Is a Single-Dose, Single-Agent Perioperative Antibiotic Protocol Adequate for Endoscopic Endonasal Skull Base Surgery? A 10-Year Review of 422 Cases

Abstract Objectives Postoperative meningitis is a rare but potentially fatal complication of endoscopic endonasal skull base surgery. Prophylactic antibiotic use varies considerably worldwide. We sought to analyze the safety of a single-agent, single-dose protocol. Design, Setting, and Participants A retrospective review of 422 procedures performed during 404 admission episodes from 2009 to 2019, encompassing sella, parasella, and other anterior skull base pathologies. Main Outcome Measures Primary outcome measure was development of meningitis within 30 days of surgery. Additional information collected: underlying pathological diagnosis, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, and primary or revision surgery. Results Of 404 admission episodes for endoscopic anterior skull base surgery, 12 cases developed meningitis. Seven had positive CSF cultures and all 12 recovered. For pathology centered on the sella (including pituitary adenoma), the rate of meningitis was 1.1% (3/283). For pathologies demanding an extended approach (including meningioma and craniopharyngioma), the rate of meningitis was 14.5% (9/62). Postoperative CSF leak requiring surgical repair increased the relative risk by 37-fold. There were no cases of meningitis following repair of long-standing CSF fistula or encephalocoele (0/26) and no cases following surgery for sinonasal tumors with skull base involvement (0/33). Conclusion For sella-centered pathologies, a single dose of intravenous co-amoxiclav (or teicoplanin) is associated with rates of meningitis comparable to those reported in the literature. Postoperative meningitis was significantly higher for extended, intradural transphenoidal approaches, especially when postoperative CSF leak occurred. Fastidious efforts to prevent postoperative CSF leak are crucial to minimizing risk of meningitis.

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Endoscopic Endonasal versus Open Repair of Anterior Skull Base CSF Leak, Meningocele, and Encephalocele: A Systematic Review of Outcomes

Journal of Neurological Surgery Part A Central European Neurosurgery ◽

10.1055/s-0032-1325636 ◽

2012 ◽

Vol 74 (04) ◽

pp. 239-250 ◽

Cited By ~ 49

Author(s):

Ricardo Komotar ◽

Robert Starke ◽

Vijay Anand ◽

Theodore Schwartz ◽

Daniel Raper

Keyword(s):

Systematic Review ◽

Skull Base ◽

Open Repair ◽

Anterior Skull Base ◽

Csf Leak ◽

Endoscopic Endonasal

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Combined endoscopy-assisted cranionasal approach for resection of infantile myofibromatosis of the ethmoid and anterior skull base

Journal of Neurosurgery Pediatrics ◽

10.3171/ped/2008/2/7/058 ◽

2008 ◽

Vol 2 (1) ◽

pp. 58-62 ◽

Cited By ~ 10

Author(s):

Ercole Galassi ◽

Ernesto Pasquini ◽

Giorgio Frank ◽

Gianluca Marucci

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Radical Resection ◽

Permanent Tooth ◽

Anterior Skull Base ◽

Facial Growth ◽

Endoscopic Endonasal ◽

Skull Base Reconstruction ◽

Endoscopic Techniques ◽

Tooth Roots

The advent and widespread development of endonasal endoscopic techniques have recently expanded the frontiers of skull base surgery. The reduced invasiveness, wider and adjustable visualization of the operative field, and lack of postoperative cosmetic defects are well-known advantages of the endonasal endoscopic approaches compared with traditional surgical exposures both in adults and in children. The need to avoid disruption of facial growth centers and permanent tooth roots represents a further special consideration in favor of these endoscopic techniques in children. The authors report on a case of solitary myofibroma involving the ethmoid, mesial orbits, and anterior skull base with intracranial intradural expansion in a 17-month-old girl. The occurrence of such proliferative disease along the skull base is exceedingly rare. The tumor was successfully excised via an endoscopy-assisted cranionasal approach in which a transcranial microsurgical exposure was combined with endonasal endoscopic access to ensure a radical resection and optimize skull base reconstruction. To the authors' knowledge, the patient in this case is the youngest reported patient in the literature who has undergone treatment with this surgical strategy. The outcome in this patient underscores the feasibility and safety of endoscopic endonasal surgery even in toddlers and early childhood.

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Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

Journal of Neurosurgery ◽

10.3171/2014.5.jns132028 ◽

2014 ◽

Vol 121 (4) ◽

pp. 961-975 ◽

Cited By ~ 27

Author(s):

Matei A. Banu ◽

Oszkar Szentirmai ◽

Lino Mascarenhas ◽

Al Amin Salek ◽

Vijay K. Anand ◽

...

Keyword(s):

Learning Curve ◽

Skull Base ◽

Skull Base Surgery ◽

Postoperative Management ◽

Csf Leak ◽

Histopathological Diagnosis ◽

Endoscopic Endonasal ◽

Postoperative Imaging ◽

Interhemispheric Fissure ◽

Csf Leaks

Object Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS. Methods The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak. Results The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks. Conclusions Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

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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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Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial

Journal of Neurosurgery ◽

10.3171/2018.4.jns172447 ◽

2019 ◽

Vol 131 (4) ◽

pp. 1172-1178 ◽

Cited By ~ 17

Author(s):

Nathan T. Zwagerman ◽

Eric W. Wang ◽

Samuel S. Shin ◽

Yue-Fang Chang ◽

Juan C. Fernandez-Miranda ◽

...

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Controlled Trial ◽

Csf Leak ◽

Inclusion Criteria ◽

Endoscopic Endonasal ◽

Randomized Controlled ◽

Lumbar Drain ◽

Prospective Randomized Controlled Trial ◽

Csf Leaks

OBJECTIVEBased on a null hypothesis that the use of short-term lumbar drainage (LD) after endoscopic endonasal surgery (EES) for intradural pathology does not prevent postoperative CSF leaks, a trial was conducted to assess the effect of postoperative LD on postoperative CSF leak following standard reconstruction.METHODSA prospective, randomized controlled trial of lumbar drain placement after endoscopic endonasal skull base surgery was performed from February 2011 to March 2015. All patients had 3-month follow-up data. Surgeons were blinded to which patients would or would not receive the drain until after closure was completed. An a priori power analysis calculation assuming 80% of power, 5% postoperative CSF leak rate in the no-LD group, and 16% in the LD group determined a planned sample size of 186 patients. A routine data and safety check was performed with every 50 patients being recruited to ensure the efficacy of randomization and safety. These interim tests were run by a statistician who was not blinded to the arms they were evaluating. This study accrued 230 consecutive adult patients with skull base pathology who were eligible for endoscopic endonasal resection. Inclusion criteria (high-flow leak) were dural defect greater than 1 cm2 (mandatory), extensive arachnoid dissection, and/or dissection into a ventricle or cistern. Sixty patients were excluded because they did not meet the inclusion criteria. One hundred seventy patients were randomized to either receive or not receive a lumbar drain.RESULTSOne hundred seventy patients were randomized, with a mean age of 51.6 years (range 19–86 years) and 38% were male. The mean BMI for the entire cohort was 28.1 kg/m2. The experimental cohort with postoperative LD had an 8.2% rate of CSF leak compared to a 21.2% rate in the control group (odds ratio 3.0, 95% confidence interval 1.2–7.6, p = 0.017). In 106 patients in whom defect size was measured intraoperatively, a larger defect was associated with postoperative CSF leak (6.2 vs 2.9 cm2, p = 0.03). No significant difference was identified in BMI between those with (mean 28.4 ± 4.3 kg/m2) and without (mean 28.1 ± 5.6 kg/m2) postoperative CSF leak (p = 0.79). Furthermore, when patients were grouped based on BMI < 25, 25–29.9, and > 30 kg/m2, no difference was noted in the rates of CSF fistula (p = 0.97).CONCLUSIONSAmong patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study’s inclusion criteria, perioperative LD used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks.Clinical trial registration no.: NCT03163134 (clinicaltrials.gov).

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Predicting post-operative cerebrospinal fluid (CSF) leak following endoscopic transnasal pituitary and anterior skull base surgery: a multivariate analysis

Acta Neurochirurgica ◽

10.1007/s00701-020-04334-5 ◽

2020 ◽

Author(s):

Cathal John Hannan ◽

Hamad Almhanedi ◽

Rafid Al-Mahfoudh ◽

Maneesh Bhojak ◽

Seamus Looby ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Multivariate Analysis ◽

Skull Base ◽

Skull Base Surgery ◽

Anterior Skull Base ◽

Csf Leak

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Use of Mixed Reality Visualization in Endoscopic Endonasal Skull Base Surgery

Operative Neurosurgery ◽

10.1093/ons/opz355 ◽

2019 ◽

Vol 19 (1) ◽

pp. 43-52 ◽

Cited By ~ 2

Author(s):

Joshua Zeiger ◽

Anthony Costa ◽

Joshua Bederson ◽

Raj K Shrivastava ◽

Alfred M C Iloreta

Keyword(s):

Skull Base ◽

Endoscopic Surgery ◽

Mixed Reality ◽

Skull Base Surgery ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

3 Dimensional ◽

Camera View ◽

Clinical Series ◽

Cerebrospinal Fluid Leaks

Abstract BACKGROUND Neuronavigation systems assist with spatial orientation during endoscopic transnasal skull base surgery, but they require a correlation of 3-dimensional (3D) views with 2-dimensional (2D) radiology studies. OBJECTIVE To outline an initial experience with a novel technology platform that provides intraoperative navigation using 3D reconstructions of patient anatomy for endoscopic surgery. METHODS A retrospective study of endoscopic anterior skull base and complex paranasal procedures was performed. Data from preoperative computed tomography and magnetic resonance imaging scans were fused to create 3D digital models of patient anatomy. Using the technology developed by Surgical Theater (Mayfield Village, Ohio), these reconstructions were designed to highlight particular anatomic regions of interest. The models were studied to guide the surgical approach and anticipate critical structures. The reconstructions were linked with the navigational technology created by Brainlab (Munich, Germany) during endoscopic surgery. A dynamic image of the reconstruction was displayed alongside a matching endoscopic camera view. These 2 views could be overlaid to provide an immersive, mixed reality image of the patient's anatomy. RESULTS A total of 134 cases were performed. The pathologies included tumors of the anterior skull base or sinonasal cavity, inflammatory sinus disease, and cerebrospinal fluid leaks. Specific anatomic structures, such as the internal carotid arteries and optic nerves, were chosen for enhancement. Surgeons felt that the technology helped to guide the extent of bony dissection and to identify critical structures. CONCLUSION We describe the first clinical series of complex skull base pathologies treated using a novel mixed reality platform.

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

Neurosurgery ◽

10.1227/01.neu.0000368395.82329.c4 ◽

2010 ◽

Vol 66 (5) ◽

pp. 883-892 ◽

Cited By ~ 66

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.

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Application of hybrid cranioendoscopic approaches in anterior skull base surgery

Neurosurgical Focus: Video ◽

10.3171/2020.4.focusvid.19913 ◽

2020 ◽

Vol 2 (2) ◽

pp. V5

Author(s):

Evan Joyce ◽

Michael Karsy ◽

Serge Makarenko ◽

Gretchen M. Oakley ◽

William T. Couldwell

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Surgical Techniques ◽

Anterior Skull Base ◽

Endoscopic Endonasal ◽

Link Type ◽

Skull Base Defect ◽

Base Lesion

Anterior skull base approaches have included endoscopic or open microsurgical approaches for intracranial pathologies. However, discussion of a combined hybrid, cranioendoscopic approach, leveraging the benefits of both techniques, has been limited. Here we describe a case of a combined endoscopic, endonasal, and open microsurgical frontotemporal approach for resection of a complex anterior skull base lesion. A 62-year-old man with a large meningioma extending intradurally through the cribiform plate and sphenoethmoidal sinuses underwent a cranioendoscopic resection. Surgical techniques, including repair of the anterior skull base defect as well as complication avoidance and the coordination of multiple surgeons, are discussed.The video can be found here: https://youtu.be/Ti9tUUdWgJc.

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