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Lee HS, Cho KR, Park K, Jeon C. Management of Cerebrospinal Fluid Leakage after Microvascular Decompression Surgery: Clinical Strategy. Life (Basel) 2023; 13:1771. [PMID: 37629628 PMCID: PMC10455648 DOI: 10.3390/life13081771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/17/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
(1) Background: Cerebrospinal fluid (CSF) leakage is one of the most common complications of microvascular decompression (MVD) surgery. Before fatal complications, such as intracranial infection, occur, early recognition and prompt treatment are essential. (2) Methods: The clinical data of 475 patients who underwent MVD surgery from September 2020 to March 2023 were retrospectively analyzed. In these patients, if there were any symptoms of CSF leakage, and if CSF leakage was evident, a lumbar drainage catheter was inserted immediately. (3) Results: CSF leakage was suspected in 18 (3.8%) patients. Five of these patients (1.1%) showed signs of CSF leakage during conservative management and subsequently underwent catheter insertion for lumbar drainage. The lumbar drain was removed after an average of 5.2 days, resulting in an average hospitalization of 14.8 days. In all 5 patients, CSF leakage was resolved without reoperation. (4) Conclusions: Our treatment strategy prevented the development of fatal complications. Close observation of the symptoms and postoperative temporal bone computed tomography and audiometry are considered to be good evaluation methods for all patients. If CSF leakage is certain, it is important to perform lumbar drainage immediately.
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Affiliation(s)
- Hyun-Seok Lee
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kyung-Rae Cho
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
| | - Kwan Park
- Department of Neurosurgery, Konkuk University Medical Center, Seoul 05030, Republic of Korea; (H.-S.L.); (K.-R.C.); (K.P.)
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06171, Republic of Korea
| | - Chiman Jeon
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan 15355, Republic of Korea
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Wong AK, Wong RH. Keyhole retrosigmoid approach without watertight dural closure - Evaluation of a minimalistic approach. Clin Neurol Neurosurg 2023; 227:107625. [PMID: 36870088 DOI: 10.1016/j.clineuro.2023.107625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 02/03/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND The retrosigmoid craniotomy is a versatile surgical approach to the cerebellopontine angle though cerebrospinal fluid leak remains a concern, with a reported prevalence of 0-22 %. A host of closure materials and strategies have been proposed to achieve a watertight dural closure to varying degrees of success. We review our series of keyhole retrosigmoid craniotomies and describe our simple, standardized method of closure without watertight dural closure. METHODS A retrospective review of all retrosigmoid craniotomies performed by the senior author was completed. Closure was achieved by placing an oversized piece of gelatin in the subdural space. The dura is grossly approximated. An oversized sheet of collagen matrix is placed as an overlay followed by gelatin sponge in the craniectomy defect held in place with titanium mesh. The superficial layers are approximated. The skin is closed with a running sub-cuticular suture followed by skin glue. Patient demographics, cerebrospinal fluid leak risk factors, and surgical outcomes were determined. RESULTS A total of 114 patients were included. There was one case (0.9 %) of CSF leak, which resolved with placement of a lumbar drain for 5 days. The patient had one defined risk factor (morbid obesity, BMI 41.0 kg/m2). CONCLUSIONS Obtaining a watertight dural layer closure has been the generally accepted strategy in preventing CSF leaks in a traditional retrosigmoid approach. In keyhole retrosigmoid approaches it may not be necessary by utilizing a simple gelfoam bolstered collagen matrix onlay technique potentially improving outcome measures including operative time.
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Affiliation(s)
- Andrew K Wong
- Department of Neurosurgery, Rush University, 1725 West Harrison St #855, Chicago, IL 60612, USA
| | - Ricky H Wong
- Department of Neurosurgery, NorthShore University Health System, 2650 Ridge Ave. Kellogg 3rd Floor, Evanston, IL 60201, USA.
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Inoue T, Shitara S, Shima A, Goto Y, Fukushima T. Double collagen matrix grafting for dural closure in microvascular decompression: an alternative use of autologous fascial grafting. Acta Neurochir (Wien) 2021; 163:2395-2401. [PMID: 33928438 DOI: 10.1007/s00701-021-04856-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/19/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Watertight dural closure is a crucial step in preventing postoperative cerebrospinal fluid (CSF) leak and subsequent infection in posterior fossa surgery. The aim of this study is to assess an alternative use of collagen matrix double grafting in microvascular decompression (MVD). METHODS Dural closure using double collagen matrix grafts was retrospectively compared with autologous fascial grafting in 120 patients who underwent MVD. Double collagen matrix grafting technique, a combination use of inlay and onlay grafting (DuraGen®, Integra Lifesciences, Plainsboro, NJ, USA, $700-800 for an MVD craniotomy size), was applied in 60 patients (the collagen matrix group). In the remaining 60 patients, an autologous fascial graft was sutured in a watertight fashion to the dural defect (the fascia group). Postoperative wound complications, such as CSF leak and infection, were retrospectively compared between the two groups. RESULTS CSF leaks were observed in 3 patients (5.0%) in the fascia group and in 2 patients (3.3%) in the collagen matrix group. All cases of CSF leakage presented with pseudomeningoceles except one patient who developed an incisional CSF leak. A repair surgery for CSF leak was required in this one patient in the fascia group. Subcutaneous abscesses were noted in 2 patients (3.3%) in the fascia group. There was no patient who developed a subcutaneous abscess in the collagen matrix group. One patient in each group developed aseptic meningitis. Statistical analyses revealed that the collagen matrix group showed non-inferior outcomes to the fascia group in CSF leaks and infectious complications. CONCLUSIONS Double grafting technique with a combination of inlay and onlay collagen sheets is a safe and secure alternative for watertight dural closure despite a cost limitation.
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Affiliation(s)
- Takuro Inoue
- Department of Neurosurgery, Subarukai Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan.
| | - Satoshi Shitara
- Department of Neurosurgery, Subarukai Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Ayako Shima
- Department of Neurosurgery, Subarukai Koto Memorial Hospital, 2-1 Hiramatsu-cho, Higashiohmi-shi, Shiga, 527-0134, Japan
| | - Yukihiro Goto
- Department of Neurosurgery, Saiseikai Shiga Hospital, Shiga, Japan
| | - Takanori Fukushima
- Division of Neurosurgery, Duke University Medical Center, Durham, NC, USA
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Agarwalla PK, Meybodi AT, Ward M, Paskhover B. The Vascularized Occipital Fascial Flap (OFF): A Novel Reconstructive Technique for Posterior Fossa Surgery. World Neurosurg 2021; 154:32-38. [PMID: 34224888 DOI: 10.1016/j.wneu.2021.06.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posterior fossa surgery is particularly prone to cerebrospinal fluid (CSF) leakage. Several methods have been introduced to address and/or prevent this complication. However, to the best of our knowledge, the use of a vascularized fascial flap based on the occipital artery for the purpose of reconstruction has not been reported. We introduce the occipital fascial flap (OFF) for reconstruction of a craniectomy defect after the retrosigmoid approach. METHODS A 57-year-old woman with a large cerebellar metastasis underwent gross total resection of the mass followed by reconstruction of the craniectomy defect using OFF. RESULTS Postoperative imaging showed flap viability and no CSF leak occurred during follow-up. CONCLUSIONS We report the first use of OFF for reconstruction of a craniectomy defect in a retrosigmoid approach. The vascularized fascial flap in posterior fossa surgery is a potentially helpful technique to reduce the risk of CSF leak in high-risk patients.
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Affiliation(s)
- Pankaj K Agarwalla
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA.
| | - Ali Tayebi Meybodi
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Max Ward
- Department of Neurological Surgery, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Boris Paskhover
- Department of Otolaryngology, Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Montano N, Signorelli F, Giordano M, D'Onofrio FG, Izzo A, D'Ercole M, Ioannoni E, Pennisi G, Caricato A, Pallini R, Olivi A. Factors associated with cerebrospinal fluid leak after a retrosigmoid approach for cerebellopontine angle surgery. Surg Neurol Int 2021; 12:258. [PMID: 34221589 PMCID: PMC8247722 DOI: 10.25259/sni_42_2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 05/20/2021] [Indexed: 11/04/2022] Open
Abstract
Background The retrosigmoid approach represents a crucial surgical route to address different lesions in the cerebellopontine angle but cerebrospinal fluid (CSF) leak still remains the most frequent complication after this approach. Here, we analyzed the impact of different factors in CSF leak development after a retrosigmoid approach. Identifying risk factors related to a specific approach may help the surgeon to tailor the perioperative management and to appropriately counsel patients regarding their risk profile. Methods We retrospectively reviewed the clinical, surgical, and outcome data of 103 consecutive patients (M/F, 47/56; mean follow-up 35.6 ± 23.9 months) who underwent a retrosigmoid approach for different cerebellopontine angle pathologies and studied the impact of different factors on the occurrence of a CSF leak to univariate and multivariate analysis. Results Seventy-nine patients (76.7%) were operated for tumors growing in the cerebellopontine angle. Twenty-four patients (23.2%) underwent microvascular decompression to treat a drug-resistant trigeminal neuralgia. Sixteen patients (15.5%) developed CSF leak in the postoperative course of which six underwent surgical revision. Performing a craniectomy as surgical procedure (P = 0.0450) and performing a reopening procedure (second surgery; P = 0.0079) were significantly associated to a higher risk of developing CSF leak. Moreover, performing a reopening procedure emerged as an independent factor for CSF developing on multivariate analysis (P = 0.0156). Conclusion Patients submitted to craniectomy and patients who underwent a second surgery showed an higher CSF leak rate. Ongoing improvement of biomaterial technology may help neurosurgeons to prevent this potentially life-threatening complication.
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Affiliation(s)
- Nicola Montano
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Francesco Signorelli
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Martina Giordano
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Alessandro Izzo
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Manuela D'Ercole
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Eleonora Ioannoni
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Pennisi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Anselmo Caricato
- Neurosurgical Intensive Care Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Roberto Pallini
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
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Khan SA, Laulloo A, Vats A, Nath F. Microvascular decompression: incidence and prevention of postoperative CSF leakage in a consecutive series of 134 patients. Br J Neurosurg 2020; 34:416-418. [PMID: 32362141 DOI: 10.1080/02688697.2020.1749989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: Microvascular decompression (MVD) is an established procedure for treating Trigeminal Neuralgia and Hemifacial Spasm. Postoperative CSF leakage is still a common complication after MVD.Material and Methods: We did a retrospective study of 134 patients who underwent microvascular decompression, mainly for Trigeminal Neuralgia and Hemifacial Spasm in our unit. All patients had an apparently watertight repair of the dura at the end of the operation done by our technique using Duraguard ® and Histacryl® glue.Results: Of the 134 patients, 129 (96.2%) had no postoperative CSF leakage. Only five (3.7%) of the patients experienced postoperative CSF leak.Conclusion: We conclude that dural repair using the described technique, with a dural substitute (Duraguard) and Histacryl glue is safe and effective in preventing postoperative CSF leakage following MVD.
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Affiliation(s)
- Shahid Ahmed Khan
- Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Asifa Laulloo
- Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Atul Vats
- Neurosurgery, James Cook University Hospital, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
| | - Fred Nath
- James Cook University Hospital, Middlesbrough, United Kingdom of Great Britain and Northern Ireland
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Go KO, Hwang K, Han JH. Surgical Nuances to Reduce and Manage Cerebrospinal Fluid Leaks after Microvascular Decompression. J Clin Med 2020; 9:jcm9040902. [PMID: 32218220 PMCID: PMC7230255 DOI: 10.3390/jcm9040902] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 11/16/2022] Open
Abstract
Background: No dural substitute has proven to be complication-free in a large clinical trial, even suggesting some benefit during watertight closure. However, primary dural closure is not always possible due to dural shrinkage from electrocautery for dural bleeding. Objective: This study is performed to analyze the clinical outcomes related to cerebrospinal fluid (CSF) leakage after microvascular decompression (MVD) using a simple surgical technique. Methods: Three hundred and sixty consecutive cases were treated with MVD and followed up for more than one month after surgery. Bleeding from the cut veins during dural incision was controlled by pulling stay sutures instead of electrocautery to avoid dural shrinkage. Additionally, a wet cottonoid was placed on the cerebellar side dural flap to prevent dural dehydration. During dural closure, primary dural closure was always attempted. If not possible, a “plugging muscle” method was used for watertight dural closure. Results: The mean age was 54.1 ± 10.8 years (range, 24–85 years), and 238 (66.1%) were female. Primary MVD was performed in 345 (95.8%) patients. The mean operation time (from skin incision to skin closure) was 96.7 ± 33.0 min (range, 38–301 min). Primary dural closure was possible in 344 (95.6%) patients. The “plugging muscle method” was performed more frequently in patients older than 60 years (8 of 99 cases, 8.08%) than in younger cases (8 of 261 cases, 3.07%) (p = 0.039; chi-squared test). After surgery, 5 (1.4%) patients were treated for middle ear effusion, and another 5 (1.4%) patients experienced transient CSF rhinorrhea, which was spontaneously resolved within 1 to 7 days. No patients required additional treatments for CSF leakage. Conclusion: A simple technique using pulling stay sutures to stop bleeding from the dural edges and placing a wet cottonoid on the exposed dura can make primary dural closure easier.
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Affiliation(s)
- Kyeong-O Go
- Department of Neurosurgery, Gyeongsang National University Hospital, Gyengsangnam-do 52727, Korea;
| | - Kihwan Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do 13620, Korea;
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jung Ho Han
- Department of Neurosurgery, Seoul National University Bundang Hospital, Gyeonggi-do 13620, Korea;
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence:
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Vargas Osorio MP, Muñoz Montoya JE, Charry Lopez ML, Rojas Romero LO. Meningitis for Streptococcus salivarius Secondary to Paradoxical Cerebrospinal Fluid Rhinorrhea as a Complication of Retrosigmoid Approach. Asian J Neurosurg 2019; 14:310-313. [PMID: 30937063 PMCID: PMC6417302 DOI: 10.4103/ajns.ajns_179_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Rhinorrhea secondary to a retrosigmoid approach is rare, but when it manifests, it is due to a paradoxical cerebrospinal fluid (CSF) leak, as a result of the communication between the mastoid cells, middle ear, and eustachian tube, which finally ends on the release of CSF through the nasopharynx. Abnormal communications increases the risk of infections, not only at the surgical site but also through an ascending path. Magnetic resonance cisternography (MRC) with intrathecal gadolinium injection through a lumbar puncture not only allows an adequate diagnosis but also helps to establish management plans. Here, we present an eighty-three-year-old female patient, with a history of trigeminal neuralgia, who underwent retrosigmoid approach to perform trigeminal microvascular decompression. After intervention, the patient consulted for rhinorrhea, fever, and headache. Lumbar puncture was performed, resulting on the isolation of Streptococcus salivarius in CSF. Nuclear MRC with intrathecal gadolinium injection was performed, identifying a paradoxical CSF leak. Failure in medical management with conservative treatment ends in surgical reexploration, identifying a bone defect in mastoid cells, which was corrected.
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Affiliation(s)
| | - Juan Esteban Muñoz Montoya
- Department of Neurosurgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogota, Colombia
| | | | - Luis Orlando Rojas Romero
- Department of Neurosurgery, Hospital Militar Central, Universidad Militar Nueva Granada, Bogota, Colombia
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