Simulation of Cerebrospinal Fluid Leak Repair Using a 3-Dimensional Printed Model

Background Acquiring proficiency for the repair of a cerebrospinal fluid (CSF) leak is challenging in great part due to its relative rarity, which offers a finite number of training opportunities. Objective The purpose of this study was to evaluates the use of a 3-dimensional (3D) printed, anatomically accurate model to simulate CSF leak closure. Methods Volunteer participants completed two simulation sessions. Questionnaires to assess their professional qualifications and a standardized 5-point Likert scale to estimate the level of confidence, were completed before and after each session. Participants were also queried on the overall educational utility of the simulation. Results Thirteen otolaryngologists and 11 neurosurgeons, met the inclusion criteria. A successful repair of the CSF leak was achieved by 20/24 (83.33%), and 24/24 (100%) during the first and second simulation sessions respectively (average time 04:04 ± 1.39 and 02:10 ± 01:11). Time-to-close-the-CSF-leak during the second session was significantly shorter than the first (p < 0.001). Confidence scores increased across the training sessions (3.3 ± 1.0, before the simulation, 3.7 ± 0.6 after the first simulation, and 4.2 ± 0.4 after the second simulation; p < 0.001). All participants reported an increase in confidence and believed that the model represented a valuable training tool. Conclusions Despite significant differences with varying clinical scenarios, 3D printed models for cerebrospinal leak repair offer a feasible simulation for the training of residents and novice surgeons outside the constrictions of a clinical environment.

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Pneumocephalus and CSF leak secondary to skull base fracture by pyrotechnical object: case report

Peruvian Journal of Neurosurgery ◽

10.53668/2021.pjns33175 ◽

2021 ◽

Vol 3 (3) ◽

Author(s):

Marcos Vilca ◽

◽

Carlos Palacios ◽

Sofía Rosas ◽

Ermitaño Bautista ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Pressure ◽

Skull Base ◽

Rare Complication ◽

Cerebrospinal Fluid Leak ◽

Standing Position ◽

Csf Leak ◽

Skull Base Fracture ◽

Timely Diagnosis ◽

The Right

Introduction: Pneumocephalus is mainly associated with traumatic injuries, being a rare complication but with high mortality rates; it behaves like a space-occupying lesion and increases intracranial pressure. The symptoms are not specific, but in the event of trauma it is necessary to suspect this entity to carry out a timely diagnosis and treatment, since being the product of the skull base fracture it can cause communication with the outside, and the appearance of cerebrospinal fluid (CSF) leak. Clinical Case: a 38-year-old male patient who suffers trauma from a pyrotechnic explosion near his right ear, when handling a pyrotechnic object (whistle) during the New Year, presenting severe pain, slight bleeding in the right ear, feeling faint and holocranial headache that increased in a standing position; likewise, he presents high-flow aqueous secretion (CSF) from the right ear. Brain and skull base tomography (CT) showed air in the intracranial cavity, fracture of the skull base, and the ossicles of the right middle ear. Conservative management was performed using rest and lumbar drainage, presenting a satisfactory evolution. Conclusion: Pneumocephalus is a frequent and expected complication of trauma with a skull base fracture. Its early and timely diagnosis using skull base CT is essential to define therapeutic measures. Accidents due to the misuse of pyrotechnics continue to be a relevant problem in our country. Knowing and disseminating its consequences can help raise awareness in the population. Keywords: Pneumocephalus, Skull Base, Intracranial Pressure, Cerebrospinal Fluid Leak. (Source: MeSH NLM)

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Repair of encephalocele and cerebrospinal fluid leak with the use of bone morphogenetic protein: A case report

Surgical Neurology International ◽

10.25259/sni-137-2019 ◽

2019 ◽

Vol 10 ◽

pp. 55 ◽

Cited By ~ 1

Author(s):

Dejan Slavnic ◽

Doris Tong ◽

Ryan Barrett ◽

Teck-Mun Soo

Keyword(s):

Cerebrospinal Fluid ◽

Bone Morphogenetic Protein ◽

Protein A ◽

Retrospective Chart Review ◽

Standard Technique ◽

Cerebrospinal Fluid Leak ◽

Sudden Onset ◽

Csf Leak ◽

Bony Defect ◽

Morphogenetic Protein

Background: Encephaloceles are rare phenomena which occur when brain parenchyma herniates through a skull defect which, if left untreated, may lead to significant issues such as cerebrospinal fluid (CSF) fistulas, meningitis, and intractable seizures. Due to the rarity and variety in size and location of encephaloceles, no standard technique has been established for the resultant defect. Herein, we demonstrate the safe and effective use of bone morphogenetic protein (BMP) in the repair of CSF leak caused by encephalocele. Case Description: A retrospective chart review was conducted on a 50-year-old female who presented with sudden onset spontaneous right nostril CSF leak due to the right lateral sphenoid sinus recess encephalocele, for which she underwent surgical repair. After resecting the encephalocele, cadaver crushed bone was used to fill the skull base defect. Following, an absorbable sponge from the extra-small BMP kit was cut in half and soaked with recombinant human BMP-2 (rhBMP-2) before being laid over the bony defect. On postoperative clinic visits at 2 weeks and at 3 months, the patient demonstrated good recovery without evidence of recurrent CSF leak. On follow-up computed tomography imaging at 9 months’ postsurgery, there was no evidence of recurrent CSF leak or encephalocele, infection, ectopic bone formation, excessive inflammation, or neoplasm. Conclusion: In this case, we demonstrate the successful use of BMP for the repair of CSF leak due to encephalocele. It is our extrapolation that the pro-inflammatory properties of rhBMP-2 lead to the prevention of recurrent CSF leak.

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

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21421 ◽

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.

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Sternberg's Canal and Defect: Is the Lateral Craniopharyngeal Canal a Source of Spontaneous Cerebrospinal Fluid Leak? Anatomic and Radiological Analysis in Pediatric and Adult Populations

Operative Neurosurgery ◽

10.1093/ons/opaa446 ◽

2021 ◽

Author(s):

Adedamola Adepoju ◽

Lucas P Carlstrom ◽

Christopher S Graffeo ◽

Avital Perry ◽

Carlos Diogenes Pinheiro-Neto ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Adult Population ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Superior Orbital Fissure ◽

Old Patients ◽

Visual Illustration ◽

Craniopharyngeal Canal ◽

High Incidence ◽

Fluid Leak

Abstract BACKGROUND The lateral craniopharyngeal or Sternberg's canal (SC) originates from superior orbital fissure (SOF) and traverses the sphenoid body into the nasopharynx. A remnant of the canal, Sternberg's defect (SD), has been debated as a source of cerebrospinal fluid (CSF) leak. The canal was described in 1888, and there is limited accurate visual illustration in the literature. OBJECTIVE To provide a detailed anatomic and radiological illustration of the canal in pediatric and adult population including the mechanism undermining the incidence of the canal, and the possibility of the canal as a source of CSF leak. METHODS A total of 195 high-resolution computed tomographies (CT) of patients (50 3-yr-old, 20 5-yr-old, and 125 adults) and 43 dry adult skulls (86 sides) were analyzed for a canal matching the description of the SC. RESULTS A SC was identified in 86% of the 3-yr-old and 40% of 5-yr–old patients. The diameter and length were 2.12 mm and 12 mm, respectively. The incidence of the canal decreased with age as sinus pneumatization extended into the sphenoid sinus. Only 0.8% of the adult skull on CT had the canal. The canal was not present on the dry adult skulls examination, but SD was found in 4.65%. CONCLUSION SC exists with high incidence in the pediatric group. Sinus pneumatization obliterates the canal in the adult population, leaving a defect in 4.65% of cases, which given the location and related anatomic structures, is unlikely to be a source of CSF leak.

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Predictive Factors, 30-Day Clinical Outcomes, and Costs Associated with Cerebrospinal Fluid Leak in Pituitary Adenoma Resection

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1679896 ◽

2019 ◽

Vol 81 (01) ◽

pp. 043-055 ◽

Cited By ~ 1

Author(s):

Adish Parikh ◽

Arjun Adapa ◽

Stephen E. Sullivan ◽

Erin L. McKean

Keyword(s):

Cerebrospinal Fluid ◽

Multivariate Analysis ◽

Pituitary Adenoma ◽

Demographic Data ◽

Cerebrospinal Fluid Leak ◽

Hospital Charges ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Financial Variables ◽

Clinical Complications

AbstractCerebrospinal fluid (CSF) leak is a complication of endoscopic endonasal pituitary adenoma resection. Previous studies examining complications of pituitary adenoma resection have not examined associations of an exhaustive list of clinical and financial variables with CSF leak. We designed a retrospective analysis of 334 consecutive patients that underwent endoscopic endonasal pituitary adenoma resection at a single institution over 5 years, analyzing associations between CSF leak and demographic data, operative data, comorbidities, clinical complications and outcomes, costs, charges, and payments. Of the 20 preoperative variables studied, none were positively associated with CSF leak in between-groups comparison, although multivariate analysis revealed an association with a history of radiation to the skull base (odds ratio [OR], 8.67; 95% confidence interval [CI], 0.94–57.03; p < 0.05). CSF leak was associated with a significantly higher rate of postoperative diabetes insipidus (Δ = 33.4%, p = 0.040) and increased length of stay after operation in between-groups comparison. Multivariate analysis on postoperative variables revealed significant associations between CSF leak and intracerebral hemorrhage (OR, 17.44; 95% CI, 0.65–275.3; p < 0.05) and postoperative intracranial infection (OR, 28.73; 95% CI, 2.04–438.7; p < 0.05). Also, CSF leak was associated with significantly higher costs (Δ = $15,643, p < 0.05) and hospital charges (Δ = $46,026, p < 0.05). Operating room time, room and board, and supplies and implants were the strongest cost drivers. This study highlights the difficulty of utilizing preoperative variables to predict CSF leak, the clinical complications and outcomes of leak, and the financial subcategories that drive the costs, charges, and payments associated with this complication.

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Recurrent Spontaneous Spinal Cerebrospinal Fluid Leak Associated with “Nude Nerve Root” Syndrome: Case Report

Neurosurgery ◽

10.1227/01.neu.0000089483.30857.11 ◽

2003 ◽

Vol 53 (5) ◽

pp. 1216-1219 ◽

Cited By ~ 26

Author(s):

Wouter I. Schievink ◽

Line Jacques

Keyword(s):

Cerebrospinal Fluid ◽

Nerve Root ◽

Intracranial Hypotension ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Magnetic Resonance Imaging Examination ◽

Computed Tomographic ◽

Computed Tomographic Myelography ◽

Increased Risk ◽

Csf Leaks

Abstract OBJECTIVE AND IMPORTANCE Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels. CLINICAL PRESENTATION A 29-year-old woman bodybuilder noted an excruciating orthostatic headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak. INTERVENTION The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her headaches. CONCLUSION A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks (“nude nerve root” syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.

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Cerebrospinal Fluid Leak in Transnasal Transsphenoidal Surgery for Pituitary Adenoma and its Management

Bengal Journal of Otolaryngology and Head Neck Surgery ◽

10.47210/bjohns.2021.v29i1.409 ◽

2021 ◽

Vol 29 (1) ◽

pp. 6-10

Author(s):

Sanajeet Singh ◽

Ravi Roy ◽

Vaibhav A Chandankhede ◽

Sunil Goyal ◽

M S Sridhar ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenoma ◽

Skull Base ◽

Cerebrospinal Fluid Leak ◽

Postoperative Recurrence ◽

Favourable Outcome ◽

Csf Leak ◽

Closure Rate ◽

Tertiary Centre ◽

Efficient Management

Introduction Over the past few decades endoscopic transnasal transsphenoidal (ETNTS) approach has been practised for excision of pituitary tumours which has minimised the rate of complications and morbidity. However, cerebrospinal fluid (CSF) leak remains a frequent complication requiring efficient management. Various skull-base repair techniques have been described in the literature all along, but there is no universal protocol for the same. Our study aims to determine an ideal strategy for skull-base repair following ETNTS surgery and suggest a protocol at the tertiary centre for the same. Materials and Methods In this prospective study, patients with pituitary adenoma undergoing ETNTS excision from January 2017 to May 2019 were included. Data were collected based on the intraoperative findings of grade of CSF leak following excision, surgical method for skull-base repair, biomaterials used, and recurrence of CSF leak postoperatively and its management. Results A total of 141 patients between 10 to 74 years of age (mean age 42.6) underwent ETNTS excision of pituitary adenoma. Intraoperative CSF leak was observed in 30.5% patients with 14.1% of grade I, 8.5% of grade II and 7.8% of grade III and repair was done with fat closure, multilayer closure and with naso-septal flap, respectively. Postoperative recurrence of CSF leak was found in 2.83% of total cases and 9.3% of patient with intraoperative leak, which were managed appropriately. Overall closure rate was 100% with no further recurrence of CSF leak. Conclusion Surgical repair of skull-base in CSF leak is challenging and requires management in careful and graded fashion for favourable outcome.

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Osteogenesis imperfecta and cerebrospinal fluid leak: a unique presentation and treatment challenge

Revista de Medicina da UFC ◽

10.20513/2447-6595.2019v59n4p74-78 ◽

2019 ◽

Vol 59 (4) ◽

pp. 74-78

Author(s):

Clara Mota Randal Pompeu ◽

Anna Caroline Rodrigues de Souza Matos ◽

Mirian Mota Randal Pompeu ◽

Luis Fernando Falcão de Castro Meireles ◽

Daniel Aguiar Dias ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Osteogenesis Imperfecta ◽

Bone Fractures ◽

Clinical Status ◽

Sella Turcica ◽

Imaging Study ◽

Cerebrospinal Fluid Leak ◽

Signs And Symptoms ◽

Bone Fragility ◽

Csf Leak

Introduction: Osteogenesis imperfecta (OI) is a heritable disorder of the connective tissue that mainly manifests as bone fragility. Other signs and symptoms may be present, such as sensorineural hearing loss, cardiac malformations, and teeth alterations. Case description: 72-year-old female patient presented with left abundant spontaneous hyaline rhinorrhea, history of several bone fractures since early childhood, and a blue grayish sclera was noted. Cerebrospinal fluid (CSF) leak was diagnosed. Neuroimaging revealed lowering of the sella turcica floor, platybasia, basilar impression, left middle fossa calcified meningioma, syringobulbia, ventricular dilatation, and left ethmoidal fistula. Due to the patient’s age and clinical status, a medical approach was chosen, and treatment with acetazolamide and furosemide in low dosages, which resulted in a decrease of the rhinorrhea. Discussion: Clinical features and imaging study are often sufficient for diagnosis of OI. The neurological and cranial features in OI are varied. CSF leak is not commonly reported and might have been a consequence of bone softening and hydrocephalus. Conclusions: This case represents a treatment challenge, as the surgical results were uncertain, once bone fragility could result in the development of new leaks. Clinical treatment was chosen and resulted in a significant improvement of the symptoms.

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A Case of Petrous Apex Meningocele: Unusual Presentation of Cerebrospinal Fluid Leak Following Adenoidectomy

Journal of Rhinology ◽

10.18787/jr.2020.00328 ◽

2020 ◽

Vol 27 (2) ◽

pp. 135-139

Author(s):

Byung Kil Kim ◽

Yujin Heo ◽

Doo-Sik Kong ◽

Sang Duk Hong

Keyword(s):

Cerebrospinal Fluid ◽

Bacterial Meningitis ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Petrous Apex ◽

Diagnostic Process ◽

Recurrent Meningitis ◽

Csf Rhinorrhea ◽

Leakage Site ◽

Fluid Leak

Cerebrospinal fluid (CSF) leak is possible and can be a cause of recurrent bacterial meningitis. Petrous apex meningocele (PAM) is mostly asymptomatic and is often found during incidental imaging tests. We experienced a case of CSF rhinorrhea with recurrent meningitis in bilateral PAM after adenoidectomy. This report highlights the diagnostic process of CSF leak, identification of leakage site, and surgical approach to petrous apex lesions.

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Cerebrospinal Fluid Leak during Stapes Surgery: Gushing Leaks and Oozing Leaks, Two Different Phenomena

Ear Nose & Throat Journal ◽

10.1177/014556131709600817 ◽

2017 ◽

Vol 96 (8) ◽

pp. 302-308 ◽

Cited By ~ 2

Author(s):

Juan Luis Quesada ◽

Giovanni Cammaroto ◽

Lilla Bonanno ◽

Francesco Galletti ◽

Pedro Quesada

Keyword(s):

Cerebrospinal Fluid ◽

Statistical Analysis ◽

Postoperative Complications ◽

Multicenter Study ◽

Cerebrospinal Fluid Leak ◽

Stapes Surgery ◽

Csf Leak ◽

Clinical Evaluations ◽

Hearing Outcomes ◽

Fluid Leak

Cerebrospinal fluid (CSF) leak is an uncommon event that can occur during stapes surgery. Such leaks can be classified as gushing leaks (stapes gushers) and oozing leaks. A stapes gusher is a massive flow of CSF through the perforated footplate that fills the middle ear suddenly, while an oozing leak is a slower and less profuse flow. We conducted a retrospective, observational, multicenter study of 38 patients—23 men and 15 women, aged 23 to 71 years (mean: 47)—who had experienced a CSF leak during stapes surgery. Patients were divided into various groups according to the type of surgical procedure performed and the type of postoperative complications they experienced. Audiometric and clinical evaluations were carried out pre- and postoperatively. Correlations among surgical variations (total or partial stapedectomy, placement of a prosthesis), hearing outcomes, and the incidence of postoperative complications (postoperative CSF leak and vertigo) were studied. Our statistical analysis revealed that gushing leaks and oozing leaks result in different degrees of hearing impairment and different rates of complications. We recommend that an individual approach be used to manage these complications.

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