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

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.

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Closure of large skull base defects after endoscopic transnasal craniotomy

Journal of Neurosurgery ◽

10.3171/2008.8.jns08236 ◽

2009 ◽

Vol 111 (2) ◽

pp. 371-379 ◽

Cited By ~ 53

Author(s):

Richard J. Harvey ◽

João F. Nogueira ◽

Rodney J. Schlosser ◽

Sunil J. Patel ◽

Eduardo Vellutini ◽

...

Keyword(s):

Skull Base ◽

Csf Leak ◽

Dural Defect ◽

Medical Centers ◽

Dural Defects ◽

Ventral Skull Base ◽

Skull Base Defects ◽

Reconstructive Techniques ◽

Csf Leaks

Object The authors describe the utility of and outcomes after endoscopic transnasal craniotomy and skull reconstruction in the management of skull base pathologies. Methods The authors conducted a observational study of patients undergoing totally endoscopic, transnasal, transdural surgery. The patients included in the study underwent treatment over a 12-month period at 2 tertiary medical centers. The pathological entity, region of the ventral skull base resected, and size of the dural defect were recorded. Approach-related complications were documented, as well as CSF leaks, infections, bleeding-related complications, and any minor complications. Results Thirty consecutive patients were assessed during the study period. The patients had a mean age of 45.5 ± 20.2 years and a mean follow-up period of 182.4 ± 97.5 days. The dural defects reconstructed were as large as 5.5 cm (mean 2.49 ± 1.36 cm). One patient (3.3%) had a CSF leak that was managed endoscopically. Two patients had epistaxis that required further care, but there were no complications related to intracranial infections or bleeding. Some minor sinonasal complications occurred. Conclusions Skull base endoscopic reconstructive techniques have significantly advanced in the past decade. The use of pedicled mucosal flaps in the reconstruction of large dural defects resulting from an endoscopic transnasal craniotomy permits a robust repair. The CSF leak rate in this study is comparable to that achieved in open approaches. The ability to manage the skull base defects successfully with this approach greatly increases the utility of transnasal endoscopic surgery.

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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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Endoscopic endonasal resection of midline cranial base tumors

JBNC - JORNAL BRASILEIRO DE NEUROCIRURGIA ◽

10.22290/jbnc.v19i2.1521 ◽

2018 ◽

Vol 19 (2) ◽

pp. 7-17

Author(s):

Enrico De Divitiis ◽

Felice Esposito ◽

Paolo Cappabianca ◽

Luigi M. Cavallo ◽

Oreste De Divitiis ◽

...

Keyword(s):

Skull Base ◽

Cranial Base ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Endoscopic Endonasal ◽

Visual Deficits ◽

Extended Transsphenoidal Approach ◽

Anterior Cranial Base ◽

Subtotal Removal

Objective: The advent of the endoscope in transsphenoidalsurgery has permitted to expand the indications of such approach also for the treatment of on tumors located in supra, para, retro and infrasellar regions, enabling the neurosurgeon to work under direct visual control in a minimally invasive way. Since 2004 we have started to use the extended endonasal transsphenoidal approach for a variety of lesions involving the midline skull base and, in particular, the suprasellar area, the cavernous sinus and the retroclival prepontine region. Methods: Over a 36-month period, sixty-four procedures have been performed. The series consisted of 29 males and 35 females, aged from 24 to 80 years (median 49.8 years). The mean follow-up was of 18 months (ranging from 3 to 36 months). Among the patients with midline lesions, who were 90.6 % of the total, seven patients had a pituitary adenoma, sixteen patients were affected by a craniopharyngioma, six patients had a suprasellar Rathke’s cleft cyst, seven subjects had a tuberculum sellae meningioma, four had an olfactorygroove meningioma, and six a clival tumor. Other lesions ofthe midline skull base were, 1 chiasmatic astrocytoma, 1 neuroendocrine tumor, 4 post-traumatic cerebro-spinal fluid rhinorrhea, and one optic nerve glioma. Three other patients had anterior cranial base meningoencephaloceles. Results: Overall, gross total removal of the lesion was achieved in 30/49 tumoral lesions (61.2%); subtotal removal was achieved in 12/49 cases (24.5%). The three cases of meningoencephaloceles were all successfully treated. Among the patients with preoperative visual deficits, most of them fully recovered or improved and only two worsened in one eye. Major complications consisted in 2 deaths (one not directly related with the surgical procedure), 6 postoperative CSF leak (one complicated with bacterial meningitis), one ICA injury, and 6 cases of permanent diabetes insipidus.Conclusion: The extended transsphenoidal approach tothe supra and parasellar lesions seems Endoscopy; Transsphenoidal surgery; Extended approach; Parasellar; Tumors; Anterior skull base. A promising minimally invasivetechnique for the removal of lesions affecting these areas,once thought to be suitable only of the transcranial routes.Concerning the lesion removal and the recurrence rate compared with the transcranial routes, it is too early to pose a definitive word, since the follow-up is still too short.

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Surgical anatomy and utility of pedicled vascularized tissue flaps for multilayered repair of skull base defects

Journal of Neurosurgery ◽

10.3171/2015.5.jns15529 ◽

2016 ◽

Vol 125 (2) ◽

pp. 419-430 ◽

Cited By ~ 10

Author(s):

Sam Safavi-Abbasi ◽

Noritaka Komune ◽

Jacob B. Archer ◽

Hai Sun ◽

Nicholas Theodore ◽

...

Keyword(s):

Skull Base ◽

Medical Records ◽

Cranial Base ◽

Vascular Supply ◽

Surgical Anatomy ◽

Pedicled Flap ◽

Nasoseptal Flap ◽

Temporal Arteries ◽

Tissue Flaps ◽

Skull Base Defects

OBJECT The objective of this study was to describe the surgical anatomy and technical nuances of various vascularized tissue flaps. METHODS The surgical anatomy of various tissue flaps and their vascular pedicles was studied in 5 colored silicone-injected anatomical specimens. Medical records were reviewed of 11 consecutive patients who underwent repair of extensive skull base defects with a combination of various vascularized flaps. RESULTS The supraorbital, supratrochlear, superficial temporal, greater auricular, and occipital arteries contribute to the vascular supply of the pericranium. The pericranial flap can be designed based on an axial blood supply. Laterally, various flaps are supplied by the deep or superficial temporal arteries. The nasoseptal flap is a vascular pedicled flap based on the nasoseptal artery. Patients with extensive skull base defects can undergo effective repair with dual flaps or triple flaps using these pedicled vascularized flaps. CONCLUSIONS Multiple pedicled flaps are available for reconstitution of the skull base. Knowledge of the surgical anatomy of these flaps is crucial for the skull base surgeon. These vascularized tissue flaps can be used effectively as single or combination flaps. Multilayered closure of cranial base defects with vascularized tissue can be used safely and may lead to excellent repair outcomes.

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Excavating Meningoencephaloceles: A Newly Recognized Entity

American Journal of Rhinology and Allergy ◽

10.2500/ajra.2017.31.4413 ◽

2017 ◽

Vol 31 (2) ◽

pp. 127-134 ◽

Cited By ~ 1

Author(s):

Patricia A. Loftus ◽

Sarah K. Wise ◽

Pedram Daraei ◽

Kristen Baugnon ◽

John M. DelGaudio

Keyword(s):

Ct Scan ◽

Skull Base ◽

Operating Room ◽

Tertiary Care ◽

Distinct Type ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Skull Base Defect ◽

Skull Base Defects ◽

Csf Leaks

Background Spontaneous cerebrospinal fluid (CSF) leaks are largely attributed to idiopathic intracranial hypertension and typically present as skull base defects with or without prolapse of intracranial contents. However, in our practice, we have encountered a distinct type of spontaneous CSF leak that presents in a different manner. Objective To discuss a newly-classified, difficult to treat, subset of spontaneous CSF leaks that present as excavation of the bone of the skull base in a tunnel- or canal-like fashion by a meningocele or meningoencephalocele instead of as a localized area of bony dehiscence. Methods A retrospective review was performed at a tertiary care rhinology practice to identify a subset of CSF leak patients with an excavating/canal-like skull base defect visualized radiographically on computed tomography (CT) scan or magnetic resonance imaging and/or endoscopically in the operating room. Results The cohort of patients consisted of 7 females and 1 male with an average age of 53.6 years and a self-reported race of 4:3:1 African-American: Caucasian-Indian. All patients presented with CSF rhinorrhea. The most common leak site was the cribriform and upper septum. Six of the 8 patients had multiple defects and/or progression of their skull base defects, and 5 patients required multiple and/or repeat repairs in the operating room. Seven of the 8 patients underwent a cisternogram because the excavating nature of the leaks made it difficult to identify the specific leak site on high-resolution CT scan alone. Conclusion In spontaneous CSF leaks that are difficult to identify or recur soon after a proper repair, an excavating pattern should be considered. Failure to recognize this type of leak and all of its tributaries, to fully unroof the excavated bone to completely resect the meningocele, and to visualize and close the site of origin will likely result in failure and recurrence of CSF leak.

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A New Porcine Skull Base Model

Otolaryngology ◽

10.1016/j.otohns.2009.03.008 ◽

2009 ◽

Vol 141 (2) ◽

pp. 184-189 ◽

Cited By ~ 14

Author(s):

John R. de Almeida ◽

Kemel Ghotme ◽

Iona Leong ◽

James Drake ◽

Adrian L. James ◽

...

Keyword(s):

Skull Base ◽

Fibrin Glue ◽

Porcine Model ◽

Endoscopic Examination ◽

Csf Leak ◽

Control Group ◽

Histopathological Analysis ◽

Experimental Animal Study ◽

Skull Base Defects ◽

Csf Leaks

OBJECTIVES: Fibrin glue is used in addition to grafts and flaps to repair cerebrospinal (CSF) leaks. We designed a porcine model to test the hypothesis that fibrin glue increases biomechanical strength. STUDY DESIGN: A randomized experimental animal study. METHODS: Ten pigs underwent craniotomy with creation of a fistula through the cribriform plate into the nasal cavity. CSF leaks were endoscopically confirmed and repaired using pericranial grafts. The animals were randomized into a fibrin glue group (n = 5) and a control group (n = 5). Seven days later, endoscopic examination assessed for CSF leaks. The skull bases were harvested and examined for the degree of graft adherence (graded I-V) and subjected to burst pressure testing and histopathological analysis. RESULTS: Eight animals survived, four in each group. There were no CSF leaks in the fibrin glue group and one in the control group. The fibrin glue group showed greater graft adherence ( P = 0.029) and higher burst pressures (13.8 ± 5.4 vs 4.6 ± 3.1 psi, P = 0.021). Histopathological analysis revealed no difference in inflammation and bone remodeling. CONCLUSIONS: The porcine model is a good model for anterior skull base defects. The model confirmed that fibrin glue reduces the rate of CSF leak by improving graft adherence and strength of repair.

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Efficacy of the pedicled nasoseptal flap without cerebrospinal fluid (CSF) diversion for repair of skull base defects: incidence of postoperative CSF leaks

International Forum of Allergy & Rhinology ◽

10.1002/alr.21040 ◽

2012 ◽

Vol 2 (5) ◽

pp. 397-401 ◽

Cited By ~ 60

Author(s):

Jean Anderson Eloy ◽

Arjuna B. Kuperan ◽

Osamah J. Choudhry ◽

Sanaz Harirchian ◽

James K. Liu

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Nasoseptal Flap ◽

Csf Diversion ◽

Skull Base Defects ◽

Csf Leaks

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Endoscopic Reconstruction of Skull Base Defects Using Tutoplast

Allergy & Rhinology ◽

10.1177/21526567211009200 ◽

2021 ◽

Vol 12 ◽

pp. 215265672110092

Author(s):

Ghassan Alokby ◽

Kholoud Mohammed AlAmari ◽

Jamal Mohammed S. Abdullah ◽

Mohammed Tayed Hazazi ◽

Fawaz Makki

Keyword(s):

Skull Base ◽

Structural Integrity ◽

Demographic Data ◽

Fascia Lata ◽

Csf Leak ◽

Graft Material ◽

Temporalis Fascia ◽

Defect Sites ◽

Endoscopic Reconstruction ◽

Skull Base Defects

Background Various graft materials that are classified as autografts, xenografts, and allografts based on their origin have been used to endoscopically repair skull base defects. Tutoplast® (Tutogen Medical GmbH), an allogeneic natural collagen matrix, is processed through chemical sterilization that preserves tissue biocompatibility and structural integrity. Objective To study the safety and efficacy of Tutoplast Fascia Lata and Tutoplast Temporalis Fascia® as primary graft materials in the endoscopic reconstruction of skull base defects of different sizes and etiologies and to compare the outcomes with those of other traditional graft materials based on our experience. Methods This is a multi-center retrospective chart review of patients who underwent cerebrospinal fluid leak (CSF) endoscopic reconstruction with Tutoplast Fascia Lata or Tutoplast Temporalis Fascia as either a stand-alone reconstruction material or a part of a multilayer reconstruction depending on the defect at Prince Sultan Military Medical City and King Faisal Specialist Hospital and Research Center in Riyadh, Saudi Arabia, between 2017 and 2020. Our inclusion criteria were CSF leak repair with Tutoplast and a transnasal endoscopic approach. We reviewed demographic data, intraoperative and postoperative complications, repair materials, repair failure, defect size and location. Results Tutoplast® was used as the primary graft material in 33 cases. Our main outcome was repair success with lack of post operative CSF leak, observed in 30 cases (90.9%). There was no significant association between postoperative CSF leaks and factors including different defect sizes, defect sites, demographic data, hospitalization duration, or postoperative radiation in oncological cases. Conclusion Tutoplast alone or in combination with other materials can be used safely and effectively for skull base defects repair.

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Vascularized middle turbinate mucoperiosteal flap in skull base defects: follow-up analysis of 20 cases

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20164786 ◽

2016 ◽

Vol 3 (1) ◽

pp. 71 ◽

Cited By ~ 1

Author(s):

Shibu George ◽

Sandeep Suresh

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Middle Turbinate ◽

Benign Intracranial Hypertension ◽

Nasoseptal Flap ◽

Csf Rhinorrhea ◽

Endoscopic Closure ◽

Mucoperiosteal Flap ◽

Skull Base Defects

Background: Vascularized flaps are preferred in repair of skull base defects since they provide quality tissue volume and allow rapid healing. Though nasoseptal flap is the gold standard it may not be available always and has its own share of pitfalls; this makes the middle turbinate flap a viable alternative. This descriptive study was designed to analyze the efficacy of middle turbinate flap in endoscopic closure of skull base defects and to define indications and limitations of the flap.Methods: 20 patients who underwent endoscopic closure of small and medium sized skull base defects using middle turbinate mucoperiosteal flap were analyzed and followed up. Etiology, presentation, site and co-morbidities associated with such defects were studied. Effectiveness of closure was analyzed by the ability to cover fully, graft uptake and complications. Results: Successful flap take up was noted in all 20 cases (100%) on long term follow up; transient cerebrospinal fluid leak was observed in 1case (5%) during the immediate post-operative period which subsided fully. Spontaneous CSF rhinorrhea (n=11 [55%]) was the most common indication for closure and unilateral watery rhinorrhea was the commonest presentation (n=13 [65%]). Benign intracranial hypertension was found to have significant association with cerebrospinal fluid rhinorrhea. Most common site of leak was the medial lamella of cribriform plate (n=11 [55%]).Conclusions: Middle turbinate flap is an effective alternative to nasoseptal flap for small and medium sized anterior skull base defects; efficacy in larger defects and posterior sellar defects cannot be substantiated.

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