scholarly journals Dural And Skull Base Reconstruction To Eliminate Postoperative Complications Related To Cerebrospinal Fluid Leakage: Technical Nuances And Surgical Outcomes

2021 ◽  
Author(s):  
YOICHI NONAKA ◽  
Takanori Fukushima ◽  
Naokazu Hayashi ◽  
Takatoshi Sorimachi ◽  
Mitsunori Matsumae
Keyword(s):  
Cerebrospinal Fluid ◽  
Postoperative Complications ◽  
Skull Base ◽  
Revision Surgery ◽  
Cerebrospinal Fluid Leakage ◽  
Neurosurgical Procedures ◽  
Posterior Fossa Surgery ◽  
Skull Base Reconstruction ◽  
Pericranial Flap ◽  
Csf Leaks

Abstract BACKGROUND: Cerebrospinal fluid (CSF) leakage is a common complication associated with neurosurgical procedures, and eliminating postoperative CSF leaks remains challenging. OBJECTIVE: Unique applications of free or vascularized flaps for watertight dural and skull base reconstruction are presented. METHODS: A total of 512 cases of cranial surgeries were examined focused on the postoperative complications that required revision surgery. These cases were divided into skull base (SB) lesions and non-SB lesions according to the site of dural opening. The postoperative complications were analyzed according to their relationship to the CSF. A free flap, including fascial, myofascial, or pericranial flap, is routinely prepared for later use in dural closure in all cranial surgeries. A pedicled vascularized pericranial flap (VPF) is also used for SB dural reconstruction in extended surgical procedures.RESULTS: There were 434 cases of SB lesions and 78 cases of non-SB lesions. Of the 512 surgical cases, 27 (5.3%) required revision surgery due to patients’ postoperative conditions or complications. There were 9 cases (1.8%) of CSF-related and 18 cases (3.5%) of non-CSF-related complications. Eight of nine cases of CSF-related complications (88.9%) were seen in posterior fossa surgery. Postoperative CSF leaks that required revision surgery were seen in 4 cases (0.8%). SB reconstruction using a VPF was performed in 40 cases of SB surgeries. No postoperative infection was seen in these 40 cases, and only 1 case (2.5%) of pseudomeningocele, which required revision surgery, occurred. CONCLUSION: Dural reconstruction using a fascial flap or VPF plays an important role in achieving successful surgery.

scholarly journals Endoscopic Endonasal Reconstruction of High-Flow Cerebrospinal Fluid Leak with Fascia Lata “Button” Graft and Nasoseptal Flap: Surgical Technique and Case Series

2019 ◽  
Vol 81 (06) ◽  
pp. 645-650
Author(s):  
Roshni V. Khatiwala ◽  
Karthik S. Shastri ◽  
Maria Peris-Celda ◽  
Tyler Kenning ◽  
Carlos D. Pinheiro-Neto
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Fascia Lata ◽  
High Flow ◽  
Csf Leak ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Csf Diversion ◽  
Csf Leaks

Abstract Background The endoscopic endonasal approach (EEA) has become increasingly used for resection of skull base tumors in the sellar and suprasellar regions. A nasoseptal flap (NSF) is routinely used for anterior skull base reconstruction; however, there are numerous additional allografts and autografts being used in conjunction with the NSF. The role of perioperative cerebrospinal fluid (CSF) diversion is also unclear. Objective This study was aimed to analyze success of high-flow CSF leak repair during EEA procedures without use of CSF diversion through lumbar drainage. Methods A retrospective chart review of patients who had intraoperative high-flow CSF leak during EEA procedures at our institution between January 2013 and December 2017 was performed. CSF leaks were repaired with use of a fascia lata button graft and nasoseptal flap, without use of perioperative lumbar drains. Results A total of 38 patients were identified (10 male, 28 female). Patient BMIs ranged from 19.7 to 49 kg/m2 (median = 31 kg/m2), with 18 patients meeting criteria for obesity (BMI > 30 kg/m2) and 12 patients overweight (25 kg/m2 < BMI < 29.9 kg/m2). There was no incidence of postoperative CSF leak. Conclusion In our experience, the nasoseptal flap used in conjunction with the fascia lata button graft is a safe, effective and robust combination for cranial base reconstruction with high-flow intraoperative CSF leaks, without need for lumbar drains.

Pericranial Flap for Endoscopic Anterior Skull-Base Reconstruction

Neurosurgery ◽  
2010 ◽  
Vol 66 (3) ◽  
pp. 506-512 ◽  
Author(s):  
Mihir R. Patel ◽  
Rupali N. Shah ◽  
Carl H. Snyderman ◽  
Ricardo L. Carrau ◽  
Anand V. Germanwala ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Preoperative Planning ◽  
Cranial Base ◽  
Anterior Skull Base ◽  
Dural Defect ◽  
Skull Base Reconstruction ◽  
Pericranial Flap ◽  
Endonasal Reconstruction ◽  
Ventral Skull Base

Abstract BACKGROUND One of the major challenges of cranial base surgery is reconstruction of the dural defect and prevention of postoperative cerebrospinal fluid (CSF) fistula. The introduction of endoscopic techniques and an endonasal approach to the ventral skull base has created new challenges for reconstruction. OBJECTIVE We have developed an endoscopic pericranial flap (PCF) for skull base reconstruction and hereby present the initial cohort of patients who had endonasal reconstruction with a PCF after endoscopic skull base resection. We also demonstrate a method to radiographically incorporate anticipated skull base defects for preoperative planning of PCF length. METHODS Dural defects after endonasal skull base resection of invasive tumors were reconstructed with an onlay PCF (n = 10). We performed radiological studies to assist preoperative planning for where to make incisions while harvesting a PCF for anterior skull base, sellar, and clival defects. RESULTS Each of the 10 patients had excellent healing of their skull base and had no evidence of any postoperative cerebrospinal fluid leaks. Eight patients had radiation therapy without flap complications. Radiographic studies demonstrate that the adequate PCF length, covering defects of the anterior skull base, sellar, and clival defects are 11.31 to 12.44 cm, 14.31 to 15.57 cm, and 18.5 to 20.42 cm, respectively. CONCLUSION The PCF provides an option for endonasal reconstruction of cranial base defects and can be harvested endoscopically. Pre-operative radiographic evaluation may guide surgical planning. There is minimal donor site morbidity, and the flap provides enough surface area to cover the entire ventral skull base.

Pericranial Flap for Closure of Paramedian Anterior Skull Base Defects

2002 ◽  
Vol 127 (6) ◽  
pp. 494-500 ◽  
Author(s):  
Michael C. Noone ◽  
J. David Osguthorpe ◽  
Sunil Patel
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Anterior Skull Base ◽  
Cerebrospinal Fluid Leakage ◽  
Flap Reconstruction ◽  
Brain Herniation ◽  
Craniofacial Resection ◽  
Pericranial Flap ◽  
Clinically Significant ◽  
Skull Base Defects

OBJECTIVE: We sought to examine the position of a pericranial flap reconstruction of anterior skull base defects with respect to the original floor of the anterior cranial fossa. STUDY DESIGN: A retrospective chart and radiology review of 17 patients (1993–2001) with pericranial flap reconstruction for anterior skull base defects and 17 controls was performed. RESULTS: At 6 or more months after surgery, the new positions of the pericranial flaps ranged from 5 mm above to 11.3 mm below the positions of the original cribriform plates. There were no complications related to the pericranial flaps such as hemorrhage, flap loss, or brain herniation except for 2 (11.8%) cerebrospinal fluid leaks, 1 of which required operative correction. CONCLUSION: Pericranial flap reconstruction is a reliable method with low morbidity for closure of the most common skull base defect from the craniofacial resection that entails removal—unilateral or bilateral—of the fovea ethmoidalis, cribriform plate, and/or superior septum. This flap creates a watertight seal between the extradural space and the nasal cavity, prevents clinically significant brain herniation, and is associated with a low rate of cerebrospinal fluid leakage even without postoperative lumbar subarachnoid drainage of the cerebrospinal fluid.

scholarly journals Cerebrospinal fluid leakage due to nasoseptal flap partial necrosis: A pitfall for skull base reconstruction of endoscopic endonasal surgery

2020 ◽  
Vol 11 ◽  
pp. 121
Author(s):  
Hiroki Yamada ◽  
Masahiro Toda ◽  
Mariko Fukumura ◽  
Ryotaro Imai ◽  
Hiroyuki Ozawa ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Flap Necrosis ◽  
Nasoseptal Flap ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Partial Necrosis ◽  
Necrotic Region

Background: Vascularized nasoseptal flaps allow for the reconstruction of large dural defects and have remarkably reduced the incidence of postoperative complications during endoscopic endonasal skull base surgery. Nevertheless, some complications related to nasoseptal flap have been reported. Flap necrosis is a rare, but serious issue is associated with meningitis and cerebrospinal fluid (CSF) leak. Case Description: We performed endoscopic endonasal removal of the tuberculum sella meningioma in a 39-year-old woman with a history of Turner syndrome using abdominal fat, fascia, and a vascularized nasoseptal flap for dural and skull base defect reconstruction. After surgery, she developed CSF leak, and reoperation revealed partial necrosis of the septal flap that caused leakage. At this time, with a concern that removal of the necrotic part may lead to the insufficient size of the flap, we filled the gap tightly with fat pieces. However, the CSF leak recurred, and thus, we performed debridement of the necrotic region and reformed the multilayered reconstruction, following which she no longer experienced CSF leakage. Conclusion: Our case suggested that partial rather than total flap necrosis could occur, possibly due to variances of vascular anatomy, leading to focal ischemia. Debridement of the necrotic region may be an important solution for recurrent cerebrospinal leakage secondary to partial necrosis of a nasoseptal flap.

scholarly journals Persistent posttraumatic cerebrospinal fluid leakage

2000 ◽  
Vol 9 (1) ◽  
pp. 1-5 ◽  
Author(s):  
Jonathan A. Friedman ◽  
Michael J. Ebersold ◽  
Lynn M. Quast
Keyword(s):  
Cerebrospinal Fluid ◽  
Antibiotic Prophylaxis ◽  
Skull Base ◽  
Frontal Sinus ◽  
Surgical Intervention ◽  
Prophylactic Antibiotic ◽  
Cerebrospinal Fluid Leakage ◽  
Additional Surgery ◽  
Csf Leakage ◽  
Csf Leaks

Object Persistent posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. Although many CSF leaks will cease without treatment, patients with CSF leaks that persist greater than 24 hours may be at increased risk for meningitis, and many will require surgical intervention. The authors reviewed their 15-year experience with posttraumatic CSF leaks that persisted longer than 24 hours. Methods The authors reviewed the medical records of 51 patients treated between 1984 and 1998 with CSF leaks that persisted for 24 hours or longer after traumatic head injury. In 27 patients (55%) spontaneous resolution of CSF leakage occurred at an average of 5 days posttrauma. In 23 patients (45%) surgery was required to resolve the leakage. Eight patients (16%) with occult CSF leaks presented with recurrent meningitis at an average of 6.5 years post-trauma. Forty-three (84%) patients with CSF leaks sustained a skull fracture, most commonly involving the frontal sinus, whereas parenchymal brain injury or extraaxial hematoma was demonstrated in only 18 patients (35%). Delayed CSF leaks, with an average onset of 13 days posttrauma, were observed in eight patients (16%). Among patients with clinically evident CSF leakage, the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved the risk of meningitis. A variety of surgical approaches was used, and no significant neurological morbidity occurred. Three (13%) of 23 surgically treated patients required additional surgery to treat continued CSF leakage. Conclusions A significant proportion of patients with CSF leaks that persist greater than 24 hours will require surgical intervention. Prophylactic antibiotic therapy may be effective in this group of patients. Patients with skull base or frontal sinus fractures should be followed to detect the occurrence of delayed leakage. Surgery-related outcome is excellent.

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