS) at discharge; and days of hospital stay. Results The location, size, and types of skull base defect and the presence of associated intracranial pathologies were the common factors identified not only for choosing the appropriate surgical approach but also for choosing the materials for defect repair, timing of the surgery, and the method used for the defect as well as leak repair. The statistically significant correlation with p < 0.001 was found in this study. Conclusion From this study, we could conclude that size, location, and types of the defect and the presence of associated intracranial injuries were the common factors that affected the surgical treatment of posttraumatic skull base defect with CSF leak. Hence, the importance of careful evaluation of these factors is essential for proper selection of the surgical approach and for avoiding unnecessary hassles.

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Traumatic Nonmissile Penetrating Transnasal Anterior Skull Base Fracture and Brain Injury with Cerebrospinal Fluid Leak: Intraoperative Leak Detection and an Effective Reconstruction Procedure for a Localized Skull Base Defect Especially After Coronavirus Disease 2019 Outbreak

World Neurosurgery ◽

10.1016/j.wneu.2020.05.236 ◽

2020 ◽

Vol 140 ◽

pp. 166-172

Author(s):

Yuichiro Yoneoka ◽

Naotaka Aizawa ◽

Yoriko Nonomura ◽

Manabu Ogi ◽

Yasuhiro Seki ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Brain Injury ◽

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Leak Detection ◽

Anterior Skull Base ◽

Reconstruction Procedure ◽

Skull Base Fracture ◽

Skull Base Defect ◽

Fluid Leak

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Extensive traumatic anterior skull base fractures with cerebrospinal fluid leak: classification and repair techniques using combined vascularized tissue flaps

Journal of Neurosurgery ◽

10.3171/2015.4.jns1528 ◽

2016 ◽

Vol 124 (3) ◽

pp. 647-656 ◽

Cited By ~ 16

Author(s):

Jacob B. Archer ◽

Hai Sun ◽

Phillip A. Bonney ◽

Yan Daniel Zhao ◽

Jared C. Hiebert ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Class Ii ◽

Anterior Skull Base ◽

Csf Leak ◽

Class Iii ◽

Skull Base Fracture ◽

Tissue Flaps ◽

Repair Techniques

OBJECT This article introduces a classification scheme for extensive traumatic anterior skull base fracture to help stratify surgical treatment options. The authors describe their multilayer repair technique for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture using a combination of laterally pediculated temporalis fascial-pericranial, nasoseptal-pericranial, and anterior pericranial flaps. METHODS Retrospective chart review identified patients treated surgically between January 2004 and May 2014 for anterior skull base fractures with CSF fistulas. All patients were treated with bifrontal craniotomy and received pedicled tissue flaps. Cases were classified according to the extent of fracture: Class I (frontal bone/sinus involvement only); Class II (extent of involvement to ethmoid cribriform plate); and Class III (extent of involvement to sphenoid bone/sinus). Surgical repair techniques were tailored to the types of fractures. Patients were assessed for CSF leak at follow-up. The Fisher exact test was applied to investigate whether the repair techniques were associated with persistent postoperative CSF leak. RESULTS Forty-three patients were identified in this series. Thirty-seven (86%) were male. The patients’ mean age was 33 years (range 11–79 years). The mean overall length of follow-up was 14 months (range 5–45 months). Six fractures were classified as Class I, 8 as Class II, and 29 as Class III. The anterior pericranial flap alone was used in 33 patients (77%). Multiple flaps were used in 10 patients (3 salvage) (28%)—1 with Class II and 9 with Class III fractures. Five (17%) of the 30 patients with Class II or III fractures who received only a single anterior pericranial flap had persistent CSF leak (p < 0.31). No CSF leak was found in patients who received multiple flaps. Although postoperative CSF leak occurred only in high-grade fractures with single anterior flap repair, this finding was not significant. CONCLUSIONS Extensive anterior skull base fractures often require aggressive treatment to provide the greatest long-term functional and cosmetic benefits. Several vascularized tissue flaps can be used, either alone or in combination. Vascularized flaps are an ideal substrate for cranial base repair. Dual and triple flap techniques that combine the use of various anterior, lateral, and nasoseptal flaps allow for a comprehensive arsenal in multilayered skull base repair and salvage therapy for extensive and severe fractures.

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Management of post-traumatic cerebrospinal fluid (CSF) leak of anterior skull base: 10 years experience

Acta Oto-Laryngologica ◽

10.3109/00016489.2013.793821 ◽

2013 ◽

Vol 133 (9) ◽

pp. 944-950 ◽

Cited By ~ 10

Author(s):

Clement Schoentgen ◽

Pierre Louis Henaux ◽

Benoit Godey ◽

Franck Jegoux

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Anterior Skull Base ◽

Csf Leak ◽

Post Traumatic

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Postoperative Cerebrospinal Fluid Leak after Septoplasty: A Potential Complication of Occult Anterior Skull Base Encephalocele

Allergy & Rhinology ◽

10.2500/ar.2013.4.0043 ◽

2013 ◽

Vol 4 (1) ◽

pp. ar.2013.4.0043 ◽

Cited By ~ 5

Author(s):

Resha S. Soni ◽

Osamah J. Choudhry ◽

James K. Liu ◽

Jean Anderson Eloy

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Anterior Skull Base ◽

Intracranial Abscess ◽

Ethmoid Bone ◽

Csf Rhinorrhea ◽

Csf Leakage ◽

Skull Base Defect ◽

Fluid Leak

Postoperative cerebrospinal fluid (CSF) rhinorrhea after septoplasty is a known entity resulting from errors in surgical technique and improper handling of the perpendicular plate of the ethmoid bone. When these occur, urgent management is necessary to prevent deleterious sequelae such as meningitis, intracranial abscess, and pneumocephalus. Encephaloceles are rare occurrences characterized by herniation of intracranial contents through a skull base defect that can predispose patients to CSF rhinorrhea. In this report, we present a case of CSF rhinorrhea occurring 2 weeks after septoplasty likely from manipulation of an occult anterior skull base encephalocele. To our knowledge, no previous similar case has been reported in the literature. Otolaryngologists should be aware of the possibility of occult encephaloceles while performing septoplasties because minimal manipulation of these entities may potentially result in postoperative CSF leakage.

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The advantages of using auto-fat tissue in the reconstruction of defects of the skull base in patients with CSF leak

OTORHINOLARYNGOLOGY 2-3(2) 2019 - OTORHINOLARYNGOLOGY ◽

10.37219/2528-8253-2018-2-18 ◽

2018 ◽

pp. 18-23

Author(s):

Dmitry Zabolotny ◽

Diana Zabolotnaya ◽

Eldar Ismagilov

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Treatment ◽

Skull Base ◽

Csf Leak ◽

Fat Tissue ◽

Cerebrospinal Fluid Fistula ◽

Overlay Technique ◽

Skull Base Defect ◽

Group 2 ◽

Fluid Fistula

Relevance: At present, the method of repair of the cerebrospinal fluid fistula using mucous flaps according to the “overlay” technique is widely used in the reconstruction of the skull base and is generally accepted. We have developed an original method for reconstructing defects of the skull base in the presence of a cerebrospinal fluid fistula, using an auto-fat tissue and placing it in two layers. Objectives: To conduct a comparative assessment of methods for the reconstruction of the skull base defect in patients with CSF leak using endoscopic endonasal approach. Materials and methods: Under our supervision there were 46 patients with CSF leak. Depending on the technique of cerebrospinal fluid fistula repair, all patients were divided into 2 groups. The first group of 20 patients consisted of patients who underwent surgery with auto-fat tissue according to our proposed technique. The second group - 26 patients were patients who underwent repair of the skull base defect using the standard overlay technique - a mucous flap on the feeding vascular pedicle. The criterion for evaluating the effectiveness of surgical treatment was patient complaints and data from objective research methods (endoscopic examination of the nasal cavity). Results: After 3 months after surgical treatment, a patient of group 1 had a recurrence of liquorrhea, patients of group 2 after 3 months had a recurrence of liquorrhea in 3 patients, after 6 months in 2 patients of group 2 there was a recurrence of liquorrhea. Findings: When the size of the bone defect of the base of the skull is up to 0.6 cm, the original technique proposed by us for plastics of the cerebrospinal fluid fistula with an auto-fat tissue in two layers provides a tight closure of the bone defect and the defect of the dura mater. When using this method of plastics, the risk of the development of a recurrence of CSF leak is significantly reduced in comparison with the plastics of the cerebrospinal fluid fistula with the use of overlay grafts.

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Gigant Transethmoidal Meningoencephalocele Operated by Full Endonasal Endoscopic Approach: Case Report

Case Reports in Medicine ◽

10.1155/2012/763259 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 2

Author(s):

Omar Lopez Arbolay ◽

Jorge Rojas Manresa ◽

Justo Gonzalez Gonzalez ◽

Jose Luis Bretón Rosario

Keyword(s):

Case Report ◽

Skull Base ◽

Skull Base Surgery ◽

Clinical Manifestations ◽

Anterior Skull Base ◽

Endoscopic Approach ◽

Surgical Morbidity ◽

Endoscopic Skull Base Surgery ◽

Watertight Closure ◽

Skull Base Defect

Intranasal meningoencephaloceles have historically been managed by neurosurgeons, although their main clinical manifestations are rhinological. Recent advances in endoscopic skull base surgery has significantly improved the treatment of these lesions and consequently diminished appreciable surgical morbidity. We report an ethmoidal meningoencephalocele case operated on by endonasal endoscopic approach for removal of the lesion and reconstructing the associated skull base. From this experience, we conclude that removal of the lesion and watertight closure of the skull base irrespective of the size of the mass and anterior skull base defect are the operation’s most important aspects.

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