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Hallenberger TJ, Rychen J, Soleman J, Fernandez-Miranda JC, Brand Y, Mariani L, Roethlisberger M. Management of Recurrent Cerebrospinal Fluid Rhinorrhea Caused by Sequential, Anatomically Separated Skull Base Defects-A Case-Based Systematic Review. World Neurosurg 2024:S1878-8750(24)01152-5. [PMID: 38986941 DOI: 10.1016/j.wneu.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 07/01/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
OBJECTIVE Recurrent cerebrospinal fluid (CSF) rhinorrhea caused by sequential, anatomically separated skull base defects is rarely reported in the literature. Neither management nor etiology has been sufficiently investigated. We present an illustrative case and a systematic review of the literature regarding etiology, diagnostics, and management of this rare phenomenon. METHODS A systematic literature search looking for articles reporting sequential CSF leaks with multiple skull base defects was performed. Data from included articles were descriptively reported, and the quality of the included studies was assessed with Grading of Recommendations Assessment, Development and Evaluation. RESULTS A 71-year-old woman with posttraumatic CSF rhinorrhea and left-sided CSF otorrhea due to a left-sided horizontal fracture of the petrous bone presented at our institution. After initial surgical repair and a 10-week symptom-free interval, CSF rhinorrhea recurred. Imaging revealed a preexisting contralateral meningoencephalocele of the lateral sphenoid recess causing recurrent CSF rhinorrhea most likely after initial traumatic laceration. The defect was successfully treated. A literature search identified 366 reports, 6 of which were included in the systematic review with a total of 10 cases. Quality was deemed good in 8 of 10 cases. The most common location for primary and sequential CSF leaks was along the sphenoid bone (4/10 and 5/10 patients, respectively). All publications except one reported the presence of a meningo (encephalo)cele as cause of the sequential CSF leak. CONCLUSIONS Occurrence of recurrent CSF rhinorrhea due to an anatomically separated sequential skull base lesion remains a rare phenomenon. Reassessment of imaging studies and a structured diagnostic workup to detect sequential CSF leaks independent of the primary lesion should is recommended.
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Affiliation(s)
- Tim Jonas Hallenberger
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Jonathan Rychen
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland; Department of Oto-Rhino-Laryngology, Kantonsspital Graubünden, Chur, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel Switzerland, Basel, Switzerland
| | | | - Yves Brand
- Department of Oto-Rhino-Laryngology, Kantonsspital Graubünden, Chur, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel Switzerland, Basel, Switzerland
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, University of Basel, Basel, Switzerland; Faculty of Medicine, University of Basel, Basel Switzerland, Basel, Switzerland
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2
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Hasegawa H, Van Gompel JJ, Choby G, Raghunathan A, Little JT, Atkinson JL. Unrecognized notochordal lesions as a likely cause of idiopathic clival cerebrospinal fluid leaks. Clin Neurol Neurosurg 2022; 224:107562. [PMID: 36549221 DOI: 10.1016/j.clineuro.2022.107562] [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: 04/06/2022] [Revised: 12/09/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To examine an association between idiopathic transclival cerebrospinal fluid (CSF) leak and notochordal lesions. METHODS This study consisted of the illustrations of institutional patients who underwent surgery for transclival CSF leak between January 1, 2009 and April 25, 2020 and comprehensive review of the existing literature conducted on April 25, 2020. The cases were classified based on the presumed etiologies that were originally proposed in the articles ("idiopathic" vs. "secondary"). The baseline characteristics were compared between the groups, and the surgical outcomes were summarized. RESULTS In 3 institutional cases, ecchordosis physaliphora (EP) was confirmed at the fistula either pathologically (1) or radiologically (2). Among 42 literature cases, 28 were recognized as idiopathic, while 14 were secondary cases with histologically (n = 12) or radiologically (n = 2) confirmed notochordal lesion at the fistula. Thus, any notochordal lesions were histologically confirmed in 13 among a total of 45 cases (28.9%). Fourteen of the idiopathic cases had undescribed radiographic signs suggestive of small ecchordosis physaliphora at the fistula. Both idiopathic and secondary cases demonstrated resemblance in their ages (mean, 51.4 and 56.6 years; p = 0.102), female predominance (male, 36% vs. 25%; P = 0.521), no association with obesity (7% vs. 18%; P = 0.350) or increased intracranial pressure (7% vs. 6%; P = 1.000). All the fistulas were in the midline or paramidline clivus within several millimeters below the dorsum sellae. All the patients were treated surgically with a multilayer closure, resulting in a success rate of 93% with one surgery. CONCLUSION Our analyses suggest the association of transclival CSF leak and notochord lesions. A prospective study is needed for definitive conclusion.
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Affiliation(s)
- Hirotaka Hasegawa
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, the University of Tokyo Hospital, Tokyo, Japan
| | | | - Garret Choby
- Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason T Little
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - John L Atkinson
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.
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3
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El Ouali I, Behyamet O, Elkettani N, Fikri M, Jiddane M, Touarsa F. Spontaneous clival meningocele. SAGE Open Med Case Rep 2022; 10:2050313X221117334. [PMID: 35966125 PMCID: PMC9364201 DOI: 10.1177/2050313x221117334] [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: 04/03/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022] Open
Abstract
The occipital bone is an uncommon location for meningoceles protrusion. This condition
occurs generally after a severe traumatism or surgical procedure. However, in some rare
cases, the herniation can happen spontaneously. Nontraumatic clival meningoceles present
an extremely rare entity and correspond to a herniating pachymeningeal collection
containing cerebrospinal fluid through a zone of fragility in the clivus. Clinical
presentation ranges from simple headache or rhinorrhea to severe complications such as
recurrent bacterial meningitis or nerve compression. Computed tomography provides an
analysis of the bone and magnetic resonance imaging provides a superior contrast
resolution, helping to distinguish among the various types of clival lesions. We report
the case of a young woman with a long history of idiopathic intracranial hypertension, who
presented with a worsening headache. Magnetic resonance imaging confirmed a clival
meningocele without other complications and the patient was put under medical
surveillance.
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Affiliation(s)
- Ibtissam El Ouali
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
| | - Onka Behyamet
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
| | - Najwa Elkettani
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
| | - Meriem Fikri
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
| | - Mohamed Jiddane
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
| | - Firdaous Touarsa
- Neuroradiology Department, Specialty Hospital of Rabat, Rabat, Morocco
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4
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Albrecht N, Arora A, Shah CC. Protrusion of brain stem into oropharynx in newborn: Unusual severe case of Chiari 1 malformation and Clival hypoplasia. Radiol Case Rep 2021; 16:262-267. [PMID: 33299506 PMCID: PMC7708654 DOI: 10.1016/j.radcr.2020.11.015] [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] [Received: 10/26/2020] [Revised: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 11/22/2022] Open
Abstract
Chiari 1 Malformation in children is defined as 6 mm or more caudal extension of cerebellar tonsils below the foramen magnum. It is one of the deformities in the spectrum of craniovertebral junction anomalies. We report an unusual case of newborn girl with hypoplasia of bassiocciput of the clivus and extension of brainstem into the oropharynx, in addition to extension of cerebellar tonsils below the foramen magnum. Right anterior arch and right posterior arch of C1 vertebra are absent. Dens of C2 vertebra is asymmetric. Laryngoscope showed a membrane covering the brainstem in the oropharynx. Endotracheal and orogastric tubes were placed. A ventriculo-peritoneal shunt was placed for hydrocephalus. The patient was discharged home at 4.5 months of age with home Hospice care. To the best of our knowledge, this has not been described in the literature. The case illustrates a rare defect in the clivus and unusual protrusion of brainstem into oropharynx.
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Affiliation(s)
- Nathan Albrecht
- University of Florida College of Medicine, Jacksonville, Florida
| | - Anurag Arora
- Nemours Children's Specialty Care, Jacksonville, Florida
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Panagopoulos D, Themistocleous M, Sfakianos G. Repair of a Transclival Meningocele Through a Transoral Approach: Case Report and Literature Review. World Neurosurg 2018; 123:259-264. [PMID: 30579031 DOI: 10.1016/j.wneu.2018.12.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 01/14/2023]
Abstract
BACKGROUND Transclival meningoceles and related primary spontaneous cerebrospinal fluid leaks at the clivus are extremely rare lesions, with only a few cases reported in the literature. CASE DESCRIPTION An infant presented with nasal airway obstruction and meningitis secondary to cerebrospinal fluid leak from a transclival meningocele. The radiologic investigation and surgical repair of the lesion are reported, along with intraoperative findings. Basic anatomy, embryology, and development of the clivus are reviewed to clarify the relationship of anatomic variants with the formation of transclival meningoceles. CONCLUSIONS Transclival meningocele should be considered in patients with spontaneous cerebrospinal fluid rhinorrhea. The existing classification of meningoencephaloceles based on the location of the defect in the cranium should probably be reconsidered, taking into consideration the described entity.
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Affiliation(s)
| | | | - Georgios Sfakianos
- Neurosurgical Department, "Agia Sophia" Children's Hospital, Athens, Greece
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6
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Johans SJ, Swong KN, Burkett DJ, Wemhoff MP, Lew SM, Patel CR, Germanwala AV. Clival meningocele causing bilateral hearing loss in a child due to superficial siderosis of the central nervous system: case report. J Neurosurg Pediatr 2018; 21:498-503. [PMID: 29451456 DOI: 10.3171/2017.11.peds17302] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Superficial siderosis (SS) of the CNS is a rare and often unrecognized condition. Caused by hemosiderin deposition from chronic, repetitive hemorrhage in the subarachnoid space, it results in parenchymal damage in the subpial layers of the brain and spinal cord. T2-weighted MRI shows the characteristic hypointensity of hemosiderin deposition, classically occurring around the cerebellum, brainstem, and spinal cord. Patients present with progressive gait ataxia and sensorineural hearing impairment. Although there have been several studies, case reports, and review articles over the years, the clear pathophysiology of subarachnoid space hemorrhage remains to be elucidated. The proposed causes include prior intradural surgery, prior trauma, tumors, vascular abnormalities, nerve root avulsion, and dural abnormalities. Surgical repair of a dural defect associated with SS has been shown to be efficacious at preventing symptomatic progression. There have been several reports of dural defects within the spinal canal treated with surgery. Here, the authors present the first known case of a dural defect of the ventral skull base, namely a clival meningocele, presumed to be causing SS. In this case report, a 10-year-old girl with a history of head trauma at the age of 3 years was found to have a clival meningocele 3 years after her original trauma. On follow-up imaging, the patient was found to have radiographic growth of the meningocele along with evidence of SS of the CNS. The patient was treated conservatively until she began to have progressive hearing loss. It was presumed that the growing meningocele was the source of her SS. An endoscopic endonasal transclival approach with a multilayer dural reconstruction was performed to fix the dural defect and repair the meningocele in hopes of mitigating the progression of her symptoms. At her 12-month postoperative follow-up, she was doing well, with audiometry showing a slightly decreased hearing threshold in the left ear but improved speech discrimination bilaterally. Postoperative MRI showed a stable level of hemosiderin deposition and meningocele repair. Long-term follow-up will be necessary to evaluate for continued clinical stabilization or possible improvement.
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Affiliation(s)
| | | | - Daniel J Burkett
- 2Loyola University Chicago Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois; and
| | | | - Sean M Lew
- 3Department of Neurological Surgery, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | | | - Anand V Germanwala
- Departments of1Neurological Surgery and.,4Otolaryngology, Loyola University Medical Center
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7
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Pagella F, Pusateri A, Matti E, Zoia C, Benazzo M, Gaetani P, Cazzador D, Volo T, Borsetto D, Emanuelli E. Endoscopic Management of Spontaneous Clival Cerebrospinal Fluid Leaks: Case Series and Literature Review. World Neurosurg 2015; 86:470-7. [PMID: 26626813 DOI: 10.1016/j.wneu.2015.11.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 11/18/2015] [Accepted: 11/19/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Spontaneous cerebrospinal fluid leaks are most commonly located along the anterior skull base. Sphenoidal localization is less common, and clival localization is even rarer. We analyzed a group of patients with spontaneous leaks and selected patients with clival localization. This article discusses surgical management of these entities and provides a brief literature review regarding spontaneous clival leaks. METHODS Of a cohort of 67 patients who presented to our departments with a spontaneous leak during the period 2005-2014, a retrospective data analysis was performed on 6 patients with clival localization of the defect. A skull base repair with a multilayered reconstruction was performed in 3 patients, and a single-layered reconstruction using a pedicled nasoseptal flap was performed in 3 patients. RESULTS The patients included 6 women with a mean age of 60 years (range, 36-91 years). The mean length of the follow-up period was 69.5 months (range, 22-114 months). The overall success rate of the primary endoscopic repair was 83.3% (5 of 6 patients); this increased to 100% after revision surgery. CONCLUSIONS This series, although numerically limited, suggests that a minimally invasive endoscopic repair of idiopathic clival leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Moreover, the pedicled nasoseptal flap has been confirmed to be the "workhorse" for the reconstruction of clival defects.
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Affiliation(s)
- Fabio Pagella
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Alessandro Pusateri
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy.
| | - Elina Matti
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Cesare Zoia
- Department of Neurosurgery, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Marco Benazzo
- Department of Otorhinolaryngology, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Paolo Gaetani
- Department of Neurosurgery, Fondazione I.R.C.C.S. Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Diego Cazzador
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Tiziana Volo
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Daniele Borsetto
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
| | - Enzo Emanuelli
- Department of Otorhinolaryngology and Otologic Surgery, Azienda Ospedaliera-Policlinico of Padova, University of Padova, Padova, Italy
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8
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Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura. Neurocirugia (Astur) 2015; 26:292-5. [DOI: 10.1016/j.neucir.2015.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 02/19/2015] [Accepted: 02/20/2015] [Indexed: 11/17/2022]
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9
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Kaul S, Khan OH, Edem I, Lwu S, Willinsky R, Vescan A, Zadeh G. Transclival pseudomeningocele secondary to ecchordosis physaliphora: case report and literature review. J Neurol Surg Rep 2013; 74:92-5. [PMID: 24303343 PMCID: PMC3836942 DOI: 10.1055/s-0033-1348956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 04/30/2013] [Indexed: 11/25/2022] Open
Abstract
We describe a 52-year-old woman who presented with meningitis secondary to a pseudomeningocele within the sphenoid sinus derived from a bony defect in the clivus. The bony defect was radiologically characteristic of an ecchordosis physaliphora (EP). She underwent surgical repair of the defect and had resolution of her symptoms. This case report will discuss the second case of transclival pseudomeningocele in the English literature and present EP as a cause.
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Affiliation(s)
- Sakshi Kaul
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Osaama H. Khan
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Idara Edem
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Shelley Lwu
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Robert Willinsky
- Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Allen Vescan
- Department of Otolaryngology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Gelareh Zadeh
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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10
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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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11
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Rocha AJD, Silva CJD. Critical basilar expansion of the sphenoidal sinus associated with a spontaneous cerebrospinal fluid fistula: the relevance of multidetector computed tomographic cisternography. ARQUIVOS DE NEURO-PSIQUIATRIA 2013; 70:905-6. [PMID: 23175209 DOI: 10.1590/s0004-282x2012001100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Antônio José da Rocha
- Section of Neuroradiology, Santa Casa de Misericórdia de São Paulo, São Paulo SP, Brazil.
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12
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Gupta M, Gupta R, Seith A. Persistent primitive hypoglossal artery associated with Chiari II malformation: Diagnosis and clinical implications. Indian J Radiol Imaging 2011; 20:258-60. [PMID: 21423899 PMCID: PMC3056621 DOI: 10.4103/0971-3026.73534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We present a case of persistent primitive hypoglossal artery (PPHA) associated with Chiari II malformation and discuss the clinical implications. There has been one reported case of PPHA associated with Chiari 1 malformation, but none in association with Chiari II. Our patient also had a widened hypoglossal canal, with cerebrospinal fluid (CSF) sac herniation through it.
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Affiliation(s)
- Mudit Gupta
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029, India
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