Endonasal Endoscopic Closure of Cerebrospinal Fluid Fistulas at the Anterior Cranial Base

1996 ◽  
Vol 105 (8) ◽  
pp. 620-623 ◽  
Author(s):  
Mislav Gjuric ◽  
Henning Keimer ◽  
Ulrich Goede ◽  
Malte Erik Wigand
Keyword(s):  
Cerebrospinal Fluid ◽  
Soft Tissue Injuries ◽  
Inferior Turbinate ◽  
Cranial Base ◽  
Csf Leak ◽  
Facial Soft Tissue ◽  
Csf Rhinorrhea ◽  
Endoscopic Closure ◽  
Anterior Cranial Base ◽  
Dural Tears

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 × 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

SURGICAL MANAGEMENT OF ANTERIOR CRANIAL BASE FRACTURES WITH CEREBROSPINAL FLUID FISTULAE

Neurosurgery ◽  
2008 ◽  
Vol 62 (2) ◽  
pp. 463-471 ◽  
Author(s):  
Martin Scholsem ◽  
Felix Scholtes ◽  
Frèderick Collignon ◽  
Pierre Robe ◽  
Annie Dubuisson ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Treatment Algorithm ◽  
Cranial Base ◽  
University Hospital ◽  
Csf Leak ◽  
Dural Tear ◽  
Csf Rhinorrhea ◽  
Csf Fistula ◽  
Associated Lesions ◽  
Anterior Cranial Base

Abstract OBJECTIVE The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience. METHODS We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear. RESULTS Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure. CONCLUSION The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

Surgical Strategy for Cerebrospinal Fluid Rhinorrhea Repair

2010 ◽  
Vol 66 (suppl_2) ◽  
pp. ons281-ons286 ◽  
Author(s):  
Pinan Liu ◽  
Shengtian Wu ◽  
Zhi Li ◽  
Bo Wang
Keyword(s):  
Cerebrospinal Fluid ◽  
Nerve Injury ◽  
Frontal Sinus ◽  
Cranial Base ◽  
Neurological Deficits ◽  
Csf Rhinorrhea ◽  
Initial Surgery ◽  
Additional Surgery ◽  
Anterior Cranial Base ◽  
Sphenoid Sinuses

Abstract OBJECTIVE Cerebrospinal fluid (CSF) rhinorrhea is leakage of CSF from the nasal cavity caused by cranial base or meningeal defects. Surgical treatment of CSF rhinorrhea is still problematic. We evaluated the clinical outcomes of 132 consecutive cases of CSF rhinorrhea treated via transcranial or transnasal endoscopic approaches according to the patient's condition. The indications for the approaches are discussed. METHODS Of 132 patients with CSF rhinorrhea, a transnasal endoscopic approach was used in 98 to repair cranial base defects in the ethmoid and sphenoid sinuses. A transcranial intradural approach was used in the remaining 34 patients for frontal sinus defects, multiple fractures of the cranial base, or combination nerve injury. RESULTS CSF rhinorrhea resolved after initial surgery in 124 of 132 patients, giving a success rate of 94%. Of the 8 failures or recurrent cases, 4 were successfully repaired by repeat endoscopic surgery, 2 were cured by transcranial revision surgery, and 2 refused additional surgery (the condition subsequently resolved without treatment in these patients). Postoperative complications included intracranial infection (8 patients) and anosmia (1 patient). No neurological deficits were apparent over the 10-month mean follow-up period. CONCLUSION Transnasal endoscopic repair is a reliable method for CSF rhinorrhea patients whose fistulae are located in the ethmoid and sphenoid sinuses. The transcranial procedure should be the treatment of choice for patients with frontal sinus fracture, multiple or complex anterior cranial base fractures, or nerve injury. A satisfactory surgical outcome depends on exact diagnosis, proper operative approach, and the surgeon's skill and experience.

The Efficacy of Computer Assisted Surgery in the Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

2005 ◽  
Vol 133 (6) ◽  
pp. 936-943 ◽  
Author(s):  
Abtin Tabaee ◽  
Tali L. Kassenoff ◽  
Ashutosh Kacker ◽  
Vijay K. Anand
Keyword(s):  
Cerebrospinal Fluid ◽  
Computer Assisted Surgery ◽  
Sinus Surgery ◽  
Csf Leak ◽  
Computer Assisted ◽  
Csf Rhinorrhea ◽  
Surgical Closure ◽  
Endoscopic Closure ◽  
Computer Assistance ◽  
Significant Difference

OBJECTIVE: To determine the outcome of endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea with and without computer assisted surgery. STUDY DESIGN: A review of all patients undergoing endoscopic closure of CSF rhinorrhea at a tertiary care medical center between 1994 and 2003. Charts from the 24 patients were reviewed for indications, location of leak, type of surgical closure, number of prior closure attempts, graft materials, use of computer assisted surgery, complications, and need for revision surgery. Analysis was performed to determine a possible correlation between success of CSF leak repair and use of computer assisted surgery. RESULTS: The etiology of the leak was previous sinus surgery in 10 patients (41.7%), trauma in 5 patients (20.8%), spontaneous leak in 5 patients (20.8%), and skull base surgery in 4 patients (16.7%). The most common sites of leak were the fovea ethmoidalis in 10 patients (41.7%), cribriform plate in 8 patients (33.3%), and sphenoid sinus in 6 patients (25%). Image guidance was employed in 66.7% (16 patients) of our first attempted repairs. Six patients underwent a total of 9 revision procedures. At last follow-up, 96% of patients had no evidence of CSF rhinorrhea. A comparison of patients in the 2 groups failed to reveal a statistically significant difference in the rate of CSF leak closure. CONCLUSION: Endoscopic closure of CSF rhinorrhea represents a minimally invasive and highly successful procedure. The use of computer assistance may improve the confidence of the surgeon and is a valuable adjunct in this procedure. Our study, however, did not demonstrate an improvement in the rates of successful closure with the use of computer assistance. EBM RATING: C

The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

2018 ◽  
Vol 69 (6) ◽  
pp. 1376-1377
Author(s):  
Razvan Hainarosie ◽  
Teodora Ghindea ◽  
Irina Gabriela Ionita ◽  
Mura Hainarosie ◽  
Cristian Dragos Stefanescu ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Cerebrospinal Fluid ◽  
Intrathecal Injection ◽  
Diagnostic Procedures ◽  
Blue Staining ◽  
Csf Leak ◽  
Glucose Content ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

scholarly journals Iatrogenic cerebrospinal fluid leak after repeated nasal swab tests for COVID-19: illustrative case

2021 ◽  
Vol 2 (17) ◽  
Author(s):  
Johnson Ku ◽  
Chieh-Yi Chen ◽  
Jason Ku ◽  
Hsuan-Kan Chang ◽  
Jau-Ching Wu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Nasal Cavity ◽  
Nasal Swab ◽  
Cerebrospinal Fluid Leak ◽  
Cribriform Plate ◽  
Csf Leak ◽  
Illustrative Case ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Csf Leakage

BACKGROUND Nasal swab tests are one of the most essential tools for screening coronavirus disease 2019 (COVID-19). The authors report a rare case of iatrogenic cerebrospinal fluid (CSF) leak from the anterior skull base after repeated nasal swab tests for COVID-19, which was treated with endoscopic endonasal repair. OBSERVATIONS A 41-year-old man presented with clear continuous rhinorrhea through his left nostril for 5 days after repeated nasal swabbing for COVID-19. There were no obvious risk factors for spontaneous CSF leak. Computed tomography cisternography showed contrast accumulation in the left olfactory fossa and along the left nasal cavity. Such findings aligned with a preliminary diagnosis of CSF leakage through the left cribriform plate. Magnetic resonance imaging confirmed the presence of a CSF fistula between his left cribriform plate and superior nasal concha. The patient underwent endoscopic endonasal repair. CSF rhinorrhea ceased after the surgery, and no recurrence was noted during the 12-week postoperative follow-up period. LESSONS Although rare, iatrogenic CSF leakage can be a serious complication following COVID-19 nasal swab tests, especially when infection may cause significant neurological sequelae. Healthcare providers should become familiar with nasal cavity anatomy and be well trained in performing nasal swab tests.

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.

Extrapolating the Limits of the Nasoseptal Flap With Pedicle Dissection to the Internal Maxillary Artery

2018 ◽  
Vol 16 (1) ◽  
pp. 37-44 ◽  
Author(s):  
Carlos D Pinheiro-Neto ◽  
Maria Peris-Celda ◽  
Tyler Kenning
Keyword(s):  
Cerebrospinal Fluid ◽  
Frontal Sinus ◽  
Cerebrospinal Fluid Leak ◽  
Cranial Base ◽  
Pedicled Flap ◽  
Maxillary Artery ◽  
Internal Maxillary Artery ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Anterior Cranial Base

Abstract BACKGROUND The nasoseptal flap is the main pedicled flap used for endoscopic cranial base reconstruction. For large anterior cranial base defects, the anterior edge is a concern for the nasoseptal flap reach. OBJECTIVE To present a surgical technique that completely releases the vascular pedicle of the nasoseptal flap from the sphenopalatine artery (SPA) foramen improving considerably the reach of the flap. METHODS A patient with left anterior cranial base fracture involving the posterior table of the frontal sinus, who presented with cerebrospinal fluid leak and contused brain herniation to the ethmoid and frontal sinuses. Unilateral endoscopic endonasal anterior cranial base reconstruction was performed with left sided nasoseptal flap. The nasoseptal flap pedicle was dissected and completely released from the SPA foramen. The flap was left attached only to the internal maxillary artery (IMAX) vascular bundle. RESULTS The flap covered the entire left anterior cranial base, from the planum sphenoidale to the posterior table of the frontal sinus. There was complete obliteration of the cerebrospinal fluid fistula postoperatively with resolution of the radiographic pneumocephalus and the patient's rhinorrhea. CONCLUSION The complete release of the nasoseptal flap pedicle from the SPA foramen is feasible and remarkably improves the reach of the flap. It also increases the reconstructive area of the flap since the entire septal mucosa can be used for reconstruction and the pedicle length is based exclusively upon the SPA/IMAX.

Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: Learning from Our Failures

2001 ◽  
Vol 15 (5) ◽  
pp. 333-342 ◽  
Author(s):  
Paolo Castelnuovo ◽  
Silvia Mauri ◽  
Davide Locatelli ◽  
Enzo Emanuelli ◽  
Giovanni Delù ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Csf Leak ◽  
Graft Material ◽  
Literature Analysis ◽  
Endoscopic Repair ◽  
Common Procedure ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea

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.

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 Extracranial Repair of Cerebrospinal Fluid Rhinorrhea

1990 ◽  
Vol 17 (3) ◽  
pp. 320-323 ◽  
Author(s):  
Ian B. Ross ◽  
Austin R.T. Colohan ◽  
Martin J. Black
Keyword(s):  
Cerebrospinal Fluid ◽  
Successful Treatment ◽  
Csf Leak ◽  
High Morbidity ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Transcranial Approach ◽  
Ethmoid Sinuses

ABSTRACT:There has been a recent renewal of interest in the extracranial repair of cerebrospinal fluid rhinorrhea because of the relatively high morbidity associated with the transcranial approach. The authors describe an extracranial approach that involves packing of the sphenoid and ethmoid sinuses on the side of the CSF leak. A case of successful treatment of CSF rhinorrhea by this method is presented. The extracranial approach may be advantageous for the repair of CSF rhinorrhea and the authors advocate an increase in its utilization by neurosurgeons and otolaryngologists working as a team.

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