Sandwich grafting technique for endoscopic endonasal repair of cerebrospinal fluid rhinorrhoea

A case series of crossbow injury to the head highlighting the importance of an interdisciplinary management approach

Background:

Penetrating crossbow head injuries are rare with no clear consensus regarding the optimal management paradigm for such injuries. We present three cases of crossbow injury to the head, with emphasis on the need for a comprehensive multidisciplinary management plan.

Case Description:

Three cases are presented of patients presenting with self-inflicted penetrating crossbow to head injuries. All three patients presented with intact neurological exam. A comprehensive multidisciplinary plan was created for all three cases with subsequent successful removal of the arrows. All three patients were discharged home with modified Rankin scale score of <2.

Conclusion:

Penetrating crossbow brain injuries are rare and require complex management. A comprehensive management strategy is necessary to manage these injuries. Moreover, careful consideration of factors such as the arrow trajectory, complexity of the injuries, and availability of the required expertise is important to increase the chances of success.

Diagnostic Value of Non-Contrast CT in Cerebrospinal Fluid Leakage After Endoscopic Transnasal Surgery for Sellar and Suprasellar Tumors

We aimed to study the relationship between pneumocephalus on non-contrast CT (NCCT) and post-operative cerebrospinal fluid leakage (p-CFL) after endoscopic transsphenoidal sellar and suprasellar tumor surgeries. Data from patients who underwent endoscopic treatment for sellar or suprasellar tumors from January 2018 to March 2020 were consecutively collected and reviewed. The NCCT pneumocephalus (NP) was measured the first day after operation and the first day after the expansive sponge was extracted. p-CFL was determined according to post-operative clinical symptoms, high resolution CT and glucose test, and expert consensus. Of the 253 patients enrolled in this study, 32 (12.6%) had p-CFL. Compared with patients without p-CFL, patients with p-CFL had a higher occurrence of intra-operative CFL, a longer operation time, a higher rate of pneumocephalus on first-day NCCT after operation (i.e., first-day NP), and a higher rate of NP volume change between two NCCT measurements (referred to as the NP change) (all p < 0.05). In multivariate regression analysis, first-day NP was independently associated with p-CFL occurrence [odds ratio (OR)=6.395, 95% confidence interval (CI)=2.236-18.290, p=0.001). After adding the NP change into the regression model, first-day NP was no longer independently associated with p-CFL, and NP change (OR = 19.457, 95% CI = 6.095–62.107, p<0.001) was independently associated with p-CFL. The receiver operating characteristic curve comparison analysis showed that NP change had a significantly better predicting value than first-day NP (area under the curve: 0.988 vs. 0.642, Z=6.451, p=0.001). NP is an effective imaging marker for predicting p-CFL after endoscopic sellar and suprasellar tumors operation, and the NP change has a better predicting value.

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks

ABSTRACT

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Complications in Skull Base Surgery and Subsequent Repair

Over the past several decades, endoscopic sinus surgery has revolutionized the approach to skull base surgery. Open skull base approaches remain a viable option for advanced skull base tumors. Complications have gone down with increased reliability of vascularized tissue transfer. In this article, the authors explore the various complications that can present following skull base surgery and review the approaches for repair when such issues are encountered.

Management of coexistent sinonasal pathology in patients undergoing endoscopic cerebrospinal fluid rhinorrhea repair

Introduction

Patients who undergo endoscopic cerebrospinal fluid rhinorrhea repair may occasionally present with coexistent sinonasal pathology which may or may not need to be addressed prior to surgical repair. Some patients may develop new onset nasal morbidity related to endoscopic repair.

Objective

To study the prevalence and management of additional sinonasal pathology in patients who undergo endoscopic repair of cerebrospinal fluid rhinorrhea

Methods

A retrospective review of patients who underwent endoscopic cerebrospinal fluid leak repair was conducted to note the presence of coexistent sinonasal morbidity preoperatively and in the followup period.

Results

Of a total of 153 patients who underwent endoscopic closure of cerebrospinal fluid leak, 97 (63.4%) were female and 56 (36.6%) males. Most patients (90.2%) were aged between 21 and 60 years, with a mean of 40.8 years. Sixty-four patients (41.8%) were found to have coexistent sinonasal morbidity preoperatively, the commonest being symptomatic deviated nasal septum (17.6%), chronic rhinosinusitis without polyps (11.1%) and chronic rhinosinusitis with polyps (3.3%). Rare instances of septal hemangioma (0.7%) and inverting papilloma (0.7%) were also seen. Postoperatively, there was cessation of cerebrospinal fluid rhinorrhea in 96.7% which rose to 100% after revision surgery in those with recurrence. Resolution of coexistent sinonasal pathology occurred in all patients with followup ranging from 10 to 192 months. New onset sinonasal morbidity which developed postoperatively included synechiae between middle turbinate and lateral nasal wall (5.9%) and sinonasal polyposis (1.3%).

Conclusion

Patients who undergo endoscopic cerebrospinal fluid leak repair may have coexistent sinonasal pathology which needs to be addressed prior to or along with repair of the dural defect. New onset sinonasal morbidity, which may arise in a few patients postoperatively, may require additional treatment. A protocol for the management of coexistent sinonasal conditions ensures a successful outcome.

Traumatic Nonmissile Penetrating Transnasal Anterior Skull Base Fracture and Brain Injury with Cerebrospinal Fluid Leak: Intraoperative Leak Detection and an Effective Reconstruction Procedure for a Localized Skull Base Defect Especially After Coronavirus Disease 2019 Outbreak

Background

Cerebrospinal fluid (CSF) leakage after penetrating skull base injury is relatively rare compared with close head injuries involving skull base fractures.

Case Description

We report the case of a 65-year-old man who had presented with epistaxis and serous rhinorrhea. When he had fallen to the ground near his bee boxes, a garden pole had poked into his right nostril. He had instantly removed the pole from his nostril himself. However, immediately after removal of the pole, he had developed nasal bleeding and serous rhinorrhea. He then drove to our emergency room. Computed tomography showed pneumocephalus with a minor cerebral contusion in the left frontal lobe and a penetrating injury in the left anterior skull base. His CSF leakage had not resolve spontaneously within 1 week after the injury with strict bed rest. We repaired the CSF leakage using a fat (adipose tissue)-on-fascia autograft plug and caulked the defect in the anterior skull base with the fat-on-fascia graft (FFG) plug through the left nostril with endoscopic guidance. The CSF rhinorrhea was successfully controlled. Intranasal local application of fluorescein aided in the detection of the direction of flow of the CSF leakage.

Conclusions

Endonasal endoscopic caulking of a skull base defect using an FFG plug can be useful to treat CSF leakage due to the localized skull base defect, especially in the coronavirus disease 2019 pandemic. It is simple, inexpensive, and timesaving. It requires no special skills nor sophisticated instruments that can cause aerosolization, reducing the risk of infection during the surgery.

Leukocyte- and platelet-rich fibrin: a new graft material in endoscopic repair of spontaneous CSF leaks

BACKGROUND

Spontaneous CSF leak is a challenging condition, with frequent recurrences following attempted surgical closure. The selection of graft materials depends on the experience of the operating surgeon. Leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation platelet concentrate that has currently invaded every surgical specialty. To our knowledge, no previous reports about the use of L-PRF in repair of CSF leak were published. The study was conducted to assess the potential role of L-PRF in spontaneous CSF leaks repair.

METHODS

This prospective controlled study was conducted on 40 patients who were randomly divided into 2 groups: In group A, L-PRF was used in addition to another layer, while patients in group B underwent multilayer repair using traditional graft materials.

RESULTS

Preoperative HRCT scan showed bony dehiscence (n = 30) and opacity in a nearby sinus (n = 9). MRI findings varied between empty sella in 28 patients, and meningocele in 19 patients. Mean preoperatively measured CSF pressure was 26.6 cm H₂O. Cribriform plate was identified as the commonest site of leaks. Multiple skull defects were detected in 2 cases. Failure of repair was found in 3 patients (15%) of group B and 1 patient (5%) of group A, this difference was statistically insignificant (P value = 0.28). Significance correlation between recurrence of CSF leak and elevated intracranial pressure was observed (P value; 0.04).

CONCLUSION

L-PRF was found to be a good adjunct material in endoscopic spontaneous CSF leaks repair. It helps in decreasing the number of layers needed for defect closure.

Contemporary Trends in the Management of Posttraumatic Cerebrospinal Fluid Leaks

The objective of this review is to provide an overview on the diagnosis and management of traumatic cerebrospinal fluid (CSF) leaks. This comprehensive review explores controversies associated with the management of CSF leaks as well as a review of the most contemporary literature. The scope of this article covers both traumatic CSF leaks of the middle and anterior cranial fossae.

Endoscopic Repair of CSF Fistulae: A Ten Year Experience

INTRODUCTION

Cerebrospinal Fluid (CFF) fistulae are repaired endoscopically with varying degrees of success around the world. Large series are still uncommon, and the results varied primarily because of the different techniques by different surgeons and also because of a variation in the patient profile in each series, for example, many series deal primarily with traumatic CSF leaks where the defects are larger and outcomes poorer.

AIM

To analyse the surgical outcomes of Endoscopic CSF rhinorrhea closure.

MATERIALS AND METHODS

This is a series of 34 cases operated upon primarily by one surgeon in two different centres over a period of 10 years.

RESULTS

Of the 34 cases, 76% of the patients were women. Among the patients only 20.6% patients had a history of trauma preceding the CSF leak. The most common site of leak was in the fovea ethmoidalis in 19 (55.8%) followed by 10 (29.4%) in the cribriform plate. An overlay technique of placing the multiple layers of fascia and mucosa was used in 26 (76.5%) patients and underlay technique in the remaining. Postoperative lumbar drain was used in all patients.

CONCLUSION

Based on the treatment outcome of the 34 patients, it can be concluded that the success rate of a single endoscopic procedure in our experience is 97% and 100% following the second. Endoscopic approach for closure of CSF leak is safe with minimal complications and little morbidity.

Endoscopic repair of cerebrospinal fluid rhinorrhoea

GOAL

The purpose of this review was to look at the success rate of transnasal endoscopic repair of CSF rhinorrhoea and the impact of patient factors, repair techniques and adjuvant treatment.

MATERIAL AND METHODS

A literature search was performed on PubMed, Medline and Cochrane Central databases, independently by two of the authors, of all studies reporting the outcomes of CSF rhinorrhoea repair, published until the 1st June 2014, using keywords Cerebrospinal fluid leak, CSF leak, CSF fistula, CSF leak or fistula repair, endoscopic sinus surgery or ESS complications. Sixty-seven papers were included for the review.

RESULT

The repair of CSF rhinorrhoea has rapidly evolved over the past 30 years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs, which carried a variable success rate and morbidity. More recently, there have been several case series and reports that describe various endoscopic methods and materials for repair, with mean success rate of 90% (range: 60-100%). The most common site of CSF leak is the ethmoid roof/cribriform plate region. Traumatic CSF leak, in particular iatrogenic, is still the most common cause. Imaging with CT and MRI remains the gold standard for localisation of CSF leaks. The sphenoid sinus is the most common location for CSF leak repair failure. Lumbar drains and antibiotics are used as adjuvant therapy to endoscopic repair, but their benefits are not clear; intrathecal fluorescein can be used to aid location of CSF leak, but should be reserved for more complex cases. Further work into graft materials used and adjuvant treatment is needed to make any meaningful conclusions about their efficacy.

CONCLUSION

The literature demonstrates that endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques.

Comprehensive review on endonasal endoscopic sinus surgery

Endonasal endoscopic sinus surgery is the standard procedure for surgery of most paranasal sinus diseases. Appropriate frame conditions provided, the respective procedures are safe and successful. These prerequisites encompass appropriate technical equipment, anatomical oriented surgical technique, proper patient selection, and individually adapted extent of surgery. The range of endonasal sinus operations has dramatically increased during the last 20 years and reaches from partial uncinectomy to pansinus surgery with extended surgery of the frontal (Draf type III), maxillary (grade 3-4, medial maxillectomy, prelacrimal approach) and sphenoid sinus. In addition there are operations outside and beyond the paranasal sinuses. The development of surgical technique is still constantly evolving. This article gives a comprehensive review on the most recent state of the art in endoscopic sinus surgery according to the literature with the following aspects: principles and fundamentals, surgical techniques, indications, outcome, postoperative care, nasal packing and stents, technical equipment.

Endoscopic Endonasal Repair of Sphenoid Sinus Cerebrospinal Fluid Leaks: Our Experience

Endoscopic endonasal approaches are becoming increasingly popular over transcranial approaches for repair of cerebrospinal leak defects. Sphenoid sinus CSF leaks pose a significant challenge and carry the risk of life-threatening intracranial complications. Their management depends upon identifying the leak using imaging techniques followed by intraoperative endoscopic localization. Our experience in the endoscopic endonasal management of sphenoid sinus CSF leaks is reported in this paper.

State of the art of endoscopic frontal sinus cerebrospinal fluid leak repair

Frontal sinus cerebrospinal fluid leaks are rare and their surgical management is difficult. Up until recently, they could only be treated by open surgery with an osteoplastic flap. With the development of endoscopic surgery, less invasive techniques such as an exclusive endoscopic approach can now be used, ensuring a simpler postoperative course. However, these techniques require a thorough knowledge of frontal sinus anatomy and endoscopic CSF leak repair. This knowledge is essential both to ensure closure of the CSF leak and to preserve frontal sinus patency.

Neuroendoscopic endonasal management of cerebrospinal fluid rhinorrhea

Neuroendoscopic endonasal approach has gained popularity in managing traumatic, spontaneous, and especially iatrogenic cerebrospinal fluid (CSF) rhinorrhea. The authors examined 8 patients presenting with CSF rhinorrhea between December 2012 and June 2014: 5 patients had iatrogenic leak, 2 patients had traumatic leak, and 1 patient had a spontaneous onset of CSF rhinorrhea. Sites of the CSF leaks were detected through computed tomographic cisternography and magnetic resonance imaging in the patients with traumatic and spontaneous leaks. All patients received neuroendoscopic endonasal surgery for the CSF leak. The largest defect was 22 mm in maximum diameter. Endoscopic supraciliary "keyhole" approach was performed in 1 patient after confirmation of a frontal sinus leak using the endoscopic endonasal approach. The success rate was 100% in the first attempt. Follow-up period ranged from 3 to 24 months, and no recurrence was reported. Identifying the leak site and choosing the appropriate surgical technique remain the most important factor in surgical success.