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

Prevention of intraoperative cerebrospinal fluid leaks by lumbar cerebrospinal fluid drainage during surgery for pituitary macroadenomas

2012 ◽  
Vol 116 (6) ◽  
pp. 1299-1303 ◽  
Author(s):  
Gautam U. Mehta ◽  
Edward H. Oldfield
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Surgical Repair ◽  
Fat Graft ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Cerebrospinal Fluid Drainage ◽  
Csf Drainage ◽  
Csf Leakage ◽  
Csf Leaks

Object Cerebrospinal fluid leakage is a major complication of transsphenoidal surgery. An intraoperative CSF leak, which occurs in up to 50% of pituitary tumor cases, is the only modifiable risk factor for postoperative leaks. Although several techniques have been described for surgical repair when an intraoperative leak is noted, none has been proposed to prevent an intraoperative CSF leak. The authors postulated that intraoperative CSF drainage would diminish tension on the arachnoid, decrease the rate of intraoperative CSF leakage during surgery for larger tumors, and reduce the need for surgical repair of CSF leaks. Methods The results of 114 transsphenoidal operations for pituitary macroadenoma performed without intraoperative CSF drainage were compared with the findings from 44 cases in which a lumbar subarachnoid catheter was placed before surgery to drain CSF at the time of dural exposure and tumor removal. Results Cerebrospinal fluid drainage reduced the rate of intraoperative CSF leakage from 41% to 5% (p < 0.001). This reduction occurred in macroadenomas with (from 57% to 5%, p < 0.001) and those without suprasellar extension (from 29% to 0%, p = 0.31). The rate of postoperative CSF leakage was similar (5% vs 5%), despite the fact that intraoperative CSF drainage reduced the need for operative repair (from 32% to 5%, p < 0.001). There were no significant catheter-related complications. Conclusions Cerebrospinal fluid drainage during transsphenoidal surgery for macroadenomas reduces the rate of intraoperative CSF leaks. This preventative measure obviated the need for surgical repair of intraoperative CSF leaks using autologous fat graft placement, other operative techniques, postoperative lumbar drainage, and/or reoperation in most patients and is associated with minimal risks.

Collagen Sponge Repair of Small Cerebrospinal Fluid Leaks Obviates Tissue Grafts and Cerebrospinal Fluid Diversion after Pituitary Surgery

Neurosurgery ◽  
2001 ◽  
Vol 49 (4) ◽  
pp. 885-890 ◽  
Author(s):  
Daniel F. Kelly ◽  
R. Jamshid Oskouian ◽  
Igor Fineman
Keyword(s):  
Cerebrospinal Fluid ◽  
Transsphenoidal Surgery ◽  
Collagen Sponge ◽  
Fat Graft ◽  
Csf Leak ◽  
Tumor Removal ◽  
Lumbar Drain ◽  
Tissue Grafts ◽  
Sellar Floor ◽  
Csf Leaks

Abstract OBJECTIVE Repair of a cerebrospinal fluid (CSF) leak created at the time of transsphenoidal surgery typically involves placement of a fat, fascial, or muscle graft and sellar floor reconstruction. In this report, a simplified repair for small, “weeping” CSF leaks using collagen sponge is described. METHODS All patients underwent an endonasal transsphenoidal procedure using the operating microscope. At the completion of tumor removal, if a small CSF leak was noted but no obvious large arachnoidal defect was present, a piece of collagen sponge was fashioned to cover the exposed diaphragma sellae. Titanium mesh was then wedged into the intrasellar, extradural space and a larger piece of collagen was placed over the reconstructed sellar floor. Nasal packing was removed within 24 hours. RESULTS During an 18-month period, 62 consecutive transsphenoidal procedures were performed for tumor removal. Of 20 patients with a small CSF leak (18 pituitary adenomas, 1 Rathke's cleft cyst, and 1 chordoma), all had successful repair with collagen sponge. At follow-up examinations at 1 to 18 months, no patient had required a lumbar drain or had developed meningitis. One other patient had a large intraoperative arachnoidal defect that was unsuccessfully repaired with the collagen sponge technique; in this patient, a second operation was required with a fat graft, sellar floor reconstruction, and lumbar drainage. CONCLUSION A simplified repair of small CSF leaks after transsphenoidal surgery using a two-layered collagen sponge technique with sellar floor reinforcement is thought to be safe and effective and obviates the need for tissue grafts, fibrin glue, or lumbar drain placement.

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 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.

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.

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.

scholarly journals Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial

2019 ◽  
Vol 131 (4) ◽  
pp. 1172-1178 ◽  
Author(s):  
Nathan T. Zwagerman ◽  
Eric W. Wang ◽  
Samuel S. Shin ◽  
Yue-Fang Chang ◽  
Juan C. Fernandez-Miranda ◽  
...  
Keyword(s):  
Skull Base ◽  
Skull Base Surgery ◽  
Controlled Trial ◽  
Csf Leak ◽  
Inclusion Criteria ◽  
Endoscopic Endonasal ◽  
Randomized Controlled ◽  
Lumbar Drain ◽  
Prospective Randomized Controlled Trial ◽  
Csf Leaks

OBJECTIVEBased on a null hypothesis that the use of short-term lumbar drainage (LD) after endoscopic endonasal surgery (EES) for intradural pathology does not prevent postoperative CSF leaks, a trial was conducted to assess the effect of postoperative LD on postoperative CSF leak following standard reconstruction.METHODSA prospective, randomized controlled trial of lumbar drain placement after endoscopic endonasal skull base surgery was performed from February 2011 to March 2015. All patients had 3-month follow-up data. Surgeons were blinded to which patients would or would not receive the drain until after closure was completed. An a priori power analysis calculation assuming 80% of power, 5% postoperative CSF leak rate in the no-LD group, and 16% in the LD group determined a planned sample size of 186 patients. A routine data and safety check was performed with every 50 patients being recruited to ensure the efficacy of randomization and safety. These interim tests were run by a statistician who was not blinded to the arms they were evaluating. This study accrued 230 consecutive adult patients with skull base pathology who were eligible for endoscopic endonasal resection. Inclusion criteria (high-flow leak) were dural defect greater than 1 cm2 (mandatory), extensive arachnoid dissection, and/or dissection into a ventricle or cistern. Sixty patients were excluded because they did not meet the inclusion criteria. One hundred seventy patients were randomized to either receive or not receive a lumbar drain.RESULTSOne hundred seventy patients were randomized, with a mean age of 51.6 years (range 19–86 years) and 38% were male. The mean BMI for the entire cohort was 28.1 kg/m2. The experimental cohort with postoperative LD had an 8.2% rate of CSF leak compared to a 21.2% rate in the control group (odds ratio 3.0, 95% confidence interval 1.2–7.6, p = 0.017). In 106 patients in whom defect size was measured intraoperatively, a larger defect was associated with postoperative CSF leak (6.2 vs 2.9 cm2, p = 0.03). No significant difference was identified in BMI between those with (mean 28.4 ± 4.3 kg/m2) and without (mean 28.1 ± 5.6 kg/m2) postoperative CSF leak (p = 0.79). Furthermore, when patients were grouped based on BMI < 25, 25–29.9, and > 30 kg/m2, no difference was noted in the rates of CSF fistula (p = 0.97).CONCLUSIONSAmong patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study’s inclusion criteria, perioperative LD used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks.Clinical trial registration no.: NCT03163134 (clinicaltrials.gov).

scholarly journals ‘Bath-plug’ technique for the endoscopic management of cerebrospinal fluid leaks

1997 ◽  
Vol 111 (11) ◽  
pp. 1042-1046 ◽  
Author(s):  
P. J. Wormald ◽  
Mike McDonogh
Keyword(s):  
Cerebrospinal Fluid ◽  
Endoscopic Sinus Surgery ◽  
Sinus Surgery ◽  
Csf Leak ◽  
Endoscopic Management ◽  
Endoscopic Repair ◽  
Lumbar Drain ◽  
A New Technique ◽  
Intradural Space ◽  
Csf Leaks

AbstractIn the past cerebrospinal fluid (CSF) leaks were managed via a craniotomy with intradural repair. With the advent of endoscopic sinus surgery, transnasal repair has become more popular. The comparatively low morbidity and high success rate of endoscopic repair has made it the treatment of choice for CSF leak repair. As more surgeons practice endoscopic sinus surgery, the incidence of iatrogenic CSF leaks has increased. It is important that endoscopic sinus surgeons be aware of the techniques for closing such leaks. The aim of this study is to present a new technique for the endoscopic repair of CSF leaks. Since the technique was devised the authors have used the technique on six patients. All patients had lumbar drains inserted and five patients had intra-thecal fluorescein inserted for location of the leak. All repairs have been successful with an average follow-up of 13 months. The technique consists of introducing a fat plug with a specifically secured vicryl suture into the intradural space and placing traction on the suture to seal the defect much as a bath plug seals a bath. There were no complications in any of the patients either intra- or post-operatively. The difficulties and possible complications of the technique as well as the use of a lumbar drain and intra-thecal fluorescein are discussed.

scholarly journals Perfusion-based human cadaveric specimen as a simulation training model in repairing cerebrospinal fluid leaks during endoscopic endonasal skull base surgery

2018 ◽  
Vol 129 (3) ◽  
pp. 792-796 ◽  
Author(s):  
Eisha A. Christian ◽  
Joshua Bakhsheshian ◽  
Ben A. Strickland ◽  
Vance L. Fredrickson ◽  
Ian A. Buchanan ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Simulation Training ◽  
Training Model ◽  
High Flow ◽  
Csf Leak ◽  
Psychomotor Skills ◽  
Endoscopic Endonasal ◽  
Cadaveric Specimen ◽  
Csf Leaks

OBJECTIVECompetency in endoscopic endonasal approaches (EEAs) to repair high-flow cerebrospinal fluid (CSF) leaks is an essential component of the neurosurgical training process. The objective of this study was to demonstrate the feasibility of a simulation model for EEA repair of anterior skull base CSF leaks.METHODSHuman cadaveric specimens were utilized with a perfusion system to simulate a high-flow CSF leak. Neurological surgery residents (postgraduate year 3 or greater) performed a standard EEA to repair a CSF leak using a combination of fat, fascia lata, and pedicled nasoseptal flaps. A standardized 5-point Likert questionnaire was used to assess the knowledge gained, techniques learned, degree of safety, benefit of CSF perfusion during repair, and pre- and posttraining confidence scores.RESULTSIntrathecal perfusion of fluorescein-infused saline into the ventricular/subarachnoid space was successful in 9 of 9 cases. The addition of CSF reconstitution offered the residents visual feedback for confirmation of intraoperative CSF leak repair. Residents gained new knowledge and a realistic simulation experience by rehearsing the psychomotor skills and techniques required to repair a CSF leak with fat and fascial grafts, as well as to prepare and rotate vascularized nasoseptal flaps. All trainees reported feeling safer with the procedure in a clinical setting and higher average posttraining confidence scores (pretraining 2.22 ± 0.83, posttraining 4.22 ± 0.44, p < 0.001).CONCLUSIONSPerfusion-based human cadaveric models can be utilized as a simulation training model for repairing CSF leaks during EEA.

Risk Factors and Reconstruction Techniques for Persistent Cerebrospinal Fluid Leak in Patients Undergoing Endoscopic Endonasal Approach to the Posterior Fossa

2021 ◽  
Author(s):  
Sergio Torres-Bayona ◽  
Nathalia Velasquez ◽  
Ana Nakassa ◽  
Aldo Eguiluz-Melendez ◽  
Vanessa Hernandez ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cerebrospinal Fluid ◽  
Posterior Fossa ◽  
Cerebrospinal Fluid Leak ◽  
Csf Leak ◽  
Control Group ◽  
Endoscopic Endonasal ◽  
Increased Risk ◽  
Dural Defects ◽  
Csf Leaks

Abstract Background High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. Objective This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Methods Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Results Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) (p = 0.02). All patients with a persistent CSF leak developed meningitis (p = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Conclusion Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial–pericranial flaps, should be considered as an early rescue option in obese patients.

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