Endoscopic third ventriculostomy in the treatment of hydrocephalus: A 20-year retrospective analysis of 209 consecutive cases

Background: Endoscopic third ventriculostomy (ETV) has been shown to be a sufficient alternative to shunts in surgical treatment of obstructive hydrocephalus. Long-term failure, age limitations, and outcome by cause are some of the issues debated in literature. The objective of this article is to analyze the clinical success and failure of ETV and its main complications. Methods: A total of 209 patients with hydrocephalus were submitted to ETV, including a mixed population of children and adults (from 0 to 59 years). Patients were divided into five groups: A – tumors, B – aqueductal stenosis, C – myelomeningocele, D – infection and hemorrhage, and E – arachnoid cyst. Variables were analyzed: age, ETV success rate, cerebrospinal fluid (CSF) fistula, mortality, and complications. Results: The two main causes of hydrocephalus were tumors (44.9%) and aqueductal stenosis (25.3%). The overall success rate was of 82.8%, and patients in Group E had the highest rate 90.9%. Group A had a success rate of 89.3%, and Group B had a rate of 88.6%. The ETV success rate was significantly higher in patients older than 1 year (P < 0.001); the former also had a lower risk of CSF fistula (P < 0.0001). The overall mortality rate was 2.8%. Conclusion: Better results were observed in the groups of patients with tumors, aqueductal stenosis, and arachnoid cysts, while those whose primary causes of hydrocephalus were myelomeningocele, infections, or bleeding had higher rates of failure after the procedure. This study demonstrated that age under 1 year and hydrocephalus caused by myelomeningocele, bleeding, and infection were considered independent risk factors of poor prognosis in ETV.

The Effectiveness and Safety of Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leaks

Background Cerebrospinal fluid (CSF) leaks can be associated with significant morbidity such as meningitis. Surgical management has proven effective, with endoscopic approaches having become the gold standard due to success rates >90%. Inability to localise the leak site prior to surgery is associated with surgical failure. The use of intrathecal fluorescein (IF) to localise CSF fistulae sites was first demonstrated in 1960. Despite this, its use in this context is unlicensed. Objective Evaluate the safety and efficacy of IF use in the management of CSF leak repairs in our centre. Methods All patients who underwent endoscopic repair of CSF fistula by a single surgeon where IF was used between January 2010 – September 2019 at a single-centre (tertiary skull base referral unit in the United Kingdom) were retrospectively analysed. Primary outcome measures were localisation of CSF fistula with IF (efficacy) and peri-operative complications likely to be attributable to IF (safety). Results There were 55 patients included (60 procedures) with a positive localisation rate of 90.0% with IF. The overall peri-operative complication rate was 8.3% (n = 5). It is likely that none were related to IF use. However, three complications may be linked giving a complication rate potentially related to IF of 5.0%. There were no peri-operative mortalities. Conclusion Many studies have demonstrated IF to be safe at low doses (<50mg) with a high sensitivity, specificity and positive predicative value. Our results demonstrate that the use of IF in our centre is safe and effective at identifying CSF fistulae. While we have reported some complications in our cohort, these were unlikely to be directly attributable IF use. We have described no serious complications such as seizures, limb weakness or death. We believe this study adds to the growing body of evidence that IF use in the management CSF fistula repairs is safe and effective.

The effect of long-term subgaleal drain retention (for 14 days) in preventing Cerebro-Spinal Fluid (CSF) fistula development in cases with an insufficiently closed dural defect after craniotomy or craniectomy

Purpose: Our aim was to determine the effectiveness of long-term subgaleal drain retention in preventing CSF fistula development that may occur in the wound site when the dura cannot be completely closed after craniotomy or craniectomy. Material and method: This study was planned to include the cases of craniotomy and craniectomy performed at Bak?rcay University Cigli Training and Research Hospital during 2017-2021. The study has been made in a retrospective manner to include a subgaleal drain group and a control group. Both groups were selected from Bak?rcay University Cigli Training and Research Hospital. A subgaleal drain was placed in 18 cases with a large or multiple defect after craniotomy or craniectomy where the defect could not be completely closed with grafts. It was planned to be kept in place for 14days with free drainage. Patients were administered antibiotics for three days after the surgery. Patients were monitored for CSF fistula and infection development. On the other hand, 12 patients having large dural defect were included in the control group. Patients in the control group were determined by a random selection method. Patients were followed for 2 days under subgaleal drainage. The Control group was also monitored for CSF fistula and infection development. Both groups statistically were compared with each other in terms of CSF fistula and infection development. Results: There were 18 cases where the dura was closed insufficiently, long-term subgaleal drainage was performed. The mean age was 66.6 (34-82) years. The surgery performed was craniotomy/craniectomy for cerebellar hematoma drainage in 3 cases, acute subdural hematoma drainage in 5 cases, supratentorial tumour resection in 5 cases, large depression fracture in 4 cases and debridement of cerebral tissue damaged by firearm injury in 1 case. The drain was withdrawn at the end of the 14th day in all patients. A CSF fistula did not occur in any of 18 patients (%0) included in the study. In all patients (%100), the wounds were healed without any problems and no signs of local or systemic infection were found. In the control group, the mean age is 62.2 (48-88) years. CSF fistula developed in 4 (%33.3) of 12 patients in the control group. We had to apply lumbal external drainage in 2(%50) of 4 patients with CSF fistula. Central nervous system infection developed in one (% 8.33) patient. Conclusion: Long-term subgaleal drainage can be used as an alternative to lumbar external drainage.

Gorham-Stout disease of the spine presenting with intracranial hypotension and cerebrospinal fluid leak: A case report and review of the literature

Background: Gorham-Stout (GS) disease or “vanishing bone disease” is rare and characterized by progressive, spontaneous osteolysis resulting in loss of bone on imaging studies. Treatment modalities include combinations of medical and/or surgical treatment and radiation therapy. Case Description: A 14-year-old female with GS disease presented with a 1-year history of thoracic back pain and atypical headaches consistent with intracranial hypotension. Magnetic resonance imaging and operative findings demonstrated a spontaneous thoracic cerebrospinal fluid leak (CSF) (e.g., that extended into the pleural cavity) and complete osteolysis of the T9-10 posterior bony elements (e.g., including the rib head, lamina, and transverse processes). The patient underwent repair of CSF fistula followed by a T6-11 instrumented fusion. Conclusion: This case of GS disease, involving a thoracic CSF fistula and absence/osteolysis of the T9-T10 bony elements, could be successfully managed with direct dural repair and an instrumented T6-T11 fusion.

Entrapment of the Basilar Artery into the Sphenoid Sinus, With CSF Fistula, without Ischaemic Stroke: A Case Report

The basilar artery herniation into the sphenoid sinus secondary to skull base fracture is a rare condition. There have been few cases described worldwide. This entity carries a potential risk of basilar artery stenosis or occlusion, resulting in ischaemia and infarction of the brainstem and cerebellum. Images study such as computed tomography (CT) and MRI plays a crucial role in diagnosing this condition. We report a rare case that shows entrapment of the basilar artery into the sphenoid sinus, after a traumatic skull base fracture, without infarction of the brainstem and cerebellum, with CSF fistula.

Cerebrospinal fluid fistula in a patient with chronic constipation related to an autonomic dysfunction and revealed by bacterial meningitis – A case report

Background: Cerebrospinal fluid (CSF) fistula represents a rare neurosurgical entity that can be defined as a communication between the subarachnoid space and nasal fossa or less commonly the ear cavity. It can be spontaneous without an evident etiology or secondary following a skull base surgery or trauma. The early diagnosis of spontaneous forms remains a challenge as clinical signs (e.g., unilateral rhinorrhea) can be absent or neglected by patients and can result in meningitis. Case Description: Here, we report the case of a 31-year-old man with chronic constipation complicated by chronic intracranial hypertension, and resulting in rhinorrhea with bacterial meningitis. The etiological assessment of chronic constipation retained an autonomic dysfunction with sympathetic hyperactivity (e.g., pure autonomic failure) as an underlying cause. Beta-2 transferrin testing associated with cerebral magnetic resonance imaging and computed tomography scan confirmed the diagnosis and localization of the fistula at the cribriform plate. The patient underwent an endoscopic endonasal approach with a repair of fistula. He presented with recurrent rhinorrhea 17 months later which required a surgical revision along with CSF diversion with a ventriculoperitoneal shunt. Conclusion: Although rare, autonomic dysfunction can result in chronic constipation in young patients, with intermittent or permanent intracranial hypertension, leading to CSF leaks. The early identification and treatment of the underlying etiology may prevent severe complications and improve the management and outcome of CSF fistula patients.