Reversal of Intracranial Hypertension‐Related Pseudomeningocele after Venous Sinus Stenting

Postoperative pseudomeningocele is a common complication of craniotomies for tumor resection. Intracranial hypertension can hinder dural repair and potentially lead to refractory or severe cases of pseudomeningocele. We present an unconventional use of venous sinus stenosis stenting to treat postcraniotomy pseudomeningocele driven by intracranial hypertension.

Anterior Skull Base Tumors and Surgery

Anterior skull base surgery requires intimate knowledge of a highly complex anatomic region containing critical neurovascular structures. A wide array of pathologies can occur along the anterior cranial base, including meningiomas, esthesioneuroblastomas, pituitary adenomas, craniopharyngiomas, chondrosarcomas, and chordomas. Advancements in endoscopic sinus surgery have allowed many of these tumors to be effectively treated via an endoscopic endonasal technique. This approach obviates the need for large incisions causing cosmetic deformity, improves magnification of the surgical field, and offers a direct path to lesions thus avoiding retraction of structures such as the brain and nerves. Surgeons must understand the limitations of endoscopic techniques and consider open or combined open and endoscopic approaches when appropriate. Reconstructive anterior skull base techniques vary depending on the size and location of defects, along with factors such as intracranial pressure and patient co-morbidities. Large skull base defects require multilayer reconstruction that include a watertight primary dural repair with either synthetic or autologous tissue, followed by local vascularized tissue flaps. This review contains 8 figures, 2 videos, 4 tables and 33 references Key words: Anterior skull base, meningioma, esthesioneuroblastoma, chordoma, pituitary, CSF leak, nasosptal flap, dural repair, expanded endonasal approaches, endoscopic surgery

How I do it: the trans-laminar, facet-joint sparing minimal invasive approach for ventral dural repair in spontaneous intracranial hypotension—a 2-dimensional operative video

Background We describe the minimally invasive, facet-sparing postero-lateral approach to the thoracic spine for a ventral dural repair in a patient with intracranial hypotension secondary to a spontaneous dural breach. Methods We performed a minimally invasive approach using a short paramedian posterior skin incision followed by a 10 × 10 mm targeted trans-laminar approach, to achieve a microsurgical repair of a symptomatic ventral dural defect causing severe disability. Conclusion The facet-sparing postero-lateral approach is safe and effective in the surgical management of thoracic dural tears, even in the most anterior ones, and avoids the traditional costotransversectomy.

An Investigation of a Novel Dural Repair Device for Intraoperative Incidental Durotomy Repair

Incidental durotomies, or dural tears, can be very difficult and time consuming to repair properly when they are encountered in confined spaces. A novel dural repair device was developed to address these situations. In this paper, the novel device was assessed against the use of traditional tools and techniques for dural repairs in two independent studies using an intricate clinical simulation model. The aim was to examine the results of the two assessments and link the outcomes to the clinical use of the novel device in the operating room. The novel device outperformed conventional techniques as measured by dural repair time, CSF leak pressure and nerve root avoidance in the simulation. The results were generally replicable clinically, however, numerous additional clinical scenarios were also encountered that the simulation model was unable to capture due to various inherent limitations. The simulation model design, potential contributors to watertightness, clinical experiences, and limitation are discussed.

Use of Saito technique to resect an anterior lumbar spine meningioma: Technical note

Background: Complete (Simpson Grade I: total removal) resections for anterior spinal meningiomas are especially challenging. This is largely attributed to difficulty obtaining a water-tight dural repair where the tumor has infiltrated the dura requiring duroplasty, thus often resulting in just a Simpson Grade II resection (i.e. coagulation of the dural implantation site). Here, we present a 56-year-old female who underwent resection of a ventral lumbar meningioma utilizing the Saito technique, that effectively separated the dura into two layers, removing just the inner layer but leaving the outer layer intact for direct dural repair. Methods: A 56-year-old female underwent a L1–L2 laminectomy. The anterior intradural resection of tumor was achieved with the Saito technique; this required cutting circumferentially around the tumor insertion site, and removing only the inner layer. Results: Postoperatively, the patient did well without tumor recurrence over 8 years. The postoperative biopsy confirmed a World Health Organization Grade I meningothelial meningioma. Conclusion: Saito’s technique proved to be a safe and effective method for achieving gross total resection of an anterior lumbar meningioma.

Primary Dural Repair Using Titanium Microclips Following Lateral Skull Base Surgery

Objective Standard techniques for primary dural repair following lateral skull base surgery are both technically challenging and time consuming without the potential for primary dural repair. Inadequate closure may result in postoperative cerebrospinal fluid (CSF) leak infectious sequalae. Traditional methods of dural repair rely on secondary obliteration of the CSF fistula. We hypothesized that the use of nonpenetrating titanium microclips may serve as a useful adjunct in primary dural repair or the establishment of an immobile repair layer following lateral skull base surgery. Methods Here, we report a novel technique for primary dural repair using nonpenetrating titanium microclips as an adjunct to standard techniques in a series of six patients with lateral skull base pathologies. Results A total of six consecutive lateral skull base tumor patients with titanium microclip dural reconstruction were included in our case series. Lateral skull base pathologies represented in this group included two jugular foramen schwannomas, one vestibular schwannoma, one petroclival meningioma, one glomus jugulare paraganglioma, and one jugular foramen chordoid meningioma. Conclusion To our knowledge, this is the first report on the use of microclips in repairing dural defects following lateral skull base surgery. Surgical outcomes for this small case series suggest that dural repair of the later skull base with nonpenetrating titanium microclips is a useful adjunct in dural repair following lateral skull base surgery.