The surgical treatment of cerebrospinal fistula: Qualitative and quantitative analysis of indications and results

Abstract

Cerebrospinal fistula might occur in different ways. CSF closure techniques have undergone significant evolution that has led to the consolidation of the transnasal endoscopic approach. Despite the existence of multiple publications, meaningful information is still lacking in clinical practice and the literature about the ideal method, material, and timing for repair of CSF. The purpose of this review was to summarize the success rate of endoscopic CSF leak repair as well as whether specific techniques or materials influence the primary success rate through a review of the latest advancements in endoscopic CSF management published in the past 10 years. The principles of multilayer reconstructions and the routine use of vascularized flaps in expanded endonasal surgery have reduced postoperative CSF leaks' failure rates between 5% and 10% (4% in this meta-analysis). Effective endoscopic anterior skull base (ASB) closure may be achieved by multiple reconstructive techniques, which should be tailored case by case according to the patient and defect conditions.cerebrospinal fistula, endoscopic treatment, meta-analysis, systematic review, transnasal endoscopic surgery

Skull base repair following endonasal pituitary and skull base tumour resection: a systematic review

“…Where meta-analyses have been attempted to compare repair techniques [ 11 , 17 , 18 ], strict inclusion criteria have been used to enable specific comparisons. Harvey et al reviewed 38 studies where the size of the bony/dural defect was reported in order to compare vascularised and non-vascularised autografts in the context of large skull base defects [ 11 ].…”

“…In the 22 studies included, a meta-analysis suggested that vascularised flaps provided maximal benefit in high flow leak situations reducing CSFR rates from 18 to 6% with their use (whilst non-vascularised multilayer regimes sufficed for low ioCSFL) [ 17 ]. Iavarone et al commented specifically on the treatment of CSFR (including non-iatrogenic aetiologies), highlighting the introduction of multilayer and vascularised repair in EEA, which may reduce CSFR rates < 5% [ 18 ]. However, these studies acknowledge the limitations of their meta-analyses in light of the repair technique and CSFR reporting heterogeneity in the primary literature [ 11 , 17 , 18 ].…”

“…Iavarone et al commented specifically on the treatment of CSFR (including non-iatrogenic aetiologies), highlighting the introduction of multilayer and vascularised repair in EEA, which may reduce CSFR rates < 5% [ 18 ]. However, these studies acknowledge the limitations of their meta-analyses in light of the repair technique and CSFR reporting heterogeneity in the primary literature [ 11 , 17 , 18 ].…”

The Role of Endonasal Endoscopic Skull Base Repair in Posttraumatic Tension Pneumocephalus

“…17,30,33,36 High closure rates have been reported, 7,26 which were up to 90% at the first attempt and 96% to 100% at the second attempt, with a low associated complication rate of 1% to 4.5%. [37][38][39][40] However, there is no level I or II evidence available that might favor EEA over TCA in the case of anterior cranial base CSF leakage. [37][38][39][40] The majority of the reported complications were minor incidences, including headaches, postoperative sinusitis, crusting, synechiae, hematoma, mucocele, and rarely meningitis, pneumocephalus, hemorrhage, and intracranial hypertension.…”

“…[37][38][39][40] However, there is no level I or II evidence available that might favor EEA over TCA in the case of anterior cranial base CSF leakage. [37][38][39][40] The majority of the reported complications were minor incidences, including headaches, postoperative sinusitis, crusting, synechiae, hematoma, mucocele, and rarely meningitis, pneumocephalus, hemorrhage, and intracranial hypertension. [37][38][39][40] Moreover, postoperative discomfort is lower for patients undergoing EEA when compared to traditional TCA, and several studies have reported good outcomes in quality-of-life measures as well as a shorter hospital stay.…”