Cerebrospinal fluid (CSF) leak closure remains one of the most difficult surgeries for skull base surgeons, particularly with frontal sinus involvement. Technological advances in endoscopic surgery increasingly allow for less morbid approaches to the frontal sinus. We describe a series of patients who underwent endoscopic frontal sinus CSF leak repair utilizing a unilateral approach, to evaluate the utility and outcomes of this method. We performed a retrospective review of four cases in tertiary care centers. Participants included patients with CSF leak involving the frontal sinus. Main outcome measures included cessation of CSF leak and frontal sinus patency. Three patients were closed on the first surgical attempt; one with a communicating hydrocephalus required a revision procedure. Leak etiologies included prior craniotomy for frontal sinus mucopyocele, spontaneous meningoencephalocele, erosion due to mucormycosis, and prior endoscopic sinus surgery. The frontal sinus remained patent in three of four patients. No patients have evidence of a leak at a minimum of 1 year after surgery. The repair of frontal sinus CSF leaks is possible in specific cases with an endoscopic unilateral approach in leaks with multiple etiologies. Surgeons should consider this approach when selecting the appropriate procedure for repair of frontal sinus CSF leaks.
Cerebrospinal fluid leak; frontal sinus; frontal recess; endoscopic repair; unilateral
This study assesses the efficacy of preoperative lumbar drain (LD) placement prior to elective open cranial and endoscopic anterior skull base (ASB) surgery in reducing postoperative cerebrospinal fluid (CSF) leak. A retrospective review of 93 patients who underwent LD placement at our institution between 2006 and 2011 was performed. Of these patients, 43 underwent elective LD placement prior to ASB surgery; 2 patients had evidence of CSF rhinorrhea prior to surgery, and 41 had no evidence of a preoperative CSF leak. Of those 41 patients, 2 developed CSF rhinorrhea (2/41= 4.9%) as a result of surgery—all in our endoscopic patient population (N = 21; 2/21= 9.5%). No postoperative CSF leaks were noted in our open ASB surgery cohort (N = 20). Other complications were rare, but we encountered two instances of delayed malignant cerebral edema in the open ASB cohort that are discussed in detail. Overall, preoperative LD placement was found to be an effective means of preventing postoperative CSF leaks after ASB approaches, but potential and significant intracranial complications may occur in select patients that merit careful consideration prior to LD placement.
cerebrospinal fluid; lumbar drain; craniotomy; anterior skull base; endoscopic
Cerebrospinal fluid (CSF) leaks result from a communication between the subarachnoid space and the upper aerodigestive tract. Because of the risk of complications such as meningitis, brain abscess, and pneumocephalus, all persistent CSF leaks should be repaired. Surgical repair may be achieved transcranially or extracranially using a wide variety of autogenous, allogenic, and synthetic patching materials. We report our results with a transnasal transsphenoidal endoscopic approach for the repair of CSF leaks coupled with a multilayer closure using acellular dermis (Alloderm™). We conducted a retrospective review of all patients presenting to our institution over the past 5 years with isolated sphenoid sinus CSF fistulas. Results: Twenty-one patients were included in the study. Nineteen patients (90.5%) had their sphenoid sinus CSF fistula repaired during the first attempt; 2 patients (9.5%) needed a second attempt. The multilayer repair of the CSF leak using acellular dermis via a transsphenoidal endoscopic approach is an effective and successful method of surgical repair of the fistula site. Neither the number, size, nor cause of the CSF fistula affected surgical outcomes. However, the presence of hydrocephalus was a significant negative variable, altering the surgical outcomes of our patients. The acellular dermis offers the advantage of not requiring autogenous tissue for the effective repair of CSF leaks in the sphenoid sinus.
Transnasal approach; multilayer repair; sphenoid sinus; CSF leak
The vascularized nasoseptal flap has become a principal reconstructive technique for the closure of endonasal skull base surgery defects. Despite its potential utility, there has been no report describing the use of the modern nasoseptal flap to repair traumatic cerebrospinal fluid (CSF) leaks and documenting the outcomes of this application. Specific concerns in skull base trauma include septal trauma with disruption of the flap pedicle, multiple leak sites, and issues surrounding persistent leaks after traumatic craniotomy. We performed a retrospective case series review of 14 patients who underwent nasoseptal flap closure of traumatic CSF leaks in a tertiary academic hospital. Main outcome measures include analysis of clinical outcome data. Defect etiology was motor vehicle collision in eight patients (57%), prior sinus surgery in four (29%), and assault in two (14%). At the time of nasoseptal flap repair, four patients had failed prior avascular grafts and two had previously undergone craniotomies for repair. Follow-up data were available for all patients (mean, 10 months). The overall success rate was 100% (no leaks), with 100% defect coverage. The nasoseptal flap is a versatile and reliable local reconstructive technique for ventral base traumatic defects, with a 100% CSF leak repair rate in this series.
Cranial base; nasoseptal flap; cerebrospinal fluid leak; reconstructive techniques; endoscopy
Objective: Endoscopic repair of cerebrospinal fluid (CSF) leaks is a recognized technique. We consider our experience and evaluate the outcomes in patients who underwent endoscopic repair of CSF leaks. Methods: A retrospective case note review of 135 patients who underwent anterior cranial repairs of CSF leaks between August 1995 and December 2004 at a tertiary referral center. We describe the technical details and outcomes of care by purely endoscopic procedures. Results: Thirteen patients had combined transcranial and endonasal repairs and 122 patients had their repairs using an endoscopic approach only. There were 64 males and 71 females with ages that ranged from 1 to 75 years (mean age 42 years, median age 44 years). The success rate for first attempt only was 93.4%. Eight of the 122 patients (6.6%) needed a second surgical repair. In one patient a bicoronal approach was necessary while in the other cases a revision endoscopic procedure was appropriate. The period of follow-up ranged from 2 months to 9 years (mean 5 years, median 39 months). Conclusions: Our experience confirmed that endoscopic surgery is an effective and safe method of treatment for most CSF leaks. A variety of different endoscopic techniques allowed CSF leaks to be repaired in almost every site of the anterior skull base with very few exceptions.
CSF leak; nasal endoscopy; duraplasty; sphenoidal meningoencephaloceles
Endoscopic repair of anterior cranial base has been widely reported. However there is still no uniformity in the technique of endoscopic repair of lateral sphenoid cerebrospinal fluid (CSF) leaks. To highlight the management of CSF leak or encephalocele in the lateral sphenoid recess and relate our experiences. We retrospectively reviewed the medical records of all our patients who underwent an endoscopic repair of CSF leaks in the lateral sphenoid recess during the period from September 2003 to January 2010 at our tertiary hospital. Fifteen cases with CSF leaks/encephalocele that were repaired by the endoscopic approach were included. The majority of our cases were spontaneous leaks. In all our cases we approached the site of defect by an end on approach. All our patients were successfully treated in the first attempt. Endoscopic repair of lateral sphenoid recess has shown better surgical outcome with reduced morbidity.
Para nasal sinus; Sphenoid sinus; Rhinorrhoea; Cerebrospinal fluid rhinorrhoea; Spontaneous cerebrospinal fluid rhinorrhoea; Surgical procedure; Endoscopic
Otolaryngologists play a major role in the management of cerebrospinal fluid (CSF) rhinorrhea. A thorough understanding of the underlying pathophysiology and the various treatment options available is essential to achieve the best possible results.
In this paper, we are highlighting the pathophysiology, diagnosis and surgical technique involved in the repair of cerebrospinal fluid rhinorrhea. A retrospective study conducted in the department of ENT and Head and Neck Surgery, Kasturba Hospital, Manipal is presented to highlight our experience with cerebrospinal fluid rhinorrhea.
Eleven patients were managed in the department of otolaryngology between 1999 and 2005. Seven had spontaneous CSF rhinorrhea, three were due to trauma and one iatrogenic, following surgery. Commonest anatomic site of leak was the cribriform plate in 4 cases. Other sites included sphenoid , lateral lamella , fovea ethmoidalis  and olfactory groove . Onlay technique was performed in 10 out of 11 patients. Closure was successful in 10 out of 11 cases in the first attempt. One patient underwent revision surgery. Patients were followed up for a period ranging from 3 months to 3 years.
CSF rhinorrhea is a potentially fatal condition which requires precise and urgent treatment. The transnasal endoscopic repair of CSF leak has a high success rate with low morbidity when performed by experienced endoscopic sinus surgeons. Our experience in managing this condition is presented.
Advances in endoscopic skull base (SB) surgery have led to the resection of increasingly larger cranial base lesions, resulting in large SB defects. These defects have initially led to increased postoperative cerebrospinal fluid (CSF) leaks. The development of the vascularized pedicled nasoseptal flap (PNSF) has successfully reduced postoperative CSF leaks. Mucocele formation, however, has been reported as a complication of this technique. In this study, we analyze the incidence of mucocele formation after repair of SB defects using a PNSF. A retrospective review was performed from December 2008 to December 2011 to identify patients who underwent PNSF reconstruction for large ventral SB defects. Demographic data, defect site, incidence of postoperative CSF leaks, and rate of mucocele formation were collected. Seventy patients undergoing PNSF repair of SB defects were identified. No postoperative mucocele formation was noted at an average radiological follow-up of 11.7 months (range, 3–36.9 months) and clinical follow-up of 13.8 months (range, 3–38.9 months), making the overall mucocele rate 0%. The postoperative CSF leak rate was 2.9%. Proper closure of SB defects is crucial to prevent CSF leaks. The PNSF is an efficient technique for these repairs. Although this flap may carry an inherent risk of mucocele formation when placed over mucosalized bone during repair, we found that meticulous and strategic removal of mucosa from the site of flap placement resulted in a 0% incidence of postoperative mucocele formation in our cohort.
Anterior skull base defect; anterior skull base floor; endoscopic endonasal approach; endoscopic skull base surgery; expanded skull base approaches; mucocele; mucosal denuding; vascularized pedicled nasoseptal flap
As endoscopic skull base resections have advanced, appropriate reconstruction has become paramount. The reconstructive options for the skull base include both avascular and vascular grafts. We review these and provide an algorithm for endoscopic skull base reconstruction. One hundred and sixty-six skull base dural defects, reconstructed with an endonasal vascular flap, were examined. As an adjunct, avascular reconstruction techniques are discussed to illustrate all options for endonasal skull base reconstruction. Cerebrospinal fluid (CSF) leak rates are also discussed. Small CSF leaks may be successfully repaired with various avascular grafting techniques. Endoscopic endonasal approaches (EEAs) to the skull base often have larger dural defects with high-flow CSF leaks. Success rates for some EEA procedures utilizing avascular grafts approach 90%, yet in high-flow leak situations, success rates are much lower (50 to 70%). Defect location and complexity guides vascularized flap choice. When nasoseptal flaps are unavailable, anterior/sellar defects are best managed with an endoscopically harvested pericranial flap, whereas clival/posterior defects may be reconstructed with an inferior turbinate or temporoparietal flap. An endonasal skull base reconstruction algorithm was constructed and points to increased use of various vascularized reconstructions for more complex skull base defects.
Skull base reconstruction; nasoseptal flap; AlloDerm; CSF leak rate; algorithm; skull base; pericranial flap; vascular reconstruction
In cases of cerebrospinal fluid (CSF) rhinorrhea following lateral skull base surgery, fibrosis and fibrin formation resulting from meningitis has been postulated as a mechanism of spontaneously resolving the CSF leak. This study was undertaken to explore any possible relationship between the cessation of CSF leak and meningitis. A retrospective study at a tertiary referral center of 232 consecutive patients was performed. Out of a total of 232 procedures, 29 patients developed CSF rhinorrhea, of whom 7 subsequently developed meningitis. Bacteria were isolated in CSF obtained at lumbar puncture in 5 cases, with the CSF analysis in the remaining 2 cases suggesting aseptic meningitis. Conservative treatment failed to stop the CSF rhinorrhea in 6 of 7 cases. In this study, the development of meningitis did not appear to aid in the resolution of the CSF rhinorrhea. We conclude that surgical intervention should not be delayed in the expectation that meningitis and conservative interventions may promote CSF leak resolution.
Meningitis; cerebrospinal fluid; skull base surgery; translabyrinthine; vestibular schwannoma complications
The incidence of cerebrospinal fluid (CSF) fistula after transtemporal skull base surgery can range from 4% to 19%. The risk of CSF leak may be related to tumor size and location, the extent of the dural defect, and the technical aspects of the wound reconstruction. Prevention of meningitis depends on the early detection and management of CSF leakage. Five hundred eighty-nine patients underwent a variety of transtemporal surgical approaches for the extirpation of skull base tumors at our institution from July 1988 to October 1999. The medical records were reviewed retrospectively to identify the tumor histology, size, and location, as well as the surgical approach, defect reconstruction technique, and the incidence of postoperative CSF leak. The risk of CSF fistulae was greatest in using the retrosigmoid approach (8%) and lowest in those who underwent a translabyrinthine approach (4%). Tumor size had no bearing on the incidence of the CSF leak and the overall incidence of meningitis was 1.0%. This article outlines our institutional objective for the prevention and management of CSF fistula after transtemporal skull base surgery. Illustrative cases will be presented.
Cerebrospinal fluid fistula; transtemporal approach; meningitis
Objective: This study is designed to describe the association between benign intracranial hypertension (BIH) and spontaneous cerebrospinal fluid (CSF) rhinorrhea and address the effect of extracranial venous flow dynamics on intracranial pressure (ICP). Methods: We present a 58-year-old woman with refractory spontaneous CSF rhinorrhea who was later found to have superior vena cava syndrome. The patient had undergone two prior transnasal endoscopic repair attempts. In retrospect, a preoperative magnetic resonance venogram (MRV) suggested very prolonged cerebral transit time, despite otherwise normal intracranial venous anatomy. Results: The CSF leak was repaired through a bifrontal craniotomy. The intraoperative and postoperative course was complicated due to the patient's significant comorbidities. She ultimately made a good recovery and has not had any further CSF rhinorrhea in more than 2 years of follow-up. Conclusions: Refractory, spontaneous CSF leak must prompt aggressive investigation for multiple causes of elevated ICP. A cerebral transit time can be obtained from scout imaging when a magnetic resonance angiogram or MRV is performed, and this may disclose elevated ICP if it is prolonged. If endoscopic transnasal repair fails, craniotomy and direct suture repair and autologous tissue reinforcement of the skull base may prove successful and durable, even if BIH persists.
Cerebrospinal fluid rhinorrhea; benign intracranial hypertension; superior vena cava syndrome; craniotomy
The treatment of cerebrospinal fluid rhinorrhea has evolved since the first recorded instance of this condition by Willis in 1676. The advancements in radiology and endoscopic nasal surgery have provided ways to solve this potentially dangerous condition. But even now quite a few questions remain unanswered while tackling this difficult clinical situation. Laboratory tests for confirming the presence of cerebrospinal fluid in nasal fluid can yield false positive results and radiological evaluation has never been foolproof when it comes to small leaks and multiple leaks. Also the postoperative recurrence needs to be brought within acceptable limits.
We have tried to evaluate endoscopic repair of CSF rhinorrhea based on a combined diagnostic approach. The methods for diagnosis of CSF rhinorrhea have been reevaluated based on our experience with a view to prevent recurrences and complications.
Materials and methods
The study group included twenty patients of CSF rhinorrhea who have been treated by endoscopic repair and spans over a period of five years from January 2001 to December 2005. A combination of retrospective and prospective methods of study has been used. Patients have been subjected to laboratory, radiological and dye studies for confirmation and localization of leak. Endoscopic repair of CSF fistula with composite graft and fibrin glue has been performed. Postoperative management included intracranial pressure reducing measures and control of primary condition in cases of spontaneous leak.
Endoscopic repair of CSF rhinorrhea produced a first time success rate of 92%. CT/MR Cisternogram could localize the defect in 85% cases while intrathecal fluorescein aided localization whenever it was used. The use of fibrin glue with composite graft and postoperative intracranial pressure reducing measures could improve the success rate.
Management of a suspected CSF leak requires a combined diagnostic approach. Endoscopic repair with composite graft and fibrin glue should be the first line of management in cases of CSF rhinorrhea requiring surgical closure. Intracranial pressure reducing measures play an important role in preventing postoperative recurrence.
Cerebrospinal fluid rhinorrhea; Endoscopic skull base surgery; Fluorescein dye; Endoscopic repair of CSF leak; Mondini’s dysplasia; CSF otorhinorrhea
Cerebrospinal fluid (CSF) leak is a devastating complication after transsphenoidal surgical approach to pituitary adenoma and sellar repair has been postulated as crucial step in this approach. In this study, we describe our experience regarding sellar repair in pure endoscopic endonasal approach in 240 patients with pituitary adenoma.
During April 2005 to April 2011, a total of 240 patients with pituitary adenomas underwent endoscopic endonasal approaches for tumor removal. The degree of intra-operative CFS leak was graded as followed: Grade 0: no leakage was observed; grade 1: leakage in form of drops; and grade 3: flow of CSF was observed. Repair was done according to degree of leak e.g. surgicel for grade 0, fat and fascia for grade 1, with adding synthetic sealant and/or lumbar drain for grade 2. The method of repair is discussed in each group and exceptions were also bolded. No sphenoid sinus obliteration was needed.
There were 208 macroadenomas and 32 microadenomas. One hundred and thirteen patients (55.4%) had grade 0 CSF leaks, 78 patients (32.5%) grade 1 CSF leaks, and 29 patients (12%) showed grade 2 leaks. There were 2 documented post operative CSF leak (0.8%) one of them was treated by lumbar drainage and the other with revision endoscopic repair. There was also one case of pneumocephalus (0.4%) with no obvious leak in nasal endoscopic exam which managed medically. There were also 2 cases of post-operation meningitis (0.8%) with no leak that one of them was due to outbreak of acinetobacter in ICU.
Findings of this study showed that intra-operative CSF leak is an important factor determining the need and extend of sellar repair in endoscopic endonasal approach for pituitary adenoma. The low rate of post-operative CSF leak is in favor of the applicability of grading system and method chosen for repair.
Sellar repair, Endoscopic endonasal transsphenoidal surgery, Pituitary adenoma,Intra-operative Cerebrospinal fluid leak
Cerebrospinal fluid (CSF) leak is a complication that may occur after translabyrinthine (translab) acoustic neuroma (AN) removal. The aim of this study is to verify the incidence of CSF leak using two techniques for dural defect closure in translab AN surgery and present a new technique for dural repair. A retrospective study was held, reviewing charts of 34 patients in a tertiary neurotologic referral center. Out of these 34 patients that underwent translab AN excision in a 1-year period, 18 had their dural defect repaired using only abdominal fat graft and 16 using synthetic dura substitute (SDS) plus abdominal fat tissue. One patient (5.5%) in the first group had CSF leak and 1 (6.2%) in the second group had CSF leak postoperatively. Our data suggest that there are no significant differences in CSF leak rates using both techniques, although studies in a larger series must be undertaken to conclude it. We believe that the development of some points in the new technique for dural repair can achieve better results and reduce the CSF leak incidence in the translabyrinthine acoustic neuroma surgery in the near future.
acoustic neuroma; translabyrinthine; cerebrospinal fluid leak; dural defect
Postoperative cerebrospinal fluid (CSF) leakage is one of the most common and aggravating complications in transsphenoidal surgery. Although primary closure of the fistula would be the most desirable solution for an intraoperatively encountered CSF leak, it is difficult to achieve in such a deep and narrow operative field. In this article, the authors report endonasal endoscopic applications of no-penetrating titanium clips to repair a CSF fistula following tumor removal. The AnastoClip Vessel Closure System (VCS; LeMaitre Vascular, Boston, MA) was used for closure of a CSF fistula in endonasal transsphenoidal surgery. In all four patients, CSF leakage was successfully obliterated primarily with two to five clips. There was no postoperative CSF rhinorrhea or complications related to the use of the VCS. Metal artifact by the clips on postoperative images was tolerable. Primary closure of the fistula using the VCS was an effective strategy to prevent postoperative CSF leakage in transsphenoidal surgery. Future application can be expanded to reconstruction of the skull base dura via endonasal skull base approaches.
CSF leakage; nonpenetrating titanium clip; endoscope; transsphenoidal surgery
Computed Tomography (CT) scan of nose and paranasal sinuses play a key role in preoperative evaluation of patients undergoing endoscopic sinus surgeries (ESS) for chronic rhinosinusitis. The asymmetry of ethmoid fovea olfactory fossa, anatomical variations of lateral lamella and course of anterior ethmoid artery are critical in ESS as it may predispose to dangerous consequences like hemorrhage. CSF leak and intracranial complications. A prospective study was done on 75 patients of clinically and diagnostically proven chronic rhinosimusits. The coronal CT scan was evaluated with special attention to anatomical variations of anterior skull base including ethmoid fovea, olfactory fossa, lateral lamella and course of anterior ethmoid artery. The endoscopic surgeon's awareness of these variations and its role in preventing complications are highlighted.
Anterior skull base; Andromical variations; CT scan; Chronic rhinosinusitis
Differences in the composition of ventricular and lumbar cerebrospinal fluid (CSF) based on single pairs of samples have previously been described. We describe a patient that developed post-surgical recurrent meningitis monitored by daily biochemical and bacteriological CSF analysis, simultaneously withdrawn from lumbar space and ventricles. A 20-year-old Caucasian man was admitted to the ICU after a resection of a chordoma that extended from the sphenoidal sinus to the anterior face of C2. CSF was continuously leaking into the pharyngeal cavity after surgery, and three episodes of recurrent meningitis, all due to Pseudomonas aeruginosa O12, occurred. Our case showed permanent ventricular-to-lumbar CSF gradients of leukocytes, protein and glucose that were increased during the acute phase of meningitis, with the greatest amplitude being observed when bacteria were present in both ventricular and lumbar CSF. This might suggest a greater extent of meningeal inflammation in the lumbar than in the ventricular region. Our case also showed that the increase in intravenous antibiotics (cefepim from 8 to 12 g/day and ciprofloxacine from 1.2 to 2.4 g/day) led to an increase in concentration in plasma but not in CSF.
chordoma; lumbar puncture; meningitis; sepsis
To evaluate the incidence and treatment of CSF leaks after resection of vestibular schwannomas and to propose a treatment algorithm for their management.
Retrospective chart review.
Tertiary referral center.
Review of 1,922 subjects who underwent resection of vestibular schwannomas from 1970 through 2010.
Surgical resection of vestibular schwannoma.
Main Outcome Measures
Patient demographics, surgical approach used, CSF leak incidence, meningitis, treatment and success in the management of CSF leaks.
Postoperative CSF leaks were observed in 12.9% of our patients. There was no significant difference between the type of approach and the presence of CSF leak with translabyrinthine, suboccipital and middle fossa CSF leak rates of 12%, 12%, and 13% respectively (p=0.07). Patients presented with a wound leak or rhinorrhea almost equally. Ultimately, 92% of patients with rhinorrhea underwent surgical intervention. The probability of a patient with rhinorrhea requiring a second intervention was higher when the initial intervention was conservative rather than surgical. However, the probability of a patient with a wound leak requiring a second intervention was essentially the same when initially treated conservatively or surgically.
Our data suggests that there is no difference in CSF leak rates between the different surgical approaches. The appropriate treatment strategy is dependent on the presentation of the CSF. While conservative treatment is effective for managing wound leaks, it is less effective in managing patients with rhinorrhea. Therefore, surgical treatments should play an early role in the treatment algorithm of patients with CSF rhinorrhea.
vestibular schwannoma; acoustic neuroma; CSF leak
Endoscopic repair of spinal fluid leaks is a commonly performed procedure with low morbidity. However, this is the first report of cerebrovasospasm, following endoscopic repair of a cerebrospinal fluid (CSF) leak. A 51-year-old woman underwent endoscopic repair of a spontaneous CSF leak. She subsequently developed symptomatic cerebrovasospasm on postoperative day 3. This was successfully treated with intraarterial verapamil infusion.
Cerebrospinal fluid leak; endoscopic repair; cerebrovasospasm; verapamil
Cerebrospinal fluid leaks of the temporal bone are rare, often occult, and sometimes challenging to localize and repair. This is a retrospective study of eight patients with spontaneous cerebrospinal fluid leak and six patients with cerebrospinal fluid leak or encephalocele discovered during chronic ear surgery who were treated in a tertiary medical center over a 5-year period. All received preoperative temporal bone computed tomography, and six also underwent magnetic resonance imaging, one computed tomography cisternography, and one radionuclide cisternography. All patients initially underwent a transmastoid surgical approach. Additional exposure was necessary in three patients; two underwent middle fossa craniotomy and another required minicraniotomy. Primary surgical repair was successful in six of the eight patients with spontaneous leaks and in all six chronic ear patients. Both recurrences required intradural middle fossa repair. An individualized approach should be taken for repair of temporal bone cerebrospinal fluid leaks. In this series, most were successfully repaired in a single stage using a transmastoid or combined approach. The transmastoid approach provides information about the precise size and location of the dural defect. A primary transcranial approach is needed for defects that are multiple, located in the petrous apex, and in revision cases.
Cerebrospinal fluid leak; temporal bone; transmastoid approach; middle fossa craniotomy; encephalocele
Cerebrospinal fluid (CSF) leaks can be responsible for significant patient morbidity and mortality. While the majority of leaks induced after head trauma will seal without intervention, spontaneous or surgically-induced leaks often require operative repair. Many modifications on standard surgical technique are available for repair of CSF fistulae, but none assures adequate closure. We have studied the efficacy of a novel fibrin-based composite tissue adhesive (CTA) for closure of experimentally-induced CSF leaks in rats. Fistulae were created in two groups of animals. Two weeks after creation of the leaks, the animals were sacrificed and analyzed for persistence of leak. A 58% leakage rate was noted in the control group (n = 12), and no leaks were noted in the experimental group closed after application of CTA to the surgical defect followed by skin closure (n = 11). Comparing the control group to the experimental group, results were statistically significant (p = 0.015). These data suggest that CTA may be effective as an adjunct for the closure of CSF fistulae.
Cerebrospinal fluid leak (CSF), clinical sign of a dural lesion of the skull base, is a relatively rare event that can present with a variety of symptoms. Every craniosinus fistula should be considered a serious, potentially life-threatening situation (even those cases with hidden CSF leak). Reports of experience concerning diagnosis and treatment of craniosinus fistulae have appeared in the Literature. In the last few years, the endoscopic nasal approach is proving effective as it makes diagnosis much easier and is the least invasive surgical approach, with the greatest percentage of success. Various classifications are being proposed to improve clinical evaluation of CSF leaks and to simplify the diagnostic and therapeutic approach. The most common parameters of classification are: aetiology (traumatic, iatrogenic, non-traumatic, etc.) site, type of flow (high or low pressure) and, as far as concerns treatment, the type of graft used, all of which have contributed to various diagnostic and therapeutic algorithms being proposed. Therefore, the subject seems to be widely schematized and the therapeutic attitude widely agreed. However, one of the diagnostic and therapeutic approaches is now being questioned. For some, it is the heart of the clinical approach, while for others, it is a useful tool yet too dangerous to be used on account of potential side effects: namely, the fluorescein test. This procedure, consisting of intrathecal injection of a colorant (fluorescein), is well known by the Food and Drug Administration (FDA) which neither explicitly prohibits it, nor allows it, intrathecal administration is, therefore. an off label use. As far as the Authors know, authorization of this procedure has not been forthcoming anywhere in the world although the procedure itself is widely employed. As far as concerns the use of intrathecal fluorescein, many scientific papers have been written, clearly supporting its clinical usefulness. One limit to the use of fluorescein derives from frequent reports of complications, often related to the intrathecal administration; such complications are, however, always due to an incorrect dosage. In order to perform correct monitoring of any complication related to the use of intrathecal fluorescein and to investigate in a strictly scientific fashion, the legal problem related to the off label use (intrathecal administration) of an authorised substance, the Authors coordinated an Italian multicentre study aimed at establishig the tolerability of the lumbar intrathecal administration of fluorescein. Aim of the study was to review the literature focusing on CSF leaks, to set up to date diagnostic and therapeutic indications of fluorescein and to report the preliminary results of the Italian multicentre study.
Craniosinusal fistula; Cerebrospinal fluid; Fluorescein; Nasal endoscopy
A 41-year-old female patient was admitted with streptococcal meningitis on a background of 5-month history of CSF rhinorrhoea. Imaging revealed an extensive skull base lesion involving the sphenoid and ethmoid sinuses, the pituitary fossa with suprasellar extension and bony destruction. Histological examination of an endonasal transethmoidal biopsy suggested a diagnosis of olfactory neuroblastoma. A profuse CSF leak occurred and the patient developed coliform meningitis. A second endonasal endoscopic biopsy was undertaken which demonstrated the tumour to be a prolactinoma. Following endonasal repair of the CSF leak and lumbar drainage, she developed profound pneumocephalus. The patient underwent three further unsuccessful CSF leak repairs. Definitive control of the CSF leak was finally achieved through a transcranial approach with prolonged lumbar drainage. This case illustrates some of the potentially devastating complications which can occur as a consequence of complex skull base lesions. A multidisciplinary approach may be required to successfully manage such cases.
An unusual case of spontaneous cerebrospinal fluid (CSF) rhinorrhea with a pneumocephalus is described in a middle-aged woman who presented with a watery nasal discharge for 1 week and headache, vomiting, and fever for 1 day. The neurological examination revealed meningeal signs and bilateral papilledema. The CSF picture suggested pyogenic meningitis, and computed tomography of the brain revealed pneumocephalus. Diagnostic nasal endoscopy showed outpouching of the dura from the left olfactory cleft with a CSF leak and granular nasal mucosa. The defect was repaired surgically, and a biopsy of that area revealed granulomatous changes suggestive of tuberculosis. The patient recovered completely with standard four-drug antitubercular therapy. To our knowledge spontaneous CSF rhinorrhea with pneumocephalus occurring secondary to nasal tuberculosis has not been previously reported.
Cerebrospinal fluid rhinorrhea; Pneumocephalus; Tuberculosis