Closure of large skull base defects after endoscopic transnasal craniotomy

2009 ◽  
Vol 111 (2) ◽  
pp. 371-379 ◽  
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.

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.

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 Endoscopic Endonasal Reconstructive Methods to the Anterior Skull Base

2017 ◽  
Vol 31 (04) ◽  
pp. 203-213 ◽  
Author(s):  
Srikant Chakravarthi ◽  
Lior Gonen ◽  
Alejandro Monroy-Sosa ◽  
Sammy Khalili ◽  
Amin Kassam
Keyword(s):  
Skull Base ◽  
Middle Turbinate ◽  
Reconstruction Algorithm ◽  
Inferior Turbinate ◽  
Anterior Skull Base ◽  
Endoscopic Endonasal ◽  
Fascial Flap ◽  
Skull Base Defects ◽  
Reconstructive Techniques ◽  
Csf Leaks

AbstractThe success of expanded endoscopic endonasal approaches (EEAs) to the anterior skull base, sellar, and parasellar regions has been greatly aided by the advancement in reconstructive techniques. In particular, the pedicled vascularized flaps have been developed and effectively cover skull base defects of varying sizes with a significant reduction in postoperative CSF leaks. There are two aims to this review: (1) We will provide our current, simplified reconstruction algorithm. (2) We will describe, in detail, the relevant anatomy, indications/contraindications, and surgical technique, with a particular emphasis on the nasoseptal flap (NSF). The inferior turbinate flap (ITF), middle turbinate flap (MTF), pericranial flap (PCF), and temporoparietal fascial flap (TPFF) will also be described. The NSF should be the primary option for reconstruction of majority of skull base defects following endonasal endoscopic surgery. In general, for the planum, cribriform, and upper two-thirds of the clivus, the NSF is ideal. For the lower-third of the clivus, the NSF may not be adequate and may require additional reconstructive options. Although limited in reach or more technically challenging, these reconstructive flaps should still be considered and kept in the surgical algorithm.

Various modifications of a vascularized nasoseptal flap for repair of extensive skull base dural defects

2020 ◽  
Vol 132 (2) ◽  
pp. 371-379 ◽  
Author(s):  
Ju Hyung Moon ◽  
Eui Hyun Kim ◽  
Sun Ho Kim
Keyword(s):  
Skull Base ◽  
Inferior Turbinate ◽  
Lateral Nasal Wall ◽  
Dural Defect ◽  
Nasoseptal Flap ◽  
Endonasal Surgery ◽  
Csf Rhinorrhea ◽  
Nasal Floor ◽  
Dural Defects ◽  
Skull Base Defects

OBJECTIVEEndonasal surgery of the skull base requires watertight reconstruction of the skull base that can seal the dural defect to prevent postoperative CSF rhinorrhea and consequent intracranial complications. Although the incidence of CSF leakage has decreased significantly since the introduction in 2006 of the vascularized nasoseptal flap (the Hadad-Bassagasteguy flap), reconstruction of extensive skull base dural defects remains challenging. The authors describe a new, modified vascularized nasoseptal flap for reconstruction of extensive skull base dural defects.METHODSA retrospective review was conducted on 39 cases from 2010 to 2017 that involved reconstruction of the skull base with an endonasal vascularized flap. Extended nasoseptal flaps were generated by adding the nasal floor and inferior meatus mucosa, inferior turbinate mucosa, or entire lateral nasal wall mucosa. The authors specifically highlight the surgical techniques for flap design and harvesting of these various modifications of the vascularized nasoseptal flap.RESULTSThirty-nine endonasal vascularized flaps were used to reconstruct skull base defects in 37 patients with nonsurgical or postoperative CSF rhinorrhea. Of the 39 procedures, extended nasoseptal flaps were used in 5 cases (13%). These included 2 extended nasoseptal flaps including the inferior turbinate mucosa and 3 extended nasoseptal flaps including the entire lateral nasal wall mucosa. These 5 extended nasoseptal flaps were used in patients who had nonsurgical CSF rhinorrhea due to extensive skull base destruction by invasive pituitary tumors. All flaps healed completely and sealed off the CSF leaks. Olfactory function slightly decreased in the 3 patients with extended nasoseptal flaps including the entire lateral nasal wall mucosa. One patient experienced nasolacrimal duct obstruction, which was treated by dacryocystorhinostomy. The authors encountered no wound complication in this series, while crusting at the donor site required daily nasal toilette and frequent debridement until the completion of mucosalization, which usually takes 8 to 12 weeks after surgery.CONCLUSIONSExtended nasoseptal flaps are a reliable and versatile option that can be used to reconstruct extensive skull base dural defects resulting from destruction by large invasive tumors or complex endoscopic endonasal surgery. An extended nasoseptal flap that includes the entire lateral nasal wall mucosa (360° flap) is the largest endonasal vascularized flap reported to date and may be an alternative for the reconstruction of extensive skull base defects while avoiding the need for additional external approaches.

Excavating Meningoencephaloceles: A Newly Recognized Entity

2017 ◽  
Vol 31 (2) ◽  
pp. 127-134 ◽  
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.

A New Porcine Skull Base Model

2009 ◽  
Vol 141 (2) ◽  
pp. 184-189 ◽  
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.

The Use of Lugol Test in Determining the CSF Leaks Location of the Anterior Skull Base

2018 ◽  
Vol 69 (2) ◽  
pp. 400-402
Author(s):  
Razvan Hainarosie ◽  
Alexandru Meius ◽  
Irina Ionita ◽  
Mura Hainarosie ◽  
Cristian Dragos Stefanescu ◽  
...  
Keyword(s):  
Skull Base ◽  
Intrathecal Injection ◽  
Anterior Skull Base ◽  
Diagnostic Methods ◽  
Csf Leak ◽  
Dural Defect ◽  
Glucose Content ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage ◽  
Csf Leaks

Cerebrospinal fluid rhinorrhea is a rare medical problem but with increased mortality potential due to the risk of meningitis. This condition can be either traumatic or nontraumatic, based on the etiology. The traumatic CSF fistulas represent almost 80% of the entire CSF fistulas, surgical procedures cause nearly 16% of the CSF leaks in the anterior skull base, and the nontraumatic CSF leaks represent only 4%, and they are divided in normal-pressure and high-pressure fistulas. The diagnosis of CSF leaks is made by demonstrating the evidence of extracranial CSF. The diagnostic methods are double ring sign, glucose content of the nasal fluid, Beta-trace protein test, Beta2-transferrin test. To eliminate this risk of meningitis, when a CSF leak is discovered, the defect must be closed surgically. The challenge is to determine the exact location of the defect, mainly in cases of spontaneous CSF fistulas. The imagistic examination consists of CT scans and MRI tests. The gold standard for detecting CSF leakage is still intrathecal injection of fluorescein with endoscopic localization of the dural defect. This paper aims to analyze a staining test, using Lugol solution, to detect the location of the CSF fistula. The Lugol staining test that we proposed is quick, cheap, it does not produce a toxic reaction, excepting the Iodine allergic patients, and it can be used to detect the location of the skull base defect and the CSF leak.

scholarly journals Impact of Multilayer Vascularized Reconstruction after Skull Base Endoscopic Endonasal Approaches

2019 ◽  
Vol 81 (02) ◽  
pp. 128-135 ◽  
Author(s):  
Juan Antonio Simal-Julián ◽  
Pablo Miranda-Lloret ◽  
Laila Pérez de San Román Mena ◽  
Pablo Sanromán-Álvarez ◽  
Alfonso García-Piñero ◽  
...  
Keyword(s):  
Skull Base ◽  
Scientific Evidence ◽  
Surgical Reconstruction ◽  
Csf Leak ◽  
Outcome Variable ◽  
Reconstruction Technique ◽  
Endoscopic Endonasal ◽  
Postoperative Leak ◽  
Skull Base Defects ◽  
Reconstructive Techniques

Abstract Background The use of vascularized flap to reconstruct the skull base defects has dramatically changed the postoperative cerebrospinal fluid (CSF) leak rates allowing the expansion of endoscopic skull base procedures. At present, there is insufficient scientific evidence to permit identification of the optimal reconstruction technique after the endoscopic endonasal approach (EEA). Objective The main purpose of this article is to establish the risk factors for failure in the reconstruction after EEA and whether the use of a surgical reconstruction protocol can improve the surgical results. Material and Methods A retrospective cohort study was conducted in our institution, selecting patients that underwent EEA with intraoperative CSF leak. Two reconstructive protocols were defined based on different reconstructive techniques; both were vascularized but one monolayer and the other multilayer. A multivariate analysis was performed with outcome variable presentation of postoperative leak. Results One hundred one patients were included in the study. Patients reconstructed with protocol 1, with the diagnosis different to the pituitary adenoma and older than 45 years old had higher risk of presenting postoperative leak, and with statistically significant differences when we adjusted for the remaining variables. Conclusion The vascularized reconstructions after endoscopic endonasal skull base approaches have demonstrated to be able to obtain a low rate of postoperative CSF leak. The multilayer vascularized technique may provide a more evolved technique, even reducing the postoperative leak rates comparing with the monolayer vascularized one. The reconstructive protocol employed in each case, as well as age and histological diagnosis, is independent risk factor for presenting postoperative leak.

The Use of Polydioxanone Plates for Endoscopic Skull Base Repair

2017 ◽  
Vol 31 (2) ◽  
pp. 122-126 ◽  
Author(s):  
Fahad Al-Asousi ◽  
Christopher Okpaleke ◽  
Anali Dadgostar ◽  
Amin Javer
Keyword(s):  
Skull Base ◽  
Tumor Resection ◽  
Case Series ◽  
Sinus Surgery ◽  
Csf Leak ◽  
Skull Base Tumor ◽  
Patient Reported ◽  
Sinonasal Tumor ◽  
Skull Base Defects

Background Many reconstructive techniques and materials have been reported for repair of skull base defects after sinonasal tumor excision, cerebrospinal fluid (CSF) leaks, and coverage of denuded bone. Synthetic materials have been developed for endoscopic skull base repair to avoid donor-site morbidity. Polydioxanone plate is a bioabsorbable implant designed for nasal septal reconstruction and has the ability to retain strength for at least 10 weeks and absorbs in 6 months. Objectives This study aimed to describe the use of polydioxanone plates in endoscopic skull base defect and CSF leak repair, and to describe our experience with the surgical technique and postoperative management. Methods This was a retrospective case series of patients who, between May 2013 and December 2015, underwent endoscopic sinus surgery and skull base repair for CSF leak or after excision of a skull base tumor by using polydioxanone plates. Patients who presented with sinonasal inflammatory disease or skull base tumors underwent endoscopic skull base repair by using polydioxanone plates in an underlay fashion and mucosal membrane grafts with or without adjuvant materials in an overlay fashion. The patients were reviewed at 6 days, 6 weeks, and 3 months after surgery. Postoperative adverse events, including CSF leak, infection, bleeding, headache, and graft failure, were recorded. Results The cases of seven patients (five women, two men; mean age, 53.9 years) were reviewed. Five patients underwent sinonasal tumor resection and two underwent repair for CSF leak. The mean (standard deviation) defect size was 16.4 ± 11.4 mm. There was no evidence of postoperative CSF leak, and lumbar drains were not used. One patient reported transient headache and facial pressure at the 6-week follow-up visit. The surgeons’ experience with polydioxanone plate placement, postoperative healing, and follow-up was satisfactory. Conclusion Polydioxanone could be used to achieve rigid repair of endoscopic skull base defects. These early results, although promising, require validation in clinical trials.

scholarly journals Correlation of spontaneous and traumatic anterior skull base CSF leak flow rates with fluid pattern on early, delayed, and subtraction volumetric extended echo train T2-weighted MRI

2019 ◽  
pp. 1-9 ◽  
Author(s):  
John W. Rutland ◽  
Satish Govindaraj ◽  
Corey M. Gill ◽  
Michael Shohet ◽  
Alfred M. C. Iloreta ◽  
...  
Keyword(s):  
Skull Base ◽  
Flow Rate ◽  
High Flow ◽  
Anterior Skull Base ◽  
Low Flow ◽  
Csf Leak ◽  
Dural Defect ◽  
Csf Leakage ◽  
Csf Leaks ◽  
Volumetric Segmentation

OBJECTIVECSF leakage is a potentially fatal condition that may result when a skull base dural defect permits CSF communication between the cranial vault and sinonasal cavities. Flow rate is an important property of CSF leaks that can contribute to surgical decision-making and predispose patients to complications and inferior outcomes. Noninvasive preoperative prediction of the leak rate is challenging with traditional diagnostic tools. The present study compares fluid configurations on early and late volumetric extended echo train T2-weighted MRI by using image tracings and sequence subtraction as a novel method of quantifying CSF flow rate, and it correlates radiological results with intraoperative findings and clinical outcomes.METHODSA total of 45 patients met inclusion criteria for this study and underwent 3-T MRI. Imaging sequences included two identical CUBE T2 (vendor trade name for volumetric extended echo train T2) acquisitions at the beginning and end of the scanning session, approximately 45 minutes apart. Twenty-five patients were confirmed to have definitive spontaneous or traumatic anterior skull base CSF leaks. Semiautomated volumetric segmentation of CSF intensity was performed on both CUBE data sets by using 3D-Slicer software, and volumes were subtracted to obtain accumulated CSF volume. These imaging-derived fluid accumulations were correlated with high- or low-flow states, as well as ultimate treatment outcomes including recurrences.RESULTSOf the 45 patients, 25 (55.6%) had definitive evidence of CSF leakage, and 22 (88%) of these underwent surgical repair. Patients with high-flow CSF leaks had higher early (4.058 cm3 vs 0.982 cm3, p = 0.04), late (4.58 cm3 vs 1.096 cm3, p = 0.04), and accumulated (0.53 cm3 vs 0.11 cm3, p = 0.01) fluid volume measurements than patients with low-flow leaks. The 5 (22.7%) patients who exhibited postoperative CSF leak recurrence had significantly greater early (6.30 cm3 vs 1.23 cm3, p = 0.008) and late (6.87 cm3 vs 1.45 cm3, p = 0.008) volumes. Accumulated volume was not significantly greater in patients with leak recurrence (0.58 cm3 vs 0.22 cm3, p = 0.07). Early, late, and accumulated volumes were significantly correlated with postoperative hospital stay as well as duration of postoperative lumbar drain placement (p < 0.05 for all measures).CONCLUSIONSHigh-resolution CUBE T2 MRI, coupled with precise volumetric segmentation and subtraction of sinonasal hyperintensity, not only demonstrated predictive value in differentiating low- and high-flow CSF leaks, but also correlated with postoperative complications such as leak recurrence. These findings may be useful in the clinical workup and neurosurgical management of patients with skull base CSF leaks.

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