Trans-canal Endoscopic Repair of Cerebrospinal Fluid (CSF) Leak Following Vestibular Schwannoma Resection

Endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea is becoming a common procedure. The purpose of this study was to perform a literature analysis centering cases of treatment failure and to review our 31 cases with a 1-year minimum follow-up. An extensive search of the literature was conducted, which focused on success rate, follow-up, diagnostic techniques, graft material used, failure rate, and comments on failures. A retrospective analysis of our 31 patients was carried out, and all cases were treated with the endoscopic approach with a 1-year minimum follow-up. From the literature analysis, the median success rate at the first endoscopic attempt is 90%. Our success rate was 87.1%. Failures were analyzed. A unique protocol for CSF leak diagnosis does not exist; we suggest our diagnostic algorithm. Graft material used depends on the authors’ experience, and based on this review of cases to date, did not significantly influence the success rate. The analysis of cases of failure shows that the majority of authors omit details. More research is needed to improve prevention of failures.

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Endoscopic cerebrospinal fluid leak repair: how we do it

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20192713 ◽

2019 ◽

Vol 5 (4) ◽

pp. 965

Author(s):

Kalpesh Patel ◽

Abhishek Gugliani ◽

Rajesh Vishwakarma

Keyword(s):

Cerebrospinal Fluid ◽

Cerebrospinal Fluid Leak ◽

Subsequent Treatment ◽

Csf Leak ◽

Open Approach ◽

Endoscopic Repair ◽

Civil Hospital ◽

Medical College ◽

Endoscopic Method ◽

Csf Rhinorrhoea

Background: Cerebrospinal fluid (CSF) rhinorrhoea is characterized by a defect in the barriers which separate the subarachnoid space from sinonasal tract resulting in the leakage of watery fluid from the nose. Management of CSF rhinorrhoea is by both conservative and/or surgical approach. Transnasal endoscopic method has become the preferred surgical method for the repair of CSF leak because of less complication as compared to the open approach. To evaluate the results of patients who underwent endoscopic repair of CSF rhinorrhoea over a period of 5 years at BJ Medical College, Civil Hospital, Ahmedabad.Methods: 118 patients were included in this retrospective study who underwent CSF leak repair by nasal endoscopy over a period of 5 years between 2011-2016 in the department of ENT at BJ Medical College, Civil Hospital, Ahmedabad. As per review of the records, these patients were diagnosed with CSF leak on the basis of their history, clinical examination, and radiological investigations. Materials used for the repair were fat, fascia lata, fibrin sealant, and/or vascular flap. Results: Primary surgery was successful in 110 (93%) of cases. In 8 (7%) cases, there was a recurrence of leak which was managed by either conservative management (5 cases, 4%) or by re-exploration (3 cases, 3%).Conclusions: Transnasal endoscope is an important tool for the evaluation and subsequent treatment of CSF rhinorrhoea. Endoscopic repair of CSF rhinorrhoea is safe, effective, has a low complication rate and has almost completely replaced the open technique.

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The endoscopic treatment of cerebrospinal fluid rhinorrhoea: the Nottingham experience

The Journal of Laryngology & Otology ◽

10.1017/s0022215100136643 ◽

1997 ◽

Vol 111 (2) ◽

pp. 125-128 ◽

Cited By ~ 48

Author(s):

R. G. M. Hughes ◽

N. S. Jones ◽

I. J. A. Robertson

Keyword(s):

Cerebrospinal Fluid ◽

Subsequent Treatment ◽

Endoscopic Approach ◽

Csf Leak ◽

Endoscopic Repair ◽

Closure Rate ◽

Endoscopic Techniques ◽

Csf Rhinorrhoea ◽

Skull Base Defect

AbstractThe conventional neurosurgical management of cerebrospinal fluid (CSF) rhinorrhoea has been by intracranial access. Otorhinolaryngologists have undertaken extracranial approaches where access has been possible, and more recently an endoscopic approach has been advocated. We report 17 patients with confirmed CSF rhinorrhoea treated with endoscopic techniques between 1993 and 1996. Follow-up ranged from four to 32 months and showed an overall closure rate of 16 out of 17 patients with no complications. No patient undergoing primary endoscopic repair developed anosmia. The use of fluorescein helped localize the site of the CSF leak in four patients in whom the computed tomography (CT) scan had not identified the site of the defect.We conclude that the endoscope is a valuable tool in the evaluation and subsequent treatment of CSF rhinorrhoea. Where the skull base defect is accessible to the endoscope, we propose that an endoscopic approach should be considered as the preferred method.

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‘Bath-plug’ technique for the endoscopic management of cerebrospinal fluid leaks

The Journal of Laryngology & Otology ◽

10.1017/s0022215100139295 ◽

1997 ◽

Vol 111 (11) ◽

pp. 1042-1046 ◽

Cited By ~ 78

Author(s):

P. J. Wormald ◽

Mike McDonogh

Keyword(s):

Cerebrospinal Fluid ◽

Endoscopic Sinus Surgery ◽

Sinus Surgery ◽

Csf Leak ◽

Endoscopic Management ◽

Endoscopic Repair ◽

Lumbar Drain ◽

A New Technique ◽

Intradural Space ◽

Csf Leaks

AbstractIn the past cerebrospinal fluid (CSF) leaks were managed via a craniotomy with intradural repair. With the advent of endoscopic sinus surgery, transnasal repair has become more popular. The comparatively low morbidity and high success rate of endoscopic repair has made it the treatment of choice for CSF leak repair. As more surgeons practice endoscopic sinus surgery, the incidence of iatrogenic CSF leaks has increased. It is important that endoscopic sinus surgeons be aware of the techniques for closing such leaks. The aim of this study is to present a new technique for the endoscopic repair of CSF leaks. Since the technique was devised the authors have used the technique on six patients. All patients had lumbar drains inserted and five patients had intra-thecal fluorescein inserted for location of the leak. All repairs have been successful with an average follow-up of 13 months. The technique consists of introducing a fat plug with a specifically secured vicryl suture into the intradural space and placing traction on the suture to seal the defect much as a bath plug seals a bath. There were no complications in any of the patients either intra- or post-operatively. The difficulties and possible complications of the technique as well as the use of a lumbar drain and intra-thecal fluorescein are discussed.

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Long-Term Outcomes of Endoscopic Repair of Cerebrospinal Fluid Leaks and Meningoencephaloceles

American Journal of Rhinology ◽

10.1177/194589240501900609 ◽

2005 ◽

Vol 19 (6) ◽

pp. 582-587 ◽

Cited By ~ 26

Author(s):

Jodi Zuckerman ◽

James A. Stankiewicz ◽

James M. Chow

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Repair ◽

Time Frame ◽

Csf Leak ◽

Endoscopic Repair ◽

Medline Search ◽

Postoperative Time ◽

Time Frames ◽

Csf Leaks

Background The management and surgical approach to cerebrospinal fluid (CSF) leaks and meningoencephaloceles have undergone transformation throughout the last 10 years. It is our interest to examine the long-term surgical outcome and reoccurrence rates of CSF leaks or meningoencephaloceles in patients having endoscopic surgical repair. Methods We performed a retrospective evaluation of 50 patients that underwent endoscopic surgical repair of a CSF leak, meningoencephalocele, or both, between September 1985 and October 2003. Results Cumulatively, reoccurrence rates were 15% (7/47) among the CSF leak patients with an average time frame for reoccurrence ranging from 1 to 25 months (average, 7 months). Patients with meningoencephaloceles had an overall reoccurrence rate of 8% (1/13). In addition, a Medline search on CSF leaks and meningoencephaloceles provided the names of 32 authors that have studied outcomes of endoscopic surgical repair. Of the 151 patients still followed in the 5- to 10-year postoperative group, there were 37 recurrences of CSF leaks and 5 reoccurrences of the meningoencephaloceles with a total recurrence rate of 27% (37 + 5/151). Of the 19 patients still followed in the >10-year postoperative group, there were three reoccurrences of CSF leaks and no reoccurrences of meningoencephaloceles, giving a reoccurrence rate of 16% (3 + 0/19). Conclusion Based on our cumulative results, a reoccurrence of a CSF leak or meningoencephalocele after endoscopic repair will occur within the first 2 years postoperatively. Once patients pass these postoperative time frames they are relatively free of reoccurrence from this very effective surgical management. Endoscopic repair results are better than craniotomy with much less morbidity.

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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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The management of massive pneumocephalus and cerebrospinal fluid rhinorrhoea as a consequence of biopsy in a patient with inverted papilloma

The Journal of Laryngology & Otology ◽

10.1017/s0022215100141374 ◽

1998 ◽

Vol 112 (7) ◽

pp. 657-659 ◽

Cited By ~ 3

Author(s):

U. S. Kale ◽

S. G. Raje ◽

R. G. Wight

Keyword(s):

Cerebrospinal Fluid ◽

Nasal Polyps ◽

Inverted Papilloma ◽

Successful Outcome ◽

Csf Leak ◽

Lateral Rhinotomy ◽

Endoscopic Repair ◽

Cerebrospinal Fluid Rhinorrhoea ◽

Csf Rhinorrhoea

AbstractNasal polypectomy is a common ENT operation. Cerebrospinal fluid (CSF) rhinorrhoea and pneumocephalus are rare complications. We present a patient who developed both these complications after biopsy of nasal polyps which subsequently proved to be an inverted papilloma. He had a defect in the ethmoid roof, which was repaired.Whilst endoscopic repair of CSF leak is increasing in popularity, in this patient because of his pathology and difficulty of access a more traditional lateral rhinotomy approach was made with a successful outcome. An overview of the management of these complications is presented.

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

Neurosurgery ◽

10.1093/neuros/nyx197 ◽

2017 ◽

Vol 82 (5) ◽

pp. 630-637 ◽

Cited By ~ 7

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.

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Fat Implant is Superior to Muscle Implant in Vestibular Schwannoma Surgery for the Prevention of Cerebrospinal Fluid Fistulae

Operative Neurosurgery ◽

10.1227/01.neu.0000310710.70769.81 ◽

2008 ◽

Vol 63 (suppl_1) ◽

pp. ONS38-ONS43 ◽

Cited By ~ 12

Author(s):

Wolf O. Lüdemann ◽

Lennart H. Stieglitz ◽

Venelin Gerganov ◽

Amir Samii ◽

Madjid Samii

Keyword(s):

Cerebrospinal Fluid ◽

Vestibular Schwannoma ◽

Inverse Correlation ◽

Tumor Grade ◽

Petrous Bone ◽

Csf Leak ◽

Fat Tissue ◽

Csf Leakage ◽

Cranial Base Surgery ◽

Air Cells

Abstract Objective: Meticulous sealing of opened air cells in the petrous bone is necessary for the prevention of cerebrospinal fluid (CSF) fistulae after vestibular schwannoma surgery. We performed a retrospective analysis to determine whether muscle or fat tissue is superior for this purpose. Methods: Between January 2001 and December 2006, 420 patients underwent retrosigmoidal microsurgical removal by a standardized procedure. The opened air cells at the inner auditory canal and the mastoid bone were sealed with muscle in 283 patients and with fat tissue in 137 patients. Analysis was performed regarding the incidence of postoperative CSF fistulae and correlation with the patient's sex and tumor grade. Results: The rate of postoperative CSF leak after application of fat tissue was lower (2.2%) than after use of muscle (5.7%). Women had less postoperative CSF leakage (3.4%) than men (5.6%). There was an inverse correlation with tumor grade. Patients with smaller tumors seemed to have a higher rate of CSF leakage than those with large tumors without hydrocephalus. Only large tumors with severe dislocation of the brainstem causing hydrocephalus showed a higher incidence of CSF leaks. Conclusion: Fat implantation is superior to muscle implantation for the prevention of CSF leakage after vestibular schwannoma surgery and should, therefore, be used for the sealing of opened air cells in cranial base surgery.

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Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases

Clinical Rhinology An International Journal ◽

10.5005/jp-journals-10013-1193 ◽

2014 ◽

Vol 7 (2) ◽

pp. 47-51 ◽

Cited By ~ 1

Author(s):

Mohnish Grover ◽

Pawan Singhal ◽

Shashank Nath Singh ◽

Man Prakash Sharma ◽

Avani Jain

Keyword(s):

Cerebrospinal Fluid ◽

Success Rate ◽

Csf Leak ◽

Endoscopic Repair ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Endoscopic Techniques ◽

The Past ◽

Intracranial Complications ◽

Csf Leaks

ABSTRACT Cerebrospinal fluid rhinorrhea results from a breakdown of barriers between the subarachnoid space and aerodigestive tract. Because of the risk of potential intracranial complications, all persistent cerebrospinal fluid (CSF) leaks should be repaired. Over the past few decades, with the advances in endoscopic techniques, the surgical management of CSF rhinorrhea has changed significantly. CSF leak repair has advanced from the conventional open intracranial approaches by neurosurgeons to the transnasal endoscopic ones by otorhinolaryngologists. In this study, 35 patients with CSF leaks underwent endoscopic repair with a 94.3% first attempt success rate, and 100% overall success rate. There were no major intraoperative or postoperative complications. To conclude, the endoscopic approach has a high success rate with minimal morbidity and has therefore, become the preferred method. How to cite this article Jain A, Singhal P, Sharma MP, Singh SN, Grover M. Transnasal Endoscopic Cerebrospinal Fluid Rhinorrhea Repair: Our Experience of 35 Cases. Clin Rhinol An Int J 2014;7(2):47-51.

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