Nasoseptal Flap Reconstruction of High Flow Intraoperative Cerebral Spinal Fluid Leaks during Endoscopic Skull Base Surgery

Background Over the past 10 years, significant anatomic, technical, and instrumentation advances have facilitated the exposure and resection of intradural lesions via a fully endoscopic expanded endonasal approach (EEA). The vascularized nasoseptal flap (based on the posterior nasoseptal artery) has become our primary endoscopic reconstructive technique. The goals of this study are to prospectively evaluate the nasoseptal flap and high-risk cerebral spinal fluid (CSF) leak variables. Methods Prospective evaluation was performed of EEA patients with intraoperative high-flow leaks (either a cistern or ventricle open to nasal cavity during tumor dissection) who underwent nasoseptal flap reconstruction. Results Seventy consecutive nasoseptal flaps for high-flow intraoperative leaks were evaluated prospectively by the primary author. Twelve risk factors were then graded at the time of the operations and correlated to CSF leak outcomes. The overall postoperative CSF leak rate was 5.7% (4/70). All four postoperative leaks were successfully managed with endoscopic repair and CSF diversion. A multivariate analysis of all 12 risk factors is detailed. Pediatric patients, large dural defects, and radiation therapy were noted to be factors in reconstructive failure. One flap death occurred in a patient with prior surgery and proton therapy, this leak was managed with a temporoparietal flap and endonasal repair. Conclusion The nasoseptal flap is an excellent anterior skull base reconstructive technique. Patients with high-flow intraoperative CSF leaks had a 94% successful reconstruction rate. Patients with skull base proton radiation therapy are at higher risk for flap failure and preparation for nonradiated tissue reconstruction should be discussed with the patient.

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

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0039-1693124 ◽

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.

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Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

Neurosurgical FOCUS ◽

10.3171/2012.5.focus1255 ◽

2012 ◽

Vol 32 (6) ◽

pp. E7 ◽

Cited By ~ 61

Author(s):

James K. Liu ◽

Richard F. Schmidt ◽

Osamah J. Choudhry ◽

Pratik A. Shukla ◽

Jean Anderson Eloy

Keyword(s):

Skull Base ◽

Skull Base Surgery ◽

Cranial Base ◽

High Flow ◽

Csf Leak ◽

Reconstruction Technique ◽

Dural Defect ◽

Nasoseptal Flap ◽

Endoscopic Skull Base Surgery ◽

Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

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Effects of Cruciate Embedding Fascia-Bone Flap Technique on Grade II - III Cerebral Spinal Fluid Leak in Endoscopic Endonasal Surgery

10.21203/rs.3.rs-496704/v1 ◽

2021 ◽

Author(s):

WenJi Zhao ◽

Gang Yang ◽

RuiChun Li ◽

Gang Huo ◽

Dong Gao ◽

...

Keyword(s):

Skull Base ◽

Cerebral Spinal Fluid ◽

Spinal Fluid ◽

Bone Flap ◽

Csf Leak ◽

Dural Defect ◽

Endoscopic Endonasal Surgery ◽

Endonasal Surgery ◽

Endoscopic Endonasal ◽

Grade Ii

Abstract Background: Cerebral spinal fluid (CSF) leak remains an important issue in endoscopic endonasal surgery. A standard protocol of skull base closure has not been established yet, and application of rigid buttress has not been given sufficient attention. To emphasize the functions of support and fixation from rigid buttress in reconstruction, we introduce a technique of cruciate embedding fascia-bone flap (CEFB) using autologous bone graft to buttress fascia lata attaching to partially sutured skull base dural defect, and evaluate its efficacy in a consecutive case series of grade II-III CSF leak in EES.METHODS: Data of consecutive patients with grade II-III CSF leak during EES were collected between May 2015 and May 2020. Skull base reconstructions were performed either with the CEFB, conventional PNSF, or combination of 2 methods. Related clinical data were compared and analyzed respectively.RESULTS: There are 110, 65, and 23 patients included in CEFB, PNSF, and combination group respectively. CEFB demonstrated statistically similar effects on postoperative CSF leak (2.7%) and intracranial infection (4.5%) compared to PNSF (3.1%, 3.1%), but with less morbidity of epistaxis (CEFB: 0%, PNSF: 6.2%) and nasal discomforts (CEFB: 0%, PNSF: 7.7%). The bed stay time (CEFB: 5.74d, PNSF: 8.83d) and hospitalization time (CEFB: 10.49d, PNSF: 13.58d) were shortened in CEFB group. Combination of CEFB and PNSF achieved 0 postoperative CSF leak in 23 highly susceptible patients with grade III leak and multiple high risk factors.CONCLUSION: The CEFB technique is reliable and feasible to prevent postoperative CSF leak in EES. It can be used safely without PNSF in suitable cases, or applied in association with PNSF with high compatibility and security when necessary.Trial Registration：Current Controlled Trials ChiCTR2100044764 (Chinese Clinical Trial Registry), as well as the date of registration 27th March, 2020. Retrospectively registered.

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Managing CSF Leak with Temporalis Muscle Flap for Challenging Skull Base Defect after Radiation Therapy

10.1055/s-0040-1702551 ◽

2020 ◽

Author(s):

Wei-Hsin Wang ◽

Ming-Ying Lan

Keyword(s):

Radiation Therapy ◽

Skull Base ◽

Muscle Flap ◽

Csf Leak ◽

Temporalis Muscle ◽

Temporalis Muscle Flap ◽

Skull Base Defect

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Endoscopic skull base reconstruction with the nasoseptal flap: complications and risk factors

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-019-05531-4 ◽

2019 ◽

Vol 276 (9) ◽

pp. 2491-2498 ◽

Cited By ~ 5

Author(s):

Anat Wengier ◽

Zvi Ram ◽

Anton Warshavsky ◽

Nevo Margalit ◽

Dan M. Fliss ◽

...

Keyword(s):

Risk Factors ◽

Skull Base ◽

Nasoseptal Flap ◽

Skull Base Reconstruction

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Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

Journal of Neurosurgery ◽

10.3171/2018.4.jns18366 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1625-1631 ◽

Cited By ~ 2

Author(s):

Takayuki Ishikawa ◽

Kazuhito Takeuchi ◽

Yuichi Nagata ◽

Jungsu Choo ◽

Teppei Kawabata ◽

...

Keyword(s):

Skull Base ◽

Transsphenoidal Surgery ◽

Skull Base Surgery ◽

Sella Turcica ◽

High Flow ◽

Anterior Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Csf Leakage ◽

Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

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Utility of the Nasoseptal “Rescue” Flap Approach: Analysis of 125 Consecutive Patients and Implications for Routine Transsphenoidal Surgery

American Journal of Rhinology and Allergy ◽

10.1177/1945892419892164 ◽

2019 ◽

Vol 34 (2) ◽

pp. 269-275

Author(s):

Zachary J. Cappello ◽

Dennis M. Tang ◽

Christopher R. Roxbury ◽

Brian C. Lobo ◽

Hamid Borghei-Razavi ◽

...

Keyword(s):

Transsphenoidal Surgery ◽

Internal Carotid ◽

Skull Base Surgery ◽

Cleveland Clinic ◽

High Flow ◽

Low Flow ◽

Csf Leak ◽

Nasoseptal Flap ◽

The Mean ◽

Csf Leaks

Introduction The nasoseptal flap (NSF) is the reconstructive workhorse for endoscopic skull base surgery (ESBS). However, there is morbidity associated with its use and it is not always required for reconstruction. The bilateral nasoseptal “rescue” flap (NSRF) technique offers a quicker alternative to upfront NSF harvest, yet permits the use of a tailored NSF if needed after the defect has been created. The utility and implications of this strategy have not been well studied. Methods We retrospectively analyzed 125 consecutive transsphenoidal cases where an NSRF approach was used from January 2015 to October 2017 at the Cleveland Clinic. Records were analyzed for conversion to NSF, outcomes, and reconstruction-related complications. Results The mean age of patients included in the study was 51 years, with 51% females. NSRF was converted to full NSF in only 16% of cases. Rationale for conversion included an unanticipated high-flow (7) or low-flow (12) cerebrospinal fluid (CSF) leak and an exposed internal carotid artery (1). NSRF was utilized and converted to formal NSF in 3 patients who had previous remote transsphenoidal surgery. One patient who had an NSRF without a full NSF raised had a postoperative CSF leak; however, no CSF leaks or flap ischemia was noted for those who had full NSFs raised, even in revision surgery. Conclusion NSRF approach provides the reliability and flexibility of vascularized reconstruction, without the perioperative disadvantages of an upfront NSF harvest. The low and successful conversion rate to NSF demonstrates the utility of this strategy which should be incorporated into the standard approach for routine transsphenoidal surgery.

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