Letter to the Editor Regarding “The ‘Parachute’ Technique for the Endoscopic Repair of High-Flow Anterior Skull-Base CSF Leaks”

OBJECTIVE Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence. METHODS A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele. RESULTS From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9–38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher’s exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred. CONCLUSIONS Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.

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Correlation of spontaneous and traumatic anterior skull base CSF leak flow rates with fluid pattern on early, delayed, and subtraction volumetric extended echo train T2-weighted MRI

Journal of Neurosurgery ◽

10.3171/2019.10.jns192500 ◽

2019 ◽

pp. 1-9 ◽

Cited By ~ 3

Author(s):

John W. Rutland ◽

Satish Govindaraj ◽

Corey M. Gill ◽

Michael Shohet ◽

Alfred M. C. Iloreta ◽

...

Keyword(s):

Skull Base ◽

Flow Rate ◽

High Flow ◽

Anterior Skull Base ◽

Low Flow ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Csf Leaks ◽

Volumetric Segmentation

OBJECTIVECSF leakage is a potentially fatal condition that may result when a skull base dural defect permits CSF communication between the cranial vault and sinonasal cavities. Flow rate is an important property of CSF leaks that can contribute to surgical decision-making and predispose patients to complications and inferior outcomes. Noninvasive preoperative prediction of the leak rate is challenging with traditional diagnostic tools. The present study compares fluid configurations on early and late volumetric extended echo train T2-weighted MRI by using image tracings and sequence subtraction as a novel method of quantifying CSF flow rate, and it correlates radiological results with intraoperative findings and clinical outcomes.METHODSA total of 45 patients met inclusion criteria for this study and underwent 3-T MRI. Imaging sequences included two identical CUBE T2 (vendor trade name for volumetric extended echo train T2) acquisitions at the beginning and end of the scanning session, approximately 45 minutes apart. Twenty-five patients were confirmed to have definitive spontaneous or traumatic anterior skull base CSF leaks. Semiautomated volumetric segmentation of CSF intensity was performed on both CUBE data sets by using 3D-Slicer software, and volumes were subtracted to obtain accumulated CSF volume. These imaging-derived fluid accumulations were correlated with high- or low-flow states, as well as ultimate treatment outcomes including recurrences.RESULTSOf the 45 patients, 25 (55.6%) had definitive evidence of CSF leakage, and 22 (88%) of these underwent surgical repair. Patients with high-flow CSF leaks had higher early (4.058 cm3 vs 0.982 cm3, p = 0.04), late (4.58 cm3 vs 1.096 cm3, p = 0.04), and accumulated (0.53 cm3 vs 0.11 cm3, p = 0.01) fluid volume measurements than patients with low-flow leaks. The 5 (22.7%) patients who exhibited postoperative CSF leak recurrence had significantly greater early (6.30 cm3 vs 1.23 cm3, p = 0.008) and late (6.87 cm3 vs 1.45 cm3, p = 0.008) volumes. Accumulated volume was not significantly greater in patients with leak recurrence (0.58 cm3 vs 0.22 cm3, p = 0.07). Early, late, and accumulated volumes were significantly correlated with postoperative hospital stay as well as duration of postoperative lumbar drain placement (p < 0.05 for all measures).CONCLUSIONSHigh-resolution CUBE T2 MRI, coupled with precise volumetric segmentation and subtraction of sinonasal hyperintensity, not only demonstrated predictive value in differentiating low- and high-flow CSF leaks, but also correlated with postoperative complications such as leak recurrence. These findings may be useful in the clinical workup and neurosurgical management of patients with skull base CSF leaks.

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Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1693124 ◽

2019 ◽

Vol 81 (06) ◽

pp. 645-650

Author(s):

Roshni V. Khatiwala ◽

Karthik S. Shastri ◽

Maria Peris-Celda ◽

Tyler Kenning ◽

Carlos D. Pinheiro-Neto

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Fascia Lata ◽

High Flow ◽

Csf Leak ◽

Nasoseptal Flap ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Csf Diversion ◽

Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

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Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

Journal of Neurosurgery ◽

10.3171/2018.4.jns18366 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1625-1631 ◽

Cited By ~ 2

Author(s):

Takayuki Ishikawa ◽

Kazuhito Takeuchi ◽

Yuichi Nagata ◽

Jungsu Choo ◽

Teppei Kawabata ◽

...

Keyword(s):

Skull Base ◽

Transsphenoidal Surgery ◽

Skull Base Surgery ◽

Sella Turcica ◽

High Flow ◽

Anterior Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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Purely Endoscopic Repair of Traumatic Cerebrospinal Fluid Rhinorrhea From the Anterior Skull Base

Neurologia medico-chirurgica ◽

10.2176/nmc.51.222 ◽

2011 ◽

Vol 51 (3) ◽

pp. 222-225 ◽

Cited By ~ 10

Author(s):

Mika KOMATSU ◽

Fuminari KOMATSU ◽

Luigi M. CAVALLO ◽

Domenico SOLARI ◽

Vita STAGNO ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Anterior Skull Base ◽

Endoscopic Repair ◽

Cerebrospinal Fluid Rhinorrhea

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Letter to the Editor Regarding “Minimally Invasive Approaches for Anterior Skull Base Meningiomas: Supraorbital Eyebrow, Endoscopic Endonasal, or Combination of Both? Anatomic Study, Limitations, and Surgical Application”

World Neurosurgery ◽

10.1016/j.wneu.2018.03.168 ◽

2018 ◽

Vol 116 ◽

pp. 474 ◽

Cited By ~ 1

Author(s):

Alhusain Nagm ◽

Tetsuyoshi Horiuchi ◽

Kazuhiro Hongo

Keyword(s):

Minimally Invasive ◽

Skull Base ◽

Anterior Skull Base ◽

Anatomic Study ◽

Endoscopic Endonasal ◽

Letter To The Editor ◽

Surgical Application ◽

Skull Base Meningiomas

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Endoscopic Repair of Anterior Skull Base Defects

Otorhinolaryngology, Head and Neck Surgery ◽

10.1007/978-3-540-68940-9_27 ◽

2010 ◽

pp. 281-285

Author(s):

Manuel Bernal-Sprekelsen ◽

Isam Alobid ◽

Joaquim Mullol ◽

Alfonso Garcia-Piñero

Keyword(s):

Skull Base ◽

Anterior Skull Base ◽

Endoscopic Repair ◽

Skull Base Defects

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

American Journal of Rhinology and Allergy ◽

10.1177/1945892418773637 ◽

2018 ◽

Vol 32 (4) ◽

pp. 310-317 ◽

Cited By ~ 3

Author(s):

Kent Lam ◽

Amber U. Luong ◽

William C. Yao ◽

Martin J. Citardi

Keyword(s):

Skull Base ◽

Tertiary Care ◽

Anterior Skull Base ◽

Fat Graft ◽

Skull Base Reconstruction ◽

Autologous Fat ◽

Fat Grafts ◽

Autologous Fat Graft ◽

Skull Base Defects ◽

Csf Leaks

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.

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