scholarly journals Circumferential Watertight Dural Repair Using Nitinol U-Clips in Expanded Endonasal and Sublabial Approaches to the Cranial Base

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons448-ons456 ◽  
Author(s):  
Francesco Acerbi ◽  
Eric Genden ◽  
Joshua Bederson
Keyword(s):  
Vascular Diseases ◽  
Cranial Base ◽  
Csf Leak ◽  
Melanoma Metastasis ◽  
Dural Repair ◽  
Dural Closure ◽  
Tuberculum Sellae ◽  
Planum Sphenoidale ◽  
Sublabial Approach ◽  
Csf Leaks

ABSTRACT BACKGROUND: In recent years, significant advances have been made in the field of expanded endonasal approaches that permit treatment of different cranial base intradural lesions. OBJECTIVE: To report our technique of cranial base dural repair by the application of nitinol U-Clips in endoscope-assisted extended endonasal or sublabial approaches. Closure techniques and postoperative cerebrospinal (CSF) leaks are reported. METHODS: We reviewed 11 patients with different kinds of cranial base tumors or vascular diseases (2 tuberculum sellae meningiomas, 1 planum sphenoidale meningioma, 4 craniopharyngiomas, 1 recurrent clival chordoma, 1 esthesioneuroblastoma, 1 ethmoidal melanoma metastasis, 1 basilar trunk aneurysm) who underwent an endoscope-assisted extended endonasal or sublabial approach. Dural repair was performed using nitinol U-Clips to circumferentially suture AlloDerm or fascia lata directly to the existing dural borders. Lumbar drainage was not used in 9 patients and was used in 2 patients for 5 days. Patients were evaluated for the appearance of CSF leaks. RESULTS: Postoperative CSF leak was observed in 1 patient (9%). This required a second transnasal repair. CONCLUSION: Circumferential dural closure with U-Clips is a useful adjunct to prevent CSF leaks after expanded endonasal or sublabial approaches to the cranial base for treatment of intracranial pathology.

Use of a Novel Absorbable Hydrogel for Augmentation of Dural Repair: Results of a Preliminary Clinical Study

2005 ◽  
Vol 57 (suppl_1) ◽  
pp. 146-151 ◽  
Author(s):  
Jeroen D. Boogaarts ◽  
J. André Grotenhuis ◽  
Ronald H.M.A. Bartels ◽  
Tjemme Beems
Keyword(s):  
Valsalva Maneuver ◽  
Csf Leak ◽  
Consecutive Series ◽  
Standard Laboratory ◽  
Dural Repair ◽  
Dural Closure ◽  
Csf Leakage ◽  
And Performance ◽  
Csf Leaks ◽  
Repair Techniques

Abstract OBJECTIVE: To evaluate the safety and performance of a synthetic dural sealant as an adjunct to standard surgical dural repair techniques to prevent cerebrospinal fluid (CSF) leakage. METHODS: This study was designed as a prospective, nonrandomized, single-center clinical trial. The dural sealant is a synthetic absorbable hydrogel. Consecutive series of patients scheduled for elective cranial and intradural spinal surgery were included until a total of 50 applications were achieved. It was used primarily as an adjunct to ensure watertight dural closure. The end point was defined as no leak with the Valsalva maneuver after dural sealant application. The patients were followed up for 3 months after surgery to check for CSF leakage, standard laboratory and neurological examinations, and possible adverse advents. RESULTS: Of the 49 patients, 46 were included and treated with the dural sealant because of spontaneous leak (n = 34; 69%) or leak after the Valsalva maneuver (n = 12; 25%). There was no leak in the other patients (n = 3; 6%). After application of the dural sealant, there was no leak in all 46 patients (100%). Of the 46 patients included, there was one case of overt CSF leak. One patient had a pseudomeningocele. There were no adverse events other than those related to the disease or to the surgical procedure itself. CONCLUSION: The dural sealant, a synthetic absorbable hydrogel, is a useful adjunct to achieve watertight dural closure. Application resulted in 100% closure of intraoperative CSF leaks. There are no evident adverse effects.

scholarly journals Assessment of Mucocele Formation after Endoscopic Nasoseptal Flap Reconstruction of Skull Base Defects

2013 ◽  
Vol 4 (1) ◽  
pp. ar.2013.4.0050 ◽  
Author(s):  
Qasim Husain ◽  
Saurin Sanghvi ◽  
Olga Kovalerchik ◽  
Pratik A. Shukla ◽  
Osamah J. Choudhry ◽  
...  
Keyword(s):  
Skull Base ◽  
Demographic Data ◽  
Cranial Base ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Inherent Risk ◽  
Defect Site ◽  
Skull Base Defects ◽  
Csf Leaks

Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.

Management of cerebrospinal fluid leaks after anterior decompression for ossification of the posterior longitudinal ligament: a review of the literature

2011 ◽  
Vol 30 (3) ◽  
pp. E13 ◽  
Author(s):  
Marcus Mazur ◽  
Gregory F. Jost ◽  
Meic H. Schmidt ◽  
Erica F. Bisson
Keyword(s):  
Treatment Options ◽  
Treatment Algorithm ◽  
Posterior Longitudinal Ligament ◽  
Postoperative Management ◽  
Csf Leak ◽  
Dural Tear ◽  
Anterior Decompression ◽  
Dural Repair ◽  
Increased Risk ◽  
Csf Leaks

Object Anterior decompression is an effective way to treat cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL); however, this approach is associated with an increased risk of a dural tear and resultant CSF leak because fusion of the dura with the ossified PLL is common in these cases. The authors review the literature and present an algorithm for treatment of CSF leaks in these patients. Methods A MEDLINE review was performed to identify papers related to CSF leak after anterior decompression for OPLL, and data were summarized to identify treatment options for various situations. A treatment algorithm was identified based on these findings and the experience of the authors. Results Eleven studies were identified that presented data on intra- and postoperative management of a CSF leak during ventral surgery for OPLL. The incidence of cervical dural tears and CSF leaks after anterior decompression procedures for OPLL ranged from 4.3% to 32%. Techniques including preventative measures, intraoperative dural repair with various materials, and postoperative drainage or shunt placement have all been used. Conclusions Although direct dural repair is the preferred treatment for CSF leak, this technique is not always technically possible. In these cases, intraoperative adjuncts in combination with postoperative measures can be used to decrease the pressure gradient across the dural tear.

Negative-pressure and low-pressure hydrocephalus: the role of cerebrospinal fluid leaks resulting from surgical approaches to the cranial base

2011 ◽  
Vol 115 (5) ◽  
pp. 1031-1037 ◽  
Author(s):  
Aristotelis S. Filippidis ◽  
M. Yashar S. Kalani ◽  
Peter Nakaji ◽  
Harold L. Rekate
Keyword(s):  
Intracranial Pressure ◽  
Negative Pressure ◽  
Subarachnoid Space ◽  
Low Pressure ◽  
Cranial Base ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Ventricular Drainage ◽  
Opening Pressure ◽  
Csf Leaks

Object Negative-pressure and low-pressure hydrocephalus are rare clinical entities that are frequently misdiagnosed. They are characterized by recurrent episodes of shunt failure because the intracranial pressure is lower than the opening pressure of the valve. In this report the authors discuss iatrogenic CSF leaks as a cause of low- or negative-pressure hydrocephalus after approaches to the cranial base. Methods The authors retrospectively reviewed cases of low-pressure or negative-pressure hydrocephalus presenting after cranial approaches complicated with a CSF leak at their institution. Results Three patients were identified. Symptoms of high intracranial pressure and ventriculomegaly were present, although the measured pressures were low or negative. A blocked communication between the ventricles and the subarachnoid space was documented in 2 of the cases and presumed in the third. Shunt revisions failed repeatedly. In all cases, temporary clinical and radiographic improvement resulted from external ventricular drainage at subatmospheric pressures. The CSF leaks were sealed and CSF communication was reestablished operatively. In 1 case, neck wrapping was used with temporary success. Conclusions Negative-pressure or low-pressure hydrocephalus associated with CSF leaks, especially after cranial base approaches, is difficult to treat. The solution often requires the utilization of subatmospheric external ventricular drains to establish a lower ventricular drainage pressure than the drainage pressure created in the subarachnoid space, where the pressure is artificially lowered by the CSF leak. Treatment involves correction of the CSF leak, neck wrapping to increase brain turgor and allow the pressure in the ventricles to rise to the level of the opening pressure of the valve, and reestablishing the CSF route.

Reconstruction After Posterior Cranial Fossa Surgery—Case Report of Application of a Synthetic Tissue Sealant to Augment Dural Closure

US Neurology ◽  
2010 ◽  
Vol 05 (02) ◽  
pp. 85
Author(s):  
Nicholas D Coppa ◽  
Johnny B Delashaw Jr ◽  
◽  
Keyword(s):  
Case Report ◽  
Patient Outcomes ◽  
Posterior Cranial Fossa ◽  
Csf Leak ◽  
Dural Closure ◽  
Wound Breakdown ◽  
Csf Leakage ◽  
Tissue Sealant ◽  
Cranial Fossa ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leakage following cranial surgery is a well-described and potentially devastating complication, particularly in posteriorcranial fossa surgery. If untreated, a persistent CSF leak can evolve into wound breakdown, a surgical-site infection, and meningitis. Themorbidity of a complication following a cranial operation is harmful to the patient. Additionally, complications are a source of elevated medicalcosts. Numerous reconstruction strategies have been developed to thwart the ill effects of CSF leaks on patient outcomes and healthcarefinances. This case report illustrates the method employed at our institution to repair posterior fossa defects following surgery in thecerebellopontine angle.

Endoscopic Reconstruction of the Cranial Base Using a Pedicled Nasoseptal Flap

2008 ◽  
Vol 63 (suppl_1) ◽  
pp. ONS44-ONS53 ◽  
Author(s):  
Amin B. Kassam ◽  
Ajith Thomas ◽  
Ricardo L. Carrau ◽  
Carl H. Snyderman ◽  
Allan Vescan ◽  
...  
Keyword(s):  
Donor Site ◽  
Cranial Base ◽  
Leak Rate ◽  
Original Position ◽  
Csf Leak ◽  
Wound Complications ◽  
Harvesting Technique ◽  
Cranial Base Surgery ◽  
Reconstructive Technique ◽  
Csf Leaks

Abstract Objective: Reconstruction of the cranial base using vascularized tissue promotes rapid and complete healing, thus avoiding complications caused by persistent communication between the cranial cavity and the sinonasal tract. The Hadad-Bassagasteguy flap (HBF), a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, seems to be advantageous for the reconstruction of the cranial base after endonasal cranial base surgery Methods: We performed a retrospective review of patients who underwent endonasal cranial base surgery at the University of Pittsburgh Medical Center from January 30, 2006 to January 30, 2007, identifying patients who experienced reconstruction with a vascularized septal mucosal flap (HBF). We analyzed the demographic data, pathological characteristics, site and extent of resection, use of cerebrospinal fluid (CSF) diversion techniques, and outcome. Results: Seventy-five patients who underwent endonasal cranial base endoscopic surgery received repair with the HBF. In this population, we encountered eight postoperative CSF leaks (10.66%), all in patients who required intra-arachnoidal dissection. When we correct the statistical analysis to include only patients with intra-arachnoidal lesions, the postoperative CSF leak rate is 14.5% (eight of 55 patients). It is notable that six CSF (33%) leaks occurred in our first 25 repairs, whereas we encountered only two postoperative leaks (4%) in the last 50 patients. The corrected CSF leak rate, considering only intra-arachnoidal lesions, was two (5.4%) of 37 patients. This improvement in the CSF leak rate reflects our growing experience and comfort with this reconstructive technique. All of our failures could be matched to a specific technical mistake In addition, we modified the flap-harvesting technique to allow for staged procedures and the removal of caudal lesions. These special circumstances require storage of the flap in the antrum during the removal of caudal lesions, and suturing of the flap in its original position for staged procedures. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with bipolar electrocautery, thereby preserving the flap blood supply. We encountered no infectious or wound complications in this series of patients. The donor site accumulates crusting, which requires debridement until mucosalization is complete; this usually occurs 6 to 12 weeks after surgery. Conclusion: The HBF is a versatile and reliable reconstructive technique for repairing defects of the anterior, middle, clival, and parasellar cranial base. Its use has resulted in a significant decrease in our incidence of CSF leaks after endonasal cranial base surgery. Attention to technical details is of paramount importance to achieve the best outcomes.

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

2012 ◽  
Vol 32 (6) ◽  
pp. E6 ◽  
Author(s):  
Tyler J. Kenning ◽  
Thomas O. Willcox ◽  
Gregory J. Artz ◽  
Paul Schiffmacher ◽  
Christopher J. Farrell ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Temporal Bone ◽  
Cranial Base ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Ventriculoperitoneal Shunting ◽  
Anterior Cranial Base ◽  
Tegmen Tympani ◽  
Treatment Paradigm ◽  
Csf Leaks

Object Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors. Methods The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect. Results The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months). Conclusions Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

Dural Closure in Confined Spaces of the Skull Base with Nonpenetrating Titanium Clips

2017 ◽  
Vol 14 (4) ◽  
pp. 375-385 ◽  
Author(s):  
Chad A Glenn ◽  
Cordell M Baker ◽  
Joshua D Burks ◽  
Andrew K Conner ◽  
Adam D Smitherman ◽  
...  
Keyword(s):  
Skull Base ◽  
Csf Leak ◽  
Dural Repair ◽  
Postoperative Imaging ◽  
Confined Spaces ◽  
Dural Closure ◽  
Skull Base Meningioma ◽  
Novel Method ◽  
Dural Defects ◽  
Titanium Clips

Abstract BACKGROUND Dural repair in areas with limited operative maneuverability has long been a challenge in skull base surgery. Without adequate dural closure, postoperative complications, including cerebrospinal fluid (CSF) leak and infection, can occur. OBJECTIVE To show a novel method by which nonpenetrating, nonmagnetic titanium microclips can be used to repair dural defects in areas with limited operative access along the skull base. METHODS We reviewed 53 consecutive surgical patients in whom a dural repair technique utilizing titanium microclips was performed from 2013 to 2016 at our institution. The repairs primarily involved difficult-to-reach dural defects in which primary suturing was difficult or impractical. A detailed surgical technique is described in 3 selected cases involving the anterior, middle, and posterior fossae, respectively. An additional 5 cases are provided in more limited detail to demonstrate clip artifact on postoperative imaging. Rates of postoperative CSF leak and other complications are reported. RESULTS The microclip technique was performed successfully in 53 patients. The most common pathology in this cohort was skull base meningioma (32/53). Additional surgical indications included traumatic dural lacerations (9/53), nonmeningioma tumors (8/53), and other pathologies (4/53). The clip artifact present on postoperative imaging was minor and did not interfere with imaging interpretation. CSF leak occurred postoperatively in 3 (6%) patients. No obvious complications attributable to microclip usage were encountered. CONCLUSION In our experience, intracranial dural closure with nonpenetrating, nonmagnetic titanium microclips is a feasible adjunct to traditional methods of dural repair.

scholarly journals Primary Dural Closure for Retrosigmoid Approaches

2017 ◽  
Vol 79 (04) ◽  
pp. 330-334 ◽  
Author(s):  
Garrett Venable ◽  
Mallory Roberts ◽  
Ryan Lee ◽  
L. Michael
Keyword(s):  
Posterior Fossa ◽  
Primary Closure ◽  
Chart Review ◽  
Tumor Resection ◽  
Retrospective Chart Review ◽  
Csf Leak ◽  
Dural Defect ◽  
Dural Closure ◽  
Lesion Type ◽  
Csf Leaks

Object Primary closure of posterior fossa dura can be challenging, and postoperative cerebrospinal fluid (CSF) leaks continue to represent a common complication of the retrosigmoid approach. We describe a simple technique to allow for primary closure of the dura following retrosigmoid approaches. The incidence of CSF leaks using this method is reported. Methods A retrospective chart review was conducted on all cases of retrosigmoid craniotomies performed by the senior surgeon from February 2009 to February 2015. The primary outcome was development of postoperative CSF leak or pseudomeningocele. Length of stay, lesion type, and other surgical complications were also reported. Results Eighty-six patients underwent a retrosigmoid craniotomy during the study period. The most common indications for retrosigmoid craniotomy were microvascular decompression (58%) and tumor resection (36%). No allo- or autografts to repair the dural defect were needed, and no lumbar drains were used. No patients developed CSF otorrhea, rhinorrhea, or incisional leak postoperatively. Conclusion Primary dural closure is possible in retrosigmoid approaches without the use of allo- or autografts and may prevent postoperative CSF leaks when combined with other posterior fossa closure techniques. Careful attention to the handling of the dural flap is necessary to achieve this.

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