Hemi-transseptal versus Combined Transseptal/Transnasal Approach to the Sellar Region: Differences in Incidence of Postoperative CSF Leak Rate

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

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Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1304 ◽

2017 ◽

Vol 10 (1) ◽

pp. 42-44

Author(s):

Satyawati Mohindra ◽

Sandeep Mohindra ◽

Kiran Joshi ◽

Harsimrat S Sodhi

Keyword(s):

Magnetic Resonance ◽

Sphenoid Sinus ◽

Lateral Wall ◽

Csf Leak ◽

Nasal Discharge ◽

Transnasal Approach ◽

Csf Rhinorrhea ◽

Repeat Magnetic Resonance Imaging ◽

Computed Tomographic ◽

General Physical

ABSTRACT Objective To report a rare case of delayed spontaneous cerebrospinal fluid (CSF) leak through clival region in the sphenoid sinus. Case report A 35-year-old female presented to our outdoor clinic with watery right nasal discharge for past 2 months, which increased on bending forward. Her medical history, general physical and neurological examinations were unremarkable. High-resolution computed tomographic scan and magnetic resonance cisternography were performed and suggestive of defect in right cribriform plate and right sphenoid sinus. Endoscopic repair was done but same symptoms occurred after 1 month. Repeat magnetic resonance imaging showed fistula in the lateral wall of right sphenoid sinus. Revision endoscopic transnasal CSF rhinorrhea repair was done. Lumbar subarachnoid drain was left in place for 5 days. No recurrence was noted at 12-week follow-up. Conclusion Endoscopic transnasal approach is the best modality of treatment for midline skull base defects. Delayed leaks can present from previously weak areas and all the doubtful areas must be examined during surgery. How to cite this article Mohindra S, Mohindra S, Joshi K, Sodhi HS. Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair. Clin Rhinol An Int J 2017;10(1):42-44.

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Modified transnasal approach to the sellar region

Clinical Neurology and Neurosurgery ◽

10.1016/s0303-8467(97)81967-1 ◽

1997 ◽

Vol 99 ◽

pp. S152-S153

Author(s):

Ari A. Pedrozo ◽

Ricardo Ramina ◽

Joāo J. Maniglia ◽

S. Meneses ◽

Sonival C. Hunhevicz

Keyword(s):

Sellar Region ◽

Transnasal Approach

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Skull base reconstruction: A question of flow? A critical analysis of 521 endoscopic endonasal surgeries

PLoS ONE ◽

10.1371/journal.pone.0245119 ◽

2021 ◽

Vol 16 (3) ◽

pp. e0245119

Author(s):

Giuseppe Di Perna ◽

Federica Penner ◽

Fabio Cofano ◽

Raffaele De Marco ◽

Bianca Maria Baldassarre ◽

...

Keyword(s):

Skull Base ◽

Surgical Approach ◽

Leak Rate ◽

Low Flow ◽

Csf Leak ◽

Anatomical Site ◽

Skull Base Tumor ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Rate Analysis

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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The Corkscrew Technique – A Minimally Invasive, Trans-nasal Anterior Skull Base Reconstruction Using a Wedge-shaped Construct for Treatment of Cerebro-Spinal Fluid Leak

10.21203/rs.3.rs-707136/v1 ◽

2021 ◽

Author(s):

Yazid Samih Badarny ◽

Iddo Paldor ◽

Samih Badarny ◽

Ziv Gil ◽

Gill Sviri

Keyword(s):

Skull Base ◽

Lateral Displacement ◽

Standard Technique ◽

Fascia Lata ◽

Anterior Skull Base ◽

Spinal Fluid ◽

Csf Leak ◽

Transnasal Approach ◽

Skull Base Reconstruction ◽

Csf Leakage

Abstract Background : Cerebro-spinal fluid rhinorrhea may follow surgical and traumatic events, and may be spontaneous. Various techniques have been employed for reconstruction of the skull base following a CSF leak. Recent years have seen the development of endoscopic, transnasal techniques for reconstruction of the anterior skull base. We describe our experience with a novel corkscrew technique (CST), which entails harvesting a fascia lata graft, and placement of a wedge-shaped construct above the aperture in the skull base dura. This technique serves to prevent dislodgement of the construct extracranially, and lateral displacement of the construct away from the opening. Methods : We operated 28 cases of CSF leak, in 26 patients, with a transnasal endoscopic approach. Twelve were operated using the CST and 16 with standard technique (ST), with a mean follow-up of over 5 years.Results : The success rate in alleviating the leak was 91.7% in the CST group, and 87.5% in the ST group. Altogether, our complication rate was 8.3% in the CST group, and 37.5% in the ST group. None of the differences were statistically significant. Conclusions : We recommend the use of a wedge-shaped, fascia lata based construct for transnasal endoscopic repair of anterior skull base CSF leaks. Keywords: rhinorrhea, pituitary adenoma, CSF leakage, endoscopic transnasal approach, fascia lata.

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Endoscopic transnasal resection of anterior cranial fossa meningiomas

Neurosurgical FOCUS ◽

10.3171/foc.2008.25.12.e8 ◽

2008 ◽

Vol 25 (6) ◽

pp. E8 ◽

Cited By ~ 101

Author(s):

Enrico de Divitiis ◽

Felice Esposito ◽

Paolo Cappabianca ◽

Luigi M. Cavallo ◽

Oreste de Divitiis ◽

...

Keyword(s):

Skull Base ◽

Complete Recovery ◽

Postoperative Recovery ◽

Anterior Cranial Fossa ◽

Csf Leak ◽

Transnasal Approach ◽

Olfactory Groove ◽

Csf Leakage ◽

Cranial Fossa ◽

Brain Retraction

Object The extended transnasal approach, a recent surgical advancements for the ventral skull base, allows excellent midline access to and visibility of the anterior cranial fossa, which was previously thought to be approachable only via a transcranial route. The extended transnasal approach allows early decompression of the optic canals, obviates the need for brain retraction, and reduces neurovascular manipulation. Methods Between 2004 and 2007, 11 consecutive patients underwent transnasal resection of anterior cranial fossa meningiomas—4 olfactory groove (OGM) and 7 tuberculum sellae (TSM) meningiomas. Age at surgery, sex, symptoms, and imaging studies were reviewed. Tumor size and tumor extension were estimated, and the anteroposterior, vertical, and horizontal diameters were measred on MR images. Medical records, surgical complications, and outcomes of the patients were collected. Results A gross-total removal of the lesion was achieved in 10 patients (91%), and in 1 patient with a TSM only a near-total (> 90%) resection was possible. Four patients with preoperative visual function defect had a complete recovery, whereas 3 patients experienced a transient worsening of vision, fully recovered within few days. In 3 patients (2 with TSMs and 1 with an OGM), a postoperative CSF leak occurred, requiring a endoscopic surgery for skull base defect repair. Another patient (a case involving a TSM) developed transient diabetes insipidus. The operative time ranged from 6 to 10 hours in the OGM group and from 4.5 to 9 hours in the TSM group. The mean duration of the hospital stay was 13.5 and 10 days in the OGM and TSM groups, respectively. Six patients (3 with OGMs and 3 with TSMs) required a blood transfusion. Surgery-related death occurred in 1 patient with TSM, in whom the tumor was successfully removed. Conclusions The technique offers a minimally invasive route to the midline anterior skull base, allowing the surgeon to avoid using brain retraction and reducing manipulation of the large vessels and optic apparatus; hastens postoperative recovery; and improves patient compliance. Further assessment and refinement are required, particularly because of the potential risk of CSF leakage. Other studies and longer follow-up periods are necessary to ascertain the benefits of the technique.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0036-1579923 ◽

2016 ◽

Vol 77 (S 01) ◽

Author(s):

Amin Kassam ◽

Martin Corsten

Keyword(s):

Leak Rate ◽

Csf Leak

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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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