Endonasal management of sellar arachnoid cysts: simple cyst obliteration technique

2012 ◽  
Vol 116 (4) ◽  
pp. 728-740 ◽  
Author(s):  
Nancy McLaughlin ◽  
Alexander Vandergrift ◽  
Leo F. Ditzel Filho ◽  
Kiarash Shahlaie ◽  
Amalia A. Eisenberg ◽  
...  
Keyword(s):  
Skull Base ◽  
Cyst Wall ◽  
Arachnoid Cysts ◽  
Neurological Deficits ◽  
Fat Graft ◽  
Csf Leak ◽  
Simple Cyst ◽  
Skull Base Reconstruction ◽  
Presenting Symptoms ◽  
Csf Leakage

Object Symptomatic sellar arachnoid cysts (ACs) have typically been treated via the transsphenoidal route. After sellar cyst wall fenestration, some authors have advocated cyst wall resection and increasing communication between the AC and suprasellar subarachnoid space (SAS). This study is a report of the authors' experience using a simplified approach to reinforce a defective diaphragma sellae or unseen arachnoid diverticulum by deliberately not enlarging the AC-SAS communication and obliterating the cyst cavity with adipose tissue followed by skull base reconstruction. Methods A retrospective analysis was conducted of patients who underwent an endonasal transsphenoidal obliteration of symptomatic ACs with a fat graft and skull base repair. Results Between July 1998 and September 2010, 8 patients with a sellar AC were identified (6 women and 2 men, mean age 57 years). Clinical presentation included headache, pituitary dysfunction, and visual dysfunction (4 patients each group). Maximal cyst diameter averaged 22 mm (range 15–32 mm). In all cases the sellar communication to the SAS was deliberately not enlarged. The endoscope was used for visualization in 8 of 9 procedures. Postoperatively, headache improved in all 4 patients, vision in all 4 patients, and partial resolution of endocrine dysfunction (hyperprolactinemia and/or recurrent hyponatremia) occurred in 3 (75%) of 4 patients. No new endocrinopathy, CSF leak, meningitis, or neurological deficits occurred. Two patients experienced cyst reaccumulation: 1 symptomatic recurrence was treated with reoperation at 43 months postsurgery, and 1 asymptomatic partial recurrence continued to be monitored at 29 months postsurgery. Conclusions Sellar ACs can be effectively treated using endonasal fenestration and obliteration with fat with resultant reversal of presenting symptoms in the majority of patients. This simplified technique of AC cavity obliteration without enlarging communication to the SAS has a low risk of CSF leakage, and in most cases appears to effectively disrupt cyst progression, although longer follow-up is required to monitor for cyst recurrence.

scholarly journals Stepwise Algorithm for Skull Base Reconstruction in Endoscopic Endonasal Surgery: From the Simple to the Complex

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Maria Belen Vega ◽  
Philippe Lavigne ◽  
Vanessa Hernandez-Hernandez ◽  
Aldo Eguiluz-Menendez ◽  
Eric Wang ◽  
...  
Keyword(s):  
Skull Base ◽  
Posterior Fossa ◽  
Free Flaps ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal Surgery ◽  
Endonasal Surgery ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Skull Base Defects

Abstract INTRODUCTION The most frequent complication of endoscopic endonasal surgery (EES) is postoperative cerebrospinal fluid (CSF) leak. This study was designed to develop a step-wise algorithm for EES reconstruction across the spectrum of skull base defects: from free mucosal graft for uncomplicated pituitary adenomas to free flaps in complex cases with recurrent leaks. METHODS All patients with skull base pathologies who underwent EES between January 2017 and December 2018 were included and retrospectively analyzed. Tumor location, reconstruction method and postoperative CSF leak were reviewed and a step-wise algorithm based on size and location of defect was developed. RESULTS Location of skull base defects was categorized as follows: anterior fossa, suprasellar, sellar and posterior fossa. For all nonsellar sites, we performed a multilayer (collagen matrix + /- fascia lata + /− fat graft + vascularized flap) reconstruction. The nasoseptal flap (NSF) was the first choice for vascularized reconstruction when available. For all sellar lesions we employed a free mucosal graft unless a high-flow CSF leak was present, in which case a single-layer reconstruction with NSF was performed. When the NSF was not available, alternative local (lateral nasal wall flap) and regional (extracranial pericranial flap) pedicled flaps were successful choices. When patients failed multiple attempts at repair, regional or microvascular free flaps were options. Lumbar spinal drainage was employed for large anterior and posterior fossa defects and during secondary repair of postoperative CSF leaks. Of 347 patients, 4.6% had a postoperative CSF leak. Of 158 patients with an intraoperative leak (45.5%), 10.1% developed a postoperative CSF leak: 7.8% for sellar/suprasellar defects and 13% for anterior/posterior fossa defects. CONCLUSION This algorithm provides a standardized, stepwise approach to the reconstruction of all skull base defects after EES based on location.

scholarly journals The Corkscrew Technique – A Minimally Invasive, Trans-nasal Anterior Skull Base Reconstruction Using a Wedge-shaped Construct for Treatment of Cerebro-Spinal Fluid Leak

2021 ◽  
Author(s):  
Yazid Samih Badarny ◽  
Iddo Paldor ◽  
Samih Badarny ◽  
Ziv Gil ◽  
Gill Sviri
Keyword(s):  
Skull Base ◽  
Lateral Displacement ◽  
Standard Technique ◽  
Fascia Lata ◽  
Anterior Skull Base ◽  
Spinal Fluid ◽  
Csf Leak ◽  
Transnasal Approach ◽  
Skull Base Reconstruction ◽  
Csf Leakage

Abstract Background : Cerebro-spinal fluid rhinorrhea may follow surgical and traumatic events, and may be spontaneous. Various techniques have been employed for reconstruction of the skull base following a CSF leak. Recent years have seen the development of endoscopic, transnasal techniques for reconstruction of the anterior skull base. We describe our experience with a novel corkscrew technique (CST), which entails harvesting a fascia lata graft, and placement of a wedge-shaped construct above the aperture in the skull base dura. This technique serves to prevent dislodgement of the construct extracranially, and lateral displacement of the construct away from the opening. Methods : We operated 28 cases of CSF leak, in 26 patients, with a transnasal endoscopic approach. Twelve were operated using the CST and 16 with standard technique (ST), with a mean follow-up of over 5 years.Results : The success rate in alleviating the leak was 91.7% in the CST group, and 87.5% in the ST group. Altogether, our complication rate was 8.3% in the CST group, and 37.5% in the ST group. None of the differences were statistically significant. Conclusions : We recommend the use of a wedge-shaped, fascia lata based construct for transnasal endoscopic repair of anterior skull base CSF leaks. Keywords: rhinorrhea, pituitary adenoma, CSF leakage, endoscopic transnasal approach, fascia lata.

Collagen Matrix With Mucoperiosteum Graft as an Effective Fatless Flapless Reconstruction After Endoscopic Pituitary Adenoma Resection

2020 ◽  
Author(s):  
Mostafa Shahein ◽  
Alaa S Montaser ◽  
Juan M Revuelta Barbero ◽  
Guillermo Maza ◽  
Alexandre B Todeschini ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Skull Base ◽  
Collagen Matrix ◽  
Leak Rate ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Skull Base Reconstruction ◽  
Group A ◽  
Group B

Abstract BACKGROUND Proper skull base reconstruction after endoscopic endonasal pituitary surgery is of great importance to decrease the rate of complications. OBJECTIVE To assess the safety and efficacy of reconstruction with materials other than fat graft and naso-septal flaps (NSF) to avoid their associated morbidities. METHODS The authors’ institutional database for patients who underwent endoscopic endonasal approach for pituitary adenoma was reviewed. Exclusion criteria included recurrence, postradiation therapy, and reconstruction by fat graft or NSF. They were divided into group A, where collagen matrix (CM) (DuraGen® Plus Matrix, Integra LifeSciences Corporation, Plainsboro, New Jersey) alone was used; group B, where CM and simple mucoperiosteum graft were used and group C, which included cases without CM utilization. RESULTS The study included 252 patients. No age, gender, or body mass index statistically significant difference between groups. Group B included the largest tumor size (23.0 mm) in comparison to groups A (18.0 mm) and C (13.0 mm). Suprasellar extension was more frequently present (49.4%) in comparison to groups A (29.8%, P = .001) and C (21.2%, P < .001). Postoperative cerebrospinal fluid (CSF) leak rate was 0%, 2.9%, and 6% in groups A, B, and C, respectively. In group B, the CSF leak rate decreased from 45.9% intraoperatively to 2.9% postoperatively (P < .001). In group A, the CSF leak reduction rate was almost statistically significant (P = .06). CONCLUSION Utilization of CM and simple mucosperiosteal graft in skull base reconstruction following pituitary adenoma surgery is an effective method to avoid the morbidities associated with NSF or fat graft.

Nasoseptal Flap Takedown in Endoscopic Skull Base Surgery

2008 ◽  
Vol 139 (2_suppl) ◽  
pp. P79-P79
Author(s):  
Adam Mikial Zanation ◽  
Carl H Snyderman ◽  
Ricardo L Carrau ◽  
Kassam Amin
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Fat Graft ◽  
Csf Leak ◽  
Great Promise ◽  
Nasoseptal Flap ◽  
Skull Base Reconstruction ◽  
Second Stage ◽  
Endoscopic Skull Base Surgery ◽  
Intradural Tumor

Objective 1) Understand the importance of the nasoseptal flap in endoscopic skull base reconstruction. 2) Learn the techniques and limitations of nasoseptal flap takedowns and reuse during second stage and revision endoscopic skull base surgery. Methods Prospective consecutive analysis of CSF leak outcomes with nasoseptal flap takedown and reuse during endoscopic skull base surgery at a tertiary care skull base center. Results 16 consecutive cases of nasoseptal flap takedown and reuse for endoscopic endonasal intradural tumor surgery were collected prospectively and evaluated for CSF leak outcomes. 10 of these cases were planned second-stage surgeries and 6 were for revision or recurrent tumors. All 16 cases had intradural tumor extension and intra operative CSF leak. 15 of 16 had successful skull base reconstruction without postoperative CSF leak. One patient required revision endoscopic CSF leak repair and bolstering of the defect with a fat graft on post operative day 3. No flap deaths occurred. Endoscopic skull base reconstructive techniques and limitations of flap takedowns are discussed. Conclusions As the limits of endoscopic skull base surgery increases, the limits of endoscopic skull base reconstruction must also increase. The pedicled nasoseptal flap has shown great promise (4% leak rate in over 300 nasoseptal flap skull base reconstructions) at the time of the initial resection. This report illustrates the ability to takedown and reuses the nasoseptal flap in revision cases with great success (94%) and minimal additional nasal morbidity.

scholarly journals Anterior Skull Base Reconstruction: Does Fat Preparation Matter?

2018 ◽  
Vol 79 (02) ◽  
pp. e31-e35 ◽  
Author(s):  
Joshua Wood ◽  
Jaron Densky ◽  
John Boughter ◽  
Merry Sebelik ◽  
Courtney Shires
Keyword(s):  
Skull Base ◽  
Anterior Skull Base ◽  
Fat Graft ◽  
Csf Leak ◽  
Surgical Time ◽  
Skull Base Reconstruction ◽  
Csf Rhinorrhea ◽  
Autologous Fat ◽  
Significant Difference ◽  
Skull Base Defect

Objectives This article aims (1) to determine whether there is any difference in cerebrospinal fluid (CSF) leak rate after anterior skull base autologous fat reconstruction based on how the fat is prepared, and (2) to measure impact on surgical times by reconstruction type. Design Translational animal model surgical technique 3-arm trial, comparing two different methods of autologous fat skull base reconstruction versus a nonreconstructed control group. Setting Animal study. Subjects Adult Sprague-Dawley rats. Main Outcome Measures Resolution of CSF rhinorrhea after repair of a surgically created anterior skull base defect. Results Both wet (uncompressed) and dry (compressed) fat reconstruction of an anterior skull base defect demonstrated lower CSF leak rates than nonreconstructed defects. Dry fat reconstruction achieved significance in superiority of controlling CSF leak over no reconstruction (64% success vs. 31%); while wet fat reconstruction trended toward significance (50% vs. 31%). Reconstruction procedure time was longer than nonreconstructed controls, but there was no significant difference between type of fat preparation in surgical time. Conclusions This study demonstrates that drying and compressing the fat graft improves autologous fat reconstruction success for anterior skull base defects, and does not add significantly to surgical time over nonprepared fat.

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

1999 ◽  
Vol 90 (4) ◽  
pp. 651-655 ◽  
Author(s):  
Marc S. Schwartz ◽  
James I. Cohen ◽  
Toby Meltzer ◽  
Michael J. Wheatley ◽  
Sean O. McMenomey ◽  
...  
Keyword(s):  
Skull Base ◽  
Free Flap ◽  
Cranial Base ◽  
Csf Leak ◽  
Content Type ◽  
Lateral Skull Base ◽  
Csf Leakage ◽  
Radial Forearm ◽  
Microvascular Free Flap ◽  
Fine Print

Object. Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage.Methods. Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation.Conclusions. Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to “low-volume” defects.

The Medially-Invasive Cholesteatoma: An Aggressive Subtype of a Common Pathology

2020 ◽  
Vol 130 (1) ◽  
pp. 38-46
Author(s):  
Geoffrey Casazza ◽  
Matthew L. Carlson ◽  
Clough Shelton ◽  
Richard K. Gurgel
Keyword(s):  
Skull Base ◽  
Tertiary Care ◽  
Case Series ◽  
Hearing Preservation ◽  
Csf Leak ◽  
Petrous Apex ◽  
Otic Capsule ◽  
Retrospective Case ◽  
Presenting Symptoms ◽  
Subtotal Petrosectomy

Objective: Describe the outcomes of treatment for patients with cholesteatomas that are medially invasive to the otic capsule, petrous apex, and/or skull base. Study Design: Retrospective case series Setting: Two tertiary care academic centers. Patients: Patients surgically managed for medially-invasive cholesteatoma at two tertiary care institutions from 2001 to 2017. Interventions: Surgical management of medially-invasive cholesteatomas. Main Outcome Measures: The presenting symptoms, imaging, pre- and post-operative clinical course, and complications were reviewed. Results: Seven patients were identified. All patients had pre-operative radiographic evidence of invasive cholesteatoma with erosion into the otic capsule beyond just a lateral semicircular canal fistula. Five patients had a complex otologic history with multiple surgeries for recurrent cholesteatoma including three with prior canal wall down mastoidectomy surgeries. Average age at the time of surgery was 41.3 years (range 20-83). Two patients underwent a hearing preservation approach to the skull base while all others underwent a surgical approach based on the extent of the lesion. Facial nerve function was maintained at the pre-operative level in all but one patient. No patient developed cholesteatoma recurrence. Conclusions: The medially-invasive cholesteatoma demonstrates an aggressive, endophytic growth pattern, invading into the otic capsule or through the perilabyrinthine air cells to the petrous apex. Surgical resection remains the best treatment option for medially-invasive cholesteatoma. When CSF leak is a concern, a subtotal petrosectomy with closure of the ear is often necessary.

scholarly journals Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients

2019 ◽  
Vol 130 (3) ◽  
pp. 861-875 ◽  
Author(s):  
Andrew Conger ◽  
Fan Zhao ◽  
Xiaowen Wang ◽  
Amalia Eisenberg ◽  
Chester Griffiths ◽  
...  
Keyword(s):  
Pituitary Adenoma ◽  
Skull Base ◽  
Middle Turbinate ◽  
Csf Leak ◽  
Skull Base Tumor ◽  
Tumor Surgery ◽  
Contributing Factors ◽  
Skull Base Reconstruction ◽  
Grade 3 ◽  
Csf Leaks

OBJECTIVEThe authors previously described a graded approach to skull base repair following endonasal microscopic or endoscope-assisted tumor surgery. In this paper they review their experience with skull base reconstruction in the endoscopic era.METHODSA retrospective review of a single-institution endonasal endoscopic patient database (April 2010–April 2017) was undertaken. Intraoperative CSF leaks were graded based on size (grade 0 [no leak], 1, 2, or 3), and repair technique was documented across grades. The series was divided into 2 epochs based on implementation of a strict perioperative antibiotic protocol and more liberal use of permanent and/or temporary buttresses; repair failure rates and postoperative meningitis rates were assessed for the 2 epochs and compared.RESULTSIn total, 551 operations were performed in 509 patients for parasellar pathology, including pituitary adenoma (66%), Rathke’s cleft cyst (7%), meningioma (6%), craniopharyngioma (4%), and other (17%). Extended approaches were used in 41% of cases. There were 9 postoperative CSF leaks (1.6%) and 6 cases of meningitis (1.1%). Postoperative leak rates for all 551 operations by grade 0, 1, 2, and 3 were 0%, 1.9%, 3.1%, and 4.8%, respectively. Fat grafts were used in 33%, 84%, 97%, and 100% of grade 0, 1, 2, and 3 leaks, respectively. Pedicled mucosal flaps (78 total) were used in 2.6% of grade 0–2 leaks (combined) and 79.5% of grade 3 leaks (60 nasoseptal and 6 middle turbinate flaps). Nasoseptal flap usage was highest for craniopharyngioma operations (80%) and lowest for pituitary adenoma operations (2%). Two (3%) nasoseptal flaps failed. Contributing factors for the 9 repair failures were BMI ≥ 30 (7/9), lack of buttress (4/9), grade 3 leak (4/9), and postoperative vomiting (4/9). Comparison of the epochs showed that grade 1–3 repair failures decreased from 6/143 (4.1%) to 3/141 (2.1%) and grade 1–3 meningitis rates decreased from 5 (3.5%) to 1 (0.7%) (p = 0.08). Prophylactic lumbar CSF drainage was used in only 4 cases (< 1%), was associated with a higher meningitis rate in grades 1–3 (25% vs 2%), and was discontinued in 2012. Comparison of the 2 epochs showed increase buttress use in the second, with use of a permanent buttress in grade 1 and 3 leaks increasing from 13% to 55% and 32% to 76%, respectively (p < 0.001), and use of autologous septal/keel bone as a permanent buttress in grade 1, 2, and 3 leaks increasing from 15% to 51% (p < 0.001).CONCLUSIONSA graded approach to skull base repair after endonasal surgery remains valid in the endoscopic era. However, the technique has evolved significantly, with further reduction of postoperative CSF leak rates. These data suggest that buttresses are beneficial for repair of most grade 1 and 2 leaks and all grade 3 leaks. Similarly, pedicled flaps appear advantageous for grade 3 leaks, while CSF diversion may be unnecessary and a risk factor for meningitis. High BMI should prompt an aggressive multilayered repair strategy. Achieving repair failure and meningitis rates lower than 1% is a reasonable goal in endoscopic skull base tumor 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.

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