Long-Term Effectiveness of a Reconstructive Protocol Using the Nasoseptal Flap After Endoscopic Skull Base Surgery

T he management of craniopharyngiomas is fraught with challenges that not only hinder achievement of optimal oncological outcomes but potentially have adverse effects on the quality of life (QOL). At time of presentation, and certainly after treatment, craniopharyngiomas can be associated with visual field defects, endocrinopathies, hypothalamic syndromes, increased cardiovascular risk, and neurocognitive sequelae. 7,9,33,37,46 Although considered benign tumors, their location can impact critical structures such as the optic nerves and chiasm, hypoabbreviatioNs ASBQ = Anterior Skull Base Quality of Life; BMI = body mass index; GTR = gross-total resection; QOL = quality of life; obJect Craniopharyngiomas are benign parasellar tumors for which surgical removal, although potentially curative, often leads to morbidity with resulting decreases in quality of life (QOL). The endonasal endoscopic approach is a minimal-access technique for removing these tumors and may reduce postoperative morbidity. The QOL following this method for resection of craniopharyngiomas has not been documented. methods The authors reviewed a database of consecutive endonasal endoscopic surgeries done at Weill Cornell Medical College. Adult patients with histologically proven craniopharyngiomas were included who had completed either only postoperative (> 9 months) or both pre- and postoperative QOL forms, the Anterior Skull Base Quality of Life (ASBQ) questionnaire, and the 22-Item Sinonasal Outcome Test (SNOT-22). Rates of gross-total resection (GTR), complications, and visual and endocrine function were collected. Retrospective independence (Wen score) was also assigned. A contemporaneous group of patients undergoing endonasal endoscopic pituitary macroadenoma resection was used as a control. results This study included 33 procedures performed in 31 patients. The average postoperative ASBQ score was 3.35 and the SNOT-22 score was 19.6. Better QOL was associated with GTR and postoperative radiation. Worse QOL was associated with persistent visual defects, hypopituitarism, tumor recurrence, increase in body mass index, and worsening Wen score. In a subset of 10 patients, both pre- and postoperative (> 9 months) QOL scores were obtained. Both ASBQ and SNOT-22 scores showed stability and a trend toward improvement, from 2.93 ± 0.51 to 2.96 ± 0.47 (ASBQ) and . Compared with 62 patients undergoing endoscopic pituitary macroadenoma resection, patients with craniopharyngiomas had worse postoperative QOL on the ASBQ (3.35 vs 3.80; p = 0.023) and p = 0.12). coNclusioNs This report of validated site-specific QOL following endoscopic surgery for craniopharyngiomas shows an overall maintenance of postoperative compared with preoperative QOL. Better QOL could be seen in patients with GTR and radiation therapy, and worse QOL was found in patients with visual or endocrine deficits. Nevertheless, patients with craniopharyngiomas still had worse QOL than those undergoing similar surgery for pituitary macroadenomas, confirming the worse prognosis of craniop...

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“…Closure was performed according to our closure algorithm, which has been described in detail. 12,26,30,35 …”

Section: Surgical Proceduresmentioning

confidence: 99%

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas

Patel

Raza

McCoul³

et al. 2015

JNS

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“…26,30,31 Accordingly, many of the CSF leaks we report in this paper occurred early in our experience, before 2008. In the early cases, we used intracranial fat and intermittent overlays of fascia lata, intermittent use of either Tisseel (Baxter) or Duraseal (Covidien), and occasional lumbar drainage.…”

Section: Operative Technique and Closure Methodsmentioning

confidence: 71%

“…6 Vascularized flaps, such as the nasoseptal flap, and robust reconstruction techniques, such as the "gasket-seal," have been shown to significantly decrease the rates of a postoperative CSF leak. 8,13,20,25,30,31 Nevertheless, a common situation encountered in the clinic following ESBS is the patient with serosanguineous nasal drainage, often a combination of nasal secretions, blood, mucus, hemostatic agents, and possibly CSF. In such a situation, the suspicion of a CSF leak is often raised and maneuvers such as checking the fluid for glucose or beta-2 transferrin may yield ambiguous results or take several days for a definitive answer.…”

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confidence: 99%

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

Banu

Szentirmai

Mascarenhas

et al. 2014

JNS

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Object Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS. Methods The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak. Results The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks. Conclusions Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

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“…We preferred to use vascularized nasoseptal flap in cases with high pressure leaks and larger defects, especially those within the sphenoid sinus. Long and wide-based nasoseptal mucosal flaps were necessary in order to seal the defects located within the sinus (20). Importantly, all seven CSF leaks in this series were successfully repaired with use of nasoseptal flaps on the first attempt.…”

Section: A B C D E F G Hmentioning

confidence: 86%

Endoscopic endonasal cerebrospinal fluid leak repair on the ventral midline skull base: a single neurosurgical center experience

İşler

Ahmedov²,

Akgün³

et al. 2017

Turkish Neurosurgery

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CSF leaks have been grouped into three distinct etiologic categories, namely, traumatic, spontaneous, and iatrogenic (due to previous operation). Furthermore, each group has been subdivided into acute and delayed types (6). The first line of treatment is surgery in all cases of spontaneous etiology and in most cases of iatrogenic cause of skull base CSF leak (36,38). On the contrary, initial conservative management has been advocated for traumatic CSF leaks (8,12). When conservative management fails, usually at the end of two weeks, surgical management of rhinorrhea is mandatory in traumatic cases (16,28). (7,10,18,19,22,29). A connection to the subarachnoid space, most likely associated with a disruption of the arachnoid and dura mater with accompanying bone defect, is a prerequisite for CSF leak and inevitably carries a risk for ascending infection to the intracranial space (15,25,26,31). AIM:To present the results of endoscopic endonasal repair of ventral midline skull base cerebrospinal fluid (CSF) leak (VMSBL) at our institution and to discuss the technique and results from a neurosurgical perspective. MATERIAL and METHODS:A retrospective analysis of all VMSBL cases that underwent endoscopic endonasal skull base approach (EESBA) for CSF leak repair at a single tertiary neurosurgical center was performed. Twenty six patients with an average age of 44.4 (range: 17-63) years were included in the study. RESULTS:The etiology of VMSBL was spontaneous in 16 patients, traumatic in 7, and iatrogenic in 3. The leakage site was the cribriform plate in 13 patients, ethmoidal cells in 7, and sphenoid sinus in 3. There were multiple leaks in 3 patients. This approach for VMSBL repair was performed 28 times on 26 patients. The success rate was 88.5% (23/26 patients) after primary endoscopic repair and 96% after the second attempt. The location of the leakage site relative to the upper attachment of the middle turbinate played a crucial role in the anteriorly located VMSBL, which made an impact on the surgical repair plan. All the 16 cases with accompanying meningoencephaloceles were treated successfully by EESBA. Use of vascularized pedicled flaps to support the repair site resulted in 100% success after primary repair. CONCLUSION:EESBA is safe and highly effective and can be a first-line surgical treatment option for VMSBL. In addition, it enables adequate reconstruction of ventral midline skull base meningoencephaloceles regardless of size and location.

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Long-Term Effectiveness of a Reconstructive Protocol Using the Nasoseptal Flap After Endoscopic Skull Base Surgery

Cited by 101 publications

References 17 publications

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas

Long-term quality of life after endonasal endoscopic resection of adult craniopharyngiomas

Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

Endoscopic endonasal cerebrospinal fluid leak repair on the ventral midline skull base: a single neurosurgical center experience

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