scholarly journals Superficial siderosis of the central nervous system associated with intraspinal hemorrhage from ventral thoracic epidural veins and a ventral spinal CSF leak: case report

2017 ◽  
Vol 26 (6) ◽  
pp. 751-753 ◽  
Author(s):  
Keisuke Takai ◽  
Takashi Komori ◽  
Manabu Niimura ◽  
Makoto Taniguchi
Keyword(s):  
Csf Leak ◽  
Superficial Siderosis ◽  
Dural Defect ◽  
Bleeding Source ◽  
Thoracic Epidural ◽  
Csf Leakage ◽  
Surgical Data ◽  
Intraspinal Hemorrhage ◽  
Transdural Approach ◽  
Dural Defect Repair

In most patients with superficial siderosis of the CNS, the exact source of bleeding remains unknown because of a lack of objective surgical data. The authors herein describe the case of a 58-year-old man with superficial siderosis of the CNS. The patient also had spinal CSF leakage due to a spinal dural defect. Repair surgery for the dural defect was performed using posterior laminoplasty with a transdural approach without spinal fixation. During repair surgery, the bleeding source was found to be the epidural vein around the defect. The intraoperative and histological results of the present case suggest that epidural veins exposed to CSF represent a chronic bleeding source in patients with superficial siderosis of the CNS complicated by CSF leakage. Dural repair surgery may result in discontinuation of the CSF leaks, resolution of the epidural CSF collection, and cessation of chronic epidural bleeding.

Superficial siderosis: bleeding from the bone marrow after laminectomy for spinal tumor removal

2014 ◽  
Vol 21 (6) ◽  
pp. 905-908 ◽  
Author(s):  
Junichi Yokosuka ◽  
Keisuke Takai ◽  
Takashi Komori ◽  
Makoto Taniguchi
Keyword(s):  
Bone Marrow ◽  
Residual Tumor ◽  
Spinal Tumor ◽  
Neurological Deficits ◽  
Superficial Siderosis ◽  
Dural Defect ◽  
Bleeding Source ◽  
Subarachnoid Bleeding ◽  
Surgical Data ◽  
Intrathecal Space

Superficial siderosis of the CNS is a rare disease characterized by the deposition of hemosiderin in the subpial layers of the CNS as the result of chronic subarachnoid bleeding. The arrest of bleeding is important for preventing the progression of this disease; however, the exact source of bleeding remains unknown in most cases because of a lack of objective surgical data. The authors of this report have described a unique case of superficial siderosis following cervical laminectomy and autograft fusion for the removal of a spinal schwannoma; the bleeding source was verified by intraoperative and histopathological findings. The patient exhibited no obvious neurological deficits, such as hearing loss or cerebellar ataxia, when the superficial siderosis was diagnosed, although there were the social impairments associated with schizophrenia. During repair surgery, the bleeding source was revealed as the bone marrow vasculature of the remaining vertebral arch, and not the fragile vessels at the dural defect or the residual tumor. Chronic bleeding was stopped before the onset of irreversible neurological deficits in this case. Bone marrow exposed to the intrathecal space may represent a chronic bleeding source in patients with superficial siderosis following CNS surgery including laminectomy or craniotomy. The following recommendations have been proposed for superficial siderosis of the CNS from both a preventative and a therapeutic perspective: 1) During CNS surgery, neurosurgeons should make every effort to prevent exposing bone marrow to the intrathecal space to avoid the risk of chronic subarachnoid bleeding. 2) In the case of a large dural defect and pseudomeningocele following CNS surgery, bone marrow around the dural defect should be considered as the bleeding source of superficial siderosis, and such cases should undergo revision surgery before the progression of this disease.

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.

Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery

2012 ◽  
Vol 32 (6) ◽  
pp. E7 ◽  
Author(s):  
James K. Liu ◽  
Richard F. Schmidt ◽  
Osamah J. Choudhry ◽  
Pratik A. Shukla ◽  
Jean Anderson Eloy
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Cranial Base ◽  
High Flow ◽  
Csf Leak ◽  
Reconstruction Technique ◽  
Dural Defect ◽  
Nasoseptal Flap ◽  
Endoscopic Skull Base Surgery ◽  
Csf Leakage

Extended endoscopic endonasal approaches have allowed for a minimally invasive solution for removal of a variety of ventral skull base lesions, including intradural tumors. Depending on the location of the pathological entity, various types of surgical corridors are used, such as transcribriform, transplanum transtuberculum, transsellar, transclival, and transodontoid approaches. Often, a large skull base dural defect with a high-flow CSF leak is created after endoscopic skull base surgery. Successful reconstruction of the cranial base defect is paramount to separate the intracranial contents from the paranasal sinus contents and to prevent postoperative CSF leakage. The vascularized pedicled nasoseptal flap (PNSF) has become the workhorse for cranial base reconstruction after endoscopic skull base surgery, dramatically reducing the rate of postoperative CSF leakage since its implementation. In this report, the authors review the surgical technique and describe the operative nuances and lessons learned for successful multilayered PNSF reconstruction of cranial base defects with high-flow CSF leaks created after endoscopic skull base surgery. The authors specifically highlight important surgical pearls that are critical for successful PNSF reconstruction, including target-specific flap design and harvesting, pedicle preservation, preparation of bony defect and graft site to optimize flap adherence, multilayered closure technique, maximization of the reach of the flap, final flap positioning, and proper bolstering and buttressing of the PNSF to prevent flap dehiscence. Using this technique in 93 patients, the authors' overall postoperative CSF leak rate was 3.2%. An illustrative intraoperative video demonstrating the reconstruction technique is also presented.

Recurrent subdural hematoma caused by cerebrospinal fluid leakage

2006 ◽  
Vol 4 (2) ◽  
pp. 183-185 ◽  
Author(s):  
Junichi Mizuno ◽  
Praveen V. Mummaneni ◽  
Gerald E. Rodts ◽  
Daniel L. Barrow
Keyword(s):  
Cerebrospinal Fluid ◽  
Computerized Tomography ◽  
Subdural Hematoma ◽  
Nerve Root ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Dural Defect ◽  
Ct Myelography ◽  
Csf Fistula ◽  
Csf Leakage

✓The authors report a case of a recurrent subdural hematoma (SDH) that was caused by a persistent cerebrospinal fluid (CSF) leak from an L1–2 fistula. A 34-year-old man experienced severe headaches due to SDH, and he underwent aspiration of subdural fluid four times due to recurrent collections. Further evaluation with computerized tomography (CT) myelography demonstrated extradural extravasation of contrast through an L1–2 fistula. The patient underwent an L1–2 laminectomy; a small dural defect with CSF leakage at the left nerve root sleeve was found and was repaired. Following the repair, the patient had no further recurrence of SDH. Recurrent SDH, caused by spontaneous CSF leakage through a lumbar CSF fistula, is extremely rare. In cases of recurrent SDH, radiographic workup with spinal CT myelography should be considered.

scholarly journals Spinal endoscopy combined with selective CT myelography for dural closure of the spinal dural defect with superficial siderosis: technical note

2018 ◽  
Vol 28 (1) ◽  
pp. 96-102 ◽  
Author(s):  
Hidetaka Arishima ◽  
Yoshifumi Higashino ◽  
Shinsuke Yamada ◽  
Ayumi Akazawa ◽  
Hiroshi Arai ◽  
...  
Keyword(s):  
Endoscopic Examination ◽  
Technical Note ◽  
Drainage Tube ◽  
Superficial Siderosis ◽  
Dural Defect ◽  
Ct Myelography ◽  
Dural Closure ◽  
Spinal Subarachnoid Space ◽  
Csf Leakage ◽  
Dural Defects

The authors describe a new procedure to detect the tiny dural hole in patients with superficial siderosis (SS) and CSF leakage using a coronary angioscope system for spinal endoscopy and selective CT myelography using a spinal drainage tube. Under fluoroscopy, surgeons inserted the coronary angioscope into the spinal subarachnoid space, similar to the procedure of spinal drainage, and slowly advanced it to the cervical spine. The angioscope clearly showed the small dural hole and injured arachnoid membrane. One week later, the spinal drainage tube was inserted, and the tip of the drainage tube was located just below the level of the dural defect found by the spinal endoscopic examination. This selective CT myelography clarifies the location of the dural defect. During surgery, the small dural hole could be easily located, and it was securely sutured. It is sometimes difficult to detect the actual location of the small dural hole even with thin-slice MRI or dynamic CT myelography in patients with SS. The use of a coronary angioscope for the spinal endoscopy combined with selective CT myelography may provide an effective examination to assess dural closure of the spinal dural defect with SS in cases without obvious dural defects on conventional imaging.

scholarly journals Successful endoscopic identification of the bleeding source in the ventral dura of the cervical spine in a case of superficial siderosis

2020 ◽  
Vol 33 (1) ◽  
pp. 73-76
Author(s):  
Yoshimichi Sato ◽  
Toshiki Endo ◽  
Tomoo Inoue ◽  
Miki Fujimura ◽  
Teiji Tominaga
Keyword(s):  
Cervical Spine ◽  
Hearing Impairment ◽  
Subarachnoid Space ◽  
Superficial Siderosis ◽  
Dural Defect ◽  
Bleeding Source ◽  
Postoperative Mri ◽  
Endoscopic Observation ◽  
Bridging Veins ◽  
Definite Treatment

The authors report on the case of a 65-year-old man suffering progressive gait disturbance and hearing impairment due to superficial siderosis (SS). According to the literature, repeated hemorrhage into the subarachnoid space causes SS; however, the bleeding source remains unknown in half of SS patients. In the presented case, preoperative MRI revealed a fluid-filled intraspinal cavity extending from C2 to T8 with a dural defect at the ventral C7 level. During surgery, the dural defect was seen to connect to the intraspinal cavity filled with xanthochromic fluid. Importantly, endoscopic observation verified that the rupture of fragile bridging veins in the cavity was the definite bleeding source. Postoperative MRI confirmed disappearance of the intraspinal cavity, and the patient’s symptoms gradually improved. The use of endoscopy helped to establish the diagnosis and led to definite treatment. Fragile bridging veins in the fluid-filled interdural layers were novelly verified as a bleeding source in SS. Recognizing this phenomenon is important since it can establish closure of the dural defect as a definite treatment in SS with an intraspinal cavity.

Regression of infratentorial superficial siderosis following surgical repair of a spontaneous spinal CSF leak

2021 ◽  
pp. 10.1212/CPJ.0000000000001068
Keyword(s):  
Surgical Repair ◽  
Spontaneous Intracranial Hypotension ◽  
Rare Condition ◽  
Csf Leak ◽  
Superficial Siderosis ◽  
Dural Defect ◽  
Surgical Closure ◽  
Progression Of Disease ◽  
The Central Nervous System ◽  
Clinical Triad

Superficial siderosis (SS) of the central nervous system is a rare condition characterized by hemosiderin deposits on the surface of the brain and spinal cord.1,2 In the classical infratentorial type, SS is centered in the superior cerebellum and there is no history of intracranial bleeding.1,2 The clinical triad of infratentorial SS is slowly progressive hearing loss, ataxia, and myelopathy.1,2 About half of patients with infratentorial SS are found to have a spinal dural defect, oftentimes a chronic ventral type 1a spinal CSF leak as is seen in patients with spontaneous intracranial hypotension.1-4 Chronic hemorrhage at the site of the spinal leak is the likely cause of the SS in these patients.5 Identifying the site of leak allows surgical closure of the ventral tear thereby eliminating the cause of the SS. The goal of surgical repair is to stop progression of disease. Improvement of SS on MRI has not been reported following surgery. We now report a patient in whom MRI showed regression of SS 38 months following surgical repair of a spontaneous ventral spinal CSF leak.

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 Intraspinal hemorrhage in spontaneous intracranial hypotension: link to superficial siderosis? Report of 2 cases

2016 ◽  
Vol 24 (3) ◽  
pp. 454-456 ◽  
Author(s):  
Wouter I. Schievink ◽  
Philip Wasserstein ◽  
M. Marcel Maya
Keyword(s):  
Differential Diagnosis ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Superficial Siderosis ◽  
Dural Tear ◽  
Epidural Blood Patching ◽  
Intraspinal Hemorrhage ◽  
Csf Leaks

Spontaneous intracranial hypotension due to a spinal CSF leak has become a well-recognized cause of headaches, but such spinal CSF leaks also are found in approximately half of patients with superficial siderosis of the CNS. It has been hypothesized that friable vessels at the site of the spinal CSF leak are the likely source of chronic bleeding in these patients, but such an intraspinal hemorrhage has never been visualized. The authors report on 2 patients with spontaneous intracranial hypotension and intraspinal hemorrhage, offering support for this hypothesis. A 33-year-old man and a 62-year-old woman with spontaneous intracranial hypotension were found to have a hemorrhage within the ventral spinal CSF collection and within the thecal sac, respectively. Treatment consisted of microsurgical repair of a ventral dural tear in the first patient and epidural blood patching in the second patient. The authors suggest that spontaneous intracranial hypotension should be included in the differential diagnosis of spontaneous intraspinal hemorrhage, and that the intraspinal hemorrhage can account for the finding of superficial siderosis when the CSF leak remains untreated.

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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