Combined Transcranial-endonasal Reconstructive Surgery for Cerebrospinal Fluid Leakage Resulting from Traumatic Anterior Skull Base Fractures Involving the Parasellar Region

Extensive traumatic anterior skull base fractures from the frontal sinus to the parasellar region are frequently accompanied by multiple dural defects that cause persistent cerebrospinal fluid (CSF) leakage. Conventional transcranial reconstruction using a frontal periosteal flap is frequently insufficient, and parasellar dural defects are often deep, complex, and difficult to identify. In this report, we describe a combined transcranial–endonasal reconstructive technique and report our experience. Simultaneous combined transcranial and endoscopic surgery was performed in three patients with CSF leakage resulting from traumatic anterior skull base fractures. Dural defects were thoroughly identified from the transcranial and endonasal surgical fields, and covered using a multilayer sealing technique. The anterior regions of the anterior skull base were reconstructed using a free fascial flap and frontal periosteal flap; posterior and parasellar regions were reconstructed using a fat graft, vascularized nasoseptal flap, and endonasal balloon. Suturing the transcranial grafts to the parasellar dura mater was performed collaboratively by the transcranial and endonasal surgeons. In our cases, complete cessation of CSF leakage was achieved without perioperative lumbar drainage in all patients. Mean time to postoperative ambulation was 7 days (range, 3–11). No surgical complications occurred. Simultaneous transcranial and endonasal procedures were helpful to detect all sites of CSF leakage and secure reconstructive grafts. The combined transcranial and endonasal reconstructive technique achieved secure skull base reconstruction without recurrence of CSF leakage, and allowed early postoperative ambulation. This technique can be a reliable surgical option to repair CSF leakage resulting from extensive anterior skull base fractures.     

Endonasal endoscopic repair of cerebrospinal fluid rhinorrhea.

Cerebrospinal fluid (CSF) rhinorrhea implies a communication between the subarachnoid space and the upper respiratory tract. Trauma and postoperative defects are the more common causes of CSF rhinorrhea. The authors review their results with endoscopic repair of skull base defects associated with CSF rhinorrhea involving the paranasal sinuses. A total of 10 patients, 7 males and 3 females, were treated under endoscopic vision from 1997 to 2001. The causes of CSF rhinorrhea were traumatic (7), postoperative (2) and spontaneous (1). Four patients had the diagnosis and the site confirmed after intrathecal fluorescein-saline injection. The obliteration of the CSF leak was achieved with fat free, mucoperichondrial, or mucoperiostal free grafts taken from the middle or inferior turbinate and kept in place by fibrin glue. Primary closure was obtained in 10 patients and one patient developed a recurrence 14 months later. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, very effective and is a valid alternative to the cranial approach.     

A Novel Graft Material for Preventing Cerebrospinal Fluid Leakage in Skull Base Reconstruction: Technical Note of Perifascial Areolar Tissue

Objectives Perifascial areolar tissue (PAT), a layer of loose connective tissue on the deep fascias with a rich vascular plexus, serves as a vital cover over defects with scarce vascularity. We report the usefulness of PAT as a nonvascularized alternative to flaps for reconstruction of dural defects in skull base surgery and transsphenoidal surgery while evaluating its effect on control of cerebrospinal fluid (CSF) leakage. Design A retrospective chart analysis was performed on patients who had undergone repair of a dural defect with PAT during skull base surgery or transsphenoidal surgery between December 2004 and October 2011. Results Twenty-one patients were included: 11 patients had received surgical treatment and/or irradiation. Fourteen of the 21 patients had pre- and/or intraoperative CSF leakage. Only one patient (4.8%) had postoperative CSF leakage requiring additional surgical repair. Ten patients underwent postoperative irradiation from 1 to 15 months after transplant of the PAT. None of the patients had postoperative CSF leakage after irradiation. Conclusion We successfully repaired dural defects using PAT in skull base surgery and transsphenoidal surgery, even in patients with a history of multiple operations and radiotherapy. PAT may serve as a valuable tool for skull base reconstruction.     

Transnasal endoscopic repair of cerebrospinal fluid fistulas and encephaloceles: surgical indications and complications.

INTRODUCTION: Transnasal endoscopic repair of cerebrospinal fluid (CSF) fistulas is recommended for patients with CSF leaks who do not respond to conservative treatment. It is a safer and more successful alternative to transcranial surgery. PATIENTS AND METHODS: We present our experience on using transnasal endoscopy for the repair of anterior skull base cerebrospinal fluid fistulas. Between 1999 and 2003 we observed 20 patients with CSF rhinorrhea. The etiology was heterogeneous: post-traumatic in 6 cases, iatrogenic in 6 cases (one interesting case of meningioma of the sphenoethmoid plate), dysembryogenetic - due to encephaloceles - in 4 patients (one with Cruzon syndrome and one with Down syndrome) and idiopathic in the other 4 patients. Use of a rigid transnasal endoscope allowed the localization and repair of all fistulas, with the use of fluorescein in 6 cases. Different grafts were used, in particular fat, bone or chondral septum with mucoperiosteum or perichondral mucosa. Generally the graft was inserted with the underlay or the sandwich technique. Lumbar drainage was used in the postoperative period only in 6 cases. No antibiotic prophylactic therapy was used. RESULTS: Endoscopy was successful in 90 % of patients at the first attempt, and in 95 % of patients at the second approach. We had two late complications such as infections. In one child with a post-traumatic fistula and shunt for hydrocephalus, we observed meningitis 2 years after the first endoscopic surgery and he underwent both transnasal endoscopic surgery and transcranial surgery. The second patient was a woman with a spontaneous fistula, who had rhinoliquorrhea three years after the first surgical treatment. During surgery a strange similar purulent material filling the submucous space of the ethmoid roof was found, suggestive for an intranasal abscess that was removed. We did not see any complications such as hematomas or seizures. The follow-up (range: 6 months to 3 years) made both with MRI and rhinoscopy has not shown any relapse until now in 19 of 20 patients treated only with endoscopy. CONCLUSIONS: The endoscopic approach is highly effective and safe in the treatment of CSF fistulas, with great visualization and minimal invasiveness, for which it is associated to a very low morbidity. The fluorescein technique is extremely helpful for the diagnosis and surgery of CSF leaks.     

Use of the radial forearm microvascular free-flap graft for cranial base reconstruction

OBJECT: Reconstruction of the cranial base after resection of complex lesions requires creation of both a vascularized barrier to cerebrospinal fluid (CSF) leakage and tailored filling of operative defects. The authors describe the use of radial forearm microvascular free-flap grafts to reconstruct skull base lesions, to fill small tissue defects, and to provide an excellent barrier against CSF leakage. METHODS: Ten patients underwent 11 skull base procedures including placement of microvascular free-flap grafts harvested from the forearm and featuring the radial artery and its accompanying venae comitantes. Operations included six craniofacial, three lateral skull base, and two transoral procedures for various diseases. Excellent results were obtained, with no persistent CSF leaks, no flap failures, and no operative infections. One temporary CSF leak was easily repaired with flap repositioning, and at one flap donor site minor wound breakdown was observed. One patient underwent a second procedure for tumor recurrence and CSF leakage at a site distant from the original operation. CONCLUSIONS: Microvascular free tissue transfer reconstruction of skull base defects by using the radial forearm flap provides a safe, reliable, low-morbidity method for reconstructing the skull base and is ideally suited to "low-volume" defects.     

CSF leaks--diagnostic and therapeutic approach

The paper presents the classification of the CSF leaks and their etiology. The authors insist on the post surgical causes and on the modem diagnostic procedures such as 2 transferrin and trace protein determination and high resolution CT. They also present their own experience in repairing defects from the anterior skull base under endoscopic control. A lot of 20 patients with CSF leak is presented and the types of approach are discussed. If the defect is in the sphenoid sinus the obliterative techniques are preferred. The ethmoidal roof defects are covered with onlay or underlay procedures depending on their dimensions. The results are compared with those from the literature. The authors conclude that the CSF leaks in the anterior and middle skull base are mainly due to trauma or iatrogenic. A clear diagnostic algorithms and a correct selection of the cases suitable for endoscopic approach are required.     

Supraorbital keyhole surgery for optic nerve decompression and dura repair

Supraorbital keyhole surgery is a limited surgical procedure with reduced traumatic manipulation of tissue and entailing little time in the opening and closing of wounds. We utilized the approach to treat head injury patients complicated with optic nerve compression and cerebrospinal fluid leakage (CSF). Eleven cases of basal skull fracture complicated with either optic nerve compression and/or CSF leakage were surgically treated at our department from February 1995 to June 1999. Six cases had primary optic nerve compression, four had CSF leakage and one case involved both injuries. Supraorbital craniotomy was carried out using a keyhole-sized burr hole plus a small craniotomy. The size of craniotomy approximated 2 x 3 cm2. The optic nerve was decompressed via removal of the optic canal roof and anterior clinoid process with high-speed drills. The defect of dura was repaired with two pieces of tensa fascia lata that were attached on both sides of the torn dural defect with tissue glue. Seven cases with optic nerve injury included five cases of total blindness and two cases of light perception before operation. Vision improved in four cases. The CSF leakage was stopped successfully in all four cases without complication. As optic nerve compression and CSF leakage are skull base lesions, the supraorbital keyhole surgery constitutes a suitable approach. The supraorbital keyhole surgery allows for an anterior approach to the skull base. This approach also allows the treatment of both CSF leakage and optic nerve compression. Our results indicate that supraorbital keyhole operation is a safe and effective method for preserving or improving vision and attenuating CSF leakage following injury.     

Endonasal endoscopic repair of ethmoid roof cerebrospinal fluid fistula by suturing the dura

Introduction  Over the past 20years, improvement in surgical techniques as well advances in surgical instruments for sinus surgery has led to surgical closure of cerebrospinal fluid (CSF) leak using endoscopic approach. Minimally invasive and having lower post op morbidity, compared to traditional intracranial techniques, repairing CSF leak endoscopically has evolved to become the standard practice for management of CSF leak. Discussion  Widespread use of endoscope in sinus surgery have made us more familiar with the anatomy of the sinuses as well as the skull base. In this paper, we will describe our experience of CSF repair by suturing dura under endoscopic guidance for the repair of small ethmoid roof (<1.2cm) defects.     

鼻内镜治疗101例颅底疾病研究

目的探讨鼻内镜径路治疗颅底疾病的价值。方法选择2009年11月～2011年2月笔者所在医院收治的101例颅底疾病行鼻内镜径路手术患者,观察术后疗效。结果各种颅底疾病手术时间、手术出血量、随访时间,复发情况及并发症发生略有不同。其中脑脊液鼻漏复发均为采取第1次手术未修补成功而复发,采取第2次手术修补均成功,随访期间未见复发。结论鼻内镜径路可以处理多种颅底疾病,是一种安全、有效、微创的手术方式,但仍需严格掌握手术适应证,特别是恶性肿瘤。     

Management of a Long-Standing Organic Intracranial Foreign Body

Organic foreign bodies of the skull base are an uncommon problem with the potential for serious morbidity that present complicated treatment dilemmas best managed by a multidisciplinary approach. A 58-year-old male presented to the emergency department with fevers and mental status changes and was found to have bacterial meningitis. Computed tomography of the sinuses revealed two adjacent defects of the ethmoid roof with associated soft tissue density concerning for an encephalocele. He had a remote history of a penetrating left maxilla injury with a stick 13 years earlier. An attempted endoscopic repair of the defects revealed a pulsating splinter of wood emanating from the ethmoid roof defect. Neurosurgery and infectious disease were consulted and several wood fragments were removed endoscopically from the intracranial space. The skull base defects were closed using a septal cartilage underlay and free mucosal overlay graft. The patient has done well in follow-up with no evidence of cerebrospinal fluid leak. Organic foreign bodies from skull base trauma can have a delayed presentation and require a multidisciplinary team approach. In the appropriate setting endoscopic removal is a minimally morbid option.     

Determinants of success in endoscopic cerebrospinal fluid leak repair.

OBJECTIVES: To identify factors influencing success in endoscopic repair of CSF leaks of the anterior skull base. METHODS: Through retrospective chart review, 24 endoscopic closures of anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome. RESULTS: Thirteen patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, whereas leaks always recurred when bony dehiscences were patched in the absence of visible dural defects. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures. CONCLUSIONS: Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Obesity is another likely factor contributing to repair failure.     

Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions

OBJECT: The extended transsphenoidal approach to the suprasellar region has the advantages of minimal invasiveness and brain manipulation in the surgical treatment of small to medium lesions. At the same time, however, it carries a higher risk of postoperative cerebrospinal fluid (CSF) leakage and related complications than those for the standard transsphenoidal approach. Effective reconstruction of large skull base defects is a major concern in such extended approaches and remains challenging. METHODS: Between January 2004 and April 2006, 21 patients affected by different suprasellar lesions underwent the extended endoscopic endonasal transtuberculum-transplanum approach. Three different techniques were used for the skull base reconstructions. In all cases, dehydrated human pericardium (Tutoplast) for dural reconstruction and a copolymer of L-lactic acid and glycolic acid (LactoSorb) as a bone substitute were used. Collagen sponges, fibrin glue, and an inflated Foley balloon catheter were also used to fill the sphenoid sinus cavity. RESULTS: Two cases of postoperative CSF leaks (9.5%) and one case of mycotic sinusitis (4.8%) occurred following the intradural (inlay) and intraextradural (inlay-overlay) graft positioning. No cases of postoperative CSF leakage occurred in cases in which the extradural-only reconstruction procedure was applied. No meningitis or other complications related to the closure were noticed. CONCLUSIONS: The rate of postoperative CSF leakage after an extended approach to the suprasellar area is higher compared with that following standard pituitary surgery. Reconstruction after craniopharyngioma surgery exposes patients to an increased risk of postoperative CSF leaks. The extradural (overlay) technique was found to be the most effective in assuring a watertight closure.     

The Fixed Combination of Collagen With Components of Fibrin Adhesive—A New Hemostypic Agent in Skull Base Procedures

CSF leak still is one of the major sources of morbidity after extensive skull base procedures. Of the various standard closure techniques of traumatic or iatrogenic dural defects, none provides a really waterlight, persistent closure. Even the supplementary use of fluid fibrin glue did not substantially improve the rate of postoperative CSF leaks. The application of a collagen sheet covered with a fixed layer of solid components of a fibrin tissue glue (TachoComb®) overcomes the major drawbacks of dural sealing in skull base surgery. The dural defects of 58 patients undergoing extensive skull base procedures were sealed with this new hemostyptic agent. The series includes 44 patients undergoing primary surgery, 6 patients with traumatic or iatrogenic tears of venous sinuses, and 8 patients with postoperative leaks after previous skull base procedures in which other sealing methods were previously used. In the group of primary surgery, none of the patients had postoperative CSF leakage or venous rebleeding. One patient developed a delayed pneumatocephalus. All cases of patent CSF fistulas were resolved without any adjuvant therapy. Preliminary experience shows that the good sealing and hemostyptic performance of this new agent will considerably reduce the risk of postoperative CSF leak and infection after skull base procedures.     

The fixed combination of collagen with components of fibrin adhesive-a new hemostypic agent in skull base procedures

CSF leak still is one of the major sources of morbidity after extensive skull base procedures. Of the various standard closure techniques of traumatic or iatrogenic dural defects, none provides a really waterlight, persistent closure. Even the supplementary use of fluid fibrin glue did not substantially improve the rate of postoperative CSF leaks. The application of a collagen sheet covered with a fixed layer of solid components of a fibrin tissue glue (TachoComb(R)) overcomes the major drawbacks of dural sealing in skull base surgery. The dural defects of 58 patients undergoing extensive skull base procedures were sealed with this new hemostyptic agent. The series includes 44 patients undergoing primary surgery, 6 patients with traumatic or iatrogenic tears of venous sinuses, and 8 patients with postoperative leaks after previous skull base procedures in which other sealing methods were previously used. In the group of primary surgery, none of the patients had postoperative CSF leakage or venous rebleeding. One patient developed a delayed pneumatocephalus. All cases of patent CSF fistulas were resolved without any adjuvant therapy. Preliminary experience shows that the good sealing and hemostyptic performance of this new agent will considerably reduce the risk of postoperative CSF leak and infection after skull base procedures.     

Primary closure of a cerebrospinal fluid fistula by nonpenetrating titanium clips in endoscopic endonasal transsphenoidal surgery: technical note

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.     

Spontaneous CSF leaks: A paradigm for definitive repair and management of intracranial hypertension

OBJECTIVE: To report our outcomes with the repair of spontaneous cerebrospinal fluid (CSF) leaks and to demonstrate how management of underlying intracranial hypertension improves outcomes. STUDY DESIGN: Retrospective review of spontaneous CSF leaks treated at the University of Pennsylvania Health System from 1996 to 2006. Data collected included demographics, nature of presentation, body mass index (BMI), site of skull base defect, surgical approach, intracranial pressure, and clinical follow-up. RESULTS: Fifty-six patients underwent repair of spontaneous CSF leaks. Eighty-two percent (46 of 56) were obese (average BMI 36.2 kg/m(2)). Nine patients had multiple CSF leaks. Fifty-four patients (96%) had associated encephaloceles. Fifty-three CSF leaks (95%) were successfully repaired at first attempt (34 months of follow-up). Intracranial pressures averaged 27 cm H(2)O. Patients were treated with acetazolamide or, in severe cases, with a ventriculoperitoneal shunt. CONCLUSIONS: Spontaneous CSF leaks have the highest recurrence rate of any etiology. With treatment of underlying intracranial hypertension coupled with endoscopic repair, the success rate (95%) approaches that of other etiologies of CSF leaks.     

Endoscopic cerebrospinal fluid rhinorrhea repair: Is a lumbar drain necessary?

OBJECTIVES: To determine the necessity for lumbar drains during endoscopic cerebrospinal fluid (CSF) rhinorrhea repair. METHODS: Thirty-three patients underwent endoscopic repair of CSF rhinorrhea without a lumbar drain during a 7-year period. The size of the dural defect ranged from a microleak (less than 1 mm dural defect) to a 3-cm dural defect of the anterior skull base. RESULTS: All of the procedures in patients with smaller defects (<5 mm) were performed on an outpatient basis. Thirty-two patients (97%) had complete resolution of their CSF leak after 1 procedure without any recurrence (average follow-up 29 months). CONCLUSION: A lumbar drain is not routinely necessary for successful closure of CSF rhinorrhea of any size. Smaller dural defects may be safely performed on an outpatient basis without complications.     

Endoscopic repair of large skull base defects after powered sinus surgery.

OBJECTIVES: To evaluate the management of patients with large skull base defects (> 2 cm) and intracranial injury caused by powered endoscopic sinus surgery.Study design and setting All patients treated for postendoscopic sinus surgery skull base injury over a 4-year period were reviewed. RESULTS: Three patients with skull base defects greater than 2 cm in size and associated intracranial injury from powered ESS were identified. All patients presented with active cerebrospinal fluid leaks. CT scans showed intracranial injury and pathology reports revealed brain tissue removal. Using image-guided endoscopic techniques, all defects were addressed with multilayer repair. Closure was achieved in all patients on the first attempt, with an average follow-up of 27 months. CONCLUSIONS: The use of powered instrumentation along the skull base can be dangerous and can result in extensive skull base defects with associated loss of dura and gray matter. Large ethmoid roof defects and significant intracranial injury, however, are not absolute contraindications to endoscopic repair.     

The Transpalatal Approach to Repair of Congenital Basal Skull Base Cephaloceles

Basal skull base herniations, including meningoceles and encephaloceles, are rare and may present with characteristic facial and neurologic features. The traditional craniotomy approach has known morbidity, and nasal endoscopy may not allow for control of large posterior basal defects, especially in newborns. We present two cases of successful repair of basal transsphenoidal meningoceles using an oral-transpalatal approach. The first patient with an intact palate presented with respiratory distress, and a palatectomy was performed for access to the skull base. The second patient had a large basal herniation that was reduced through a congenital midline cleft palate, and a calvarial bone graft was used to repair the defect. A literature search revealed 10 previous successful cases using the transpalatal repair, which allows for excellent access, low morbidity, and a team-oriented method to skull base surgery.     

Subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques.

OBJECTIVE: To determine the efficacy of subcranial transnasal repair of cerebrospinal fluid rhinorrhea with free autologous grafts by the combined overlay and underlay techniques using the surgical microscope and/or endoscope. PATIENTS AND METHODS: Twenty patients with CSF rhinorrhea were included in this retrospective study. They were 13 males and 7 females. Their age ranged from 7 to 62 years (mean: 39.35). The etiologies of the leak were iatrogenic in 10 cases, spontaneous in 5 cases, traumatic in 4 cases and one case was associated with meningeo-encephalocele. Preoperative nasal endoscopic examination, computed tomography (CT) with intrathecal non-ionic contrast and magnetic resonance imaging (MRI) were done when indicated. Endoscopic and/or microscopic repair of the CSF fistula was done by a combination of both underlay and overlay repair with free autologous grafts as follows: Gelfoam with fibrin glue, strips of fat, facia lata, Gelfoam with fibrin glue (underlay), septal cartilage, Gelfoam with fibrin glue and strips of fat (overlay). RESULTS: Complete closure of the leak was achieved in all patients. In one case of spontaneous CSF leak which was operated endoscopically, the leak recurred 6 months postoperatively and ceased spontaneously after a month with conservative medical treatment. No major complications were seen and no patients developed meningitis or postoperative anosmia. CONCLUSION: Subcranial transnasal repair with free autologous grafts by the combined overlay and underlay techniques using the endoscope or surgical microscope is a safe and successful method of treating CSF leaks, provided that the CSF leak is precisely located and the site can be reached with the endoscope or surgical microscope.