scholarly journals Snare technique for the remodeling of the redundant arachnoid pouch to prevent cerebrospinal fluid rhinorrhea and hematoma collection during transsphenoidal surgery for suprasellar-extended pituitary tumors

2016 ◽  
Vol 125 (6) ◽  
pp. 1443-1450 ◽  
Author(s):  
Ju Hyung Moon ◽  
Eui Hyun Kim ◽  
Sun Ho Kim
Keyword(s):  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Csf Leak ◽  
Arachnoid Membrane ◽  
Csf Rhinorrhea ◽  
Resection Cavity ◽  
Postoperative Hematoma ◽  
Csf Leakage ◽  
Suprasellar Extension

OBJECTIVE Transsphenoidal surgery (TSS) is considered a most effective treatment for pituitary tumors with huge suprasellar extension. However, the chance of developing CSF leakage is relatively high, because tearing of the arachnoid membrane is common and there could be multiple tear points during the dissection of suprasellar tumors from the overlying arachnoid membrane. If there are multiple leaking points in the arachnoid membrane packing methods such as using fat or multilayered fascia graft may not be sufficient to seal off the leaking points. Moreover, the packing material may not provide sufficient tamponade to stop bleeding, and thus generates postoperative hematoma formation in the tumor resection cavity. To prevent these complications, the authors have developed a new technique for remodeling the redundant arachnoid pouch (the so-called snare technique) to reconstruct the diaphragm, seal off the CSF leak points completely, and reduce the dead space in the tumor resection cavity. METHODS In 9 patients with huge macroadenomas (> 2.5 cm in diameter) with suprasellar extension, the snare technique was used to remodel the arachnoid pouch after tumor removal via standard TSS between July 2009 and August 2014. Complications were investigated, including postoperative CSF rhinorrhea, postoperative hematoma collection, and visual compromise. RESULTS During the resection of the tumor, CSF leakage was encountered in 8 cases, all of which were sealed off using the snare technique. In 1 case without intraoperative CSF leakage, the snare technique was also applied after intentional puncturing of the arachnoid membrane to reduce the volume and tension of the arachnoid pouch. None of the 9 patients experienced postoperative CSF rhinorrhea. Lumbar CSF drainage was not required in any case. Magnetic resonance imaging studies performed 24 hours after surgery revealed a remarkable reduction in the height of the diaphragm in all cases. Visual deficits improved in all patients immediately after surgery. CONCLUSIONS Remodeling of the arachnoid pouch using the snare technique is simple and effective for completely sealing off the CSF leak point and preventing hematoma collection in the tumor resection cavity after TSS for huge pituitary tumors with suprasellar extension.

Transsphenoidal extracapsular approach to pituitary tumors

1986 ◽  
Vol 64 (1) ◽  
pp. 16-20 ◽  
Author(s):  
Nobuo Hashimoto ◽  
Hajime Handa ◽  
Tatsuhito Yamagami
Keyword(s):  
Pituitary Adenomas ◽  
Transsphenoidal Surgery ◽  
Pituitary Tumors ◽  
Hormonal Control ◽  
Arachnoid Membrane ◽  
Content Type ◽  
Tumor Capsule ◽  
Suprasellar Extension ◽  
Fine Print ◽  
Transsphenoidal Resection

✓ Two years' experience with an extracapsular transsphenoidal approach to pituitary adenomas is presented. Some pituitary tumors contain an inordinate amount of connective tissue that often makes transsphenoidal resection difficult. By opening the tumor capsule and adjacent arachnoid membrane, such tumors with suprasellar extension can be safely removed. In some cases of functioning adenoma, resection of the diaphragma sellae and adjacent arachnoid membrane results in hormonal control. Among 62 cases of transsphenoidal surgery for pituitary adenomas, eight cases required this procedure. The surgical procedure is described and the cases are summarized. The indication and limitations of this procedure are discussed.

Prevention of Cerebrospinal Fluid Rhinorrhea After Transsphenoidal Surgery by Collagen Fleece Coated With Fibrin Sealant Without Autologous Tissue Graft or Postoperative Lumbar Drainage

2011 ◽  
Vol 68 (suppl_1) ◽  
pp. ons130-ons137 ◽  
Author(s):  
Jin Mo Cho ◽  
Jung Yong Ahn ◽  
Jong Hee Chang ◽  
Sun Ho Kim
Keyword(s):  
Cerebrospinal Fluid ◽  
Fibrin Sealant ◽  
Transsphenoidal Surgery ◽  
Csf Leak ◽  
Autologous Tissue ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Tissue Graft ◽  
Csf Leakage ◽  
Sellar Floor

Abstract BACKGROUND: Autologous tissue grafting and postoperative lumbar cerebrospinal fluid (CSF) drainage (PLD) have been used to prevent CSF rhinorrhea after transsphenoidal surgery. OBJECTIVE: To describe the technical details and efficacy of our techniques of using collagen fleece coated with fibrin sealant (TachoComb, Nycomed, Linz, Austria) instead of an autologous tissue graft and refraining from the use of PLD. METHODS: We retrospectively reviewed 307 consecutive patients who underwent a transsphenoidal surgery for pituitary adenoma from November 2005 to February 2008. Among them, 90 cases of intraoperative CSF leaks were repaired with TachoComb without an autologous tissue graft or PLD. The repair procedures were tailored according to CSF leakage type, and we used only Bioglue (Cryolife Inc, Atlanta, Georgia) for sellar floor reconstruction. RESULTS: The overall rate of CSF rhinorrhea was 2.2% (2 of 90 cases). The 2 cases of CSF rhinorrhea resulted from large arachnoid defects, and there were no adverse effects from TachoComb such as transmission of viral disease or infection. CONCLUSION: Our technique is an alternative method to the traditional autologous tissue graft technique. PLD is not an essential procedure for the prevention of CSF rhinorrhea if the intraoperative CSF leak is completely sealed off during the transsphenoidal surgery. However, in cases of large arachnoid defects, aggressive repair of the arachnoid defect and sellar floor reconstruction with bone or bony substitutes should be considered in conjunction with our methods.

scholarly journals Endoscopic Endonasal Excision of Pituitary Tumors Using a Mono-nostril Technique

2019 ◽  
Vol 23 (4) ◽  
Author(s):  
AMIR AZIZ ◽  
YASER-UD- DIN ◽  
ZUBAIR AHMED ◽  
SHARUKH RIZVI ◽  
HABIB SULTAN ◽  
...  
Keyword(s):  
Tumor Resection ◽  
Pituitary Tumors ◽  
Invasive Procedure ◽  
Early Discharge ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Visual Status ◽  
Good Cosmetic ◽  
Partial Excision

Objectives: The purpose of this study is to assess the effectiveness and advantage of endoscopic mono-nostril approach to the pituitary tumors.Materials and Methods: We analyzed 70 patients undergoing transsphenoidal mono-nostril excision of pituitary tumors from September, 2016 to March, 2018.Results: We operated 70 patients, out of which 51 were males and 19 were females; the age of the patients ranged from 15 years to 65 years.In our study, out of 70 patients, 61 (87.1%) patients had excellent results with total tumor resection, marked visual improvement, early discharge on the second post-operative day, resuming their daily activities within two weeks and recurrence free interval of 1 year. Nine (12.8%) of our patients had a partial excision of the tumor, whereby there was improvement of headaches in all of them while visual status remained at the pre-operative status. Five (7.1%) of our patients had a post-operative cerebral spinal fluid (CSF) rhinorrhea, 4 (5.7%) in total excision group and 1 (1.4%) in partial excision group. These patients of CSF leak were retained in hospital and their mean stay in hospital was 12  4. Conclusion: We consider that endoscopic mono-nostril excision of the pituitary tumor is a relatively safer, effective, minimally invasive procedure; whereby there is a fast recovery, early discharge and good cosmetic results.

The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

2018 ◽  
Vol 69 (6) ◽  
pp. 1376-1377
Author(s):  
Razvan Hainarosie ◽  
Teodora Ghindea ◽  
Irina Gabriela Ionita ◽  
Mura Hainarosie ◽  
Cristian Dragos Stefanescu ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Cerebrospinal Fluid ◽  
Intrathecal Injection ◽  
Diagnostic Procedures ◽  
Blue Staining ◽  
Csf Leak ◽  
Glucose Content ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

scholarly journals Iatrogenic cerebrospinal fluid leak after repeated nasal swab tests for COVID-19: illustrative case

2021 ◽  
Vol 2 (17) ◽  
Author(s):  
Johnson Ku ◽  
Chieh-Yi Chen ◽  
Jason Ku ◽  
Hsuan-Kan Chang ◽  
Jau-Ching Wu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Nasal Cavity ◽  
Nasal Swab ◽  
Cerebrospinal Fluid Leak ◽  
Cribriform Plate ◽  
Csf Leak ◽  
Illustrative Case ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Csf Leakage

BACKGROUND Nasal swab tests are one of the most essential tools for screening coronavirus disease 2019 (COVID-19). The authors report a rare case of iatrogenic cerebrospinal fluid (CSF) leak from the anterior skull base after repeated nasal swab tests for COVID-19, which was treated with endoscopic endonasal repair. OBSERVATIONS A 41-year-old man presented with clear continuous rhinorrhea through his left nostril for 5 days after repeated nasal swabbing for COVID-19. There were no obvious risk factors for spontaneous CSF leak. Computed tomography cisternography showed contrast accumulation in the left olfactory fossa and along the left nasal cavity. Such findings aligned with a preliminary diagnosis of CSF leakage through the left cribriform plate. Magnetic resonance imaging confirmed the presence of a CSF fistula between his left cribriform plate and superior nasal concha. The patient underwent endoscopic endonasal repair. CSF rhinorrhea ceased after the surgery, and no recurrence was noted during the 12-week postoperative follow-up period. LESSONS Although rare, iatrogenic CSF leakage can be a serious complication following COVID-19 nasal swab tests, especially when infection may cause significant neurological sequelae. Healthcare providers should become familiar with nasal cavity anatomy and be well trained in performing nasal swab tests.

scholarly journals Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery

2019 ◽  
Vol 131 (5) ◽  
pp. 1625-1631 ◽  
Author(s):  
Takayuki Ishikawa ◽  
Kazuhito Takeuchi ◽  
Yuichi Nagata ◽  
Jungsu Choo ◽  
Teppei Kawabata ◽  
...  
Keyword(s):  
Skull Base ◽  
Transsphenoidal Surgery ◽  
Skull Base Surgery ◽  
Sella Turcica ◽  
High Flow ◽  
Anterior Skull Base ◽  
Csf Leak ◽  
Dural Defect ◽  
Csf Leakage ◽  
Dural Suturing

OBJECTIVETranssphenoidal surgery (TSS) is commonly used for anterior skull base surgery, especially in the sella turcica (sellar) region. However, because of its anatomical position, CSF leakage is a major complication of this approach. The authors introduced a new grading reconstruction strategy for anterior skull base surgery with continuous dural suturing in 2013. In this paper the authors report on their methods and results.METHODSAll patients with sellar or anterior skull base lesions that were removed with TSS or extended TSS by a single neurosurgeon between April 2013 and March 2017 at Nagoya University Hospital and several cooperating hospitals were retrospectively identified. Three methods of suturing dura were considered, depending on the dural defect.RESULTSThere were 176 TSS cases (141 conventional TSS cases and 35 extended endoscopic TSS cases) and 76 cases of Esposito’s grade 2 or 3 intradural high-flow CSF leakage. In the high-flow CSF leak group, there were 3 cases of CSF leakage after the operation. The rates of CSF leakage after surgery corresponding to grades 2 and 3 were 2.9% (1/34) and 4.7% (2/42), respectively.CONCLUSIONSDural suturing is a basic and key method for reconstruction of the skull base, and continuous suturing is the most effective approach. Using this approach, the frequency of cases requiring a nasoseptal flap and lumbar drainage can be reduced.

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

2012 ◽  
Vol 116 (4) ◽  
pp. 749-754 ◽  
Author(s):  
Wouter I. Schievink ◽  
Marc S. Schwartz ◽  
M. Marcel Maya ◽  
Franklin G. Moser ◽  
Todd D. Rozen
Keyword(s):  
Skull Base ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Spinal Imaging ◽  
Radiological Data ◽  
Single Instance ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature

2012 ◽  
Vol 32 (6) ◽  
pp. E2 ◽  
Author(s):  
Grace Lam ◽  
Vivek Mehta ◽  
Gabriel Zada
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Somatostatin Analogs ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Review Of The Literature ◽  
Csf Rhinorrhea ◽  
Clinical Scenarios ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous and medically induced CSF leaks are uncommonly associated with pituitary adenomas. The aim of this study was to further characterize the clinical scenarios most closely associated with this phenomenon. Methods A review of the literature was conducted to identify all cases of nonsurgical CSF leaks associated with pituitary adenomas. The authors aimed to identify associated risk factors and management strategies used to treat these tumors and repair the CSF leak site. Results Fifty-two patients with spontaneous or medically induced CSF leaks in the setting of a pituitary adenoma were identified from 29 articles published from 1980 through 2011. In 38 patients (73%), CSF rhinorrhea developed following initiation of medical therapy, whereas spontaneous CSF leakage developed as the presenting symptom in 14 patients (27%). The patients' mean age was 42.8 years (range 23–68 years). There were 35 males and 17 females. Forty-two patients (81%) had a prolactinoma, with the remaining patients having the following tumors: nonfunctioning pituitary adenoma (6 patients), growth hormone–secreting adenoma (2 patients), mammosomatotroph cell adenoma (1 patient), and ACTH-secreting adenoma (1 patient). Infrasellar tumor invasion into the paranasal sinuses was specifically reported in 56% of patients. The medical agents associated with CSF leakage were dopamine agonists (97%) and somatostatin analogs (3%). The average time from initialization of medical treatment to onset of rhinorrhea was 3.3 months (range 3 days–17 months). Nonsurgical management was successful in 4 patients, including 1 who had successful resolution with a temporary lumbar drain. Forty-six patients (88%) underwent surgical intervention to treat the CSF leak and/or resect the tumor. In 2 patients, surgery was not performed due to medical contraindications or patient preference. Conclusions Nonsurgical development of CSF rhinorrhea may occur in the setting of pituitary adenomas, especially following favorable response of invasive prolactinomas to initiation of dopamine agonist therapy. Additional cases have been reported as the presenting symptom of a pituitary adenoma and are likely to be related to decreased tumor volume due to intrinsic infarction or hemorrhage, ongoing invasion, and/or increases in intracranial pressure. Surgical repair, preferentially via a transsphenoidal approach, is the recommended initial treatment for definitive repair of the CSF leak and achievement of maximal tumor resection.

Clipping Technique for the Repair of the Intraoperative Cerebrospinal Fluid Leakage during Transsphenoidal Pituitary Tumor Surgery

2019 ◽  
Vol 17 (4) ◽  
pp. 382-388
Author(s):  
Eui Hyun Kim ◽  
Ju Hyung Moon ◽  
Sun Ho Kim
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Anterior Pituitary ◽  
Pituitary Function ◽  
Cerebrospinal Fluid Leakage ◽  
Arachnoid Membrane ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Anterior Pituitary Function ◽  
Clipping Technique

Abstract BACKGROUND During transsphenoidal surgery (TSS) for a pituitary adenoma with a large suprasellar extension, cerebrospinal fluid (CSF) leakage commonly develops from a defect in the arachnoid recess or the arachnoid membrane. OBJECTIVE To evaluate the usefulness of a newly developed clipping technique for the repair of intraoperative CSF leakage. METHODS Between September 2012 and November 2016, 698 patients with pituitary adenoma were operated on with TSS. Intraoperative CSF leakage was encountered in 301 patients (43.1%). The clipping technique was used to repair CSF leakage in 144 patients: from the arachnoid recess in 100 patients and from the arachnoid membrane in 44 patients. The clipping technique used titanium clips and a newly designed clip applier. We evaluated anterior pituitary function of the patients whose CSF leakage was closed by clipping, and compared this with function in another patient group treated with different repair techniques. RESULTS We successfully applied clip technique in 140 out of 144 patients. This clipping technique was faster and easier for repairing CSF leakage than our previously published suture technique. In our early series, 4 patients developed unexpected CSF rhinorrhea after TSS. We found no difference in anterior pituitary function between a clipping group and others. Although titanium clip was identified on postoperative MRI, its metallic scattered artifact was very minimal and did not hinder the detection of possible remnant and recurrent tumors. CONCLUSION This clipping technique is a very simple and reliable method for repairing intraoperative CSF leakage when properly applied with caution.

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