Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

2012 ◽  
Vol 32 (6) ◽  
pp. E6 ◽  
Author(s):  
Tyler J. Kenning ◽  
Thomas O. Willcox ◽  
Gregory J. Artz ◽  
Paul Schiffmacher ◽  
Christopher J. Farrell ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Temporal Bone ◽  
Cranial Base ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Ventriculoperitoneal Shunting ◽  
Anterior Cranial Base ◽  
Tegmen Tympani ◽  
Treatment Paradigm ◽  
Csf Leaks

Object Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors. Methods The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect. Results The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months). Conclusions Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

Surgical treatment of spontaneous spinal cerebrospinal fluid leaks

1998 ◽  
Vol 88 (2) ◽  
pp. 243-246 ◽  
Author(s):  
Wouter I. Schievink ◽  
Vittorio M. Morreale ◽  
John L. D. Atkinson ◽  
Fredric B. Meyer ◽  
David G. Piepgras ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Treatment ◽  
Intracranial Hypotension ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Content Type ◽  
Surgical Exploration ◽  
Fine Print ◽  
Csf Leaks

Object. Spontaneous spinal cerebrospinal fluid (CSF) leaks are an increasingly recognized cause of intracranial hypotension and may require neurosurgical intervention. In the present report the authors review their experience with the surgical management of spontaneous spinal CSF leaks. Methods. Between 1992 and 1997, 10 patients with spontaneous spinal CSF leaks and intracranial hypotension were treated surgically. The mean age of the seven women and three men was 42.3 years (range 22–61 years). Preoperative imaging showed a single meningeal diverticulum in two patients, a complex of diverticula in one patient, and a focal CSF leak alone in seven patients. Surgical exploration in these seven patients demonstrated meningeal diverticula in one patient; no clear source of CSF leakage could be identified in the remaining six patients. Treatment consisted of ligation of the diverticula or packing of the epidural space with muscle or Gelfoam. Multiple simultaneous spinal CSF leaks were identified in three patients. Conclusions. All patients experienced complete relief of their headaches postoperatively. There has been no recurrence of symptoms in any of the patients during a mean follow-up period of 19 months (range 3–58 months; 16 person-years of cumulative follow up). Complications consisted of transient intracranial hypertension in one patient and leg numbness in another patient. Although the disease is often self-limiting, surgical treatment has an important role in the management of spontaneous spinal CSF leaks. Surgery is effective in eliminating the headaches and the morbidity is generally low. Surgical exploration for a focal CSF leak, as demonstrated on radiographic studies, usually does not reveal a clear source of the leak. Some patients may have multiple simultaneous CSF leaks.

Extended transsphenoidal approach for pituitary adenomas invading the anterior cranial base, cavernous sinus, and clivus: a single-center experience with 126 consecutive cases

2010 ◽  
Vol 112 (1) ◽  
pp. 108-117 ◽  
Author(s):  
Bing Zhao ◽  
Yu-Kui Wei ◽  
Gui-Lin Li ◽  
Yong-Ning Li ◽  
Yong Yao ◽  
...  
Keyword(s):  
Postoperative Complications ◽  
Cavernous Sinus ◽  
Pituitary Adenomas ◽  
Tumor Resection ◽  
Cranial Base ◽  
Transsphenoidal Approach ◽  
Preoperative Imaging ◽  
Surgical Removal ◽  
Extended Transsphenoidal Approach ◽  
Anterior Cranial Base

Object The standard transsphenoidal approach has been successfully used to resect most pituitary adenomas. However, as a result of the limited exposure provided by this procedure, complete surgical removal of pituitary adenomas with parasellar or retrosellar extension remains problematic. By additional bone removal of the cranial base, the extended transsphenoidal approach provides better exposure to the parasellar and clival region compared with the standard approach. The authors describe their surgical experience with the extended transsphenoidal approach to remove pituitary adenomas invading the anterior cranial base, cavernous sinus (CS), and clivus. Methods Retrospective analysis was performed in 126 patients with pituitary adenomas that were surgically treated via the extended transsphenoidal approach between September 1999 and March 2008. There were 55 male and 71 female patients with a mean age of 43.4 years (range 12–75 years). There were 82 cases of macroadenoma and 44 cases of giant adenoma. Results Gross-total resection was achieved in 78 patients (61.9%), subtotal resection in 43 (34.1%), and partial resection in 5 (4%). Postoperative complications included transient cerebrospinal rhinorrhea (7 cases), incomplete cranial nerve palsy (5), panhypopituitarism (5), internal carotid artery injury (2), monocular blindness (2), permanent diabetes insipidus (1), and perforation of the nasal septum (2). No intraoperative or postoperative death was observed. Conclusions The extended transsphenoidal approach provides excellent exposure to pituitary adenomas invading the anterior cranial base, CS, and clivus. This approach enhances the degree of tumor resection and keeps postoperative complications relatively low. However, radical resection of tumors that are firm, highly invasive to the CS, or invading multidirectionally remains a big challenge. This procedure not only allows better visualization of the tumor and the neurovascular structures but also provides significant working space under the microscope, which facilitates intraoperative manipulation. Preoperative imaging studies and new techniques such as the neuronavigation system and the endoscope improve the efficacy and safety of tumor resection.

Significance of Empty Sella in Cerebrospinal Fluid Leaks

2003 ◽  
Vol 128 (1) ◽  
pp. 32-38 ◽  
Author(s):  
Rodney J. Schlosser ◽  
William E. Bolger
Keyword(s):  
Cerebrospinal Fluid ◽  
Intracranial Hypertension ◽  
Sella Turcica ◽  
Radiographic Finding ◽  
Empty Sella ◽  
Senior Author ◽  
Csf Leak ◽  
Benign Intracranial Hypertension ◽  
Cerebrospinal Fluid Leaks ◽  
Csf Leaks

OBJECTIVE: The role of elevated cerebrospinal fluid (CSF) pressures in the pathophysiology of various CSF leaks is not clear. Empty sella syndrome (ESS) is a radiographic finding that can be associated with elevated CSF pressures and may represent a radiographic indicator of intracranial hypertension. We present our experience with CSF leaks of various causes, the prevalence of ESS in the spontaneous and nonspontaneous categories, and the potential pathophysiology and unique management issues of the spontaneous CSF leak group. METHODS: We conducted a retrospective review of medical records, imaging studies, and surgical treatment of CSF leaks in patients treated by the senior author. RESULTS: Sixteen patients with spontaneous CSF leaks and 12 patients with nonspontaneous CSF leaks were surgically treated from 1996 through 2002. In the spontaneous group, 15 patients had complete imaging of the sella turcica. Ten had completely empty sellae and 5 had partially empty sellae, for a total of 100% (15 of 15). In the nonspontaneous group, 9 patients had complete imaging of the sella. Only 11% (1 of 9) had a partially empty sella and that was a congenital leak. Comparison of proportions between these 2 groups was significant ( P = 0.01). The spontaneous group consisted primarily of obese, middle-aged females (13 of 16 patients). CONCLUSION: Empty sella probably represents a sign of elevated intracranial pressure that leads to idiopathic, spontaneous CSF leaks. Spontaneous CSF leaks are strongly associated with the radiographic finding of an empty sella and are more common in obese females, similar to benign intracranial hypertension. This unique population may require more aggressive surgical and medical treatment to prevent recurrent or multiple leaks.

Endonasal Endoscopic Closure of Cerebrospinal Fluid Fistulas at the Anterior Cranial Base

1996 ◽  
Vol 105 (8) ◽  
pp. 620-623 ◽  
Author(s):  
Mislav Gjuric ◽  
Henning Keimer ◽  
Ulrich Goede ◽  
Malte Erik Wigand
Keyword(s):  
Cerebrospinal Fluid ◽  
Soft Tissue Injuries ◽  
Inferior Turbinate ◽  
Cranial Base ◽  
Csf Leak ◽  
Facial Soft Tissue ◽  
Csf Rhinorrhea ◽  
Endoscopic Closure ◽  
Anterior Cranial Base ◽  
Dural Tears

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 × 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

scholarly journals Circumferential Watertight Dural Repair Using Nitinol U-Clips in Expanded Endonasal and Sublabial Approaches to the Cranial Base

2010 ◽  
Vol 67 (suppl_2) ◽  
pp. ons448-ons456 ◽  
Author(s):  
Francesco Acerbi ◽  
Eric Genden ◽  
Joshua Bederson
Keyword(s):  
Vascular Diseases ◽  
Cranial Base ◽  
Csf Leak ◽  
Melanoma Metastasis ◽  
Dural Repair ◽  
Dural Closure ◽  
Tuberculum Sellae ◽  
Planum Sphenoidale ◽  
Sublabial Approach ◽  
Csf Leaks

ABSTRACT BACKGROUND: In recent years, significant advances have been made in the field of expanded endonasal approaches that permit treatment of different cranial base intradural lesions. OBJECTIVE: To report our technique of cranial base dural repair by the application of nitinol U-Clips in endoscope-assisted extended endonasal or sublabial approaches. Closure techniques and postoperative cerebrospinal (CSF) leaks are reported. METHODS: We reviewed 11 patients with different kinds of cranial base tumors or vascular diseases (2 tuberculum sellae meningiomas, 1 planum sphenoidale meningioma, 4 craniopharyngiomas, 1 recurrent clival chordoma, 1 esthesioneuroblastoma, 1 ethmoidal melanoma metastasis, 1 basilar trunk aneurysm) who underwent an endoscope-assisted extended endonasal or sublabial approach. Dural repair was performed using nitinol U-Clips to circumferentially suture AlloDerm or fascia lata directly to the existing dural borders. Lumbar drainage was not used in 9 patients and was used in 2 patients for 5 days. Patients were evaluated for the appearance of CSF leaks. RESULTS: Postoperative CSF leak was observed in 1 patient (9%). This required a second transnasal repair. CONCLUSION: Circumferential dural closure with U-Clips is a useful adjunct to prevent CSF leaks after expanded endonasal or sublabial approaches to the cranial base for treatment of intracranial pathology.

scholarly journals Transmastoid Repair of Temporal Meningoencephaloceles and Cerebrospinal Fluid Otorrhea

2011 ◽  
Vol 3 (1) ◽  
pp. 31-41 ◽  
Author(s):  
Werner Garavello ◽  
Lorenzo Gaini ◽  
Diego Zanetti
Keyword(s):  
Cerebrospinal Fluid ◽  
Temporal Bone ◽  
Process Management ◽  
Diagnostic Process ◽  
Mastoid Cavity ◽  
Tegmen Tympani ◽  
Surgical Options ◽  
Conductive Hearing ◽  
Transmastoid Approach ◽  
Csf Leaks

ABSTRACT This paper reviews the diagnosis and treatment of temporal bone meningoencephaloceles, defined as the herniation of meninges or brain tissue into empty spaces within the temporal bone, i.e. tympanic or mastoid cavity, through the tegmen tympani or antri respectively. It also describes the current methods of control of cerebrospinal fluid (CSF) leaks, which commonly present as serous otorrhea or rhinorrhea in addition to a variety of symptoms, such as conductive hearing loss. Imaging is the mainstay of the diagnostic process. Management of the condition is surgical, and this review outlines the surgical options with special emphasis on the transmastoid approach and the materials applicable for repair of the bony dehiscences.

scholarly journals Endoscopic endonasal resection of midline cranial base tumors

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.

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.

A Unique Subset: Idiopathic Intracranial Hypertension Presenting as Spontaneous CSF Leak of the Anterior Skull Base

2021 ◽  
Author(s):  
Christopher S. Hong ◽  
Adam J. Kundishora ◽  
Aladine A. Elsamadicy ◽  
Eugenia M. Vining ◽  
R. Peter Manes ◽  
...  
Keyword(s):  
Literature Review ◽  
Intracranial Hypertension ◽  
Skull Base ◽  
Idiopathic Intracranial Hypertension ◽  
Empty Sella ◽  
Csf Leak ◽  
Presenting Symptoms ◽  
History Of ◽  
Sinus Stenosis ◽  
Csf Leaks

Abstract Background Spontaneous cerebrospinal fluid (CSF) leaks represent a unique clinical presentation of idiopathic intracranial hypertension (IIH), lacking classical features of IIH, including severe headaches, papilledema, and markedly elevated opening pressures. Methods Following a single-institution retrospective review of patients undergoing spontaneous CSF leak repair, we performed a literature review of spontaneous CSF leak in patients previously undiagnosed with IIH, querying PubMed. Results Our literature review yielded 26 studies, comprising 716 patients. Average age was 51 years with 80.8% female predominance, and average body mass index was 35.5. Presenting symptoms included headaches (32.5%), visual disturbances (4.2%), and a history of meningitis (15.3%). Papilledema occurred in 14.1%. An empty sella was present in 77.7%. Slit ventricles and venous sinus stenosis comprised 7.7 and 31.8%, respectively. CSF leak most commonly originated from the sphenoid sinus (41.1%), cribriform plate (25.4%), and ethmoid skull base (20.4%). Preoperative opening pressures were normal at 22.4 cm H2O and elevated postoperatively to 30.8 cm H2O. 19.1% of patients underwent shunt placement. CSF leak recurred after repair in 10.5% of patients, 78.6% involving the initial site. A total of 85.7% of these patients were managed with repeat surgical intervention, and 23.2% underwent a shunting procedure. Conclusion Spontaneous CSF leaks represent a distinct variant of IIH, distinguished by decreased prevalence of headaches, lack of visual deficits, and normal opening pressures. Delayed measurement of opening pressure after leak repair may be helpful to diagnose IIH. Permanent CSF diversion may be indicated in patients exhibiting significantly elevated opening pressures postoperatively, refractory symptoms of IIH, or recurrent CSF leak.

The critical importance of a vascularized flap in preventing recurrence after endoscopic repair of spontaneous cerebrospinal fluid leaks and meningoencephaloceles

2021 ◽  
pp. 1-8
Author(s):  
Alex P. Michael ◽  
Osama Elbuluk ◽  
Apostolos John Tsiouris ◽  
Abtin Tabaee ◽  
Ashutosh Kacker ◽  
...  
Keyword(s):  
Skull Base ◽  
Treatment Algorithm ◽  
Anterior Skull Base ◽  
Csf Leak ◽  
Preoperative Imaging ◽  
Consecutive Series ◽  
Common Site ◽  
Endoscopic Repair ◽  
Phone Calls ◽  
Csf Leaks

OBJECTIVE Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence. METHODS A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele. RESULTS From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9–38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher’s exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred. CONCLUSIONS Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.

Sign in / Sign up

Export Citation Format

Share Document