scholarly journals Risk Factors for 30-Day Non-Neurological Morbidity and Cerebrospinal Fluid Leak in Patients Undergoing Surgery for Vestibular Schwannoma

2019 ◽  
Vol 81 (05) ◽  
pp. 546-552
Author(s):  
Yaroslav Gelfand ◽  
Michael Longo ◽  
Naomi Berezin ◽  
Jonathan P. Nakhla ◽  
Rafael De la Garza-Ramos ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Functional Status ◽  
Vestibular Schwannoma ◽  
Operative Time ◽  
Csf Leak ◽  
Nerve Sheath Tumor ◽  
Preoperative Anemia ◽  
Duration Of Surgery ◽  
Csf Leaks

Introduction We analyzed perioperative risk factors for morbidity and mortality for the patients undergoing surgical intervention for vestibular schwannoma along with rates of cerebrospinal fluid (CSF) leaks that required surgery.Materials and Methods Patients undergoing surgery vestibular schwannoma were identified in the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 using current procedural terminology (CPT) codes for posterior fossa surgical approaches and International Classification of Diseases 9th revision (ICD 9) and ICD 10 codes for peripheral nerve sheath tumor. Preoperative laboratories, comorbidities, and operative times were analyzed along with CSF leaks and unplanned returns to the operating room.Results Nine-hundred ninety-three patients fit the inclusion criteria. Average age was 51, 41% were male, and 58% were female. Mortality within 30 days of the operation was very low at 0.4%, complications were 7% with infection being the most common at 2.3%, and unplanned reoperations happened in 7.4% of the cases. Dependent functional status (odds ratio [OR]: 5.7, 95% confidence interval [CI]: 1.9–16.6, p = 0.001), preoperative anemia (OR: 2.4, 95% CI: 1.2–4.5, p = 0.009), and operative time over 8 hours (OR: 1.9, 95% CI: 1.1–3.4, p = 0.017) were the only significant predictors of perioperative complications. CSF leak postoperatively occurred in 37 patients (3.7%). Reoperation for CSF leak was necessary in 56.3% of the cases. Operative time over 8 hours was the only independent significant predictor of postoperative CSF leak (OR: 2.2, 95% CI: 1.1–4.3, p = 0.028).Conclusion Dependent functional status preoperatively, preoperative anemia, and duration of surgery over 8 hours are the greatest predictors of complications in the 30-day postoperative period.

scholarly journals Are there modifiable risk factors to prevent a cerebrospinal fluid leak following vestibular schwannoma surgery?

2015 ◽  
Vol 122 (2) ◽  
pp. 312-316 ◽  
Author(s):  
William R. Copeland ◽  
Grant W. Mallory ◽  
Brian A. Neff ◽  
Colin L. W. Driscoll ◽  
Michael J. Link
Keyword(s):  
Risk Factors ◽  
Vestibular Schwannoma ◽  
Operative Time ◽  
Cerebrospinal Fluid Leak ◽  
Extent Of Resection ◽  
Csf Leak ◽  
Morbidly Obese ◽  
Included Patient ◽  
Increased Risk ◽  
History Of

OBJECT The following study was conducted to identify risk factors for a postoperative CSF leak after vestibular schwannoma (VS) surgery. METHODS The authors reviewed a prospectively maintained database of all patients who had undergone resection of a VS at the Mayo Clinic between September 1999 and May 2013. Patients who developed a postoperative CSF leak within 30 days of surgery were compared with those who did not. Data collected included patient age, sex, body mass index (BMI), tumor size, tumor side, history of prior tumor treatment, operative time, surgical approach, and extent of resection. Both univariate and multivariate regression analyses were performed to evaluate all variables as risk factors of a postoperative CSF leak. RESULTS A total of 457 patients were included in the study, with 45 patients (9.8%) developing a postoperative CSF leak. A significant association existed between increasing BMI and a CSF leak, with those classified as overweight (BMI 25–29.9), obese (BMI 30–39.9), or morbidly obese (BMI ≥ 40) having a 2.5-, 3-, and 6-fold increased risk, respectively. Patients undergoing a translabyrinthine (TL) approach experienced a higher rate of CSF leaks (OR 2.5, 95% CI 1.3–4.6; p = 0.005), as did those who had longer operative times (OR 1.04, 95% CI 1.02–1.07; p = 0.0006). The BMI, a TL approach, and operative time remained independent risk factors on multivariate modeling. CONCLUSIONS Elevated BMI is a risk factor for the development of a postoperative CSF leak following VS surgery. Recognizing this preoperatively can allow surgeons to better counsel patients regarding the risks of surgery as well as perhaps to alter perioperative management in an attempt to decrease the likelihood of a leak. Patients undergoing a TL approach or having longer operative times are also at increased risk of developing a postoperative CSF leak.

Risk Factors for Readmission with Cerebrospinal Fluid Leakage Within 30 Days of Vestibular Schwannoma Surgery

Neurosurgery ◽  
2017 ◽  
Vol 82 (5) ◽  
pp. 630-637 ◽  
Author(s):  
Ali A Alattar ◽  
Brian R Hirshman ◽  
Brandon A McCutcheon ◽  
Clark C Chen ◽  
Thomas Alexander ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Surgical Resection ◽  
Vestibular Schwannoma ◽  
Health Planning ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Case Volume ◽  
Csf Leakage ◽  
First Admission

Abstract BACKGROUND Cerebrospinal fluid (CSF) leak is a well-recognized complication after surgical resection of vestibular schwannomas and is associated with a number of secondary complications, including readmission and meningitis. OBJECTIVE To identify risk factors for and timing of 30-d readmission with CSF leak. METHODS Patients who had undergone surgical resection of a vestibular schwannoma from 1995 to 2010 were identified in the California Office of Statewide Health Planning and Development database. The most common admission diagnoses were identified by International Classification of Disease, ninth Revision, diagnosis codes, and predictors of readmission with CSF leak were determined using logistic regression. RESULTS A total of 6820 patients were identified. CSF leak, though a relatively uncommon cause of admission after discharge (3.52% of all patients), was implicated in nearly half of 490 readmissions (48.98%). Significant independent predictors of readmission with CSF leak were male sex (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.32-2.25), first admission at a teaching hospital (OR 3.32, 95% CI 1.06-10.39), CSF leak during first admission (OR 1.84, 95% CI 1.33-2.55), obesity during first admission (OR 2.10, 95% CI 1.20-3.66), and case volume of first admission hospital (OR of log case volume 0.82, 95% CI 0.70-0.95). Median time to readmission was 6 d from hospital discharge. CONCLUSION This study has quantified CSF leak as an important contributor to nearly half of all readmissions following vestibular schwannoma surgery. We propose that surgeons should focus on technical factors that may reduce CSF leakage and take advantage of potential screening strategies for the detection of CSF leakage prior to first admission discharge.

Risk Factors and Reconstruction Techniques for Persistent Cerebrospinal Fluid Leak in Patients Undergoing Endoscopic Endonasal Approach to the Posterior Fossa

2021 ◽  
Author(s):  
Sergio Torres-Bayona ◽  
Nathalia Velasquez ◽  
Ana Nakassa ◽  
Aldo Eguiluz-Melendez ◽  
Vanessa Hernandez ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Control Group ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Dural Defects ◽  
Csf Leaks

Abstract Background High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p = 0.02). All patients with a persistent CSF leak developed meningitis (p = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients.

scholarly journals Cerebrospinal fluid leakage after cranial surgery in the pediatric population—a systematic review and meta-analysis

2021 ◽  
Author(s):  
Emma M. H. Slot ◽  
Kirsten M. van Baarsen ◽  
Eelco W. Hoving ◽  
Nicolaas P. A. Zuithoff ◽  
Tristan P. C van Doormaal
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Cerebrospinal Fluid ◽  
Pediatric Population ◽  
Meta Analysis ◽  
Leakage Rate ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Cranial Surgery ◽  
Csf Leakage

Abstract Background Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors. Methods The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model. Results Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9). Conclusion The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as “leakage of CSF through the skin,” as an unambiguous definition is fundamental for future research.

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

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.

Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

2018 ◽  
Vol 158 (4) ◽  
pp. 774-776 ◽  
Author(s):  
Zixiang Cong ◽  
Kaidong Liu ◽  
Guodao Wen ◽  
Liang Qiao ◽  
Handong Wang ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Csf Leak ◽  
Anatomical Reconstruction ◽  
Endoscopic Endonasal ◽  
Reconstructive Technique ◽  
Sellar Reconstruction ◽  
Sellar Floor ◽  
Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

2021 ◽  
Author(s):  
Peter A. Benedict ◽  
Joseph R. Connors ◽  
Micah R. Timen ◽  
Nupur Bhatt ◽  
Richard Lebowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Postoperative Period ◽  
Skull Base Surgery ◽  
Tertiary Care ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Predictive Values ◽  
Ventral Skull Base ◽  
Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

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

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.

scholarly journals Delayed Cranioplasty: Outcomes Using Frozen Autologous Bone Flaps

2015 ◽  
Vol 8 (3) ◽  
pp. 190-197 ◽  
Author(s):  
Daniel Hng ◽  
Ivan Bhaskar ◽  
Mumtaz Khan ◽  
Charley Budgeon ◽  
Omprakash Damodaran ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Decompressive Craniectomy ◽  
High Rate ◽  
Csf Leak ◽  
Infection Rates ◽  
Skull Defects ◽  
Patient Morbidity ◽  
Duration Of Surgery ◽  
Autologous Bone ◽  
Infective Complications

Reconstruction of skull defects following decompressive craniectomy is associated with a high rate of complications. Implantation of autologous cryopreserved bone has been associated with infection rates of up to 33%, resulting in considerable patient morbidity. Predisposing factors for infection and other complications are poorly understood. Patients undergoing cranioplasty between 1999 and 2009 were identified from a prospectively maintained database. Records and imaging were reviewed retrospectively. Demographics, the initial craniectomy and subsequent cranioplasty surgeries, complications, and outcomes were recorded. A total of 187 patients underwent delayed cranioplasty using autologous bone flaps cryopreserved at −30°C following decompressive craniectomy. Indications for craniectomy were trauma (77.0%), stroke (16.0%), subarachnoid hemorrhage (2.67%), tumor (2.14%), and infection (2.14%). There were 64 complications overall (34.2%), the most common being infection (11.2%) and bone resorption (5.35%). After multivariate analysis, intraoperative cerebrospinal fluid (CSF) leak was significantly associated with infection, whereas longer duration of surgery and unilateral site were associated with resorption. Cranioplasty using frozen autologous bone is associated with a high rate of infective complications. Intraoperative CSF leak is a potentially modifiable risk factor. Meticulous dissection during cranioplasty surgery to minimize the chance of breaching the dural or pseudodural plane may reduce the chance of bone flap.

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

1998 ◽  
Vol 88 (2) ◽  
pp. 243-246 ◽  
Author(s):  
Wouter I. Schievink ◽  
Vittorio M. Morreale ◽  
John L. D. Atkinson ◽  
Fredric B. Meyer ◽  
David G. Piepgras ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Intracranial Hypotension ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Content Type ◽  
Surgical Exploration ◽  
Fine Print ◽  
Csf Leaks

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

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