scholarly journals Primary Spontaneous Cerebrospinal Fluid Leaks Located at the Clivus

2013 ◽  
Vol 4 (2) ◽  
pp. ar.2013.4.0053 ◽  
Author(s):  
Thibaut Van Zele ◽  
Adriano Kitice ◽  
Eduardo Vellutini ◽  
Leonardo Balsalobre ◽  
Aldo Stamm
Keyword(s):  
Cerebrospinal Fluid ◽  
Intraoperative Complications ◽  
Reconstruction Technique ◽  
Retrospective Case ◽  
Closure Rate ◽  
Transnasal Approach ◽  
Duration Of Symptoms ◽  
Csf Rhinorrhea ◽  
Presenting Symptoms ◽  
Csf Leaks

Transclival meningoceles and primary spontaneous cerebrospinal fluid (CSF) leaks at the clivus are extremely rare lesions and only few of them have been reported in the literature. We report here six cases of transclival primary spontaneous CSF leaks through the clivus. A retrospective case study was performed. We reviewed six cases involving sinonasal CSF leaks located at the clivus treated between 1997 and 2009. Presenting symptoms, duration of symptoms, defect size, site of defect, surgical approach and technique of defect closure, intraoperative complications, postoperative complications, and recurrences are discussed. All CSF leaks were located in the upper central part of the clivus. two of six patients showed signs of increased intracranial pressure (ICP) including arachnoid pits and/or empty sella. For three patients a purely transnasal approach was used with multilayer reconstruction using a nonvascularized graft, and three patients underwent a transnasal transseptal approach with a multilayer reconstruction, with nasoseptal flap. No recurrences of CSF leaks at clivus or other sites were observed to date with a mean follow-up of 10.3 years (range, 3–15 years). Spontaneous CSF rhinorrhea located at the clivus is an extremely rare condition. To date, only eight cases have been described. Here, we report the largest group of six consecutive cases. Irrespective of the used reconstruction technique in all cases a 100% closure rate was achieved. However, identification of increased ICP is an essential aspect and this condition should be treated either medically or surgically.

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

2021 ◽  
Author(s):  
Peter A. Benedict ◽  
Joseph R. Connors ◽  
Micah R. Timen ◽  
Nupur Bhatt ◽  
Richard Lebowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Postoperative Period ◽  
Skull Base Surgery ◽  
Tertiary Care ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Predictive Values ◽  
Ventral Skull Base ◽  
Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

scholarly journals Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control

2004 ◽  
Vol 62 (3b) ◽  
pp. 827-831 ◽  
Author(s):  
José Alberto Landeiro ◽  
Marlo S. Flores ◽  
Bruno C.R. Lázaro ◽  
Maria Helena Melo
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Management ◽  
Inferior Turbinate ◽  
Saline Injection ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Endoscopic Control ◽  
Free Grafts ◽  
Cranial Approach ◽  
Csf Leaks

The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.

Untreated Non-Functioning Pituitary Adenoma Causing Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case Report

2020 ◽  
Vol 103 (9) ◽  
pp. 960-963
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Transsphenoidal Surgery ◽  
Case Reports ◽  
Medical Attention ◽  
Nasal Discharge ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Presenting Symptoms ◽  
Csf Leakage

Cerebrospinal fluid (CSF) leakage is common with traumatic brain injury or after transsphenoidal surgery (TSS). In contrast, spontaneous rhinorrhea caused by pituitary adenoma (PA) without prior treatment is rather unusual. Moreover, cases of non-functioning PA (NFPA) who seek medical attention without visual or hormonal symptoms but with watery nasal discharge, mistaken for rhinitis, and misled to delayed diagnosis, are extremely rare. The authors presented a case of spontaneous CSF rhinorrhea, confirmed by clinical, laboratory, and radiographic studies, caused by NFPA. Endoscopic TSS came across a typical PA, and subsequently, the sellar defect was successfully repaired. Pathological diagnosis of NFPA was established. The patient had an uncomplicated postoperative course and complete resolution of her presenting symptoms. A short review of prior case reports is also provided. Keywords: Spontaneous cerebrospinal fluid rhinorrhea, Pituitary adenoma, Non-functioning, Endoscopic transsphenoidal surgery

scholarly journals Purely endoscopic pterional extradural approach: A novel technique for repair of cerebrospinal fluid rhinorrhea

2016 ◽  
Vol 07 (02) ◽  
pp. 310-313 ◽  
Author(s):  
Ajit Kumar Sinha ◽  
Sumit Goyal
Keyword(s):  
Cerebrospinal Fluid ◽  
Neurological Deficit ◽  
Frontal Sinus ◽  
Intraoperative Complications ◽  
Posterior Wall ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Novel Technique ◽  
Extradural Approach

ABSTRACT Study Design: Retrospective descriptive study of an innovative surgical technique. Objective: To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope. Summary of Background Data: Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches. Materials and Methods: Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6–18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit. Results: Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed. Conclusion: This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches.

Evaluation of CSF Rhinorrhea by Computerized Tomography with Metrizamide

1989 ◽  
Vol 100 (2) ◽  
pp. 99-105 ◽  
Author(s):  
James M. Chow ◽  
David Goodman ◽  
Mahmood F. Mafee
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Computerized Tomography ◽  
The Other ◽  
High Success Rate ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Csf Leaks

This study evaluates the ability of metrizamide computerized tomographic cisternography (MCTC) to delineate the site of leakage in patients with cerebrospinal fluid (CSF) rhinorrhea. From 1981 to 1986, thirteen patients were examined by MCTC to localize the site of CSF leakage. A total of 17 studies were performed. Thirteen scans (76%) identified the site of CSF leakage. Nine of these scans were confirmed surgically. The other four scans were performed on patients who refused surgery. Of the 15 scans in patients with active CSF leaks, 13 (87%) were positive. Of the two patients with inactive CSF leaks, neither was positive. One patient is presented in whom MCTC was both diagnostic and therapeutic. In conclusion, MCTC has a high success rate in localizing the site of active CSF leaks.

scholarly journals Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

2017 ◽  
Vol 79 (02) ◽  
pp. 193-199 ◽  
Author(s):  
Zi Yang Jiang ◽  
Caitlin McLean ◽  
Carlos Perez ◽  
Samuel Barnett ◽  
Deborah Friedman ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Visual Field ◽  
Lumbar Puncture ◽  
Treatment Algorithm ◽  
Postoperative Management ◽  
Empty Sella ◽  
Success Rates ◽  
Csf Rhinorrhea ◽  
Visual Field Deficits ◽  
Csf Leaks

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture (n = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

Microscopic Endonasal Surgery for Repair of CSF Leaks

1993 ◽  
Vol 7 (1) ◽  
pp. 1-4 ◽  
Author(s):  
Ronald G. Amedee ◽  
Wolf J. Mann ◽  
Joachim Gilsbach
Keyword(s):  
Computed Tomography ◽  
Cerebrospinal Fluid ◽  
Abdominal Fat ◽  
Endonasal Surgery ◽  
Closure Rate ◽  
Csf Fistula ◽  
Field Of Vision ◽  
External Incisions ◽  
Sphenoid Sinuses ◽  
Csf Leaks

This manuscript will detail our experience using a microscopic endonasal surgery (MES) approach in the repair of spontaneous, traumatic, and/or iatrogenic cerebrospinal fluid (CSF) fistula into the ethmoid and sphenoid sinuses. The location of the fistula in 22 patients was determined by a direct endoscopic or microscopic visualization, intrathecal fluorescein, or computed tomography (CT) with metrizamide. Several of these patients had been treated unsuccessfully with previous neurosurgical, intracranial, and extracranial approaches to stop the leak. The CSF fistulas in all these patients were repaired with a MES approach, packing the leak with either a septal mucosal graft, or abdominal fat and fascia, and no external incisions were utilized. Furthermore, this approach allowed for an overall closure rate of 95% and offered a direct means to locate the fistula at the time of surgery. It also allowed for precise placement of grafts to cover the defect, an opportunity to perform bimanual dissection, and in general afforded an excellent field of vision.

scholarly journals Minimally invasive endoscopic repair of refractory lateral skull base cerebrospinal fluid rhinorrhea: case report and review of the literature

2018 ◽  
Vol 44 (3) ◽  
pp. E8 ◽  
Author(s):  
Brandon Lucke-Wold ◽  
Erik C. Brown ◽  
Justin S. Cetas ◽  
Aclan Dogan ◽  
Sachin Gupta ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Minimally Invasive ◽  
Skull Base ◽  
Congenital Defects ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Lateral Skull Base ◽  
Csf Diversion ◽  
Csf Leaks

Cerebrospinal fluid (CSF) leaks occur in approximately 10% of patients undergoing a translabyrinthine, retrosigmoid, or middle fossa approach for vestibular schwannoma resection. Cerebrospinal fluid rhinorrhea also results from trauma, neoplasms, and congenital defects. A high degree of difficulty in repair sometimes requires repetitive microsurgical revisions—a rate of 10% of cases is often cited. This can not only lead to morbidity but is also costly and burdensome to the health care system. In this case-based theoretical analysis, the authors summarize the literature regarding endoscopic endonasal techniques to obliterate the eustachian tube (ET) as well as compare endoscopic endonasal versus open approaches for repair. Given the results of their analysis, they recommend endoscopic endonasal ET obliteration (EEETO) as a first- or second-line technique for the repair of CSF rhinorrhea from a lateral skull base source refractory to spontaneous healing and CSF diversion. They present a case in which EEETO resolved refractory CSF rhinorrhea over a 10-month follow-up after CSF diversions, wound reexploration, revised packing of the ET via a lateral microscopic translabyrinthine approach, and the use of a vascularized flap had failed. They further summarize the literature regarding studies that describe various iterations of EEETO. By its minimally invasive nature, EEETO imposes less morbidity as well as less risk to the patient. It can be readily implemented into algorithms once CSF diversion (for example, lumbar drain) has failed, prior to considering open surgery for repair. Additional studies are warranted to further demonstrate the outcome and cost-saving benefits of EEETO as the data until now have been largely empirical yet very hopeful. The summaries and technical notes described in this paper may serve as a resource for those skull base teams faced with similar challenging and otherwise refractory CSF leaks from a lateral skull base source.

LOCALIZATION OF CEREBROSPINAL FLUID LEAKS BY GADOLINIUM-ENHANCED MAGNETIC RESONANCE CISTERNOGRAPHY

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 584-589 ◽  
Author(s):  
Kubilay Aydin ◽  
Ege Terzibasioglu ◽  
Serra Sencer ◽  
Altay Sencer ◽  
Yusufhan Suoglu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Vital Signs ◽  
Imaging Method ◽  
Csf Rhinorrhea ◽  
Mr Cisternography ◽  
Csf Leakage ◽  
Dural Tears ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

Abstract OBJECTIVE Intrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application. METHODS Fifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patient's neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations. RESULTS Gd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years. CONCLUSION Gd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

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