Neuroendoscopic endonasal management of cerebrospinal fluid rhinorrhea

Comparison of the Efficacy and Safety of Neuroendoscopic Endonasal Transsphenoidal Surgeries and Intracranial Endoscopic Pterional Approach in Resection of Tuberculum Sellae Meningiomas

Objective

To compare of the efficacy and safety of neuroendoscopic endonasal transsphenoidal surgeries and intracranial endoscopic pterional approach in resection of tuberculum sellae meningioma.

Methods

From January 2014 to June 2021, 60 patients with tuberculum sellae meningioma diagnosed and treated in our hospital were enrolled and randomly divided into study group and control group. The tuberculum sellae meningioma was removed by neuroendoscopic endonasal transsphenoidal surgeries in the study group, while the intracranial endoscopic pterional approach was used in the control group. The chi-square test was used to compare the differences of tumor complete resection rate, visual acuity improvement rate, total effective rate at 3 months after operation, and adverse reactions between the two groups.

Results

The clinical characteristics of the two groups were comparable (P > 0.05). After surgical treatment, the complete resection rate in the study group was higher than that in the control group (93.3% vs 70.0%), and the difference was statistically significant (P=0.020). After treatment, the visual acuity improvement rate of the study group was 83.3% (25/30), which was significantly higher than that of the control group (60.0%, 18/30), and the difference was statistically significant (χ ² = 4.022, P=0.045). After surgical treatment, the total effective rate at 3 months after operation was higher in the study group than in the control group (96.7% vs 83.3%), with statistical significance (P=0.041). There was no significant difference in postoperative adverse reactions between the study group and control group (33.3% vs 30.0%, P=0.781).

Conclusion

The neuroendoscopic endonasal transsphenoidal surgeries has significant efficacy and can significantly improve the visual acuity of patients without increasing adverse reactions, which is worthy of clinical promotion.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature

BACKGROUND

Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures.

METHODS

PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes.

RESULTS

We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery.

CONCLUSIONS

ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.

Chronic Aspiration Pneumonitis Caused by Spontaneous Cerebrospinal Fluid Fistulae of the Skull Base

OBJECTIVES/HYPOTHESIS

Spontaneous cerebrospinal fluid (CSF) leaks of the skull base are associated with obesity, multiparity, and elevated intracranial pressure. Although spontaneous CSF leaks often present with rhinorrhea, they can be an underdiagnosed cause of chronic aspiration pneumonitis, a complication that has not been previously reported in detail.

STUDY DESIGN

Retrospective case series.

METHODS

The authors retrospectively reviewed all patients undergoing surgical repair of CSF fistulae at the University of Southern California between 2011 and 2018 to identify those presenting with pulmonary symptoms including dyspnea, aspiration, chronic cough, and shortness of breath caused by chronic noniatrogenic CSF pneumonitis.

RESULTS

Symptomatic chronic pneumonitis was evident in six of 20 patients with spontaneous CSF rhinorrhea. Five women (mean body mass index = 36) had CSF leaks arising from the fovea ethmoidalis (n = 4) and lateral sphenoid region (n = 1). One man had a middle fossa floor dehiscence draining through the eustachian tube. All patients had bilateral ground-glass opacities in their lungs on computed tomography imaging that were attributed to spontaneous CSF fistulae arising from noniatrogenic skull base defects, and one patient underwent a biopsy of a lung lesion at another hospital showing chronic bronchiolitis and adjacent peribronchiolar metaplasia. Five patients underwent endoscopic endonasal repair using an autologous fascial graft and pedicled nasoseptal flap, and one underwent craniotomy for repair. All patients underwent successful repair with no complications or evidence of recurrence. Upon repair of the spontaneous CSF leaks, both pneumonitis symptoms and ground-glass opacities on imaging resolved in all six cases.

CONCLUSIONS

Skull base CSF fistulae should be considered as a reversible cause of chronic pneumonitis that is not alleviated or worsens with standard treatment.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:462-466, 2021.

Brain Ventricular System and Cerebrospinal Fluid Development and Function: Light at the End of the Tube: A Primer with Latest Insights

The brain ventricular system is a series of connected cavities, filled with cerebrospinal fluid (CSF), that forms within the vertebrate central nervous system (CNS). The hollow neural tube is a hallmark of the chordate CNS, and a closed neural tube is essential for normal development. Development and function of the ventricular system is examined, emphasizing three interdigitating components that form a functional system: ventricle walls, CSF fluid properties, and activity of CSF constituent factors. The cellular lining of the ventricle both can produce and is responsive to CSF. Fluid properties and conserved CSF components contribute to normal CNS development. Anomalies of the CSF/ventricular system serve as diagnostics and may cause CNS disorders, further highlighting their importance. This review focuses on the evolution and development of the brain ventricular system, associated function, and connected pathologies. It is geared as an introduction for scholars with little background in the field.

Endoscopic Endonasal Repair of Spontaneous Cerebrospinal Fluid Leaks Using Multilayer Composite Graft and Vascularized Pedicled Nasoseptal Flap Technique

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.

Success Rate and Complications of Cerebrospinal Fluid Rhinorrhea Treated With a Transcranial Approach

The aim of this study was to evaluate the clinical outcomes of cerebrospinal fluid (CSF) rhinorrhea in patients treated with transcranial surgery. Here, we retrospectively reviewed 23 patients with CSF rhinorrhea between 2008 and 2015 at our university hospital. Nine (39.1%) patients were treated conservatively, whereas 12 (52.2%) patients were treated with a transcranial approach. Our results showed that 7 (30.4%), 11 (47.8%), and 5 (21.7%) patients had spontaneous, traumatic, and iatrogenic CSF leakage, respectively. In our study, the cribriform plate was the most common site of leakage, and it was found to be involved in 5 (21.7%) patients. The mean diameter defect of the fistula was 130.40 ± 190.47 mm and there was no significant difference between this defect and the different etiology types. In our study, meningitis, third nerve palsy, and vasospasm were the main complications that arose during the treatment of CSF rhinorrhea. Moreover, 6 (26.1%) of 7 (30.4%) patients had spontaneous CSF leaks that were treated with surgery. Notably, spontaneous CSF leaks did not stop when treated with conservative measures. In addition, there were no significant differences between etiology types and CSF leaks. The primary surgical repair rate was 78.3% and the secondary surgery repair rate was 91.6%. Importantly, as we preferred using this type of transcranial surgery in our clinic, there has been a higher success rate with endoscopic treatments and fewer major complications from CSF rhinorrhea in the literature.

The Surgical Treatment of Posttraumatic Skull Base Defects with Cerebrospinal Fluid Leak

Objectives  The objective was to explore further the surgical treatment of posttraumatic skull base defects with cerebrospinal fluid (CSF) leak and to identify the most common factors affecting the surgical treatment of posttraumatic skull base defect with CSF leak retrospectively. Materials and Methods  This study included 144 patients with head trauma having skull base defect with CSF leak who had been surgically treated at Sun Yat-Sen Memorial Hospital of Sun Yat-Sen University from 1998 to June 2016. There were 113 (78.5%) males and 31 (21.5%) females, with age ranging from 1 to 78 years and mean age of 26.58 ± 14.95 years. We explored the surgical approaches for the treatment of the skull base defect and the graft materials used and also measured the association among surgical approaches; location, size, and type of skull base defects; presence or absence of associated intracranial pathologies; postoperative complications; outcome; age; Glasgow outcome score (GOS) at discharge; and days of hospital stay. Results  The location, size, and types of skull base defect and the presence of associated intracranial pathologies were the common factors identified not only for choosing the appropriate surgical approach but also for choosing the materials for defect repair, timing of the surgery, and the method used for the defect as well as leak repair. The statistically significant correlation with p  < 0.001 was found in this study. Conclusion  From this study, we could conclude that size, location, and types of the defect and the presence of associated intracranial injuries were the common factors that affected the surgical treatment of posttraumatic skull base defect with CSF leak. Hence, the importance of careful evaluation of these factors is essential for proper selection of the surgical approach and for avoiding unnecessary hassles.