Headache, Cerebrospinal Fluid Leaks, and Pseudomeningoceles after Resection of Vestibular Schwannomas: Efficacy of Venous Sinus Stenting Suggests Cranial Venous Outflow Compromise as a Unifying Pathophysiological Mechanism

Abstract

Background Regardless of the operative approach, headache, cerebrospinal fluid (CSF) leaks, and pseudomeningoceles remain disproportionately common problems after surgery for vestibular schwannomas and have a significant negative impact on quality of life and potential to return to full employment. Recent work has raised the possibility that these problems may, in part, be related to acquired obstruction of cranial venous outflow. This article explores this idea further with respect to a group of patients with severe and intractable symptoms. Objective The main objective of this article is to describe our experience diagnosing, investigating, and treating cranial venous outflow obstruction following translabyrinthine resection of vestibular schwannomas. Methods Retrospective review of all patients (n = 9) at our institution referred for sigmoid sinus stenting following translabyrinthine surgery. Results Headache resolved or improved after sigmoid stenting in all five patients in whom it was the primary symptom. CSF leak was the primary problem in two patients. In one, the leak was unchanged, but headache improved. In the other, the leak resolved, and headache improved. Two patients had symptomatic pseudomeningoceles and both resolved Conclusion Assuming a meticulous approach to wound closure, a CSF leak following surgery for vestibular schwannoma can be viewed as a pathological, but essentially homeostatic, response to raised intracranial pressure caused by acquired obstruction to cranial venous outflow. Postoperative headache (from high or low intracranial pressure) and CSF leaks, therefore, may all respond to measures aimed at eliminating the obstructing lesion.

Falx Cerebelli Meningioma: Case Report of a Rarely Occurring Tumor, Management Nuances, and Literature Review

“…12 Postoperative posterior fossa pseudomeningoceles can be related to underlying hydrocephalus, ligation of the occipital sinus, thrombosis of the sinuses, and other factors such as difficult dural closure. 3,12,16 However, there are various dural substitutes, sealants, and modified surgical techniques that can be utilized to obtain a watertight dura closure to help prevent postoperative pseudomeningocele. 12 In this case, animal allograft, a nonsuturable collagen matrix, and fibrin sealant were used to lower the risk of CSF leak.…”

Spontaneous Intracranial Hypotension Complicated by Subdural Effusions Treated by Surgical Relief of Cranial Venous Outflow Obstruction

“…In the first place, it reinforces the notion that cranial venous outflow obstruction can be the driving force behind a CSF leak. 12 13 Second, his response to the second surgical procedure, lends weight to the idea that obstruction to cranial venous outflow can be symptomatic in its own right, before any leak develops. Spontaneous intracranial hypotension therefore could be regarded as a complication of a syndrome— cranial venous outflow obstruction—that is subclinical, or unrecognized, until the dura ruptures; the symptoms he experienced between his two surgical procedures—headache, fatigue, cognitive, and memory impairment—giving an indication of its likely clinical features.…”

“… 12 Instead of focusing on the site of rupture, therefore, investigation and treatment could be directed at locating and relieving the obstructing venous lesion, allowing intracranial venous and CSF pressures to fall and the dural defect to heal. 12 13 The case we describe illustrates this idea in clinical practice. Moreover, since there was more than one intervention, it also provides an opportunity to consider particular symptoms in relation to cerebral venous insufficiency in its own right.…”

Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study

“…6 Therefore, we can hypothesize that the restoration of a functional venous CSF outflow pathway with venous stenting may result in amelioration of the lymphatic outflow and thus resolution of the CSF leak in some patients. 5,[9][10][11][12] Thus, rather than treating the leak and its effects downstream, the goal is to help treat the cause of the leak upstream. Venous sinus stenting (VSS) has emerged as a promising treatment for IIH during the last decade.…”

“…13 However, its efficiency on idiopathic CSF rhinorrhea has not been very well addressed. [9][10][11][12] Venous stenting as a successful first-line approach has only been reported in a single case report so far. 10 The objective of our study is to report the results of TS stenting without surgical repair in a case series of patients with idiopathic CSF rhinorrhea.…”