A retrospective study to analyze treatment of post traumatic cerebro spinal fluid rhinorrhea and role of trans cranial pedicled pericranial repair in present day context

: Skull base fractures are a major cause of morbidity and mortality in head injury. Anterior cranial Fossa (ACF) skull base fracture, leading to Cerebro Spinal Fluid (CSF) Rhinorrhea is one of the most commonly encountered presentation in ACF base fractures. The key to successful management of such cases lies in early diagnosis and surgical management before it leads to meningitis and avoidable mortality.To evaluate the cases of post traumatic CSF rhinorrhea and analyze the parameters utilized to guide the management strategies. An attempt was made to come up with guidelines for its management in a tertiary care hospital.This was a retrospective study in which all cases of traumatic CSF Rhinorrhea admitted to Tertiary care hospital were included. Patients were divided into three groups. First group was conservatively managed in which the rhinorrhea and serial imaging findings showed favourable response.In thesecond group patients were subjected to endoscopic repair by the ENT surgeon based on anatomical considerations. The third group included patients who were had failed the trial of conservative management and the site of leak did not favor endoscopic repair.The outcomes in all these groups were analyzed and conclusions drawn.A total of 54 patients were included in the study which was conducted between Jan 2014 to 2020. 24 were successfully managed conservatively,10 were managed with endoscopic repair and 20 were managed by bifrontal craniotomy and pedicled pericranial ACF Base repair. There was one case from the first group who developed CSF leak after one month necessitating ACF base repair. There was no recurrence reportedin the cases managed endoscopically, whereas one case subjected to craniotomy had recurrence requiring lumbar drain placement. With each transcranial surgery there was a refinement in the technique further minimizing complications. We have elaborated on the surgical nuances to ensurebetter outcomes. : Pedicledpericranial flap ACF base repair is an elegant approach which requires an understanding of the mechanism of CSF leak from skull base fractures. This procedure can easily be mastered and when performed correctly provides best results for cases where there are multiple ACF defects, those not accessible by endoscope and also in those cases where imaging is not able to localize the exact site of defect leading to CSF rhinorrhea. Anosmia is an in evitable complication of this procedure. However, the trade off between mortality resulting from meningitis versus anosmia makes it a viable and attractive treatment option.

Microsurgical reconstruction of the skull base and midface after orbitomaxillary resections for malignant tumors

Background. Orbitomaxillary resection includes exenteration of the orbital contents with resection of the inferior orbital and medial walls. The main goals are: reconstruction of soft tissue and bone structure defects, tamponade of the orbital cavity and/or its preparation for further ocular prosthetics, and reconstruction of the skull base defect. The purpose of the study to present the immediate results of orbitomaxillary resections in patients with malignant neoplasms of the skull base and midface. Material and methods. Between 2014 and 2020, 6 patients who previously underwent surgery for primary cancer (n=3) and recurrent cancer (n=3) were treated at the Head and Neck cancer department of N.N. Blokhin National medical Research center of oncology. To reconstruct defects after resection of bone structures (maxilla, frontal and nasal bones) and skin, a musculocutaneous alt-flap was used in 3 (50 %) cases and a fascial skin radial flap in 3 (50 %) cases. Results. The aesthetic result was assessed in 6 patients. In all cases, a satisfactory result was obtained. None of the patients who underwent resection of the dura mater followed by reconstruction had no symptoms of liquorrhea in the postoperative period. Conclusion. Flap selection depends on the defect size. In cases with a small defect size (up to 70 cm3), reconstruction with the radial fascial skin flap can be performed. If the defect size is more than 71 cm3, reconstruction with musculocutaneous alt flap can be the method of choice.

Intraoperative Magnetic Resonance Imaging Assisted Endoscopic Endonasal Resection of Clival Chordomas

BackgroundCranial base chordomas are typically indolent and usually appear as encapsulated tumors. They slowly grow by infiltrating the bone, along with the lines of least resistance. Due to its relationship with important neurovascular structures, skull base chordoma surgery is challenging.ObjectiveThe usefulness of intraoperative magnetic resonance imaging (IO-MRI) in achieving the goal of surgery, is evaluated in this study.MethodsBetween March 2018 and March 2020, 42 patients were operated on for resection of skull base chordomas in our institution. All of them were operated on under IO-MRI. Patients were analyzed retrospectively for identifying common residue locations, complications and early post-operative outcomes.ResultsIn 22 patients (52,4%) gross total resection was achieved according to the final IO-MRI. In 20 patients (47,6%) complete tumor removal was not possible because of extension to the petrous bone (8 patients), pontocerebellar angle (6 patients), prepontine cistern (4 patients), temporobasal (1 patient), cervical axis (1 patient). In 13 patients, the surgery was continued after the first IO-MRI control was performed, which showed a resectable residual tumor. 7 of these patients achieved total resection according to the second IO-MRI, in the other 6 patients all efforts were made to ensure maximal resection of the tumor as much as possible without morbidity. Repeated IO-MRI helped achieve gross total resection in 7 patients (53.8%).ConclusionsOur study proves that the use of IO-MRI is a safe method that provides the opportunity to show the degree of resection in skull base chordomas and to evaluate the volume and location of the residual tumor intraoperatively. Hence IO-MRI can improve the life expectancy of patients because it provides an opportunity for both gross total resection and maximal safe resection in cases where total resection is not possible.

Anterior Skull Base Meningioma: Surgical approach and complication avoidance

Background: Endoscopic endonasal approach (EEA) and keyhole transcranial approaches are being increasingly used in anterior skull base meningioma (ASBM) surgery. Objective: We compare tumor resection rates and complication profiles of EEA and supraorbital key hole approach (SOKHA) against conventional transcranial approaches (TCA). Methods: Fifty-four patients with ASBM [olfactory groove (OGM), n=19 and planum sphenoidale/tuberculum sellae (PS/TSM), n=35) operated at a single centre over 7 years were retrospectively analyzed. Results: The overall rate of GTR was higher in OGM (15/19, 78.9%) than PS-TSM group (23/35, 65.7%, p=0.37). GTR rate with OGM was 90% and 75% with TCA and EEA. Death (n=1) following medical complication (TCA) and CSF leak requiring re-exploration (n=2, one each in TCA and EEA) accounted for the major complications in OGM. For the PS/TSM group, the GTR rates were 73.3% (n=11/15), 53.8% (n=7/13) and 71.4% (n=5/7) with TCA, EEA and SOKHA respectively. Seven patients (20%) of PS-TSM developed major postoperative complications including 4 deaths (one each in TCA, SOKHA and 2 in EEA group) and 3 visual deteriorations. Direct and indirect vascular complications were common in lesser invasive approaches to PS-TSM especially if the tumor has encased intracranial arteries. Conclusions: No single approach is applicable to all ASBMs. TCA is still the best approach to obtain GTR but has tissue trauma related problems. SOKHA may be a good alternative to TCA in selected PS-TSMs while EEA may be an alternate option in some OGMs. A meticulous patient selection is needed to derive reported results of EEA for PS-TSM.