Reconstruction Following EEA: A 0.5% CSF Leak Rate in 200 Consecutive Cases

Introduction Post-operative CSF leak still represents the main drawback of Endoscopic Endonasal Approach (EEA), and different reconstructive strategies have been proposed in order to decrease its rate. Objective To critically analyze the effectiveness of different adopted reconstruction strategies in patients that underwent EEA. Materials and methods Adult patients with skull base tumor surgically treated with EEA were retrospectively analyzed. Data recorded for each case concerned patient demographics, type of surgical approach, histotype, anatomical site of surgical approach, intra-operative CSF leak grade (no leak (INL), low flow (ILFL), high flow (IHFL)), reconstructive adopted strategy, Lumbar Drain positioning, post-operative CSF leak rate and intra/post-operative complications. Results A total number of 521 patients (January 2012-December 2019) was included. Intra-operative CSF leak grade showed to be associated with post-operative CSF leak rate. In particular, the risk to observe a post-operative CSF leak was higher when IHFL was encountered (25,5%; Exp(B) 16.25). In particular, vascularized multilayered reconstruction and fat use showed to be effective in lowering post-operative CSF leaks in IHFL (p 0.02). No differences were found considering INL and ILFL groups. Yearly post-operative CSF leak rate analysis showed a significative decreasing trend. Conclusion Intra-operative CSF leak grade strongly affected post-operative CSF leak rate. Multilayer reconstruction with fat and naso-septal flap could reduce the rate of CSF leak in high risk patients. Reconstructive strategies should be tailored according also to the type and the anatomical site of the approach.

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Evaluation of CSF Leak Rate in Acoustic Neuroma Resection and Techniques of Internal Auditory Canal Reconstruction

10.1055/s-0039-1679773 ◽

2019 ◽

Author(s):

Laura Henry ◽

James Naples ◽

Jason Brant ◽

Adam Kaufman ◽

Douglas Bigelow ◽

...

Keyword(s):

Acoustic Neuroma ◽

Internal Auditory Canal ◽

Leak Rate ◽

Csf Leak

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Cerebrospinal Fluid Leak Rate after Vestibular Schwannoma Surgery via Middle Cranial Fossa Approach

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0038-1675752 ◽

2018 ◽

Vol 80 (04) ◽

pp. 437-440 ◽

Cited By ~ 1

Author(s):

Noga Lipschitz ◽

Gavriel D. Kohlberg ◽

Kareem O. Tawfik ◽

Zoe A. Walters ◽

Joseph T. Breen ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Vestibular Schwannoma ◽

Middle Cranial Fossa ◽

Leak Rate ◽

Gross Total Resection ◽

Csf Leak ◽

Tumor Diameter ◽

Total Resection ◽

Csf Leakage ◽

Cranial Fossa

Objective Evaluate the cerebrospinal fluid (CSF) leak rate after the middle cranial fossa (MCF) approach to vestibular schwannoma (VS) resection. Design Retrospective case series. Setting Quaternary referral academic center. Participants Of 161 patients undergoing the MCF approach for a variety of skull base pathologies, 66 patients underwent this approach for VS resection between 2007 and 2017. Main Outcome Measure Postoperative CSF leak rate. Results There were two instances of postoperative CSF leak (3.0%). Age, gender, and BMI were not significantly associated with CSF leak. In the two cases with CSF leakage, tumors were isolated to the internal auditory canal (IAC) and both underwent gross total resection. Both CSF leaks were successfully treated with lumbar drain diversion. For the 64 cases that did not have a CSF leak, 51 were isolated to the IAC, 1 was located only in the cerebellopontine angle (CPA), and 12 were located in both the IAC and CPA. 62 patients underwent gross total resection and 2 underwent near-total resection. Mean maximal tumor diameter in the CSF leak group was 4.5 mm (range: 3–6 mm) versus 10.2 mm (range: 3–19 mm) in patients with no CSF leak (p = 0.03). Conclusions The MCF approach for VS resection is a valuable technique that allows for hearing preservation and total tumor resection and can be performed with a low CSF leakage rate. This rate of CSF leak is less than the reported rates in the literature in regard to both translabyrinthine and retrosigmoid approaches.

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Outcome of hospital discharge on postoperative Day 1 following uncomplicated tethered spinal cord release

Journal of Neurosurgery Pediatrics ◽

10.3171/2015.10.peds15318 ◽

2016 ◽

Vol 17 (6) ◽

pp. 651-656 ◽

Cited By ~ 4

Author(s):

Seerat Poonia ◽

Sarah Graber ◽

C. Corbett Wilkinson ◽

Brent R. O'neill ◽

Michael H. Handler ◽

...

Keyword(s):

Spinal Cord ◽

Length Of Stay ◽

Postoperative Management ◽

Leak Rate ◽

Csf Leak ◽

Quality Improvement Initiative ◽

Dural Defect ◽

The Mean ◽

Spinal Cord Tethering ◽

Csf Leaks

OBJECTIVE Postoperative management following the release of simple spinal cord–tethering lesions is highly variable. As a quality improvement initiative, the authors aimed to determine whether an institutional protocol of discharging patients on postoperative day (POD) 1 was associated with a higher rate of postoperative CSF leaks than the prior protocol of discharge on POD 2. METHODS This was a single-center retrospective review of all children who underwent release of a spinal cord–tethering lesion that was not associated with a substantial fascial or dural defect (i.e., simple spinal cord detethering) during 2 epochs: prior to and following the institution of a protocol for discharge on POD 1. Outcomes included the need for and timing of nonroutine care of the surgical site, including return to the operating room, wound suturing, and nonsurgical evaluation and management. RESULTS Of 169 patients identified, none presented with CSF-related complications prior to discharge. In the preintervention group (n = 113), the postoperative CSF leak rate was 4.4% (5/113). The mean length of stay was 2.3 days. In the postintervention group, the postoperative CSF leak rate was 1.9% (1/53) in the patients with postdischarge follow-up. The mean length of stay in that group was 1.3 days. CONCLUSIONS At a single academic children's hospital, a protocol of discharging patients on POD 1 following uncomplicated release of a simple spinal cord–tethering lesion was not associated with an increased rate of postoperative CSF leaks, relative to the previous protocol. The rates identified are consistent with the existing literature. The authors' practice has changed to discharge on POD 1 in most cases.

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Bone Cement Cranioplasty Reduces Cerebrospinal Fluid Leak Rate after Microvascular Decompression: A Single-Institutional Experience

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0040-1715607 ◽

2020 ◽

Author(s):

Daniel I. Wolfson ◽

Jordan A. Magarik ◽

Saniya S. Godil ◽

Hamid M. Shah ◽

Joseph S. Neimat ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Logistic Regression ◽

Regression Model ◽

Bone Cement ◽

Microvascular Decompression ◽

Cranial Nerve ◽

Logistic Regression Model ◽

Nerve Compression ◽

Leak Rate ◽

Csf Leak

Abstract Background Microvascular decompression (MVD) is a common surgical treatment for cranial nerve compression, though cerebrospinal fluid (CSF) leak is a known complication of this procedure. Bone cement cranioplasty may reduce rates of CSF leak. Objective To compare rates of CSF leak before and after implementation of bone cement cranioplasty for the reconstruction of cranial defects after MVD. Methods Retrospective chart review was performed of patients who underwent MVD through retrosigmoid craniectomy for cranial nerve compression at a single institution from 1998 to 2017. Study variables included patient demographics, medical history, type of closure, and postoperative complications such as CSF leak, meningitis, lumbar drain placement, and ventriculoperitoneal shunt insertion. Cement and noncement closure groups were compared, and predictors of CSF leak were assessed using a multivariate logistic regression model. Results A total of 547 patients treated by 10 neurosurgeons were followed up for more than 20 years, of whom 288 (52.7%) received cement cranioplasty and 259 (47.3%) did not. Baseline comorbidities were not significantly different between groups. CSF leak rate was significantly lower in the cement group than in the noncement group (4.5 vs. 14.3%; p < 0.001). This was associated with significantly fewer patients developing postoperative meningitis (0.7 vs. 5.2%; p = 0.003). Multiple logistic regression model demonstrated noncement closure as the only independent predictor of CSF leak (odds ratio: 3.55; 95% CI: 1.78–7.06; p < 0.001). Conclusion CSF leak is a well-known complication after MVD. Bone cement cranioplasty significantly reduces the incidence of postoperative CSF leak and other complications. Modifiable risk factors such as body mass index were not associated with the development of CSF leak.

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Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection

Operative Neurosurgery ◽

10.1093/ons/opaa212 ◽

2020 ◽

Author(s):

Mostafa Shahein ◽

Alaa S Montaser ◽

Juan M Revuelta Barbero ◽

Guillermo Maza ◽

Alexandre B Todeschini ◽

...

Keyword(s):

Pituitary Adenoma ◽

Skull Base ◽

Collagen Matrix ◽

Leak Rate ◽

Fat Graft ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Group A ◽

Group B

Abstract BACKGROUND Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS The authors’ institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P < .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P < .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.

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Endoscopic Reconstruction of the Cranial Base Using a Pedicled Nasoseptal Flap

Operative Neurosurgery ◽

10.1227/01.neu.0000297074.13423.f5 ◽

2008 ◽

Vol 63 (suppl_1) ◽

pp. ONS44-ONS53 ◽

Cited By ~ 157

Author(s):

Amin B. Kassam ◽

Ajith Thomas ◽

Ricardo L. Carrau ◽

Carl H. Snyderman ◽

Allan Vescan ◽

...

Keyword(s):

Donor Site ◽

Cranial Base ◽

Leak Rate ◽

Original Position ◽

Csf Leak ◽

Wound Complications ◽

Harvesting Technique ◽

Cranial Base Surgery ◽

Reconstructive Technique ◽

Csf Leaks

Abstract Objective: Reconstruction of the cranial base using vascularized tissue promotes rapid and complete healing, thus avoiding complications caused by persistent communication between the cranial cavity and the sinonasal tract. The Hadad-Bassagasteguy flap (HBF), a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, seems to be advantageous for the reconstruction of the cranial base after endonasal cranial base surgery Methods: We performed a retrospective review of patients who underwent endonasal cranial base surgery at the University of Pittsburgh Medical Center from January 30, 2006 to January 30, 2007, identifying patients who experienced reconstruction with a vascularized septal mucosal flap (HBF). We analyzed the demographic data, pathological characteristics, site and extent of resection, use of cerebrospinal fluid (CSF) diversion techniques, and outcome. Results: Seventy-five patients who underwent endonasal cranial base endoscopic surgery received repair with the HBF. In this population, we encountered eight postoperative CSF leaks (10.66%), all in patients who required intra-arachnoidal dissection. When we correct the statistical analysis to include only patients with intra-arachnoidal lesions, the postoperative CSF leak rate is 14.5% (eight of 55 patients). It is notable that six CSF (33%) leaks occurred in our first 25 repairs, whereas we encountered only two postoperative leaks (4%) in the last 50 patients. The corrected CSF leak rate, considering only intra-arachnoidal lesions, was two (5.4%) of 37 patients. This improvement in the CSF leak rate reflects our growing experience and comfort with this reconstructive technique. All of our failures could be matched to a specific technical mistake In addition, we modified the flap-harvesting technique to allow for staged procedures and the removal of caudal lesions. These special circumstances require storage of the flap in the antrum during the removal of caudal lesions, and suturing of the flap in its original position for staged procedures. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with bipolar electrocautery, thereby preserving the flap blood supply. We encountered no infectious or wound complications in this series of patients. The donor site accumulates crusting, which requires debridement until mucosalization is complete; this usually occurs 6 to 12 weeks after surgery. Conclusion: The HBF is a versatile and reliable reconstructive technique for repairing defects of the anterior, middle, clival, and parasellar cranial base. Its use has resulted in a significant decrease in our incidence of CSF leaks after endonasal cranial base surgery. Attention to technical details is of paramount importance to achieve the best outcomes.

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Impact of Reconstruction With Hydroxyapatite Bone Cement on CSF Leak Rate in Retrosigmoid Approach to Vestibular Schwannoma Resection

Otology & Neurotology ◽

10.1097/mao.0000000000003072 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Tiffany Peng Hwa ◽

Neil Luu ◽

Laura E. Henry ◽

James G. Naples ◽

Adam C. Kaufman ◽

...

Keyword(s):

Bone Cement ◽

Vestibular Schwannoma ◽

Retrosigmoid Approach ◽

Leak Rate ◽

Csf Leak

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Barrier-Limited Multimodality Closure for Reconstruction of Wide Sellar Openings

Operative Neurosurgery ◽

10.1227/neu.0b013e318241af25 ◽

2011 ◽

Vol 71 (suppl_1) ◽

pp. ons68-ons76 ◽

Cited By ~ 2

Author(s):

Marvin Bergsneider ◽

Kai Xue ◽

Jeffrey D. Suh ◽

Marilene B. Wang

Keyword(s):

Comparison Group ◽

Medical Center ◽

Mass Effect ◽

Leak Rate ◽

Fat Graft ◽

Csf Leak ◽

Nasoseptal Flap ◽

Membrane Barrier ◽

Cranial Base Surgery ◽

Csf Leaks

Abstract BACKGROUND: Obtaining a watertight reconstruction with a fat graft with wide sellar exposures can be challenging, including the risk of reinstating mass effect with the fat graft. The alternative, a vascularized pedicle nasoseptal flap, may require several days to heal and still has a >5% cerebrospinal fluid (CSF) leak rate. OBJECTIVE: To assess the efficacy of a barrier-limited multimodality (BLMM) closure, consisting of an autograft fat-based watertight seal and limited by a membrane barrier, together with the vascularized nasoseptal flap. METHODS: This is a retrospective review of 27 consecutive patients undergoing endonasal cranial base surgery limited to the sellar-parasellar region at the UCLA Medical Center who experienced an intraoperative CSF leak that was repaired with the BLMM technique. The results of 43 prior case-controlled reconstructions using a nasoseptal flap, without the full BLMM technique, were analyzed as a comparison group. RESULTS: There were no postoperative CSF leaks in the patients reconstructed with the BLMM closure technique. The CSF leak rate for the comparison group receiving nasoseptal flaps was 19%. CONCLUSION: A BLMM closure may further decrease the incidence of postoperative CSF leaks compared with predominant reliance on a nasoseptal flap. The novel membrane barrier allows a watertight inner closure by preventing herniation of the fat autograft into the resection cavity. An outer-layer nasoseptal flap provides a living barrier for optimal long-term defense.

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