The Association of Meningitis with Postoperative Cerebrospinal Fluid Fistula

Objective To determine the risk factors for and the clinical course of postoperative meningitis following lateral skull base surgery and to determine its relationship to cerebrospinal fluid (CSF) fistula.Patients Patients undergoing lateral skull base surgery between July 1999 and February 2010 at an academic tertiary referral center. All subjects had culture-proven meningitis or suspected bacterial meningitis in the postoperative period. Medical records were compared with the lateral skull base patients who did not develop meningitis.Results Of 508 procedures, 16 patients developed meningitis (3.1%). The most common diagnosis was acoustic neuroma in 81.3%; 68.8% of patients had a CSF leak prior to onset of meningitis, and 50% received a lumbar drain. The median time from surgery to the onset of meningitis was 12 days with a range of 2 to 880 days. The relative risk of developing meningitis in the setting of postoperative CSF fistula is 10.2 (p < 0.0001). No meningitis-associated mortality was observed.Conclusions Postoperative meningitis occurred in a small number of patients undergoing lateral skull base surgery. A postoperative CSF fistula leads to an increased risk of meningitis by a factor of 10.2.     

The Management of Spontaneous Otogenic CSF Leaks: A Presentation of Cases and Review of Literature

Objective The types of otogenic cerebrospinal fluid (CSF) fistulae were previously classified into defects through, adjacent to, or distal to the otic capsule. This article presents cases of the three different types of spontaneous CSF fistulae and reviews pertinent literature. We examine the management of the different types of otogenic CSF leaks with modern audiovestibular testing, imaging, and surgical techniques. Design Case series and review of the literature. Setting Academic tertiary neurotologic referral practice. Participants Four patients identified through a retrospective search. Main outcome measures Resolution of CSF leak and absence of meningitis. Results Surgical intervention was performed on the four cases described in this series; none had a return of CSF otorrhea in the postoperative period or meningitis. Conclusions Otogenic CSF fistulae may lead to life-threatening infection and in congenital forms are typically not diagnosed unless meningitis has occurred. Rapid and proper recognition, work-up, and treatment of such leaks decrease the risk of permanent neurologic sequelae as well as recurrent meningitis.     

Combined Approach for Tegmen Defects Repair in Patients with Cerebrospinal Fluid Otorrhea or Herniations: Our Experience

Objectives To describe our departmental experience in the surgical repair of tegmen tympani defects using a combined transmastoid/minicraniotomic approach. Design Retrospective review of videos from surgery and patients'' charts. Setting Tertiary university referral center. Participants Twenty-two patients who underwent surgical repair of tegmen defects associated with cerebrospinal fluid (CSF) leakage and/or meningocele/meningoencephalocele by a combined transmastoid/minicraniotomic approach. Main Outcome Measures A retrospective review of videos of surgery and charts of patients with tegmen tympani or tegmen antri defects and CSF leakage, temporal lobe encephalocele, and/or meningoencephalocele. Results All patients underwent the combined approach and had their defects closed, without significant intraoperative or postoperative complications. Conclusions Mastoidectomy with temporal minicraniotomy represents an effective approach in patients with tegmen tympani dehiscence; the advantages of this technique are the control of the floor of the middle cranial fossa and the possibility to reach bony defects located anteriorly without manipulation of the ossicular chain and temporal lobe.     

Cerebrospinal fluid otorrhea treated by extended subtotal petrosectomy with obliteration

Extended subtotal petrosectomy as a treatment for stubborn cerebrospinal fluid (CSF) otorrhea is presented. Nine patients were successfully operated on by this technique, all previously having undergone surgery for brain or base of skull lesions, other interventions used had failed to seal the fistula. The retrosigmoid cells, facial cells, and internal auditory canal were found in our study to be the most commonly involved during pervious neurosurgery and so constituted the usual path for CSF leakage. Total exenteration of middle ear and mastoid cell tracts, skeletization of sigmoid sinus, jugular bulb and facial nerve, drilling out of the semicircular canals, vestibulum, and cochlea, and skeletization of the internal auditory canal are the main steps of this approach.     

Cerebrospinal Fluid Otorrhea Treated by Extended Subtotal Petrosectomy with Obliteration

Extended subtotal petrosectomy as a treatment for stubborn cerebrospinal fluid (CSF) otorrhea is presented. Nine patients were successfully operated on by this technique, all previously having undergone surgery for brain or base of skull lesions, other interventions used had failed to seal the fistula. The retrosigmoid cells, facial cells, and internal auditory canal were found in our study to be the most commonly involved during pervious neurosurgery and so constituted the usual path for CSF leakage. Total exenteration of middle ear and mastoid cell tracts, skeletization of sigmoid sinus, jugular bulb and facial nerve, drilling out of the semicircular canals, vestibulum, and cochlea, and skeletization of the internal auditory canal are the main steps of this 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.     

Spontaneous cerebrospinal fluid fistula in association with congenital inner ear anomaly: a case report

A case of inner ear anomaly (Mondini dysplasia) associated with recurrent meningitis found in a 10 year-old boy is reported. The patient had suffered from bacterial meningitis and CSF rhinorrhea five times in 7 years. The origin of CSF leakage had not been detected by bifrontal craniotomy or trans-sphenoidal operation. In May 1985, the dysplasia of the temporal bone and the inner ear had been pointed out by an otologist. And he underwent operations a few times for closing the CSF fistula at the floor of the internal auditory meatus by translabyrinthine approaches, but in vain. On the 7th of November 1985, under the control of intracranial pressure by continuous ventricular drainage, re-operation was performed. Packing the internal auditory meatus with several pieces of muscle and gelatine sponge stopped the CSF leakage and the recurrence of meningitis.     

Communicating Hydrocephalus and Vestibular Schwannomas: Etiology,Treatment, and Long-Term Follow-Up

Background Large vestibular schwannomas (VSs) can cause hydrocephalus by obstructing the fourth ventricle. Little is known about the communicating hydrocephalus that is seen with a smaller VS.Methods The clinicopathological findings and follow up of three patients with communicating hydrocephalus associated with a small VS are presented.Results Four patients aged 40 to 66 years (mean: 57.7) presented with ataxia, dementia, and urinary incontinence. The VS were 2.0 to 2.4 cm. The cerebrospinal fluid (CSF) protein was elevated in three patients in whom it was measured (1.7 to 6 times normal). The VS was resected in two patients. All of the patients required ventriculoperitoneal shunting (VPS). All of the patients were asymptomatic or improved at follow-up at 9 months to 13 years.Conclusion Communicating hydrocephalus associated with a VS can occur in younger patients than was previously thought. An elevated CSF protein appears to be important, but other factors may be involved. A shunting procedure is often required to relieve the symptoms of hydrocephalus even if the tumor is resected. Possible etiological causes of communicating hydrocephalus in patients with a small VS are discussed.     

A Minimal Access Far-Lateral Approach to Foramen Magnum Lesions

Objectives The far-lateral approach is widely used to treat pathology of the ventral foramen magnum. Numerous methods of exposure have been described, most of which utilize long skin incisions and myocutaneous flaps. Here we present our experience with gaining exposure through a small paramedian incision using a muscle-splitting technique. Design A cadaveric anatomical study was first performed to verify the feasibility of the approach. We then describe our experience with using the approach in 13 patients. A retrospective chart review was performed and data regarding pathology, imaging, and complications were collected. Results The cadaveric study confirmed that a small paramedian muscle-splitting approach allows sufficient exposure to approach many foramen magnum lesions. Our case series included 10 patients with meningioma, one brainstem glioblastoma, one posterior inferior cerebellar artery aneurysm, and one odontoid pannus. The exposure was adequate in all cases. For the meningioma patients, six had gross total resections and four had subtotal resection because of tumor adherence to neurovascular structures. Two patients experienced postoperative cardiovascular complications. There were no new neurologic deficits, cerebrospinal fluid leaks, or wound complications. Conclusions A small paramedian incision may be used to gain exposure and perform successful far-lateral approaches. The small exposure is likely to reduce the risk of local complications such as cerebrospinal fluid fistula and pseudomeningocele when compared with larger exposures.     

Sellar Reconstruction and Rates of Delayed Cerebrospinal Fluid Leak after Endoscopic Pituitary Surgery

Objectives Delayed cerebrospinal fluid (CSF) leaks are a complication in transsphenoidal surgery, potentially causing morbidity and longer hospital stays. Sella reconstruction can limit this complication, but is it necessary in all patients? Design Retrospective review. Setting Single-surgeon team (2005–2012) addresses this trend toward graded reconstruction. Participants A total of 264 consecutive patients with pituitary adenomas underwent endoscopic transsphenoidal resections. Sellar defects sizable to accommodate a fat graft were reconstructed. Main outcomes Delayed CSF leak and autograft harvesting. Results Overall, 235 (89%) had reconstruction with autograft (abdominal fat, septal bone/cartilage) and biological glue. Delayed CSF leak was 1.9%: 1.7%, and 3.4% for reconstructed and nonreconstructed sellar defects, respectively (p = 0.44). Complications included one reoperation for leak, two developed meningitis, and autograft harvesting resulted in abdominal hematoma in 0.9% and wound infection in 0.4%. Conclusion In our patients, delayed CSF leaks likely resulted from missed intraoperative CSF leaks or postoperative changes. Universal sellar reconstruction can preemptively treat missed leaks and provide a barrier for postoperative changes. When delayed CSF leaks occurred, sellar reconstruction often allowed for conservative treatment (i.e., lumbar drain) without repeat surgery. We found universal reconstruction provides a low risk of delayed CSF leak with minimal complications.     

Transmastoid Repair of Superior Semicircular Canal Dehiscence

Objective/Hypothesis Superior semicircular canal (Sup SC) dehiscence syndrome is a rare condition, causing a variety of auditory and vestibular symptoms. The traditional surgical management is a middle cranial fossa, extradural approach to resurface the Sup SC. Recently, a transmastoid approach for plugging of the Sup SC has been developed. We present further data supporting the use of the transmastoid approach in preference to the middle fossa approach.Design This is a retrospective multi-institutional case series.Method We included 10 patients in this case series from two tertiary otology institutions. Sup SC dehiscence was confirmed by correlation of clinical symptoms with positive audiometric, vestibular evoked myogenic potential, and computed tomography findings. A transmastoid approach was used for plugging of the Sup SC. Either a single fenestration was created at the site of dehiscence or separate fenestrations sited ampullopetal and ampullofugal to the dehiscence.Results All patients who underwent this procedure had good symptom control and hearing preservation postoperatively.Conclusion In patients with adequate temporal bone pneumatization, the transmastoid approach provides a safe and effective alternative to the middle cranial fossa approach. This series has demonstrated excellent symptom control and preservation of hearing with the transmastoid approach.     

Endoscopic Endonasal Transclival Approaches: Case Series and Outcomes for Different Clival Regions

Objective Transclival endoscopic endonasal approaches to the skull base are novel with few published cases. We report our institution''s experience with this technique and discuss outcomes according to the clival region involved. Design Retrospective case series. Setting Tertiary care academic medical center Participants All patients who underwent endoscopic endonasal transclival approaches for skull base lesions from 2008 to 2012. Main Outcome Measures Pathologies encountered, mean intraoperative time, intraoperative complications, gross total resection, intraoperative cerebrospinal fluid (CSF) leak, postoperative CSF leak, postoperative complications, and postoperative clinical course. Results A total of 49 patients underwent 55 endoscopic endonasal transclival approaches. Pathology included 43 benign and 12 malignant lesions. Mean follow-up was 15.4 months. Mean operative time was 167.9 minutes, with one patient experiencing an intraoperative internal carotid artery injury. Of the 15 cases with intraoperative cerebrospinal fluid (CSF) leaks, 1 developed postoperative CSF leak (6.7%). There were six other postoperative complications: four systemic complications, one case of meningitis, and one retropharyngeal abscess. Gross total resection was achieved for all malignancies approached with curative intent. Conclusions This study provides evidence that endoscopic endonasal transclival approaches are a safe and effective strategy for the surgical management of a variety of benign and malignant lesions. Level of Evidence 4.     

Immediate Single-Stage Reconstruction of Complex Frontofaciobasal Injuries: Part I

Objective To determine if immediate (within 6 hours of adequate resuscitation) single-stage repair of complex craniofacial injuries could be accomplished with acceptable morbidity and mortality taking into consideration the cosmetic appearance of the patient. Patients and Methods A total of 26 patients (19 men, 7 women) ranging in age from 8 to 58 years with Glasgow Coma Scale scores of 5 to 15 all had a combined single-stage repair of their complex craniofacial injuries within 6 hours of their admission. After initial assessment and adequate resuscitation, they were evaluated with three-dimensional computed tomography of the face and head. Coronal skin flap was used for maximum exposure for frontal sinus exenteration as well as dural repair, cortical debridement, calvarial reconstruction, and titanium mesh placement. Results Neurosurgical outcome at both the early and late evaluations was judged as good in 22 of 26 patients (85%), moderate in 3 of 26 (11%), and poor in 1 of the 26 (3.8%). Cosmetic surgical outcome at the early evaluation showed 17 of 26 (65%) to be excellent, 4 of 26 (15.5%) to be good, 4 patients (15.5%) to be fair, and 1 patient (3.8%) to be poor. At the late reevaluation, the fair had improved to good with an additional reconstructive procedure, and the poor had improved to fair with another surgery. There was no calvarial osteomyelitis, graft resorption, or intracranial abscess. Complications included three patients (11%): one (3.8%) had tension pneumocephaly and meningitis, one (3.8%) had delayed cerebrospinal fluid leak with recurrent attacks of meningitis, and one had a maxillary sinus infection (3.8%) secondary to front maxillary fistula. Conclusion The immediate single-stage repair of complex craniofacial injuries can be performed with acceptable results, a decreased need for reoperation, and improved cosmetic and functional outcomes.     

Decreased Rate of CSF Leakage Associated with Complete Reconstruction of Suboccipital Cranial Defects

Background Cerebrospinal fluid (CSF) leakage represents a major source of morbidity following microvascular decompression (MVD) surgery. The objective of this study was to retrospectively assess whether complete versus incomplete reconstruction of the suboccipital cranial defect influences the incidence of CSF leakage following MVD.Methods We reviewed the charts of 100 patients who consecutively underwent MVD for trigeminal neuralgia by two attending neurosurgeons between July 2004 and April 2010. Operative variables including incomplete or complete calvarial reconstruction, primary dural closure or dural closure with adjunct, and use of lumbar drainage were recorded. The effect of complete calvarial reconstruction on the incidence of postoperative CSF leakage was examined using a multivariate logistic regression model.Results Of the 36 patients whose wound closure was reconstructed with a complete cranioplasty, 2 (5.6%) patients experienced a postoperative CSF leak. Of the 64 patients whose wound closure was augmented with an incomplete cranioplasty, 15 (23.4%) experienced a postoperative CSF leak. There was suggestive but inconclusive evidence that the risk of CSF leakage following MVD was smaller with complete reconstruction of calvarial defect than with incomplete reconstruction (two-sided p value = 0.059), after accounting for age, dural closure method, use of lumbar drainage, and previous MVD.Conclusion Complete reconstruction of the suboccipital cranial defect decreases the risk of CSF leakage.     

Cerebrospinal fluid leak due to inner ear malformations

A case of inner ear anomalies associated with recurrent meningitis found in a 66-year-old female is reported. The patient had had 2 episodes of meningitis in the previous one year period. Multidetector-row CT of the temporal bone and three-demensional fast imaging employing steady-state acquisition MRI revealed dysplasia of the bony labyrinth and enlarged fundus of the internal auditory canal (IAC). During surgical treatment, we confirmed the cerebrospinal fluid (CSF) leakage through a bony defect in the stapedial footplate. The inner ear was obliterated and contained small pieces of temporal fascia. A meningitis or CSF leakage due to inner ear malformation is extreamly rear condition for neurosurgeon. Though we always have to take it into condideration as a cause of CSF leakage.     

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

BACKGROUND: The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. METHODS: A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. RESULTS: Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. CONCLUSIONS: Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.     

Delayed appearance of posttraumatic cerebrospinal fluid fistula

A case of CSF fistula, formed as a result of old fracture of the anterior cranial fossa, presented with recurrent meningitis and CSF rhinorrhea due to herniation of markedly dilated right frontal horn of lateral ventricle into the right ethmoid sinus through fractures of right frontal bone, cribriform plate of ethmoid and roof of orbit is reported. Attention was drawn to the CSF fistula only after recurrent meningitis and detailed imaging studies. Using a right frontal craniotomy approach, successful repair of the CSF fistula was performed and patient was discharged symptom-free.     

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Objective To describe our experience of cerebrospinal fluid (CSF) rhinorrhea management.Design Retrospective.Setting Charing Cross Hospital, London, a tertiary referral center.Participants Fifty-four patients with CSF rhinorrhea managed from 2003 to 2011.Main outcome measures Surgical technique; Recurrence.Results Etiologically, 36 were spontaneous and 18 traumatic. Eight patients with spontaneous and two with traumatic leaks had previous failed repairs in other units. Success rates after first and second surgery were 93% and 100%, respectively. Mean follow-up was 21 months. Four patients, all of spontaneous etiology, had recurrences; three of these underwent successful second repair with three layered technique, and the fourth had complete cessation of the leak after gastric bypass surgery and subsequent weight reduction. Adaptation of anatomic three-layered repair since then averted any further failure in the following 7 years. Mean body mass index was 34.0 kg/m² in spontaneous and 27.8 kg/m² in traumatic cases (p < 0.05). Fifty percent of spontaneous leaks were from the cribriform plate, 22% sphenoid, 14% ethmoid, and 14% frontal sinus. In the traumatic CSF leak group: 33.3% were from the cribriform plate, 33.3% sphenoid, 22.2% ethmoid, and 11.1% frontal.Conclusion Endoscopic CSF fistula closure is a safe and effective operation. All sites of leak can be accessed endoscopically. We recommend the use of an anatomic three-layered closure in difficult cases.     

Anterior Petrosectomy: Consecutive Series of 46 Patients with Attention to Approach-Related Complications

Objective Anterior petrosectomy(AP) was popularized in the 1980s and 1990s as micro-neurosurgery proliferated. Original reports concentrated on the anatomy of the approach and small case series. Recently, with the advent of additional endonasal approaches to the petrous apex, the morbidity of AP remains unclear. This report details approach-related morbidity around and under the temporal lobe. Methods A total of 46 consecutive patients identified from our surgical database were reviewed retrospectively. Results Of the 46 patients, 61% were women. Median age of the patients was 50 years (mean: 48 ± 2 years). Median follow-up of this cohort was 66 months. Most procedures dealt with intradural pathology (n = 40 [87%]). Approach-related morbidity consisted of only two patients (4%) with new postoperative seizures. There were only two significant postoperative hemorrhages (4%). Cerebrospinal fluid leakage occurred in two patients (4%) requiring reoperation. Conclusion Approach-related complications such as seizures and hematoma were infrequent in this series, < 4%. This report describes a contemporary group of patients treated with open AP and should serve as a comparison for approach-related morbidity of endoscopic approaches. Given the pathologies treated with this approach, the morbidity appears acceptable.