scholarly journals Evaluating the Role of Pre-operative Cerebrospinal Fluid Diversion by Lumbar Drain in Transnasal Transsphenoidal Tumor Surgeries

2021 ◽  
Vol 7 (2) ◽  
pp. 75-84
Author(s):  
Ajay Choudhary ◽  
◽  
Rahul Varshney ◽  
Pushkar Ranade ◽  
Kaviraj Kaushik ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Hospital Stay ◽  
Length Of Hospital Stay ◽  
Electrolyte Imbalance ◽  
Csf Leak ◽  
Common Symptom ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Lumbar Drain ◽  
Csf Drainage

Background and Aim: The major concerns related to the Endoscopic Endonasal Transsphenoidal (EET) surgery for sellar and suprasellar tumors include the risks of post-operative Cerebrospinal Fluid (CSF) leak, leading to morbidity and at times mortality, due to severe meningitis. Time is required to develop possible preventive measures that can reduce the risk of post-operative CSF rhinorrhea. The present study aimed to evaluate the effects of pre-operative CSF diversion by lumbar drainage in EET tumor surgeries on preventing post-operative CSF leak and its effect on the length of hospital stay. Methods and Materials/Patients: We conducted a prospective study on 20 patients with a pituitary tumor that underwent EET surgery between October 2018 and December 2019. Preoperative Lumbar Drain (LD) was inserted after induction in all explored patients. The tumor was excised with continuous intraoperative CSF drainage. Post-operatively, the LD was kept for 3 days and clamped for the next 24 hours. If no evidence of CSF rhinorrhea was present, it was removed. Complications related to CSF drainage, CSF leak, and hospital stays were evaluated. Results: Our study population consisted of 13(65%) men and 7(35%) women, with Mean±SD age of 39.8±10.71 years. The most commonly presented complaint was visual disturbance (60%) and the least common symptom was urinary disturbance (5%). The intra-operative leak was detected in 9(45%) patients, while the post-operative leak was present in only 1(5%) patient. LD blockage significantly contributed to post-operative CSF leak (P=0.001). The Mean±SD hospital stay in the post-operative period was 8.85±3.22 days with 65% of patients having a hospital stay of <7 days. Other post-operative complications (e.g. diabetes insipidus, electrolyte imbalance, and hormonal disturbances) were mainly responsible for prolonged post-operative hospital stay (P=0.001). Conclusion: Pre-operative LD, apart from helping to reduce the incidence of post-operative CSF leak, is not associated with an overall increased post-operative hospital stay.

scholarly journals Prevention of Intra-Operative Cerebrospinal Fluid Leaks by Lumbar Cerebrospinal Fluid Drainage during Endoscopic Endonasal Trans- Sphenoidal Surgery for Pituitary Macroadenomas

2020 ◽  
Vol 10 (1) ◽  
pp. 52-56
Author(s):  
Mohammad Shahnawaz Bari ◽  
Shaireen Akhtar ◽  
Md Shamsul Alam ◽  
Md Atikur Rahman ◽  
Asifur Rahman ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Pituitary Macroadenoma ◽  
Endoscopic Endonasal ◽  
Lumbar Drain ◽  
Csf Drainage ◽  
Csf Leaks ◽  
Pituitary Macroadenomas

Aim and Objective: Postoperative cerebrospinal fluid leak is a recognized complication of endoscopic endonasal trans- sphenoidal surgery for pituitary macroadenomas. In this study we assess the utility of prophylactic use of lumbar drain in preventing intra-operative cerebrospinal fluid leakage during endscopic endonasal transsphenoidal surgery for pituitary macroadenoma which will ultimately reduce the rate of persistent post-operative cerebrospinal fluid leakage. Materials and Methods: 34 patients who underwent endscopic endonasal transsphenoidal surgery for pituitary macroadenoma were dividedd into two groups by non-probability convenient sampling technique. In one group of which lumbar subarachnoid drain were given just before induction of anesthesia named LD Group and another group went through conventional method without giving lumbar drain named No LD Group. In all patients of LD Group 20-30 ml of CSF was drawn through lumbar drain before giving dural incision. Valsalva maneuver was used in each group to identify intraoperative CSF leaks at the end of definitive surgery before repairing the sellar floor.Zero degree rigid endoscope was used in all cases. Intraoperative CSF leak was categorized as ‘Yes’ or ‘No’ which was decided by surgeon.Lumbar drains were removed within 24 hours of operation in 16 patients of LD Group and in case 1,who developed intraoperative CSF leak, lumbar drain was removed later. Results: Thirty four patients were eligible for inclusion, of which 17 were assigned to the LD Group and 17 to the no LD Group. There were no statistically significant differences in patient demographics, tumor pathology, or radiology between the two groups. In LD Group intraoperative CSF leak occurred in 1(5.9%) patient and leak did not occur in 16(94.1%) patients, in No LD Group intraoperative CSF leak occurred in 14(82.4%) patients and leak did not occur in 3(17.6%) patients. Intraoperative CSF drainage significantly reduced the incidence of intraoperative CSF leaks from 82.4% in the No LD group to 5.9% in the LD group (P < 0.001). There were no catheter related complications. Conclusion: Intraoperative CSF drainage significantly reduces the incidence of intraoperative CSF leakage in patients undergoing endoscopic endonasal transsphenoidal surgery for pituitary macroadenomas. Bang. J Neurosurgery 2020; 10(1): 52-56

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 Endoscopic endonasal cerebrospinal fluid rhinorrhea repair: a cohort study in Iraq

2021 ◽  
Vol 37 (1) ◽  
Author(s):  
Ammar Abdulkadhim Hasan ◽  
Saad Farhan Al-Saedi ◽  
Mukhallad Mahdi Saleh ◽  
Hani Musa Al-Akbi
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Fascia Lata ◽  
Csf Leak ◽  
Surgical Approaches ◽  
Tensor Fascia Lata ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Wide Range

Abstract Background Cerebrospinal fluid (CSF) rhinorrhea is a condition where the protective fluid that surrounds the brain finds its way into the nose and sinuses, often appearing as a very watery runny nose. The main surgical approaches for the surgical repair of CSF leaks are intracranial and extracranial. Over the last decade, endoscopic surgery has established itself as the most widely used technique for the repair of CSF fistula. The current study aimed to describe the use of nasal endoscopic technique in the management of cerebrospinal fluid rhinorrhea repair. Results Results of our study showed that in addition to CSF leak, 40% of the patients had headache and 17.5% had repeated meningitis. Half of the etiologies for the CSF leak were spontaneous, 35% were congenital, and 15% were traumatic. The more frequent site of leak was left cribriform plate (37.5%). In the majority of patients, 37/40 (92.5%), the type of graft was tensor fascia lata and fat, while in the remaining 3 patients, type of graft was tensor fascia lata and bone, bone and fat, and tensor fascia lata. The repair succeeded in 35 patients giving a success rate of 87.5%. Conclusion It can be concluded that wide range of age groups from 2–62 years presented as CSF rhinorrhea with female predominance, and there was high success rate of endoscopic CSF rhinorrhea repair with low morbidity.

Management of Cerebrospinal Fluid Leaks After Acoustic Tumor Removal

2007 ◽  
Vol 61 (suppl_3) ◽  
pp. ONS-35-ONS-40 ◽  
Author(s):  
Rick A. Friedman ◽  
Robert D. Cullen ◽  
Jeffrey Ulis ◽  
Derald E. Brackmann
Keyword(s):  
Cerebrospinal Fluid ◽  
Eustachian Tube ◽  
Csf Leak ◽  
Surgical Removal ◽  
Middle Fossa ◽  
Tumor Removal ◽  
Csf Rhinorrhea ◽  
Lumbar Drain ◽  
Hearing Status ◽  
Acoustic Tumor

Abstract Objective: To present a logical algorithm for management of postoperative cerebrospinal fluid (CSF) leak that occurs after acoustic tumor removal, and to describe a method for eustachian tube resection. Clinical Presentation: We present an algorithm in the form of a flow chart, describe middle fossa craniotomy for eustachian tube resection, and present three cases in which this technique was used. Technique: For CSF leak, pressure dressing at the wound and bed rest for the patient are advised; lumbar drain is indicated if the leak does not resolve. Occasionally, wound exploration is required. CSF rhinorrhea is treated first with a lumbar drain. If this approach is unsuccessful, the choice of treatment depends on the patient's hearing status. If a patient has no hearing, we perform a blind sac closure of the ear canal and pack the eustachian tube. If a patient has hearing, wound reexploration and lumbar drainage are advised. When conservative and initial surgical procedures for resolving CSF leak fail, we perform a middle fossa craniotomy to identify, divide, and remove a segmental portion of the cartilaginous eustachian tube and then cauterize and occlude both ends. Conclusion: At centers where surgical removal of acoustic tumors is frequently performed, a logical protocol should be in place for treatment of postoperative CSF leak. The leak location and the patient's hearing status are factors in determining the appropriate treatment method. Middle fossa craniotomy for resection of the eustachian tube is a safe, definitive management option for treatment of recalcitrant CSF rhinorrhea that occurs after acoustic tumor surgery.

scholarly journals Use of the Hadad-Bassagasteguy Flap for Repair of Recurrent Cerebrospinal Fluid Leak after Prior Transsphenoidal Surgery

2013 ◽  
Vol 4 (3) ◽  
pp. ar.2013.4.0072 ◽  
Author(s):  
Joseph Brunworth ◽  
Tina Lin ◽  
David B. Keschner ◽  
Rohit Garg ◽  
Jivianne T. Lee
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Retrospective Chart Review ◽  
Pedicled Flap ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Csf Drainage ◽  
Advanced Planning ◽  
Csf Leaks

The Hadad-Bassagasteguy vascularized nasoseptal pedicled flap (HBF) is an effective technique for reconstruction of skull base defects with low incidence of postoperative cerebrospinal fluid (CSF) leak. Advanced planning is required as posterior septectomy during transsphenoidal surgery can preclude its use due to destruction of the vascular pedicle. We present four cases in which the HBF was successfully used to repair recurrent CSF leaks despite prior posterior septectomy and transsphenoidal surgery. A retrospective chart review was performed on all patients who developed recurrent CSF leak after transsphenoidal surgery over a 7-year period (2006–2013). Data were collected regarding demographics, clinical presentation, intraoperative findings, and surgical outcomes. Four patients who developed recurrent CSF drainage after transsphenoidal surgery were managed with HBF reconstruction during the study period. Two were men and two were women with a mean age of 37 years (range, 24–48 years). All had previously undergone resection of a pituitary macroadenoma via a transsphenoidal approach, with intraoperative CSF leaks repaired using multilayered free grafts. Recurrent CSF rhinorrhea arose 0.37–12 months (mean, 2.98 months) after the initial pituitary surgery. Active CSF drainage could be visualized intraoperatively with posterior septal perforations present. The HBF was successfully used in all cases, with no evidence of recurrent CSF leak after a mean follow-up of 2.35 years. The HBF may be salvaged for repair of recurrent CSF leaks even in the context of prior posterior septectomy and transsphenoidal surgery. However, longer follow-up is necessary to determine the long-term efficacy of this procedure in such revision cases.

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 Transsphenoidal endoscopic appro ach in the treat ment of spontaneous cerebrospinal fluid (CSF) leak

2019 ◽  
Vol 178 (2) ◽  
pp. 10-14
Author(s):  
V. Y. Cherebillo ◽  
S. A. Karpischenko ◽  
N. S. Puzakov ◽  
O. A. Stancheva
Keyword(s):  
Cerebrospinal Fluid ◽  
Nasal Cavity ◽  
Pathological Condition ◽  
Research Centre ◽  
Csf Leak ◽  
Medical Institute ◽  
Large Defect ◽  
Endoscopic Endonasal ◽  
National Medical ◽  
Treat Ment

Introduction. Spontaneous nasal liquorrhea is a pathological condition associated with defect between nasal cavity and intracranial structures that lead to the expiration of the CSF from the nasal cavity.The objective is to evaluate the effectiveness of endoscopic endonasal approach in the CSF leak treatment.Material and methods. For the period from 2008 to 2018, 38 patients with spontaneous nasal liquorrhea were examined and treated in Pavlov First Saint Petersburg State Medical University, the clinic of neurosurgery of Kirov Medical Institute and Almazov National Medical Research Centre. All patients underwent plastic surgery of the CSF fistula by endoscopic endonasal aproach.Results. Only in 4 cases, there was a large defect, the failure of the closure of which required repeated surgical intervention in 1–2 weeks after the initial operation.Conclusion. The use of autologous tissues (muscle or fat autograft) is the method of choice for repeated surgical plastics of the cerebrospinal fluid fistula or in a large size defect (more than 5 mm).

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

2018 ◽  
Vol 158 (4) ◽  
pp. 774-776 ◽  
Author(s):  
Zixiang Cong ◽  
Kaidong Liu ◽  
Guodao Wen ◽  
Liang Qiao ◽  
Handong Wang ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Csf Leak ◽  
Anatomical Reconstruction ◽  
Endoscopic Endonasal ◽  
Reconstructive Technique ◽  
Sellar Reconstruction ◽  
Sellar Floor ◽  
Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: Learning from Our Failures

2001 ◽  
Vol 15 (5) ◽  
pp. 333-342 ◽  
Author(s):  
Paolo Castelnuovo ◽  
Silvia Mauri ◽  
Davide Locatelli ◽  
Enzo Emanuelli ◽  
Giovanni Delù ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Csf Leak ◽  
Graft Material ◽  
Literature Analysis ◽  
Endoscopic Repair ◽  
Common Procedure ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea

Endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea is becoming a common procedure. The purpose of this study was to perform a literature analysis centering cases of treatment failure and to review our 31 cases with a 1-year minimum follow-up. An extensive search of the literature was conducted, which focused on success rate, follow-up, diagnostic techniques, graft material used, failure rate, and comments on failures. A retrospective analysis of our 31 patients was carried out, and all cases were treated with the endoscopic approach with a 1-year minimum follow-up. From the literature analysis, the median success rate at the first endoscopic attempt is 90%. Our success rate was 87.1%. Failures were analyzed. A unique protocol for CSF leak diagnosis does not exist; we suggest our diagnostic algorithm. Graft material used depends on the authors’ experience, and based on this review of cases to date, did not significantly influence the success rate. The analysis of cases of failure shows that the majority of authors omit details. More research is needed to improve prevention of failures.

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