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Madoure A, Penubarthi LK. Unmasking the Masquerade: Lessons from a Case of Spontaneous Mid-Clival CSF Leak Mimicking an Ethmoidal Leak. Indian J Otolaryngol Head Neck Surg 2024; 76:2062-2065. [PMID: 38566655 PMCID: PMC10982161 DOI: 10.1007/s12070-023-04399-5] [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: 10/23/2023] [Accepted: 11/22/2023] [Indexed: 04/04/2024] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) leaks are an uncommon clinical entity, often challenging to diagnose accurately. We present a unique case of a patient with symptoms suggestive of an ethmoidal CSF leak, initially supported by radiological findings, but ultimately revealed to be a mid-clival CSF leak (from the posterior wall of the sphenoid sinus). This case underscores the complexities of diagnosing CSF leaks and highlights the importance of surgical exploration in cases where radiological evidence appears contradictory. The patient's Computed Tomography scan indicated a CSF leak in the cribriform plate, prompting a surgical approach to address this region. However, intraoperative findings surprisingly revealed no evidence of leak in the cribriform plate but instead a posterior wall of the sphenoid defect as the culprit. This report emphasizes the critical role of interdisciplinary collaboration, meticulous preoperative and intraoperative assessment, and adaptability in managing challenging cases of CSF leaks, ultimately leading to successful surgical repair and improved patient outcomes. It serves as a valuable reminder for clinicians to consider the possibility of a masquerading CSF leak when clinical and radiological findings do not align, thereby facilitating more precise diagnosis and targeted treatment.
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Affiliation(s)
- Anbarasi Madoure
- Department of ENT, Jawaharlal Nehru Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
| | - Lokesh Kumar Penubarthi
- Department of ENT, Jawaharlal Nehru Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, 605006 India
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Chadaram S, Parida PK, Chappity P, Sharma P, Pradhan P, Sarkar S, Samal DK. Endoscopic Repair of CSF Rhinorrhea: Our Experience at a Tertiary Centre. Indian J Otolaryngol Head Neck Surg 2023; 75:727-732. [PMID: 37206806 PMCID: PMC10188697 DOI: 10.1007/s12070-022-03272-1] [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: 01/01/2022] [Accepted: 10/26/2022] [Indexed: 11/21/2022] Open
Abstract
Spontaneous or post-traumatic CSF (cerebrospinal-fluid) rhinorrhea occurs when there is a skull-base defect. In our study, we tried endoscopic approach, exclusively as surgical modality. To study feasibility of trans-nasal endoscopic approach for repair of skull-base defects and success rates at each anatomical subsite, with complications. Patients, who underwent endoscopic repair of CSF rhinorrhea between 2016 and 2019 were recruited into study. Details of investigative work-up, aetiology, surgery done, site of leak, number of surgical procedures done, post-operative complications and their management, success rate for each anatomical sub-site, was retrieved retrospectively and analyzed. All patients were initially managed with conservative measures before taking up for surgery. Eighteen-patients (male-11, female-7, mean age-40.3 years) with CSF rhinorrhea {spontaneous-5(27.7%), traumatic-13(62.3%)} were found. Sites of leak were cribriform-plate (CP), fovea-ethmoidalis (FE) and posterior-table of frontal-sinus (FS) in 8(44.4%), 5(27.7%) and 5(27.7%) respectively. Twelve (66.6%) patients had no postoperative complications. No patients with defects in CP had post-operative complication. Two (11.1%) patients with FS defect had meningitis, one (5.5%) patient with FS defect developed pneumocephalus. One (5.5%) patient developed frontal sinusitis at end of 4-months. Two (11.1%) patients, each with defects in FE and FS needed a revision repair on postoperative day 0 and 90-till date, none of the patients have any delayed procedure related complications or recurrences. Endoscopic repair of CSF leaks is the norm of the current day due to its minimally invasive nature. However, endoscopic repair of leaks through the frontal sinus were challenging and was associated with a high rate of complications.
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Affiliation(s)
- Srinivas Chadaram
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Pradipta Kumar Parida
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Preetam Chappity
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Prity Sharma
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Pradeep Pradhan
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Saurav Sarkar
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
| | - Dillip Kumar Samal
- Department of Otorhinolaryngology, Head and Neck Surgery, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, India
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Ramdani N, Rguyeg A, Benfdil D, Lachkar A, Elayoubi F. Sphenoethmoidal Meningocele: Endoscopic Approach. Cureus 2023; 15:e35022. [PMID: 36938298 PMCID: PMC10022704 DOI: 10.7759/cureus.35022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2023] [Indexed: 02/17/2023] Open
Abstract
The sphenoethmoidal meningocele is a herniation of the meninges through a communication of the skull base with an aeric cavity. It means the presence of an osteomeningeal breach, which is manifested by cerebrospinal rhinorrhea and nasal obstruction. iIs diagnosis is based on a very specific radiological assessment and biology allows the dosage of certain substances to confirm the nature of the cerebrospinal fluid, such as beta-2-transferrin, Once the breach has been found, the endoscopic route exclusively allows the pathology to be treated and the defect to be reconstructed using different materials before the occurrence of serious complications such as meningitis.
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Affiliation(s)
- Naoufal Ramdani
- Otorhinolaryngology, Centre Hospitalier Universitaire Mohammed V, Faculty of Medicine and Pharmacy, Mohamed First University, Oujda, MAR
| | - Abdelilah Rguyeg
- Head and Neck Surgery, Centre Hospitalier Universitaire Mohammed V, Faculty of Medicine and Pharmacy, Mohamed First University, Oujda, MAR
| | - Drissia Benfdil
- Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire Mohammed V, Faculty of Medicine and Pharmacy, Mohamed First University, Oujda, MAR
| | - Azzedine Lachkar
- Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire Mohammed V, Faculty of Medicine and Pharmacy, Mohamed First University, Oujda, MAR
| | - Fahd Elayoubi
- Otorhinolaryngology, Head and Neck Surgery, Centre Hospitalier Universitaire Mohammed V, Faculty of Medicine and Pharmacy, Mohamed First University, Oujda, MAR
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Sunaga Y, Takayama Y, Yokosako S, Mizuno T, Kouno M, Tashiro M, Iwasaki M, Sasaki M. Drug-resistant temporal lobe epilepsy due to middle fossa meningoencephalocele in a child: A surgical case report. Brain Dev 2023; 45:82-86. [PMID: 36115749 DOI: 10.1016/j.braindev.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/25/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Meningoencephalocele (ME) of the temporal lobe through a bone defect in the middle cranial fossa is a rare known cause of refractory temporal lobe epilepsy (TLE). ME-induced drug-resistant TLE has been described in adults; however, its incidence in children is very rare. CASE REPORT A 7-year-old girl presented at our hospital with brief episodes of impaired consciousness and enuresis. Initial brain MRI results were interpreted as normal. Her seizures could not be controlled even with multiple anti-seizure medications. She was diagnosed with drug-resistant TLE, which presented with prolonged impaired awareness seizures for 30-60 s and secondary bilateral tonic seizures. At 9 years of age, brain MRI revealed a left temporal anteroinferior ME with a congenital bone defect in the left middle cranial fossa. She was referred for presurgical epilepsy evaluation. Long-term video electroencephalography (EEG) failed to reveal regional abnormality in the left temporal lobe; invasive evaluation using stereoelectroencephalography (SEEG) was thus indicated. Ictal onset SEEG was identified in the temporal pole near the ME which was rapidly propagated to the mesial temporal structures and other cortical regions. The left temporal pole including the ME was micro-surgically disconnected while preserving the hippocampus and amygdala. The patient's seizures have been completely controlled for 1 year and 6 months post-operatively. CONCLUSION SEEG revealed rapid propagation of ictal activity in this patient's case, confirming that the ME was epileptogenic. Since the majority of patients with refractory epilepsy caused by ME have favorable postoperative seizure outcomes, it is important to carefully check for ME in drug-resistant TLE patients with apparently normal MRI.
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Affiliation(s)
- Yasuo Sunaga
- Department of Pediatrics, JCHO Gunma Central Hospital, Gunma, Japan.
| | - Yutaro Takayama
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Suguru Yokosako
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Takahisa Mizuno
- Department of Pediatrics, JCHO Gunma Central Hospital, Gunma, Japan
| | - Miyuki Kouno
- Department of Pediatrics, JCHO Gunma Central Hospital, Gunma, Japan
| | - Masahiko Tashiro
- Department of Pediatrics, JCHO Gunma Central Hospital, Gunma, Japan
| | - Masaki Iwasaki
- Department of Neurosurgery, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Masayuki Sasaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Japan
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Piscopo AJ, Dougherty MC, Woodiwiss TR, Ankrah N, Hughes T, Seaman SC, Walsh JE, Graham SM, Greenlee JDW. Endoscopic Reconstruction of the Anterior Skull Base Following Tumor Resection: Application of a Novel Bioabsorbable Plate. Laryngoscope 2022; 133:1092-1098. [PMID: 36477852 DOI: 10.1002/lary.30501] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/30/2022] [Accepted: 11/18/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Endoscopic repair of skull base defects is required following resection of intracranial pathology via the endoscopic endonasal approach (EEA). Many closure techniques have been described, but choosing between techniques remains controversial. We report outcomes of 560 EEA procedures of skull base reconstruction performed on 508 patients over a 15-year-period. Halfway through this period, we adopted the use of a rigid, bioabsorbable extrasellar plate for reconstruction, enabling a comparison between this technique and those used previously. METHODS All patients undergoing EEA from 2005 to 2019 at our institution were retrospectively reviewed. Demographic information, surgical pathology, tumor dimensions and radiographic features, reconstructive technique, and patient-related outcomes were collected and analyzed with univariate and multivariate statistical modeling. RESULTS Five-hundred sixty procedures were performed on 508 patients. The series complication rate was 8.2%. Overall, cerebrospinal fluid (CSF) leak rate was 5.0% but varied significantly across closure techniques (p < 0.001). Critically, the CSF leak rate in the 272 cases prior to our 2013 adoption of the Resorb-X Plate (RXP) was 8.5%, whereas leak rate in the subsequent 288 cases was 1.7%. RXP was protective against CSF leak (p = 0.001), whereas gross total resection (GTR) correlated with increased leak rate (p = 0.001). Patient BMI was significantly associated with risk of leak (p = 0.047). Other variables did not impact leak risk. CONCLUSION Reconstructive technique, extent of resection, and patient BMI significantly contributed to CSF leak rate. GTR was associated with increased leak risk while the RXP was protective. The bioabsorbable RXP is an effective option for rigid skull base repair with comparatively few complications. LEVEL OF EVIDENCE 3 Laryngoscope, 133:1092-1098, 2023.
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Affiliation(s)
| | | | | | - Nii‐Kwanchie Ankrah
- Department of Radiation Oncology University of Alabama at Birmingham Birmingham Alabama USA
| | - Tyler Hughes
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Scott C. Seaman
- Department of Neurosurgery University of Iowa Iowa City Iowa USA
| | - Jarrett E. Walsh
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
| | - Scott M. Graham
- Department of Otolaryngology University of Iowa Iowa City Iowa USA
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Kotani S, Takahashi Y, Morisako T, Yamanaka T, Hashimoito N. Bacterial meningitis caused by nontraumatic cerebrospinal fluid rhinorrhea with aqueductal stenosis: A case report. Surg Neurol Int 2022; 13:439. [PMID: 36324965 PMCID: PMC9609807 DOI: 10.25259/sni_610_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background: Nontraumatic cerebrospinal fluid (CSF) rhinorrhea associated with aqueductal stenosis is rare. The resulting CSF leakage may cause bacterial meningitis, and appropriately timed surgical treatment should be considered. Case Description: A 28-year-old woman with obstructive hydrocephalus secondary to aqueductal stenosis presented with intermittent nasal discharge. CSF rhinorrhea was suspected, but she refused surgery. During the course of conservative treatment, she developed meningitis. Exacerbation of hydrocephalus and CSF rhinorrhea was suspected, and the patient underwent endoscopic third ventriculostomy after recovery from meningitis. Postoperatively, ventricular size decreased and CSF leakage completely resolved. There was no recurrence of hydrocephalus or rhinorrhea. Conclusion: Patients with intermittent CSF rhinorrhea due to exacerbation of hydrocephalus are at high risk for bacterial meningitis. Appropriately timed surgical treatment results in a favorable outcome.
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Missale F, Ioppi A, Ascoli A, Camerino PL, Camillo Carobbio AL, Larghi M, Castello EM, Guastini L, Peretti G, Criminelli D, Parrinello G, Bagnasco D, Mauritz Canevari FR. Cerebrospinal Fluid Leak Repair: Usefulness of Intrathecal Fluorescein for Correct Topographic Identification of the Skull Base Defects. World Neurosurg 2022; 160:e267-e277. [PMID: 34999266 DOI: 10.1016/j.wneu.2022.01.004] [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: 10/05/2021] [Revised: 12/31/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND In the management of cerebrospinal fluid (CSF) leak, the identification of the exact discharge spot is paramount. This process can represent a challenge for the radiologist and the surgeon. In the present study, we analyzed a series of patients affected by endonasal CSF leak who underwent endoscopic surgical reconstruction aided by the use of ITF. The purpose of this work is to assess the efficacy of intraoperative ITF in addition to computed tomography (CT) and magnetic resonance imaging for correct topographic localization of the CSF leak. METHODS Eighty-three patients were enrolled in the study. The main outcome was the concordance between the supposed radiologic defect site and the actual one seen intraoperatively. Recurrence-free survival was evaluated as secondary outcome. RESULTS ITF better defined the defect site, allowing a change in the treatment in 21 patients (25.3%), in whom nonconcordance was observed between the suspected radiologic site and the actual surgical site. Good agreement was found between the specific topographic localization (κ = 0.737; P < 0.0001), whereas fair agreement was observed considering the side of the defect (κ = 0.362; P = 0.0009) and correct identification of multiple sites (κ = 0.044; P = 0.666). The 10-year 96% estimate of recurrence-free survival confirmed the correct repair of the fistula site in most cases. CONCLUSIONS Our data show the usefulness and safety of intraoperative ITF for management of patients affected by endonasal CSF leak. ITF improved the topographic diagnosis of the leak site, ensuring the best target reconstruction and very low recurrence rate.
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Affiliation(s)
- Francesco Missale
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Alessandro Ioppi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Alessandro Ascoli
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Paola Lovino Camerino
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Andrea Luigi Camillo Carobbio
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Section of Otorhinolaryngology, Head and Neck Surgery-Azienda Ospedaliera di Padova, University of Padua, Padua, Italy
| | - Marco Larghi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | | | - Luca Guastini
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giorgio Peretti
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | | | | | - Diego Bagnasco
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Allergy and Respiratory Diseases, DIMI Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Frank Rikki Mauritz Canevari
- IRCCS Ospedale Policlinico San Martino, Genova, Italy; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.
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Muranjan SN, Singhal DD, Shah SH, Shah AK. Bilateral idiopathic temporal bone meningoencephaloceles - An unusual presentation. J Postgrad Med 2021; 67:228-231. [PMID: 34845891 PMCID: PMC8706532 DOI: 10.4103/jpgm.jpgm_566_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Meningoencephaloceles (MECs) occur due to herniation of brain tissue through a bony defect in the skull base. They can be spontaneous or acquired. These are secondary to trauma, infection or neoplasia. Adult-onset spontaneous or idiopathic MECs are rare. Temporal bone MECs can present with watery discharge from the ear, conductive hearing loss or symptoms of meningitis like headache, fever, vomiting or seizures. These symptoms mimic chronic suppurative or serous otitis media. Computed tomography scan and magnetic resonance imaging differentiate between them. Awareness of this disease entity is necessary for early detection to avoid complications. We report a case of bilateral idiopathic temporal bone MECs with a rare presentation of autophony as the chief complaint. The differentiating features on computed tomography scan and magnetic resonance imaging and the surgical management are discussed.
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Affiliation(s)
- S N Muranjan
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - D D Singhal
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - S H Shah
- Department of Radiology, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - A K Shah
- Department of ENT, Bombay Hospital Institute of Medical Sciences, Mumbai, Maharashtra, India
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Nadeem M, Deora H, Shashidhar A, Bhaskara Rao M. Image guided repair of spontaneous CSF rhinorrhoea secondary to double skull base defect – Case report and review of literature. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Haseeb S, Bokhari SA, Gondal MUR, Wali H, Ansari SS. Zipline Into a Case of Spontaneous Cerebrospinal Fluid Rhinorrhea. Cureus 2021; 13:e17277. [PMID: 34540498 PMCID: PMC8448257 DOI: 10.7759/cureus.17277] [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] [Accepted: 08/18/2021] [Indexed: 11/05/2022] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) rhinorrhea is an uncommon phenomenon. One of the complications associated with CSF rhinorrhea is meningitis, which is associated with high mortality. Therefore, the prompt diagnosis of CSF rhinorrhea is essential. We present a case of a patient, who after zip-lining, developed CSF rhinorrhea. She had no history of trauma and none of the conventional comorbidities associated with spontaneous CSF rhinorrhea. She was diagnosed with the help of radiological studies and biochemical tests. Our case is unique as there are no published case reports of spontaneous CSF rhinorrhea occurring after atraumatic zip-lining.
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Affiliation(s)
- Shahan Haseeb
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | - Syed A Bokhari
- Internal Medicine, Shifa International Hospital, Islamabad, PAK
| | | | - Hadia Wali
- Otolaryngology - Head and Neck Surgery, Shifa International Hospital, Islamabad, PAK
| | - Shayan S Ansari
- Otolaryngology - Head and Neck Surgery, Shifa International Hospital, Islamabad, PAK
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Shelesko EV, Chernikova NA, Kravchuk AD, Strunina YV, Okhlopkov VA, Belov AI. [Multiple skull base defects: features of pathogenesis, diagnosis and treatment]. ZHURNAL VOPROSY NEĬROKHIRURGII IMENI N. N. BURDENKO 2021; 85:58-63. [PMID: 34463451 DOI: 10.17116/neiro20218504158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine the risk factors of multiple skull base defects, as well as features of diagnosis and treatment of this pathology. MATERIAL AND METHODS A retrospective analysis included 39 patients who underwent surgery for nasal CSF leakage at the Burdenko Neurosurgical Center in 2000-2019. The study recruited patients with multiple simultant skull base defects. RESULTS Traumatic defects were observed in 23 (59%) patients, spontaneous defects - in 16 (41%) cases. All patients underwent endoscopic endonasal closure of skull base defects with autografts. CONCLUSION Multiple defects are more common in severe traumatic brain injury. The main risk factors of multiple spontaneous defects are female sex and overweight. Adequate diagnosis implies high-resolution CT (slice width 0.5-1 mm), as well as intraoperative control of all suspicious and «weak» areas. Endoscopic endonasal technique is effective and safe for multiple skull base defects (efficiency 97%).
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Affiliation(s)
| | | | | | | | | | - A I Belov
- Burdenko Neurosurgical Center, Moscow, Russia
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12
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Abstract
OBJECTIVE Spontaneous cerebrospinal fluid (CSF) leaks are thought to arise due to elevated intracranial pressure which is distributed across the skull base, potentially predisposing the development of multifocal CSF leaks. The aims of this study are to evaluate the characteristics of this population at presentation and surgical outcomes. STUDY DESIGN Retrospective case series. SETTING Tertiary referral center. PATIENTS Patients 18 years or older with spontaneous CSF leak diagnosis were eligible for study inclusion. Multifocal spontaneous CSF leak was defined as leaks originating from more than one skull base defect at anatomically distinct subsites. INTERVENTION None. MAIN OUTCOME MEASURE Clinical presentation and surgical outcome. RESULTS Two hundred ninety-three patients with diagnosis of spontaneous CSF leak were identified. Of these, 11 (3.8%) were characterized as having multifocal spontaneous CSF leaks. Mean body mass index was significantly higher in multifocal CSF leak patients (31.5 ± 8.5 vs 46.2 ± 9.9, p < 0.0001). There was also higher prevalence of women (100% vs 63.8%, p = 0.012) and African-Americans (63.6% vs 23.4%, p = 0.003). The overall success rate of CSF leak repair was 95%. Fifty percent of patients developed headaches or blurry vision after surgical repair, and two patients required ventriculoperitoneal shunting. CONCLUSIONS Multifocal spontaneous CSF leaks are rare and occurred in 3.8% of patients with spontaneous CSF. These patients were morbidly obese and more likely to be female and African American. Surgical repair conferred excellent outcomes. However, these patients have high risk of developing symptoms suggestive of elevated intracranial pressure postoperatively and should be counseled accordingly.
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13
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Alokby G, Albathi A, Alshurafa Z, AlQahtani A. Endoscopic endonasal repair of a temporal lobe meningoencephalocele in the pterygoid fossa: A case report and literature review. Int J Surg Case Rep 2021; 83:105963. [PMID: 34022760 PMCID: PMC8164042 DOI: 10.1016/j.ijscr.2021.105963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 04/30/2021] [Accepted: 05/08/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction Meningoceles are defined as herniation of the meninges through a skull base defect. If brain tissue is herniated as well, then it is called meningoencephalocele. The most common locations of meningoceles are the cribriform plate and the lateral recess of the sphenoid sinus, with the most common presentation being CSF leakage. We present a case of temporal lobe meningocele that herniated through a defect in the greater wing of the sphenoid bone to the pterygoid fossa and that was diagnosed incidentally while evaluating the patient for seizures. Methodology Case report and literature review. Conclusion The endonasal endoscopic approach is a suitable minimally invasive approach for the management of pterygoid fossa lesions, including meningoceles. In this case, the patient had epilepsy with the surgery resulting in the resolution of the seizures. Endonasal approach can be considered as a minimally invasive approach for lesions in the pterygoid fossa. Meningocele are to be considered as a possible etiology for pterygoid fossa masses connected with the middle cranial fossa. Surgical resection of encephalomeningocele should be considered for the management of intractable seizures.
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Affiliation(s)
- Ghassan Alokby
- Department of Otolaryngology, Head and Neck Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Department of Otolaryngology, Head and Neck Surgeery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; AlFaisal University, Riyadh, Saudi Arabia.
| | - Abeer Albathi
- Department of Otolaryngology, Head and Neck Surgeery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Abdulaziz AlQahtani
- Department of Otolaryngology, Head and Neck Surgeery, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; Department of Otolaryngology, Head and Neck Surgery, King Fahad Medical City, Riyadh, Saudi Arabia
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14
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Takao N, Sakurai K, Hino S, Yamano Y. [A case of nasal discharge resulting in recurrent bacterial meningitis]. Rinsho Shinkeigaku 2021; 61:177-181. [PMID: 33627580 DOI: 10.5692/clinicalneurol.cn-001505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 47-year-old man who was previously hospitalized three times due to bacterial meningitis experienced a headache and posterior neck pain in May. He was admitted to our hospital because of a fever 3 h later. He was fully conscious and febrile, with a headache and signs of meningeal irritation. A cerebrospinal fluid examination showed an increased number of cells with polynuclear cell predominance and decreased glucose levels, leading to the diagnosis of bacterial meningitis. Steroid and antibiotic treatment was initiated, at which time, large amounts of nasal discharge were observed. Cisternal scintigraphy was performed, and cerebrospinal fluid was detected in the nasal discharge. The cause was idiopathic, and endoscopic repair was performed. The nasal fluid leakage was suggested to be the cause of the recurrent bacterial meningitis in this case.
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Affiliation(s)
- Naoki Takao
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Kenzo Sakurai
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Sakae Hino
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
| | - Yoshihisa Yamano
- Division of Neurology, Department of Internal Medicine, St. Marianna University School of Medicine
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15
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Nguyen DT, Helleringer M, Klein O, Jankowski R, Rumeau C. The relationship between spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 138:177-182. [PMID: 33257267 DOI: 10.1016/j.anorl.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Surgical treatment of spontaneous cerebrospinal fluid (CSF) leak is now performed by ENT surgeons, endonasal endoscopy being preferred to craniotomy as less invasive. However, it is often the symptom of underlying idiopathic intracranial hypertension, which lies outside the traditional sphere of ENT competence. Surgery is a necessary step, but should not obscure the need to treat the underlying pathology. This treatment is complex, and requires multidisciplinary team-work between otorhinolaryngologist, ophthalmologist, neurologist, neurosurgeon, radiologist, dietician, endocrinologist and psychotherapist. The present update details this multidisciplinary management to which the ENT surgeons must be attentive before and after spontaneous CSF leak repair.
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Affiliation(s)
- D-T Nguyen
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France.
| | - M Helleringer
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - O Klein
- Service de neurochirurgie, CHRU de Nancy, hôpital Central, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54035 Nancy, France
| | - R Jankowski
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France
| | - C Rumeau
- Service d'ORL et chirurgie cervico-faciale, hôpitaux de Brabois, CHRU de Nancy, rue du Morvan, 54500 Vandoeuvre-lès-Nancy, France; EA3450 DevAH, développement adaptation et handicap, université de Lorraine, 9, avenue de la Forêt-de-Haye, 54505 Lorraine, France
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16
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McCormick JP, Tilak A, Lampkin HB, Thompson HM, Miller PL, West JM, Cho DY, Riley KO, Grayson JW, Woodworth BA. An Expedited Intracranial Pressure Monitoring Protocol Following Spontaneous CSF Leak Repair. Laryngoscope 2020; 131:E408-E412. [PMID: 32797680 DOI: 10.1002/lary.28929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/29/2020] [Accepted: 06/19/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Spontaneous cerebrospinal fluid (CSF) leaks represent a unique subset of skull base pathology and require distinctive management. Perioperative evaluation and management of intracranial hypertension are essential in preventing further erosion of the skull base and development of recurrent leak. The objective of this study is to evaluate the safety and utility of an expedited protocol for recording and managing intracranial hypertension following endoscopic repair of spontaneous CSF leaks. METHODS Prospectively collected data was reviewed in patients undergoing endoscopic repair of spontaneous CSF leaks between January 2017 and March 2020. A standard intracranial pressure monitoring protocol was compared to an expedited protocol (EP), and data regarding the two groups was compared for leak location, short-term success of skull base repair, complications, hospital length of stay, and cost-based analysis. RESULTS Fifty-five patients (standard protocol, n = 28 vs. EP, n = 27) were included in the study. Leak location was similar between cohorts, with the lateral recess being the most common locations in both groups (37.9% vs. 40.6%; P = .90). Postoperative complications (3.6% vs. 7.4%; P = .53) and ventriculoperitoneal shunt rate (32.1% vs. 22.2%; P = .41) were similar among cohorts. There was no difference in lumbar drain complications (0% vs. 7.4%; P = .14) or recurrent leak (7.1% vs. 0%; P = .16). Length of stay was shorter in the EP group [median(interquartile range): 3(1) vs. 2 (1); P < .01]. Total hospital charges were similar between groups (median (USD/$1,000): 83.57 ± 49.58 vs. 83.93 ± 46.11; P = .18). CONCLUSION An expedited monitoring protocol shortened hospital stay without increased risk of complications. LEVEL OF EVIDENCE III Laryngoscope, 131:E408-E412, 2021.
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Affiliation(s)
- Justin P McCormick
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Ashwini Tilak
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - H Brooks Lampkin
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Harrison M Thompson
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Peter L Miller
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - John M West
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Do-Yeon Cho
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Kristen O Riley
- Department of Neurosurgery, University of Alabama at Birmingham; Birmingham, Birmingham, Alabama, U.S.A
| | - Jessica W Grayson
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
| | - Bradford A Woodworth
- Department of Otolaryngology - Head and Neck Surgery, University of Alabama at Birmingham, Birmingham, Alabama, U.S.A
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Wang EW, Zanation AM, Gardner PA, Schwartz TH, Eloy JA, Adappa ND, Bettag M, Bleier BS, Cappabianca P, Carrau RL, Casiano RR, Cavallo LM, Ebert CS, El-Sayed IH, Evans JJ, Fernandez-Miranda JC, Folbe AJ, Froelich S, Gentili F, Harvey RJ, Hwang PH, Jane JA, Kelly DF, Kennedy D, Knosp E, Lal D, Lee JYK, Liu JK, Lund VJ, Palmer JN, Prevedello DM, Schlosser RJ, Sindwani R, Solares CA, Tabaee A, Teo C, Thirumala PD, Thorp BD, de Arnaldo Silva Vellutini E, Witterick I, Woodworth BA, Wormald PJ, Snyderman CH. ICAR: endoscopic skull-base surgery. Int Forum Allergy Rhinol 2020; 9:S145-S365. [PMID: 31329374 DOI: 10.1002/alr.22326] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 02/12/2019] [Accepted: 02/15/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS). METHODS Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus. RESULTS The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated. CONCLUSION A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Adam J Folbe
- Michigan Sinus and Skull Base Institute, Royal Oak, MI
| | | | | | - Richard J Harvey
- University of Toronto, Toronto, Canada.,University of New South Wales, Sydney, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Charles Teo
- Prince of Wales Hospital, Randwick, Australia
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18
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Sanghvi S, Sarna B, Alam E, Pasol J, Levine C, Casiano RR. Role of Adjunct Treatments for Idiopathic CSF Leaks After Endoscopic Repair. Laryngoscope 2020; 131:41-47. [PMID: 32401375 DOI: 10.1002/lary.28720] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/06/2020] [Accepted: 04/09/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE A higher incidence of recurrent cerebrospinal fluid (CSF) leaks has been reported with idiopathic CSF leaks. A growing number of institutions advocate for routine use of intracranial pressure-lowering adjunct treatments after endoscopic repair. We report our results in a patient cohort in which only symptomatic patients are subjected to further testing and treatment. STUDY DESIGN Retrospective review. METHODS A retrospective review of patients who underwent endoscopic transnasal repair of idiopathic CSF rhinorrhea was performed at the University of Miami, Florida, from July 2010 to July 2017. The database was queried for demographical data, surgical details, radiological findings, and postoperative outcomes. Only patients with greater than a 12-month follow-up were included. RESULTS Thirty-three patients underwent endoscopic repair of an idiopathic CSF leak. Twenty-six (79%) were females, with an average age of entire study population being 48 years. The average body mass index (BMI) of the cohort was 33 kg/m2 , with 89% being overweight (BMI > 25 kg/m2 ). The skull base defect was found to be mainly at the cribriform plate (64%) and sphenoid sinus (30%). Endoscopic repair was performed successfully as a single repair in 32 patients (97%). The average follow-up was 47 months. Postoperative adjunct medications were used on four patients (12%) with symptomatic idiopathic intracranial hypertension. CONCLUSION Endoscopic repair of idiopathic CSF leaks was found to have a high rate of success in our study. Postoperatively, only four patients required additional measures to medically reduce symptomatic intracranial hypertension. Routine postoperative adjunct treatments are unnecessary and may expose patients to adverse long-term side effects. LEVEL OF EVIDENCE 4 Laryngoscope, 131:41-47, 2021.
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Affiliation(s)
- Saurin Sanghvi
- Department of Otolaryngology-Head & Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
| | - Brooke Sarna
- Department of Otolaryngology-Head & Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
| | - Elie Alam
- Department of Otolaryngology-Head & Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
| | - Joshua Pasol
- Department of Opthalmology/Bascom Palmer Eye Institute, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
| | - Corinna Levine
- Department of Otolaryngology-Head & Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
| | - Roy R Casiano
- Department of Otolaryngology-Head & Neck Surgery, University of Miami-Miller School of Medicine, Miami, Florida, U.S.A
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19
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Tang C, Zhu J, Feng K, Yang J, Cong Z, Cai X, Qiao L, Ma C. Successful Treatment of Spontaneous Cerebrospinal Fluid Rhinorrhea With Endoscopic Third Ventriculostomy and Lumboperitoneal Shunt: A Case Report. Front Neurosci 2020; 14:57. [PMID: 32082119 PMCID: PMC7006486 DOI: 10.3389/fnins.2020.00057] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/14/2020] [Indexed: 11/16/2022] Open
Abstract
Spontaneous cerebrospinal fluid (CSF) rhinorrhea represents an important clinical entity that is being observed with increasing prevalence, ranging from 14 to 55%. Spontaneous CSF rhinorrhea is associated with elevated intracranial pressure (ICP), which is rarely stopped without surgical intervention. Endoscopic endonasal repair is typically warranted for CSF rhinorrhea. However, the recurrence rate of CSF leaks after the endoscopic endonasal repair of skull base defects due to ICP is usually high. We describe a 25-year-old man without a history of head injury, tumor, or obesity. The onset of his symptoms occurred in 1 week in the form of a persistent clear left nostril rhinorrhea. Computed tomography (CT) and magnetic resonance images (MRI) showed signs of CSF in the left sphenoidal sinus, meningocele in the left frontal sinus, empty sella, hydrocephalus, and Chiari I malformation (CIM). Cine-MRI revealed the flow of CSF was obstructed at the aqueduct and the outlet of the fourth ventricle. Endoscopic third ventriculostomy (ETV) was performed for the patient with obstructive hydrocephalus. Post-operative CSF pressure measurement demonstrated elevated ICP. The patient still had case of CSF rhinorrhea, and subsequently underwent lumboperitoneal shunt (LPS) for treatment of ICP. The patient showed a prompt resolution of CSF leak. Ten months later, the patient showed a significant improvement in terms of his herniated tonsil and cessation of CSF rhinorrhea.
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Affiliation(s)
- Chao Tang
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Junhao Zhu
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Kaiyang Feng
- Arkansas Colleges of Health Education, Fort Smith, AR, United States
| | - Jin Yang
- School of Medicine, Nanjing Medical University, Nanjing, China
| | - Zixiang Cong
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Xiangming Cai
- School of Medicine, Southeast University, Nanjing, China
| | - Liang Qiao
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
| | - Chiyuan Ma
- Department of Neurosurgery, Jinling Hospital, School of Medicine, Nanjing University, Nanjing, China
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20
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Kosmidou P, Ntarladima V, Katsimantas A, Filippou D, Georgalas C. Endoscopic Surgical Repair of a Giant, Postoperative, Neglected Meningoencephalocele. Cureus 2020; 12:e6739. [PMID: 32133261 PMCID: PMC7034767 DOI: 10.7759/cureus.6739] [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: 11/15/2022] Open
Abstract
Meningoencephalocele is a rare and potentially lethal disease, requiring early diagnosis and treatment. A 30-year-old male patient was diagnosed with a massive meningoencephalocele. His medical history included cerebrospinal fluid (CSF) rhinorrhea since the age of 7 years, which was attributed to right eye mining during infancy due to Coats disease. Following failed attempts of open surgical repair and CSF diversion during childhood, no further attempts of surgical management were made. He presented a long history of recurrent episodes of meningitis, resulting in long-lasting hospitalization in the intensive care unit. Eventually, he underwent surgical repair through an endoscopic multilayer approach. Subsequent endoscopic and radiological assessment demonstrated no recurrence during a follow-up period of one year. Endoscopic treatment is highly successful. An effective and definite surgical repair is of paramount importance in order to avoid life-threatening complications, improve patient’s and caregiver’s quality of life, and avoid unnecessary health-system costs.
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Affiliation(s)
- Panagiota Kosmidou
- Otolaryngology - Head and Neck Surgery, Evangelismos General Hospital, Athens, GRC
| | - Vasiliki Ntarladima
- Otolaryngology - Head and Neck Surgery, Evangelismos General Hospital, Athens, GRC
| | | | - Dimitrios Filippou
- Surgery, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
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21
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Ito CJ, May N, Kountakis S. Endoscopic repair of cribriform plate cerebrospinal fluid leaks: An easy and reproducible technique sparing the middle turbinate. Am J Otolaryngol 2020; 41:102339. [PMID: 31727338 DOI: 10.1016/j.amjoto.2019.102339] [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: 10/26/2019] [Revised: 10/29/2019] [Accepted: 11/01/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate the outcomes of patients with cribriform cerebrospinal fluid leaks undergoing endoscopic repair with an easy and reproducible middle turbinate-sparing technique. MATERIAL AND METHODS Date was obtained by retrospective chart review and includes a description of the technique with technical pearls and contraindications to the approach. RESULTS We report 17 patients who underwent repair of cribriform cerebrospinal fluid leaks with a middle turbinate-sparing technique with 100% success rate at a mean follow up of 38 months. One patient complained of hyposmia. There were no other complications. CONCLUSIONS The endoscopic middle turbinate-sparing approach to repair cribriform cerebrospinal fluid leaks using a free mucosal graft is easy, effective, and reproducible.
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22
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Kim-Orden N, Shen J, Or M, Hur K, Zada G, Wrobel B. Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Leaks Using Multilayer Composite Graft and Vascularized Pedicled Nasoseptal Flap Technique. ALLERGY & RHINOLOGY 2019; 10:2152656719888622. [PMID: 31763054 PMCID: PMC6854761 DOI: 10.1177/2152656719888622] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Endoscopic repair of cerebrospinal fluid (CSF) fistulas is a fundamental practice in anterior skull base surgery due to high success rates and low morbidity profile. However, spontaneous CSF (sCSF) leaks have the highest recurrence rate compared to other etiologies. The most effective management is undetermined due to variations in graft materials and limited evidence. Objective We present the largest study of a standardized endoscopic repair technique for sCSF leaks. Methods Single-institution retrospective review of patients who underwent endoscopic sCSF leak repair between October 2011 and January 2018. All patients underwent repair using a temporary lumbar drain, intrathecal fluorescein, and multilayer reconstruction using bilayered fascia lata autograft and vascularized nasoseptal flap. Results Twenty patients (100% female, mean age: 53.2 years) with 25 separate sCSF leak sites were included. Obesity was present in 15 of 20 patients (mean body mass index [BMI] = 35.3). No patients had previous sinus surgery. Locations of skull base defects included: cribriform plate (44%), ethmoid (32%), lateral sphenoid (12%), and planum sphenoidale (12%). The mean follow-up was 22.8 months and 92% of the leak sites (23/25) were successfully repaired primarily. There were no neurological complications or cases of meningitis. Two patients (mean BMI = 52) with persistent postoperative CSF leaks and elevated intracranial pressure were successfully managed with ventriculoperitoneal shunt placement. BMI was associated with likelihood of repair failure (P = .003). Conclusions At our institution, endoscopic repair of sCSF leaks using a composite autograft of fascia and a nasoseptal flap demonstrates high success rates. Elevated BMI was a statistically significant risk factor for revision.
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Affiliation(s)
- Natalie Kim-Orden
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jasper Shen
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Maya Or
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin Hur
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Gabriel Zada
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Bozena Wrobel
- Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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23
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Lewis KM, Sweet J, Wilson ST, Rousselle S, Gulle H, Baumgartner B. Safety and Efficacy of a Novel, Self-Adhering Dural Substitute in a Canine Supratentorial Durotomy Model. Neurosurgery 2019; 82:397-406. [PMID: 28575349 PMCID: PMC6018778 DOI: 10.1093/neuros/nyx216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 04/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) leaks increase postoperative risk for complication, likelihood of reoperation, and costs. OBJECTIVE To investigate a novel, self-adhering polyethylene glycol-coated collagen pad (PCC) as a dural substitute relative to Duragen XS (DGX; Integra LifeSciences Corporation, Plainsboro, New Jersey) and as a dural sealant relative to Tachosil (Takeda Austria GmbH, Linz, Austria), a fibrinogen and thrombin-coated collagen pad (FTC). METHODS A canine supratentorial durotomy surgical model was used to investigate the safety and efficacy of PCC. For safety, 4 animals were bilaterally treated with DGX or PCC and recovered for 1, 8, or 16 wk; total 24 animals. Each animal underwent physical and neurological examinations weekly and 16-wk animals underwent a magnetic resonance imaging (MRI) examination at each time point. For efficacy, 9 animals were unilaterally treated with FTC or PCC and underwent a burst pressure test intraoperatively or 14 d postoperatively; total 36 animals. RESULTS In the safety study, no abnormal clinical signs or changes were noted on physical and neurological examinations, or in clinical pathology, CSF analysis or histopathology of DGX or PCC-treated animals. No consistent signs of cerebral compression, CSF leak, hemorrhage, or hydrocephalus were noted on MRI. In the efficacy study, no significant difference was found between FTC and PCC at each time point or overall (13.9 vs 12.3 mm Hg, n = 18 per group, P = .46). CONCLUSION PCC is safe for use as a dural substitute and effective as a dural sealant. The novel, self-adhering combination of a polyethylene glycol-based sealant and a collagen pad may offer unique benefits to the advancement of duraplasty.
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Affiliation(s)
| | | | | | | | - Heinz Gulle
- Baxter Medical Products GmbH, Vienna, Austria
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24
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Gholampour S, Bahmani M, Shariati A. Comparing the Efficiency of Two Treatment Methods of Hydrocephalus: Shunt Implantation and Endoscopic Third Ventriculostomy. Basic Clin Neurosci 2019; 10:185-198. [PMID: 31462974 PMCID: PMC6712634 DOI: 10.32598/bcn.9.10.285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/28/2018] [Accepted: 08/26/2018] [Indexed: 11/29/2022] Open
Abstract
Introduction: Hydrocephalus is one of the most common diseases in children, and its treatment requires brain operation. However, the pathophysiology of the disease is very complicated and still unknown. Methods: Endoscopic Third Ventriculostomy (ETV) and Ventriculoperitoneal Shunt (VPS) implantation are among the common treatments of hydrocephalus. In this study, Cerebrospinal Fluid (CSF) hydrodynamic parameters and efficiency of the treatment methods were compared with numerical simulation and clinical follow-up of the treated patients. Results: Studies have shown that in patients under 19 years of age suffering from hydrocephalus related to a Posterior Fossa Brain Tumor (PFBT), the cumulative failure rate was 21% and 29% in ETV and VPS operation, respectively. At first, the ETV survival curve shows a sharp decrease and after two months it gets fixed while VPS curve makes a gradual decrease and reaches to a level lower than ETV curve after 5.7 months. Post-operative complications in ETV and VPS methods are 17% and 31%, respectively. In infants younger than 12 months with hydrocephalus due to congenital Aqueduct Stenosis (AS), and also in the elderly patients suffering from Normal Pressure Hydrocephalus (NPH), ETV is a better treatment option. Computer simulations show that the maximum CSF pressure is the most reliable hydrodynamic index for the evaluation of the treatment efficacy in these patients. After treatment by ETV and shunt methods, CSF pressure decreases about 9 and 5.3 times, respectively and 2.5 years after shunt implantation, this number returns to normal range. Conclusion: In infants with hydrocephalus, initial treatment by ETV was more reasonable than implanting the shunt. In adult with hydrocephalus, the initial failure in ETV occurred sooner compared to shunt therapy; however, ETV was more efficient.
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Affiliation(s)
- Seifollah Gholampour
- Department of Biomedical Engineering, Faculty of Electrical & Computer Engineering, Tehran North Branch, Islamic Azad University, Tehran, Iran
| | - Mehrnoush Bahmani
- Department of Biomedical Engineering, Faculty of Electrical & Computer Engineering, Tehran North Branch, Islamic Azad University, Tehran, Iran
| | - Azadeh Shariati
- Department of Biomedical Engineering, Faculty of Electrical & Computer Engineering, Tehran North Branch, Islamic Azad University, Tehran, Iran
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25
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Allensworth JJ, Rowan NR, Storck KA, Woodworth BA, Schlosser RJ. Endoscopic repair of spontaneous skull base defects decreases the incidence rate of intracranial complications. Int Forum Allergy Rhinol 2019; 9:1089-1096. [DOI: 10.1002/alr.22399] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 01/01/2023]
Affiliation(s)
- Jordan J. Allensworth
- Department of Otolaryngology‒Head & Neck SurgeryMedical University of South Carolina Charleston SC
| | - Nicholas R. Rowan
- Department of Otolaryngology‒Head & Neck SurgeryThe Johns Hopkins University School of Medicine Baltimore MD
| | - Kristina A. Storck
- Department of Otolaryngology‒Head & Neck SurgeryMedical University of South Carolina Charleston SC
| | - Bradford A. Woodworth
- Department of Otolaryngology‒Head & Neck SurgeryUniversity of Alabama at Birmingham School of Medicine Birmingham AL
| | - Rodney J. Schlosser
- Department of Otolaryngology‒Head & Neck SurgeryMedical University of South Carolina Charleston SC
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26
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Transnasal endoscopic repair of adult spontaneous cerebrospinal fluid rhinorrhea with assistance of computer-assisted navigation system: an analysis of 21 cases. Eur Arch Otorhinolaryngol 2019; 276:2835-2841. [DOI: 10.1007/s00405-019-05570-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
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27
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Jakob M, Bertlich M, Eichhorn KW, Thudium M, Bootz F, Send T. Reconstruction of the skull base in spontaneous rhinoliquorrhea. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2019; 8:Doc11. [PMID: 31355127 PMCID: PMC6637698 DOI: 10.3205/iprs000137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Objective/Hypothesis: Spontaneous rhinoliquorrhea often occurs due to defects of the skull base. It is often misinterpreted as rhinitis and is surgically the most difficult rhinoliquorrhea entity to close. Methods: We conducted a retrospective chart analysis of patients that were diagnosed with spontaneous rhinoliquorrhea at the University Hospital Bonn between 2001 and 2017. Results: Overall, twelve patients were included in this study. On average, the time between occurrence of nasal discharge and diagnoses of rhinoliquorrhea was 123 days. In ten patients, the localization of the skull base defect could be localized by computed tomography or MRI cisternography. Ten patients underwent surgery, of which 9 remained recurrence free. One patient underwent revision surgery and from thereon was recurrence free. Conclusion: Spontaneous rhinoliquorrhea still remains a diagnostic and therapeutic challenge. Whenever persistent watery nasal discharge appears in a patient, rhinoliquorrhea must be considered. Endoscopic surgical reconstruction of the skull base is the therapeutic gold standard and should be attempted as soon as the diagnosis is secured.
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Affiliation(s)
- Mark Jakob
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Germany
| | - Mattis Bertlich
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Munich, Germany
| | - Klaus W Eichhorn
- Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Germany
| | - Marcus Thudium
- Department of Anesthesiology, University Hospital Bonn, Germany
| | - Friedrich Bootz
- Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Germany
| | - Thorsten Send
- Otorhinolaryngology, Head and Neck Surgery, University Hospital Bonn, Germany
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Naumenko AN, Gaidukov SS, Gulyaev DA, Konoplev OI, Chernushevich II, Zakharova GP. [Skull base defects multilayer plasty in patients with spontaneous cerebrospinal fluid leak: our experience]. Vestn Otorinolaringol 2019; 84:51-54. [PMID: 30938343 DOI: 10.17116/otorino20198401151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Spontaneous cerebrospinal fluid (CSF) leak is one of the types of non-traumatic CSF leaks in which the etiologic factor is unknown. Skull base defects transnasal endoscopic plasty is the initial method of surgical repair of spontaneous cerebrospinal fluid leaks. METHODS: Forty-five patients with spontaneous CSF leaks were managed using multilayer transplant technique. The basic choice criteria of endoscopic transnasal surgical approach and materials to reconstruction of skull base defects were the size of defect and its localization. In all cases pediculated flaps in combination with free graft were used. RESULTS: In 43 (96%) cases CSF leaks was successfully managed in primary surgery, which indicates high efficiency of the described surgical interventions.
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Affiliation(s)
- A N Naumenko
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - S S Gaidukov
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - D A Gulyaev
- V.A. Almazov National Medical Research Centre, Saint Petersburg, Russia, 197341
| | - O I Konoplev
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - I I Chernushevich
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
| | - G P Zakharova
- Saint Petersburg Research institute of Ear, Throat, Nose and Speech, Saint Petersburg, Russia, 190013
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Luk LJ, Ikeda A, Wise SK, DelGaudio JM. Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair. Otolaryngol Head Neck Surg 2019; 161:522-528. [PMID: 31039072 DOI: 10.1177/0194599819847944] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects. STUDY DESIGN A retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years. SETTING Tertiary care rhinology practice. SUBJECTS Adult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic). METHODS Patients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate. RESULTS Of 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed (P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%. CONCLUSIONS We present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.
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Affiliation(s)
- Lauren J Luk
- 1 Orange County Sinus Institute, Southern California Permanente Medical Group, Irvine, California, USA
| | - Allison Ikeda
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - Sarah K Wise
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
| | - John M DelGaudio
- 2 Department of Otolaryngology-Head and Neck Surgery, Emory University, Atlanta, Georgia, USA
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30
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Radonjic A, Kassab AM, Moldovan ID, Kilty S, Alkherayf F. Idiopathic intracranial hypertension presenting as bilateral spontaneous lateral intrasphenoidal and transethmoidal meningoceles: a case report and review of the literature. J Med Case Rep 2019; 13:62. [PMID: 30832738 PMCID: PMC6399895 DOI: 10.1186/s13256-018-1959-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 12/19/2018] [Indexed: 11/10/2022] Open
Abstract
Background Basal meningoceles are rare herniations of the meninges that tend to present unilaterally with cerebrospinal fluid rhinorrhea. Growing evidence suggests that intracranial hypertension contributes considerably to the formation of spontaneous basal meningoceles. Case presentation A 50-year-old man of Middle East ethnicity presented with a 16-week history of cerebrospinal fluid rhinorrhea, short-term memory loss, and slight decline in cognitive function. We present a case of bilateral spontaneous meningoceles with bone defects in the left lateral sphenoid sinus and right anterior cribriform plate, as well as with a remodeled sella. A neuronavigation-assisted expanded endoscopic endonasal surgery was performed to resect the meningoceles. Postoperative imaging demonstrated complete resolution of the bilateral meningoceles. Conclusions This case reports the first bilateral basal spontaneous meningoceles in the literature. Furthermore, based on this case’s imaging results and the literature reviewed, elevated intracranial pressure may be a determining factor behind the development of spontaneous meningoceles.
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Affiliation(s)
| | | | - Ioana D Moldovan
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Room C2218, Ottawa, Ontario, K1Y 4E9, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Shaun Kilty
- Department of Otolaryngology - Head & Neck Surgery, The Ottawa Hospital, Ottawa, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Canada.,The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Fahad Alkherayf
- Division of Neurosurgery, Department of Surgery, The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Room C2218, Ottawa, Ontario, K1Y 4E9, Canada. .,Faculty of Medicine, University of Ottawa, Ottawa, Canada. .,The Ottawa Hospital Research Institute, Ottawa, Canada.
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Tilak AM, Koehn H, Mattos J, Payne SC. Preoperative management of spontaneous cerebrospinal fluid rhinorrhea with acetazolamide. Int Forum Allergy Rhinol 2018; 9:265-269. [DOI: 10.1002/alr.22245] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/23/2018] [Accepted: 10/23/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | - Heather Koehn
- University of Virginia School of Medicine; Charlottesville VA
| | - José Mattos
- University of Virginia School of Medicine; Charlottesville VA
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Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years. Eur Arch Otorhinolaryngol 2018; 275:2487-2494. [PMID: 30109406 DOI: 10.1007/s00405-018-5089-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/07/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE Most cases of non-traumatic nasal cerebrospinal fluid (CSF) leaks occur spontaneously without any obvious reason. Severe and life-threatening complications are possible consequences. Endoscopic repair is considered the gold standard; however, diagnosis and therapy of these CSF leaks stay challenging. METHODS In this retrospective analysis, patients who presented with spontaneous nasal CSF leaks from 2006 to 2017 were included. Symptoms, diagnostics, localization of the skull base defect, surgical method, outcome, and postoperative treatment were recorded. RESULTS Twenty four patients were included. 8 patients presented with symptoms of meningitis. The skull base defects were most commonly located in the anterior ethmoid roof-especially in the cribriform plate-and in the lateral part of the sphenoid sinus. 21 patients had a BMI above 25. In only 13 cases the defect could be detected preoperatively via computed tomography or additional magnetic resonance imaging. In all patients intraoperative visualization of the CSF leak was possible using intrathecal application of sodium-fluorescein. Endoscopic repair was the initial surgical method for all patients and proved to be successful in 80% of the cases. In most cases surgical revision was performed endoscopically; however, in two patients an open transpterygoidal approach was necessary. CONCLUSIONS Spontaneous nasal CSF leaks often initially present with symptomatic meningitis. Imaging does not always clearly identify the skull base defect. Common localizations are the anterior ethmoid roof and the lateral sphenoid sinus. Obesity seems to be a predisposing factor. In most cases, endoscopic repair with low morbidity is possible; however, an individualized approach is necessary.
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O'Cearbhaill RM, Kavanagh EC. Beta-2 Transferrin and IR. J Vasc Interv Radiol 2018; 29:439. [PMID: 29455884 DOI: 10.1016/j.jvir.2017.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 10/01/2017] [Accepted: 10/02/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
- Roisin M O'Cearbhaill
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
| | - Eoin C Kavanagh
- Department of Radiology, Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland
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Quatre R, Attye A, Righini CA, Reyt E, Giai J, Schmerber S, Karkas A. Spontaneous Cerebrospinal Fluid Rhinorrhea: Association with Body Weight and Imaging Data. J Neurol Surg B Skull Base 2017; 78:419-424. [PMID: 28875121 DOI: 10.1055/s-0037-1603731] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Accepted: 05/04/2017] [Indexed: 10/19/2022] Open
Abstract
Objective Spontaneous cerebrospinal fluid rhinorrhea (SCSFR) might be the only clinical manifestation of idiopathic intracranial hypertension (IIH), which has been historically related to overweight. Our goal was to search for an association between SCSFR and increased body weight on the one hand and SCSFR and imaging findings suggestive of IIH on the other hand. Materials and Methods We retrospectively collected clinical and radiological data of patients operated on endoscopically for SCSFR in our institution from 1993 to 2013. Analyzed factors were body mass index (BMI), extended sphenoid sinus pneumatization on computed tomography, and empty sella and distention of the optic nerve sheath on magnetic resonance imaging. Results There were 15 patients: 8 females/7 males; mean age 50 years. Primary surgical success rate was 86.7%. Regarding body weight, 80% were overweight (BMI ≥ 25) versus 32% in the French general population ( p < 0.001). Among patients with SCSFR, 20% were obese (BMI ≥ 30) versus 15% in French individuals without SCSFR ( p = 0.483). Increased pneumatization of sphenoid sinuses was observed in 92.9 versus 27.5% in the general population ( p < 0.0001). Empty sella was found in 46.2 versus 3% in the general population ( p < 0.00001). Dilation of the optic nerve sheath was observed in 46.2 versus 15% in the general population ( p < 0.01). Conclusion We found statistically significant associations between SCSFR and overweight, increased pneumatization of sphenoid sinuses, empty sella, and dilation of optic nerve sheath, but not with obesity, which did not have any additional impact of CSF leak than did overweight.
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Affiliation(s)
- Raphaële Quatre
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Grenoble University Hospital, Grenoble, France
| | - Arnaud Attye
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Neuroradiology, Grenoble University Hospital, Grenoble, France
| | - Christian Adrien Righini
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Grenoble University Hospital, Grenoble, France
| | - Emile Reyt
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Grenoble University Hospital, Grenoble, France
| | - Joris Giai
- Department of Epidemiology and Public Health, Grenoble University Hospital, Grenoble, France.,Department of Biostatistics, Lyon University Hospital, Lyon, France.,Claude Bernard University of Lyon 1, UFR Medecine, University of Lyon, Lyon, France
| | - Sébastien Schmerber
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Grenoble University Hospital, Grenoble, France
| | - Alexandre Karkas
- Joseph Fourier University, UFR Medecine, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Grenoble University Hospital, Grenoble, France.,Department of Otolaryngology-Head and Neck Surgery, Saint-Etienne University Hospital, Saint-Etienne, France
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Spontaneous cerebrospinal fluid fistula in the clivus. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134:431-434. [PMID: 28410953 DOI: 10.1016/j.anorl.2016.10.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/27/2016] [Accepted: 10/12/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Spontaneous cerebrospinal fluid (CSF) fistulas are infrequent and only 10 cases in the literature have been located in the clivus. We describe two new cases of CSF fistulas in this site and review the literature. CASE REPORT The first patient was a 52-year-old woman referred to our centre for intermittent rhinorrhea that had been diagnosed after an episode of meningitis. The second case was a 69-year-old man who was visited for rhinorrhea of one-year duration; he also developed meningitis during the preoperative study. In both cases, the spontaneous CSF fistula was diagnosed by beta-2-transferrin testing, CT scan and MRI. We performed an endonasal endoscopic transsphenoidal approach and used free grafts and vascularized flaps to close the clival defect. Treatment was successful in both cases. DISCUSSION The physiopathology of spontaneous CSF fistulas remains unknown. Possible explanations given to date in this location are pulsatility of the basilar artery, repeated Valsalva maneuvers and Marfan's disease, the two latter also related to CSF fistulas in other locations. Closure of a CSF leak towards the nasal cavity is mandatory due to potential complications. Our results support the endoscopic transsphenoidal approach using free grafts and/or pediculated flaps as a good alternative to open surgery.
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36
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Luk LJ, DelGaudio JM, Wise SK. Advancements in Skull Base Reconstruction. CURRENT OTORHINOLARYNGOLOGY REPORTS 2016. [DOI: 10.1007/s40136-016-0135-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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37
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Moreno-Luna R, Cárdenas Ruiz-Valdepeñas E, Tato JI, Rivero-Garvia M, Márquez-Rivas J, Mochón Martín A. Basiespinal Cerebrospinal Fluid Leak as a Complication After Adenoidectomy: Case Report and Literature Review. World Neurosurg 2016; 93:484.e9-484.e12. [PMID: 27452970 DOI: 10.1016/j.wneu.2016.07.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/12/2016] [Accepted: 07/13/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adenoidectomy is one of the most common procedures in the field of pediatric otolaryngology. Postoperative bleeding is one of the most frequent complications (0.4%). In turn, cerebrospinal fluid fistula is a very uncommon but critical complication in this type of surgery. METHODS We report the case of a 3-year-old patient who underwent adenoidectomy and presented a cerebrospinal fluid leak associated with pneumocephalus and meningitis. RESULTS The solution provided was a suture in layers of the fistula tract, reinforced with basipharyngeal vascularized and rotation random flap of mucosa, and a free graft of muscle, through a transoral endoscopic approach. CONCLUSIONS Cerebrospinal fluid leak as a complication after adenoidectomy is exceedingly rare. These pharyngospinal fistulae are determined by the anatomic features associated with intraoperative hemorrhagic complications, and it is essential that we take them into account when facing postoperative complications in the follow-up. The use of vascularized flaps based on the irrigation of the ascending pharyngeal artery with endoscopic techniques offers low-morbidity solutions, which are more efficient than traditional methods.
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Affiliation(s)
- Ramón Moreno-Luna
- Rhinology Unit, Department of Otolaryngology, University Hospital Virgen Macarena, Sevilla, Spain.
| | | | - José Ignacio Tato
- Department of Otolaryngology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Monica Rivero-Garvia
- Department of Neurosurgery, University Hospital Virgen del Rocío and Virgen Macarena, Sevilla, Spain
| | - Javier Márquez-Rivas
- Department of Neurosurgery, University Hospital Virgen del Rocío and Virgen Macarena, Sevilla, Spain
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Campbell RG, Farquhar D, Zhao N, Chiu AG, Adappa ND, Palmer JN. Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension: Long-term Outcomes of Endoscopic Repairs. Am J Rhinol Allergy 2016; 30:294-300. [DOI: 10.2500/ajra.2016.30.4319] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea secondary to idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri or benign intracranial hypertension, has varying success rates, from 25–87%, with minimal morbidity. However, often these series have a relatively short-term follow-up. Given the pathophysiology of IIH, long-term follow-up is necessary to identify true CSF leak recurrence rates. Our investigation aimed to evaluate long-term outcomes in endoscopically repaired CSF leaks. Methods A retrospective chart review of all the patients with CSF rhinorrhea due to IIH who met inclusion criteria between 1996 and 2009. Outcome measures included the following: demographics, intracranial pressure, location of skull base defect, presence of encephalocele and/or meningoencephalocele, surgical repair technique, treatment with acetazolamide, whether a ventriculoperitoneal shunt was inserted, location of recurrence, history of meningitis or previous sinus surgery, and duration of follow-up. Results Thirty-two patients with a total of 44 skull base defects were reviewed over a mean follow-up of 10.2 years. The mean body mass index and intracranial pressure were 36.8 kg/m2 and 27.7 cm H2O, respectively. Seven patients (18%) required revision surgery at the same site or a distant site. We found no statistical significance that identified the recurrence risk in the outcome measurements most likely due to our small failure rate. However, early recurrences were noted to recur at the same repair site, whereas late recurrences were noted to recur at a distant site along the skull base. Conclusion IIH is an increasingly recognized entity treated by otorhinolaryngologists. We present the first long-term IIH CSF leak repair series. Long-term follow-up is necessary because delayed CSF leaks occur in this population.
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Affiliation(s)
- Raewynn G. Campbell
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas Farquhar
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nina Zhao
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alexander G. Chiu
- Department of Otolaryngology Head and Neck Surgery, The University of Arizona, Tucson, Arizona
| | - Nithin D. Adappa
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - James N. Palmer
- Department of Otolaryngology Head and Neck Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Yadav YR, Parihar V, Janakiram N, Pande S, Bajaj J, Namdev H. Endoscopic management of cerebrospinal fluid rhinorrhea. Asian J Neurosurg 2016; 11:183-93. [PMID: 27366243 PMCID: PMC4849285 DOI: 10.4103/1793-5482.145101] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Cerebrospinal fluid (CSF) rhinorrhea occurs due to communication between the intracranial subarachnoid space and the sinonasal mucosa. It could be due to trauma, raised intracranial pressure (ICP), tumors, erosive diseases, and congenital skull defects. Some leaks could be spontaneous without any specific etiology. The potential leak sites include the cribriform plate, ethmoid, sphenoid, and frontal sinus. Glucose estimation, although non-specific, is the most popular and readily available method of diagnosis. Glucose concentration of > 30 mg/dl without any blood contamination strongly suggests presence and the absence of glucose rules out CSF in the fluid. Beta-2 transferrin test confirms the diagnosis. High-resolution computed tomography and magnetic resonance cisternography are complementary to each other and are the investigation of choice. Surgical intervention is indicated, when conservative management fails to prevent risk of meningitis. Endoscopic closure has revolutionized the management of CSF rhinorrhea due to its less morbidity and better closure rate. It is usually best suited for small defects in cribriform plate, sphenoid, and ethmoid sinus. Large defects can be repaired when sufficient experience is acquired. Most frontal sinus leaks, although difficult, can be successfully closed by modified Lothrop procedure. Factors associated with increased recurrences are middle age, obese female, raised ICP, diabetes mellitus, lateral sphenoid leaks, superior and lateral extension in frontal sinus, multiple leaks, and extensive skull base defects. Appropriate treatment for raised ICP, in addition to proper repair, should be done to prevent recurrence. Long follow-up is required before leveling successful repair as recurrences may occur very late.
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Affiliation(s)
- Yad Ram Yadav
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Vijay Parihar
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Narayanan Janakiram
- Department of Otolaryngology, Royal Pearl Hospital, Trichy, Tamil Nadu, India
| | - Sonjay Pande
- Department of Radio Diagnosis, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Jitin Bajaj
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
| | - Hemant Namdev
- Department of Neurosurgery, NSCB Medical College, Jabalpur, Madhya Pradesh, India
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Endoscopic Endonasal Repair of Spontaneous and Traumatic Cerebrospinal Fluid Rhinorrhea: A Review and Local Experience. Neurosurg Clin N Am 2016; 26:333-48. [PMID: 26141354 DOI: 10.1016/j.nec.2015.03.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This article presents an overview of endoscopic endonasal repair of cerebrospinal fluid (CSF) rhinorrhea. In recent years, endoscopic repair has become the standard of care for managing this condition, because it gradually replaces the traditional open transcranial approach. Discussion includes the etiologic classification of CSF rhinorrhea, management paradigm for each category, diagnosis algorithm, comprehensive description of the surgical technique, and an updated review of the literature regarding the safety and efficacy of this procedure. In addition, the authors present their experience, including 2 surgical videos demonstrating endoscopic repair of CSF rhinorrhea in 2 distinct clinical scenarios.
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41
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Lieberman SM, Chen S, Jethanamest D, Casiano RR. Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects. Am J Rhinol Allergy 2015; 29:77-81. [PMID: 25590325 DOI: 10.2500/ajra.2015.29.4121] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. OBJECTIVE The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. METHODS We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. RESULTS Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). CONCLUSION A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time.
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Affiliation(s)
- Seth M Lieberman
- Department of Otolaryngology, New York University School of Medicine, New York, New York, USA
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Spontaneous sphenoid sinus cerebrospinal fluid leak and meningoencephalocele - are they due to patent Sternberg's canal? Wideochir Inne Tech Maloinwazyjne 2014; 10:347-58. [PMID: 26240642 PMCID: PMC4520829 DOI: 10.5114/wiitm.2014.47097] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 07/05/2014] [Accepted: 09/01/2014] [Indexed: 11/17/2022] Open
Abstract
Sternberg's canal is a congenital bony defect in the lateral wall of the sphenoid sinus. If it persists to adulthood, it may become a source of spontaneous cerebrospinal fluid leak (CSF) and meningoencephalocele. The aim of the study was to describe the authors' experience and review articles related to spontaneous sphenoid sinus CSF leaks and Sternberg's canal. We analysed patients managed surgicallly due to sphenoid sinus CSF leak and performed a PubMed database search. Two female patients with spontaneous CSF leak of sphenoid origin were found. Both patients underwent surgery with the endoscopic endonasal approach, and the defect was closed using the multi-layer technique. Twelve articles related to CSF leaks of sphenoid origin (due to Sternberg's canal) were found in the PubMed database. Lines of lesser resistance within sphenoid bone may underlie CSF leak pathology together with intracranial hypertension. The endoscopic transnasal approach to the sphenoid sinus is an excellent alternative to standard transcranial procedures.
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Management of spontaneous cerebrospinal fluid leaks of the sphenoid sinus: our experience. The Journal of Laryngology & Otology 2014; 128:797-802. [PMID: 25180632 DOI: 10.1017/s0022215114001698] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Closure of spontaneous sphenoid sinus cerebrospinal fluid leaks can be challenging because of the relative inaccessibility of the lateral recess and the presence of intracranial hypertension. We present our experience of such cases and highlight factors associated with a successful outcome. METHODS Eleven patients with spontaneous, laboratory confirmed, sphenoid sinus cerebrospinal fluid leaks were included. All patients underwent endoscopic closure by either a three-layer technique or fat obliteration. RESULTS In all but one patient, the leak was successfully sealed (success rate, 90.9 per cent; mean follow up, 37.1 months). Elevated intracranial pressure was measured in eight patients, two of whom did not exhibit relevant clinical or radiological characteristics. Five patients received diuretics and dietary advice for weight reduction. In one patient with recurrence two weeks after repair, successful revision was performed by additional placement of a ventriculoperitoneal shunt (follow up, 67 months). CONCLUSION Long-lasting cerebrospinal fluid fistula sealing in the sphenoid sinus requires stable reconstruction of the defect in three layers or fat obliteration if the anatomy is unfavourable. All patients should be intra- and post-operatively screened for elevated intracranial pressure to identify those who need additional intracranial pressure reduction measures.
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Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol 2014; 33:330-7. [PMID: 24042170 DOI: 10.1097/wno.0b013e318299c292] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Idiopathic intracranial hypertension (IIH) is increasingly recognized as a cause of spontaneous cerebrospinal fluid (CSF) leak in the otolarnygological and neurosurgical literature. The diagnosis of IIH in patients with spontaneous CSF leaks typically is made a few weeks after surgical repair of the leak when symptoms and signs of elevated intracranial pressure (ICP) appear. METHODS Case reports and literature review. Two young obese women developed spontaneous CSF rhinorrhea related to an empty sella in one and a cribriform plate encephalocele in the other. Both patients underwent surgical repair of the CSF leak. A few weeks later, they developed chronic headaches and bilateral papilledema. Lumbar punctures showed elevated CSF opening pressures with normal CSF contents, with temporary improvement of headaches. A man with a 3-year history of untreated IIH developed spontaneous CSF rhinorrhea. He experienced improvement of his headaches and papilledema after a CSF shunting procedure, and the rhinorrhea resolved after endoscopic repair of the leak. RESULTS These cases and the literature review confirm a definite association between IIH and spontaneous CSF leak based on: 1) similar demographics; 2) increased ICP in some patients with spontaneous CSF leak after leak repair; 3) higher rate of leak recurrence in patients with raised ICP; 4) patients with intracranial hypertension secondary to tumors may develop CSF leak, confirming that raised ICP from other causes than IIH can cause CSF leak. CONCLUSIONS CSF leak occasionally may keep IIH patients symptom-free; however, classic symptoms and signs of intracranial hypertension may develop after a CSF leak is repaired, exposing these patients to a high risk of recurrence of the leak unless an ICP-lowering intervention is performed.
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Melo NAD, Borges BBP, Magliarelli Filho PA, Godoy MDCL, Pereira LV, Pinna FDR, Voegels RL. Lateral sphenoid sinus recess cerebrospinal fluid leak: a case series. Eur Arch Otorhinolaryngol 2014; 271:2587-94. [PMID: 24748381 DOI: 10.1007/s00405-014-3049-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 04/03/2014] [Indexed: 10/25/2022]
Abstract
The lateral recess of the sphenoid sinus is one of the most common sites of meningocele and spontaneous cerebrospinal fluid (CSF) leak. Despite the availability of several techniques for closure of skull base defects occurring in this location, recurrence still poses a major challenge. This report reviews the experience of surgical repair of lateral sphenoid sinus recess CSF leak at a tertiary referral center and provides a brief discussion of this rare lesion. Nine surgeries were performed for six cases of spontaneous lateral sphenoid sinus recess CSF leak (two revisions and one repair of a new defect). Two patients presented with intracranial hypertension (ICH) and four with meningocele or meningoencephalocele. The transpterygoid approach was used in two procedures. A multilayer graft was used in seven cases and a nasoseptal flap in two. Three patients received lumbar or ventricular shunts, and one received acetazolamide for ICH management. Two minor complications were recorded, and the overall surgical success rate was 78 %. We conclude that nasoseptal flaps are a valid option for repair of recurrent CSF leaks, particularly in the lateral sphenoid sinus recess. Furthermore, identification and correction of ICH plays an essential role in the success of treatment in this patient population.
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Abstract
OBJECTIVE MRI abnormalities have been described in patients with increased intracranial pressure (ICP), including in those with idiopathic intracranial hypertension (IIH). Spontaneous CSF-filled outpouchings of the dura (meningoceles) and secondary CSF leaks can occur from elevated ICP in patients with IIH; however, few studies have evaluated these findings. Our objective was to evaluate the frequency of spontaneous intracranial meningoceles among IIH patients and determine their association with visual outcome. MATERIALS AND METHODS We performed a retrospective case-control study of consecutive IIH patients between 2000 and 2011 who underwent MRI that included T2-weighted imaging. Demographics, presenting symptoms, CSF opening pressure, and visual outcome were collected for the first and last evaluations. Control subjects included patients without headache or visual complaints who had normal brain MRI results. Stratified analysis was used to control for potential confounding by age, sex, race, and body mass index. RESULTS We included 79 IIH patients and 76 control subjects. Meningoceles were found in 11% of IIH patients versus 0% of control subjects (p<0.003). Prominent Meckel caves without frank meningoceles were found in 9% of IIH patients versus 0% of control subjects (p<0.003). Among IIH patients, the presence of meningocele or prominent Meckel caves was not associated with demographics, symptoms, degree of papilledema, CSF opening pressure, visual acuity, or visual field defect severity. CONCLUSION Meningoceles are significantly more common in IIH patients than in control subjects and can be considered an additional imaging sign for IIH. Meningoceles are not, however, associated with decreased CSF opening pressure or better visual outcome in IIH.
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Rapid Spontaneous Cerebrospinal Fluid Leak Detected in the Gastrointestinal Tract. Clin Nucl Med 2014; 39:198-9. [DOI: 10.1097/rlu.0000000000000292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Banu MA, Kim JH, Shin BJ, Woodworth GF, Anand VK, Schwartz TH. Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks. Clin Neurol Neurosurg 2014; 116:28-34. [DOI: 10.1016/j.clineuro.2013.11.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 10/01/2013] [Accepted: 11/09/2013] [Indexed: 11/30/2022]
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Lieberman SM, Ojo RB, Casiano RR. Distant pseudomeningoceles of the ventral skull base: a report of 2 cases. Int Forum Allergy Rhinol 2013; 3:1021-4. [PMID: 24343990 DOI: 10.1002/alr.21242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 09/17/2013] [Accepted: 09/24/2013] [Indexed: 11/08/2022]
Abstract
BACKGROUND The objective of this case series was to report what is to the best of our knowledge the first reports of nasopharyngeal and soft palate pseudomeningoceles tracking submucosally from the sphenoid sinus. METHODS Analysis of cases through medical records. RESULTS Two cases of middle-aged male patients presented to our tertiary care university teaching hospital for recurrent meningitis and a history of cerebrospinal fluid (CSF) rhinorrhea. Both were found to have pseudomeningoceles distant from the sphenoid sinus. One was tracking to the mucosa of the Eustachian tube, and the other to the dorsum of the soft palate. Both were found to be tracking submucosally from the sphenoid sinus, to the vidian canal, to the lateral nasopharyngeal wall, to their respective locations at the Eustachian tube and dorsum of the soft palate. CSF closure was performed with a transnasal endoscopic repair using the pedicled nasoseptal flap for 1 patient and Alloderm for the other, both with successful cessation of CSF rhinorrhea. CONCLUSION We present these cases of distant spontaneous CSF leaks. We review the literature and discuss case management.
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Affiliation(s)
- Seth M Lieberman
- Department of Otolaryngology, New York University (NYU), New York, NY
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Van Zele T, Kitice A, Vellutini E, Balsalobre L, Stamm A. Primary spontaneous cerebrospinal fluid leaks located at the clivus. ALLERGY & RHINOLOGY 2013; 4:e100-4. [PMID: 24124635 PMCID: PMC3793111 DOI: 10.2500/ar.2013.4.0053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Transclival meningoceles and primary spontaneous cerebrospinal fluid (CSF) leaks at the clivus are extremely rare lesions and only few of them have been reported in the literature. We report here six cases of transclival primary spontaneous CSF leaks through the clivus. A retrospective case study was performed. We reviewed six cases involving sinonasal CSF leaks located at the clivus treated between 1997 and 2009. Presenting symptoms, duration of symptoms, defect size, site of defect, surgical approach and technique of defect closure, intraoperative complications, postoperative complications, and recurrences are discussed. All CSF leaks were located in the upper central part of the clivus. two of six patients showed signs of increased intracranial pressure (ICP) including arachnoid pits and/or empty sella. For three patients a purely transnasal approach was used with multilayer reconstruction using a nonvascularized graft, and three patients underwent a transnasal transseptal approach with a multilayer reconstruction, with nasoseptal flap. No recurrences of CSF leaks at clivus or other sites were observed to date with a mean follow-up of 10.3 years (range, 3-15 years). Spontaneous CSF rhinorrhea located at the clivus is an extremely rare condition. To date, only eight cases have been described. Here, we report the largest group of six consecutive cases. Irrespective of the used reconstruction technique in all cases a 100% closure rate was achieved. However, identification of increased ICP is an essential aspect and this condition should be treated either medically or surgically.
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Affiliation(s)
- Thibaut Van Zele
- Department of Otorhinolaryngology, Ghent University Hospital, Ghent, Belgium
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