Study on Closure of Skull Base Defect Post–Endoscopic Endonasal Transsphenoid Pituitary Surgery: A Novel Flap Design

2019 ◽  
Author(s):  
Gokul Gopi ◽  
Saurav Sarkar ◽  
Sudipta Mohakud ◽  
Ashis Patnaik ◽  
Sumit Bansal ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Fascial Closure ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Flap Repair ◽  
Skull Base Defect ◽  
Nasal Septal Flap

Abstract Objective This study was aimed to compare the closure of skull base defect in endoscopic endonasal transsphenoid surgery of pituitary tumors, using bipedicled nasal septal flap versus fascial closure. The study hypothesis being that bipedicled nasal septal flap is better, compared with fascial closure of skull base defect post–endoscopic endonasal transsphenoid surgery of pituitary tumors. Methods All the eligible patients were randomly divided into two groups and then randomly allocated to the surgeons. In one group, fat and fascia lata was used for closure of the skull base defect and nasal septal flap was not harvested whereas in the other, nasal septal flap was used for closure. Result There was a statistically significant difference in postoperative cerebrospinal fluid leak between the two groups. Patients who had undergone flap repair had lower incidence of postoperative cerebrospinal fluid (CSF) leak. Duration of postoperative hospital stay was also less among the group who underwent flap repair (statistically significant). Conclusion Bipedicled nasal septal flap serves an excellent cover for the skull base defect following endoscopic endonasal transsphenoidal pituitary surgery. It can prevent postoperative CSF leak even in cases where tissue glue is not used.

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.

Endoscopic Endonasal Transethmoidal Transcribriform Transfovea Ethmoidalis Approach to the Anterior Cranial Fossa and Skull Base

Neurosurgery ◽  
2010 ◽  
Vol 66 (5) ◽  
pp. 883-892 ◽  
Author(s):  
Jeffrey P. Greenfield ◽  
Vijay K. Anand ◽  
Ashutosh Kacker ◽  
Michael J. Seibert ◽  
Ameet Singh ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Sphenoid Sinus ◽  
Malignant Tumors ◽  
Anterior Skull Base ◽  
Anterior Cranial Fossa ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Lumbar Drainage ◽  
Cranial Fossa

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.

scholarly journals Differential Diagnosis of Pneumonia as a Complication of Nasal Liquorrhea in the Context of the COVID-19 Pandemic

2021 ◽  
Vol 11 (6) ◽  
pp. 472-480
Author(s):  
E. V. Shelesko ◽  
O. E. Sharipov ◽  
N. A. Chernikova ◽  
O. N. Ershova ◽  
P. L. Kalinin ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Rna Virus ◽  
Endoscopic Endonasal ◽  
Skull Base Defect ◽  
Coronavirus Infection ◽  
Polymerase Chain ◽  
Tomography Scan ◽  
Frosted Glass

Nasal liquorrhea — the outflow of cerebrospinal fluid from the cerebrospinal fluid spaces of the cranial cavity into the nasal cavity or paranasal sinuses due to the presence of a congenital or acquired defect in the bones of the skull base and meninges of various etiologies. Nasal liquorrhea leads to potentially fatal complications: meningitis, meningoencephalitis, pneumocephalus, brain abscess. Also, with nasal liquorrhea, less dangerous complications may occur: aspiration bronchopneumonia and gastritis. The article presents a case of aspiration pneumonitis in two patients with nasal liquorrhea treated at the N.N. N.N. Burdenko during the COVID-19 pandemic. Both patients noted the profuse nature of the nasal liquorrhea, complained of coughing in a horizontal position. In both cases, no RNA virus (SARS-CoV-2) was detected during the polymerase chain reaction. Antibodies (IgG, IgM) to coronavirus were not detected. Computed tomography of the chest organs in both cases revealed areas of frosted glass darkening. Since no data was obtained for coronavirus infection (negative tests for coronavirus, lack of antibodies), changes in the lungs were interpreted as a consequence of constant aspiration of cerebrospinal fluid. The patients were admitted to a separate ward. Both patients underwent endoscopic endonasal plasty of the skull base defect. The postoperative period in both cases was uneventful. In both cases, the patients underwent computed tomography scan of the chest organs one month later. On the photographs, the signs of pneumontis completely regressed.

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

2017 ◽  
Vol 79 (02) ◽  
pp. 205-216 ◽  
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.

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

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.

scholarly journals Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

2018 ◽  
Vol 129 (3) ◽  
pp. 792-796 ◽  
Author(s):  
Eisha A. Christian ◽  
Joshua Bakhsheshian ◽  
Ben A. Strickland ◽  
Vance L. Fredrickson ◽  
Ian A. Buchanan ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Simulation Training ◽  
Training Model ◽  
High Flow ◽  
Csf Leak ◽  
Psychomotor Skills ◽  
Endoscopic Endonasal ◽  
Cadaveric Specimen ◽  
Csf Leaks

OBJECTIVECompetency in endoscopic endonasal approaches (EEAs) to repair high-flow cerebrospinal fluid (CSF) leaks is an essential component of the neurosurgical training process. The objective of this study was to demonstrate the feasibility of a simulation model for EEA repair of anterior skull base CSF leaks.METHODSHuman cadaveric specimens were utilized with a perfusion system to simulate a high-flow CSF leak. Neurological surgery residents (postgraduate year 3 or greater) performed a standard EEA to repair a CSF leak using a combination of fat, fascia lata, and pedicled nasoseptal flaps. A standardized 5-point Likert questionnaire was used to assess the knowledge gained, techniques learned, degree of safety, benefit of CSF perfusion during repair, and pre- and posttraining confidence scores.RESULTSIntrathecal perfusion of fluorescein-infused saline into the ventricular/subarachnoid space was successful in 9 of 9 cases. The addition of CSF reconstitution offered the residents visual feedback for confirmation of intraoperative CSF leak repair. Residents gained new knowledge and a realistic simulation experience by rehearsing the psychomotor skills and techniques required to repair a CSF leak with fat and fascial grafts, as well as to prepare and rotate vascularized nasoseptal flaps. All trainees reported feeling safer with the procedure in a clinical setting and higher average posttraining confidence scores (pretraining 2.22 ± 0.83, posttraining 4.22 ± 0.44, p < 0.001).CONCLUSIONSPerfusion-based human cadaveric models can be utilized as a simulation training model for repairing CSF leaks during EEA.

scholarly journals Cerebrospinal fluid rhinorrhoea in young women after 6.5 years of therapy giant prolactinoma with Cabergolin

2018 ◽  
Vol 11 (4) ◽  
pp. 201-208
Author(s):  
Ludmila I. Astafyeva ◽  
Boris A. Kadashev ◽  
Pavel L. Kalinin ◽  
Maxim A. Kutin ◽  
Yuliya G. Sidneva ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Prolactin Level ◽  
Rare Complication ◽  
Csf Leak ◽  
Complete Regression ◽  
Endoscopic Endonasal ◽  
Giant Prolactinoma ◽  
Long Time ◽  
Case Closure

Cerebrospinal fluid (CSF) leak is a rare complication in of the prolactinomas treatment with dopamine agonists. In most cases CSF leak develops within the first three months of treatment starting. The article presents a rare clinical case – later development of CSF leak after pharmacological treatment of giant prolactinoma. Women 29 years with giant endo-supra-infra-laterasellar pituitary adenoma (8,7 cm in diameter), visual impairment, cachexia, secondary amenorrhea and prolactin level more than 2 million 200 thousand mU/l treated with cabergoline. On this background, complete regression of the tumor, recovery of visual function, body mass and normalization of prolactin level was marked. Nevertheless, after 6.5 years after beginning of cabergoline therapy CSF leak occured, which required endoscopic endonasal surgery with the plastic of a CSF fistula. All patients with large and giant prolactinomas which invade into skull base structures, receiving cabergoline even for a long time, should be aware of the possibility of such complications as CSF leak and, if necessary, should urgent appeals to the otolaryngologist and the neurosurgeon. In this case closure of skull base defect is a main tactics of treatment.

scholarly journals The advantages of using a fragment of the fascia lata and autobone in the reconstruction of defects in the base of the skull in patients with CSF leak

2019 ◽  
pp. 14-20
Author(s):  
Diana Zabolotnaya ◽  
Eldar Ismagilov
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
Csf Leak ◽  
Cerebrospinal Fluid Fistula ◽  
Nasoseptal Flap ◽  
Reconstruction Surgery ◽  
Skull Base Defect ◽  
Base Of The Skull ◽  
Fluid Fistula

Relevance: Diagnosis and treatment of patients with CSF leak, today, is not a fully resolved problem. With small defects in the base of the skull, the overlay technique has worked relatively well. However, when the size of the bone defect is more than 0.6 cm, the surgeon has to resort to the underlay technique of transplant placement. Thus, the search for the optimal technique for reconstruction surgery of the cerebrospinal fluid fistula, especially with large defects of the skull base, is a complex and urgent problem. Purpose of the study: To conduct a comparative assessment of the techniques for reconstruction of the skull base defect lager than 0,6 cm in the anterior cranial fossa in patients with CSF leak using endoscopic endonasal approach. Materials and methods: We observed 44 patients with CSF leak. Depending on the technique of cerebrospinal fluid fistula repair, all patients were divided into 2 groups. The first group of 21 patients was patients who underwent reconstruction surgery of the skull base defect using a generally accepted technique using a fragment of the fascia lata and nasoseptal flap. The second group – 23 patients, consisted of patients who underwent reconstruction surgery with a fragment o fascia lata with fixation of it by a fragment of an autobone according to our technique, followed by the use of a nasoseptal flap. The criterion for evaluating the effectiveness of the surgical treatment was lack of relapse of CSF leak and data from objective research methods (endoscopic examination of the nasal cavity). Results: 1 month after surgical treatment, 3 (14,28%)patients of the 1st group experienced a recurrence of CSF leak, and 1(4,34%) patient of the 2nd group had a recurrence of CSF leak. In 2 patients of the 1st group there was a relapse of CSF leak in the 3rd month of observation, there was no recurrence of CSF leak in patients of the 2nd group, after 6 months in 1 patient of the 1st group there was a relapse of liquorrhea. Conclusions: In patients with CSF leak with a bone defect greater than 0.6 cm, it is appropriate to use the sandwich technique. The technique of reconstruction CSF fistula using a fascia lata with its fixation by autologous bone can significantly reduce the risk of CSF recurrence in comparison with the use of generally accepted techniques for CSF leak. The use of autobone in reconstruction of the cerebrospinal fluid fistula does not affect the change in the architectonics of the nose compared to the generally accepted technique.

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