Management of Anterior Skull Base Cerebrospinal Fluid Leaks

Le, Christopher H.; Strong, E. Bradley; Luu, Quang

doi:10.1055/s-0036-1584229

Cited by 53 publications

(41 citation statements)

References 43 publications

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“…3). In this study, when a patient presented with concern for a delayed leak, confirmation was achieved through a variety of maneuvers including a tilt test, nasal endoscopy combined with a provoking maneuver, computed tomography scan (to ascertain the presence of pneumocephalus), and β 2 ‐transferrin testing 14 . Intraoperative identification of occult defects in patients with clinical CSF leaks may also be aided with the use of intrathecal fluorescein to help visualize the precise location of the defect.…”

Section: Discussionmentioning

confidence: 99%

Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm

London

Mohyeldin

Montaser

et al. 2020

Int Forum Allergy Rhinol

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Background: Delayed postoperative cerebrospinal fluid (CSF) leaks are uncommon and largely unstudied complications. In this study we aim to identify their etiology and understand the efficacy of various reconstruction strategies. Methods:A retrospective chart analysis of 1017 endonasal skull base surgeries performed by a single neurosurgeon was completed identifying delayed CSF leaks (occurring >1 week a er surgery).Results: Seventeen cases of early (1-2 weeks a er surgery) or delayed (>2 weeks a er surgery) postoperative CSF leak were identified. The most common reconstruction during the initial surgery consisted of an inlay or gasket seal collagen matrix (82.4% of patients) with an onlay pedicled flap (76.5% of patients). Presenting symptoms of delayed CSF leak included rhinorrhea (82.4%), headache (41.2%), and meningitis (23.5%). The most common causes included flap dehiscence (17.6%); provoking events such as emesis, sneezing, or fall (17.6%); flap necrosis (11.8%); flap displacement (11.8%); and inadequate apposition of the flap, that is, folded flap (11.8%). Reconstructive techniques of the delayed CSF leak included fortification of the initial reconstruction with free fat gra s (29.4% of patients), combined collagen matrix with a fat gra (23.5% of patients), repositioning of the previous flap (11.8% of patients), and repair with a new flap (11.8% of patients). CSF diversion (spinal/ventricular drain or shunt) was used in 17.6% of patients. Conclusion:This study identifies the most common etiologic factors leading to a delayed CSF leak and its initial symptoms. Furthermore, it serves as the foundation for a reconstructive algorithm based on reinforcement of the initial repair with free abdominal fat gra with or without collagen matrix. C 2020 ARS-AAOA, LLC. Key Words: cerebrospinal fluid leak; nasoseptal flap; skull base reconstruction; skull base surgery How to Cite this Article: London NR, Jr, Mohyeldin A, Montaser AS, et al. Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm. Int Forum Allergy Rhinol. 2020;10:779-784. T he primary goal of cerebrospinal fluid (CSF) leak repair is to re-establish a watertight seal between the

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Section: Discussionmentioning

confidence: 99%

Contributing factors for delayed postoperative cerebrospinal fluid leaks and suggested treatment algorithm

London

Mohyeldin

Montaser

et al. 2020

Int Forum Allergy Rhinol

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“…However, this method has not been approved yet and might lead to postoperative complications, such as headache, seizures, and coma, especially at high concentrations. 9 Moreover, it delays the surgical procedure both for the time taken to perform the lumbar puncture and for the time required to allow the fluorescein to diffuse into the CSF. 9 In this study, fluorescein was not used due to these reasons.…”

Section: Discussionmentioning

confidence: 99%

Spontaneous Nasal Cerebrospinal Fluid Leak Repaired With Single-Layer Mucoperichondrial Graft: Long-term Results

Alicandri‐Ciufelli

Fermi

Rosa

et al. 2020

Am J Rhinol�Allergy

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Background Spontaneous cerebrospinal fluid leak (sCSFL) has been historically related to obesity and elevated intracranial pressure (ICP), with a lower rate of success of endoscopic repair reported in the literature. Moreover, defects related to this condition have been largely repaired with multilayer reconstructions and pedicled flaps. Long-term postoperative results have not been appropriately discussed yet. Objective The aim of this study is to investigate the outcome of a cohort of patients treated with single-layer mucoperichondrial graft. Methods A retrospective review of clinical records of a consecutive series of patients who underwent endonasal endoscopic surgery for sCSFL was carried out at a tertiary care referral center for skull base pathologies. All patients underwent reconstruction with single-layer mucoperichondrial free graft. Local flap failures and postoperative outcomes, in terms of recurrence of sCSFL or brain herniation, were registered. Results Neither intraoperative nor perioperative complications were reported. Definitive closure was achieved in 27 of 29 (93%) patients after the first attempt, while in 2 cases, a revision surgery was required. In both of these, an inadequate position of the graft was detected and was repaired likewise with the same mucoperichondrial graft. None of the patients required postoperative lumbar drain placement. After a median follow-up period of 57 months, only 1 patient developed a meningocele without CSFL about 2 years after surgery at the contralateral lateral recess of the sphenoid sinus. None of the patients reported symptoms referable to elevated ICP nor underwent ventricular derivation. Conclusions Single-layered mucoperichondrial free graft was safe and effective in the majority of the examined patients. In 7% of the study population, a surgical revision was necessary due to local failure of the graft. However, during long-term follow-up, only 1 case of recurrent meningocele without CSFL was reported in a patient who presented borderline ICP.

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“…Intrathecal application of sodium fluorescein in combination with the use of blue light and a blocking filter over the endoscope's eyepiece will precisely guide the endoscopic surgeon to the site of the lesions. Laboratory techniques such as Beta-2-transferrin and beta-trace protein testing are the standard tests that help to differentiate non-CSF-related nasal secretion from the true CSF in an unclear situation (Le et al, 2016[ 6 ]).…”

Section: Discussionmentioning

confidence: 99%