Staged or simultaneous operations for ventriculoperitoneal shunt and cranioplasty: Evidence from a meta-analysis

OBJECTIVE

To date, there is no consensus on the surgery strategies of cranioplasty (CP) and ventriculoperitoneal shunt (VPS) placement. This meta-analysis aimed to investigate the safety of staged and simultaneous operation in patients with comorbid cranial defects with hydrocephalus to inform future surgery protocols.

METHODS

A meta-analysis of PubMed, Ovid, Web of Science, and Cochrane Library databases from the inception dates to February 8, 2023 adherent to PRISMA guidelines was conducted. The pooled analyses were conducted using RevMan 5.3 software. The outcomes included postoperative infection, reoperation, shunt obstruction, hematoma, and subdural effusion.

RESULTS

Of the 956 studies initially retrieved, 10 articles encompassing 515 patients were included. Among the total patients, 193 (37.48%) and 322 (62.52%), respectively, underwent simultaneous and staged surgeries. The finding of pooled analysis indicated that staged surgery was associated with lower rate of subdural effusion (14% in the simultaneous groups vs. 5.4% in the staged groups; OR = 2.39, 95% CI: 1.04-5.49, p = 0.04). However, there were no significant differences in overall infection (OR = 1.92, 95% CI: 0.74-4.97, p = 0.18), central nervous system infection (OR = 1.50, 95% CI: 0.68-3.31, p = 0.31), cranioplasty infection (OR = 1.58, 95% CI: 0.50-5.00, p = 0.44), shunt infection (OR = 1.30, 95% CI: 0.38-4.52, p = 0.67), reoperation (OR = 1.51, 95% CI: 0.38-6.00, p = 0.55), shunt obstruction (OR = 0.73, 95% CI: 0.25-2.16, p = 0.57), epidural hematoma (OR = 2.20, 95% CI: 0.62-7.86, p = 0.22), subdural hematoma (OR = 1.20, 95% CI: 0.10-14.19, p = 0.88), and intracranial hematoma (OR = 1.31, 95% CI: 0.42-4.07, p = 0.64). Moreover, subgroup analysis failed to yield new insights.

CONCLUSIONS

Staged surgery is associated with a lower rate of postoperative subdural effusion. However, from the evidence of sensitivity analysis, this result is not stable. Therefore, our conclusion should be viewed with caution, and neurosurgeons in practice should make individualized decisions based on each patient's condition and cerebrospinal fluid tap test.

Diabetic ketoacidosis (DKA) induced cerebral edema complicating small chronic subdural hematoma/hygroma/ at Zewuditu memorial hospital: a case report

BACKGROUND

While both DKA & CSDH/subdural hygroma/ are known to cause significant morbidity and mortality, there is no a study that shows the role & effect of DKA on CSDH/subdural hygroma/ & vice versa to authors' best knowledge; hence this work will show how important relation does exist between DKA & CSDH/ hygroma. This study highlights the diagnostic & management challenges seen for a case of a 44 years old female black Ethiopian woman admitted with a diagnosis of newly diagnosed type 1 DM with DKA + small CSDH/subdural hygroma/ after she presented with sever global headache and a 3 month history of lost to her work. She needed burrhole & evacuation for complete clinical improvement besides DKA's medical treatment.

CONCLUSION

DKA induced cerebral edema on the CSDH/subdural hematoma/ can have a role in altering any of the parameters (except the thickness of CSDH) for surgical indication of patients with a diagnosis of both CSDH +DM with DKA. Hence, the treating physicians should be vigilant of different parameters that suggests tight brain &/ cerebral edema (including midline shift, the status of cisterns, fissures & sulci) and should not be deceived of the thickness of the CSDH/subdural hygroma/alone; especially when there is a disproportionately tight brain for the degree of collection. Whether DKA induced cerebral edema causes a subdural hygroma is unknown and needs further study.

Surgical complications of decompressive craniectomy in patients with head injury

INTRODUCTION

Decompressive craniectomy is an important method for managing refractory intracranial hypertension. Although decompressive craniectomy is a relatively simple procedure, various complications may arise. The aim of our paper was to determine the incidence of complications of decompressive craniectomy in patients with head injury and to analyse their risk factors.

METHODS

We retrospectively analysed a group of 94 patients after decompressive craniectomy for head injury between 01 Jan 2014 and 31 Dec 2018. Postoperative complications were evaluated based on clinical examination and postoperative CT scan. The impact of potential risk factors on the occurrence of complications was assessed (age, worse initial clinical condition, any haemocoagulation disorder).

RESULTS

Twenty patients died within the first month after surgery. Control CT scan showed one complication in 78 patients (83%), while 46 patients (49%) had more than one complication. We had to reoperate 22 patients (23.4%) due to a complication. The following complications were found: postoperative acute subgaleal/subdural haematoma (30× - 32%), subgaleal/subdural cerebrospinal fluid effusion (29× - 31%), soft tissues oedema (29× - 31%), haemorrhagic progression of brain contusion (17× - 18%), malignant brain oedema (8× - 8.5%), hydrocephalus (8× - 8.5%), temporal muscle atrophy (7× - 7.5%), peroperative massive bleeding ( 6× - 6.4%), epilepsy (4× - 4.3%), syndrome of the trephined (2× - 2.1%), skin necrosis (2× - 2.1%). Patients with a haemocoagulation disorder had a significantly higher incidence of complications (p=0.01).

CONCLUSION

Complications of decompressive craniectomy after head injury are frequent. The potential benefit of decompressive craniectomy can be adversely affected by the occurrence of many complications.

Ruptured intracranial arachnoid cysts in the subdural space: evaluation of subduro-peritoneal shunts in a pediatric population

PURPOSE

Rupture of arachnoid cysts (AC) in the subdural space after trauma may cause a subacute/chronic subdural hematoma or a hygroma. Treatment of this complication still remains controversial, and no consensual strategy is to date clearly proposed. In this study, the authors evaluated the clinical and radiological evolution of patients treated by a subduro-peritoneal shunt for symptomatic subdural collections complicating ruptured AC.

METHODS

Medical records of the 10 patients treated at our institution between January 2005 and December 2018 for a subdural collection associated with an intracranial AC were reviewed. Subduro-peritoneal shunts consisted of low-pressure valves from 2005 to 2012 (6 cases) and medium-pressure valves after 2012 (4 cases).

RESULTS

A benign head trauma was retrospectively found in the history of 8 patients. The mean time to diagnosis ranged from 15 days to 5 months. Symptoms resulted mainly from intracranial hypertension. Six patients had an ipsilateral hygroma to the AC, 2 patients had a bilateral hygroma predominantly to the AC side, and 2 patients presented an ipsilateral chronic subdural hematoma. Arachnoid cysts were classified as Galassi I in 5 cases and Galassi II in 5 cases. Patients with chronic subdural hematoma were given a medium-pressure valve. Patients with subdural hygroma received a low-pressure valve in 6 cases and a medium-pressure valve in 2 cases. There were no complications during surgical procedures. All patients were rapidly free of symptoms after surgery and were discharged from hospital 1 to 4 days postoperatively. The subdural collection completely disappeared in all cases. In the long term, only 2 patients with low-pressure valves underwent shunt removal without any consequences, while a second surgical procedure was necessary to treat recurrence of intracranial hypertension in the 4 remaining cases. All the medium-pressure valves were removed without problems. The size of the AC was reduced in 3 cases, remained stable in 4 cases, and increased in 3 cases. No patients experienced recurrence of subdural collection during follow-up.

CONCLUSIONS

Medium-pressure subduro-peritoneal shunts should be considered as part of the arsenal of surgical strategy in symptomatic ruptured AC in the subdural space. The procedure is simple with a very low morbidity, and it allows rapid improvement of symptoms. Although the shunt is located in the subdural space, we strongly recommend avoiding devices which may create an overdrainage and expose the patient to shunt dependency such as low-pressure shunts.

Symptomatic posterior fossa and supratentorial subdural hygromas as a rare complication following transarticular screw fixation with posterior wiring for atlantoaxial instability: A case report

RATIONALE

Atlantoaxial transarticular screw fixation has been an effective and appealing method for inducing fusion of the C1-C2 complex. This technique is usually performed with Gallie fusion. In performing Gallie fusion using sublaminar wiring, a major concern is the risk of dural tear associated with passing sublaminar wires through the epidural space. We present the first report on symptomatic symptomatic subdural hygroma (SDH) due to transarticular screw fixation with posterior wiring.

PATIENTS CONCERNS

A 50-year-old man had sustained dens fracture 20 years ago and presented with severe neck pain following a recent traffic accident. The images showed atlantoaxial instability due to nonunion of the dens fracture and the patient underwent transarticular screw fixation with posterior sublaminar wiring using Gallie technique. When the U-shaped wire was passed under the arch of C1 from inferior to superior, a dural tear and cerebrospinal fluid (CSF) leak occurred. The site of dural tear was repaired by direct application of sutures. The patient was discharged in good condition. Fifteen day after surgery, the patient was readmitted with a history of a progressive headache associated with vomiting and vertigo.

DIAGNONSIS

Brain CT and MRI showed bilateral posterior fossa and a right-sided supratentorial SDH.

INTERVENTIONS

The patient underwent right occipital burr hole and evacuation of posterior fossa SDH due to deteriorating neurological status.

OUTCOMES

The patient's condition gradually improved after the operation and became asymptomatic at 3-year follow-up.

LESSONS

Posterior fossa and supratentorial SDH could occur resulting from any intraoperative dural tear and CSF leakage during posterior cervical spinal surgery. Symptomatic SDH after posterior cervical spinal surgery should be cautiously assessed and treated.

LEVEL OF EVIDENCE

5.

Minicraniotomy with a subgaleal pocket for the treatment of subdural fluid collections in infants

OBJECTIVE

Various surgical techniques have been described to treat subdural fluid collections in infants, including transfontanelle aspiration, burr holes, subdural drain, subduroperitoneal shunt, and minicraniotomy. The purpose of this study was to describe a modification of the minicraniotomy technique that avoids the implantation of external drainage catheters and potentially carries a higher success rate.

METHODS

In this retrospective study, the authors describe 11 cases involving pediatric patients who underwent parietal minicraniotomies for the evacuation of subdural fluid collections. In contrast to cases previously described in the literature, no patient received a drain; instead, a subgaleal pocket was created such that the fluid could flow from the subdural to the subgaleal space. Preoperative and postoperative data were reviewed, including neurological examination findings, radiological findings, complications, hospital length of stay, and findings on follow-up examinations and imaging. The primary outcome was failure of the treatment strategy, defined as an increase in subdural fluid collection requiring further intervention.

RESULTS

Eleven patients (8 boys and 3 girls, median age 4.5 months) underwent the described procedure. Eight of the patients had complete resolution of the subdural collection on follow-up imaging, and 2 had improvement. One patient had a new subdural collection due to a second injury. Only 1 patient underwent aspiration and subsequent surgical repair of a pseudomeningocele after the initial surgery. Notably, no patients required subduroperitoneal shunt placement.

CONCLUSIONS

The authors describe a new surgical option for subdural fluid collections in infants that allows for more aggressive evacuation of the subdural fluid and eliminates the need for a drain or shunt placement. Further work with more patients and direct comparison to other alternative therapies is necessary to fully evaluate the efficacy and safety of this new technique.

Subdural Hygroma Following Endoscopic Third Ventriculostomy: Understanding the Pathophysiology

BACKGROUND

Endoscopic third ventriculostomy (ETV) has overtaken the use of a ventriculoperitoneal shunt for the treatment of congenital hydrocephalus. Although ETV is relatively safe, several postoperative complications have been reported. One of the least described and understood complications is subdural hygroma following third ventriculostomy.

METHODS

In this series, we retrospectively analyzed patients who were managed for postventriculostomy subdural hygroma and analyzed the possible factors responsible for this condition.

RESULTS

A total of 248 patients who underwent ETV between 2014 and 2016 were included in this study. Twelve patients (4.8%) had developed subdural hygroma, including 6 patients with bilateral hygroma, 2 with contralateral hygroma, and 4 with ipsilateral subdural hygroma. Only 4 patients (1.6%) were symptomatic, with complains of pseudomeningocele, persistent vomiting, or headache. Significant mass effect was present in 2 patients with unilateral subdural hygroma, which improved after placement of a subduroperitoneal shunt. In 1 patient, the subdural hygroma decreased with persistent ventriculomegaly and improved after ventriculoperitoneal shunt implantation. One patient with posttraumatic hydrocephalus who had a bilateral subdural hygroma following ETV improved with conservative management. At a 12-month follow-up, all patients remained asymptomatic.

CONCLUSIONS

Post-ETV subdural hygroma may result from poor absorption of cerebrospinal fluid (CSF) in the subarachnoid space, dysfunction of the stoma with persistence of the ventriculosubdural fistula, or altered CSF cytology, such as hemorrhage. Most of these patients remain asymptomatic and improve with time. Symptomatic patients should be properly evaluated for the cause of the formation of subdural hygroma, which will guide the appropriate interventions.

Subdural hygroma secondary to rupture of an intracranial arachnoid cyst: description of 2cases and review of the literature

The appearance of a subdural hygroma after the rupture of an arachnoid cyst wall is extremely rare, with very few cases described in the literature. Most cases are due to a traumatic cause. The therapeutic approach in symptomatic cases is controversial, with a current tendency toward conservative management initially. In those cases that require surgical treatment, multiple therapeutic options are available, with fenestration techniques being recommended as first-line treatment. We describe 2cases treated in our centre and review the literature.

Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele

OBJECTIVE

Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele.

METHODS

The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period.

RESULTS

Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH.

CONCLUSIONS

Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.

[Management of arachnoid cysts of the middle cranial fossa accompanied by subdural effusions]

Subdural effusions are uncommon but known complications of arachnoid cysts of the middle cranial fossa. They mainly occur after minor head traumas in young patients. Here, we report eight cases of arachnoid cyst of the middle cranial fossa associated with subdural hematoma in five cases and hygroma in three cases. Major symptoms are signs of raised intracranial pressure. CT scan and MRI showed the cyst and the subdural effusion. An excellent therapeutic result was achieved with evacuation of the subdural fluid via burr holes in the five cases of subdural hematoma while in the two cases of hygroma a subduro-peritoneal shunt was necessary. In the last case, a temporal craniotomy was performed with evacuation of the hygroma and fenestration of the cyst. We suggest treating only the complicating event in the case of a subdural hematoma via burr holes evacuation. Whereas, in the case of hygroma we think that craniotomy with fenestration of the cyst or the use of a subdural shunt are more often needed.

Hypothalamic dysfunctions as a late consequence of surgical opening of the lamina terminalis. A controversial hypothesis

BACKGROUND

Opening of the lamina terminalis is often used in surgery of the optico-chiasmatic region. Consequently, alteration of cerebral-spinal fluid (CSF) dynamics can occur after this manoeuvre, thus potentially translating into clinical complications. Herein, we describe 2 cases in which clinically relevant hypothalamic dysfunctions developed after few days opening of the lamina terminalis both patients showed mild to moderate preoperative hydrocephalus which improved postoperatively.

CASES DESCRIPTION

In a patient with ruptured aneurysm of the basilar bifurcation, opening of the lamina terminalis was performed prior to acute-stage clipping. On postoperative day 7th, the patient developed significant subdural hygroma, mild disturbances of consciousness and increase of ADH concentration. These clinical features resolved only following subdural hygroma drainage and ventricular-peritoneal shunting. One previously operated patient in whom the lamina terminalis had been opened to remove a sizeable parasellar tumour showed a similar post-operative course. In this patient, sole subdural hygroma drainage was not an effective treatment, and the patient died subsequently for complications related to long-standing, though mild, hypothalamic dysfunction.

CONCLUSIONS

Our experience may suggest that hypothalamic dysfunctions should be reminded as a possible, although rare, complication following the opening of the lamina terminalis. This clinical condition, if not properly managed, may contribute to trigger severe life-threatening complications.

Management of infratentorial subdural hygroma complicating foramen magnum decompression: a report of three cases

Decompression of the foramen magnum for symptomatic Chiari malformation attends a small but significant risk of infratentorial subdural extra-arachnoid hygroma when an arachnoid-sparing procedure is attempted. We present three cases whereby an arachnoid-sparing procedure was carried out and resulted in infratentorial subdural hygroma and hydrocephalus. The complication was managed by re-exploration of the posterior fossa and wide arachnoidotomy. In cases whereby the decision has been made to open the dura, we recommend routine arachnoidotomy in foramen magnum decompression, avoiding the risks of infratentorial subdural hygroma. In cases where arachnoid-sparing procedures have been attempted and subdural hygroma subsequently develops, we advocate re-exploration of the posterior fossa rather than cerebrospinal fluid diversion.

Arachnoid cysts of the middle cranial fossa accompanied by subdural effusions--experience with 60 consecutive cases

BACKGROUND

Subdural effusions (SDEs) can complicate arachnoid cysts of the middle cranial fossa (ACMFs). While there is a consensus that at least in adults asymptomatic ACMFs should not be operated, those with concomitant subdural and/or intracystic effusions are clinically apparent in the majority of cases and should be surgically treated. But it remains unclear, which surgical procedure is best.

METHODS

Since 1980, 60 out of 343 patients with an ACMF presented with accompanying SDEs. Four categories of SDEs were differentiated radiologically. This collective was controlled in a follow-up study up to 60 months after conservative or operative treatment by clinical and radiological means.

RESULTS

In 54 of the 60 patients, we saw an indication for surgical treatment. Twenty-nine patients received a burr hole, 13 cases were treated by craniotomy, seven by endoscopical means, three patients underwent shunting and two combined procedures. Six patients were treated conservatively. An excellent final clinical outcome was observed in 55 cases. While craniotomy succeeded best to reduce the cyst volume in postoperative CT, the final clinical outcome did not differ significantly compared with burr hole trepanation.

CONCLUSIONS

Patients with small effusions can be treated conservatively in selected cases. Based on our experience, we prefer a differentiated therapy. As first procedure, burr hole and subdural drainage were performed, leaving the cyst alone, seeming sufficient for the majority of cases. Craniotomy or endoscopical means should be reserved as treatment of choice for special cases, depending on category and acuteness of SDE and size/localisation of the ACMF.

[Dilation of subarachnoid space around the optic nerve in a patient with subdural effusion: a case report]

A fifty-year-old man who had a history of minor head injury a month previously presented with headache, visual disturbance and papilloedema. Brain MR imaging showed bilateral subdural effusion and fat saturated orbital MR imaging demonstrated dilated subarachnoid space around the optic nerve. The diameter of the subarachnoid space behind the globe was 7.0 mm and that of the optic nerve was 3.5 mm. Bilateral simple drainage was performed to prevent deterioration of the visual disturbance. Light bloody fluid with a subdural pressure of 10.5 cmH2O was drained from the burr hole at the left side, and colorless fluid was drained from the right. Orbital MR imaging during continuous drainage revealed shrinkage of the subarachnoid space around the optic nerve. However, follow-up MR imaging 5 months after drainage showed disappearance of the subdural effusion and the reappearance of the subarachnoid space around the optic nerve, even though the size was smaller than before surgery. These findings suggest that the diameter of the optic subarachnoid space co-relates with the intracranial pressure, and may be an indication for increased intracranial pressure.

Posterior fossa subdural hygroma with supratentorial chronic subdural haematoma

Posterior fossa subdural hygromas are very rare. They tend to occur following direct occipital trauma. We present an unusual case of complex subdural hygroma of the posterior fossa, which was associated with a supratentorial chronic subdural haematoma. This developed after an apparently minor injury to the head. The unusual features of our case are discussed. We also review the literature and discuss the natural history and pathogenesis of subdural hygroma.

The posterior pedicle inferior turbinate flap: a new vascularized flap for skull base reconstruction

BACKGROUND

Expanded endonasal approaches (EEA) for the resection of lesions of the anterior and ventral skull base can create large defects with a significant risk of postoperative cerebrospinal fluid (CSF) leaks or exposure of the internal carotid artery. In these cases, a reconstruction using a vascularized flap facilitates rapid and complete healing of the defect. The Hadad-Bassagasteguy flap (HBF), a posterior pedicle nasoseptal flap, is our preferred reconstructive option; however, a prior posterior septectomy or prior wide sphenoidotomies preclude its use. We have developed two additional pedicled flaps to reconstruct these selected patients: the transpterygoid temporoparietal fascia flap, which is suitable for large defects, and the posterior pedicle inferior turbinate flap (PPITF), the subject of this paper.

METHODS

We developed a flap comprising the inferior turbinate mucoperiosteum pedicled on the inferior turbinate artery, a terminal branch of the posterior lateral nasal artery, which arises from the sphenopalatine artery. We retrospectively reviewed the clinical data of four patients who underwent a skull base reconstruction using a PPITF.

RESULTS

Four patients underwent a reconstruction with the PPITF after undergoing an EEA that produced a skull base defect associated with a CSF fistula (n = 2), an exposed internal carotid artery (n = 1), or a basilar aneurysm clip (n = 1). All patients had undergone posterior septectomies as part of previous EEAs. All flaps healed uneventfully and covered the entire defect.

CONCLUSION

The PPITF is a viable reconstructive option for patients with skull base defects of a limited size defect and in whom the HBF is not available.

Anterior Skull Base Reconstruction With a Galeal-Pericranial Flap

Excision of neoplasm and trauma involving the anterior cranial base may often result in communication between the intracranial and extracranial compartments. Many techniques have been proposed to obtain a watertight separation. We report our 5 years of experience in the management of anterior skull base defects using a galeal-pericranial flap. Between January 2001 and April 2006, 22 patients were treated for a cranial base reconstruction at the University of Messina. Five of them presented with persistent cerebrospinal fluid (CSF) leak after previous craniofacial trauma. Ten underwent a combined maxillofacial-neurosurgical approach for the removal of a benign tumor involving the anterior skull base. Seven had severe craniofacial trauma, which required an intervention of reconstruction of the anterior skull base. In the whole series, a galeal-pericranial flap was used to separate intra- and extracranial compartments. No patients developed postoperative brain contusions or subdural-epidural blood collections. Throughout the follow-up period, there was no evidence of flap failure. In all but one patient, no postoperative CSF leak was evident. In one patient, a mild transient postoperative CSF leakage was present. There has been no recurrent CSF leak or meningitis. The follow up average of 23 months shows no incidence of infection. Even if our series does not comprise malignancies and previously irradiated patients, our data confirm the validity of the galeal- pericranial flap for the surgical management of minimal and moderately sized defects of anterior cranial base.

[A case of hydrocephalus in follow-up of post-traumatic subdural effusion]

We report an interesting case of hydrocephalus following traumatic subdural effusion. A 50-year-old male was diagnosed as a traumatic subdural effusion. Three months later, he was transferred to our hospital again because of conscious disturbance and incontinence. Emergent CT showed characteristic hydrocephalus. The lateral ventricle and the third ventricle were remarkably enlarged. After Ventriculo-peritoneal shunt, the symptoms and radiographical findings were resolved. Both the compression of arachnoid villi around the superior saggital sinus and stenosis of the aqueduct by subdural effusion could be associated with the cause of hydrocephalus in this case.

Chiari-like tonsillar herniation associated with intracranial hypotension in Marfan syndrome

The authors describe the case of a 12-year-old girl with Marfan syndrome, sacral dural ectasia, and tonsillar herniation, who presented with headache. Initially, it was hypothesized that the headaches were secondary to the tonsillar herniation, and the patient consequently underwent surgical decompression of the foramen magnum. Postoperatively, the patient's condition did not improve, and additional magnetic resonance (MR) imaging demonstrated evidence of a cerebrospinal fluid (CSF) leak at the level of the dural ectasia. It was surmised that the girl's symptoms were due to spontaneous intracranial hypotension (SIH) and that the tonsillar herniation was caused by the leakage. The patient responded well to application of a blood patch at the level of the demonstrated leak, and her headache resolved. This appears to be the first reported case of a patient with Marfan syndrome presenting with a symptomatic spontaneous CSF leak complicated by tonsillar herniation. In this rare association of SIH and connective tissue disorders, recognition of the clinical signs and typical MR imaging features of SIH may lead to more appropriate and less invasive treatment, potentially avoiding surgery.

Determinants of success in endoscopic cerebrospinal fluid leak repair

OBJECTIVES

To identify factors influencing success in endoscopic repair of CSF leaks of the anterior skull base.

METHODS

Through retrospective chart review, 24 endoscopic closures of anterior skull base CSF leaks were analyzed for factors correlating with initial repair outcome.

RESULTS

Thirteen patients with either spontaneous leaks or iatrogenic leaks arising from FESS were repaired with significantly lower recurrence rate (8%) than 11 patients with leaks induced by skull base procedures (45%). However, in the latter group, only 14% recurred when the dural defect was directly visualized, whereas leaks always recurred when bony dehiscences were patched in the absence of visible dural defects. Such defects were least frequently localized in patients with craniotomy-induced leaks. A trend toward morbid obesity was also noted among repair failures.

CONCLUSIONS

Direct visualization of the dural defect is essential for endoscopic repair of anterior skull base CSF leaks, with craniotomy-induced leaks being the most challenging to localize. Obesity is another likely factor contributing to repair failure.