1
|
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.
Collapse
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
| |
Collapse
|
2
|
Li Z, Ge S, Zhao T, Zhang X, Zhao L, Qu Y. Trans-Defect Underlay Watertight Duraplasty for Traumatic Anterior Skull Base Dural Defect: Technical Report. World Neurosurg 2024; 186:1-6. [PMID: 38395353 DOI: 10.1016/j.wneu.2024.02.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/13/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Watertight duraplasty is essential for surgical management of traumatic anterior skull base (ASB) dural defect but challenging in the deep and narrow operative corridor. Here, the authors report a trans-defect underlay watertight duraplasty (TDUWD) technique for traumatic ASB dural defect. METHODS TDUWD was performed by inserting a free pericranium graft under the dural defect. The diameter of the pericranium graft was larger than the dural defect. The pericranium graft was sutured to the dural defect watertightly in an "inside-to-outside" direction, with the needle not penetrating the inner layer of pericranium graft. The pedicled pericranium flap was used as a second layer of reconstruction. The characteristics, complications, and outcomes of patients who received TDUWD are reported. RESULTS A total of 29 patients received TDUWD. Immediate postoperative cessation of cerebrospinal fluid (CSF) leak occurred in 28 patients. One patient recovered after lumber drainage. No patient needed a second operation or reported delayed recurrence of CSF leak. No complication related to the surgical technique was observed. CONCLUSIONS Use of TDUWD for traumatic ASB dural defect results in an immediate, 1-stage, and definitive correction of CSF leak and seems to be simple, safe, and reliable for large and deeply located dural defects.
Collapse
Affiliation(s)
- Zhihong Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Shunnan Ge
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Tianzhi Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Xingye Zhang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Lanfu Zhao
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China
| | - Yan Qu
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, Shannxi, China.
| |
Collapse
|
3
|
Caro-Osorio E, Acevedo-Castillo CD, Garza-Baez A, Perez-Ruano LA, Figueroa-Sanchez JA. Indirect Fistula: A New Terminology for Cerebrospinal Fluid Fistula With Different 'Apparent Origin' and 'Real Origin'. Cureus 2024; 16:e60250. [PMID: 38872666 PMCID: PMC11170227 DOI: 10.7759/cureus.60250] [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] [Accepted: 04/29/2024] [Indexed: 06/15/2024] Open
Abstract
Fistulas are abnormal communications between body cavities. They can occur between the CNS and the extracranial space, presenting clinically as CSF leaks. Due to the variety of features, multiple classifications have been implemented to better study this pathology. A systematic review was conducted using the Scopus, Medline, and Web of Science databases. Observational studies such as cohort studies, case reports, case series, cross-sectional studies, systematic reviews, and publications that assess the classification of CSF leaks were included. The systematic review identified 29 publications that met the required criteria for inclusion. Although the primary focus of most of these publications was not on classification, they briefly mentioned it. The included publications describe classifications according to etiology, exiting flow pressure, anatomic site, and some new classification proposals. Of the 29 included studies, 11 referred to the appearance of CSF rhinorrhea or otorrhea with no relationship between the cause or site of origin and the site of the CSF leak. However, none of these publications names this situation. These results clearly indicate that a term for this circumstance needs to be established; none of the previously listed publications provide a name for this condition. This systematic review aims to demonstrate the necessity of implementing a new term to describe CSF leaks where the 'apparent origin' does not correspond to the 'real origin.' The results show no existing term that considers such cases; therefore, we propose the term 'Indirect Fistula' to designate these cases.
Collapse
Affiliation(s)
| | - Carlos D Acevedo-Castillo
- Medicine, Instituto de Neurología y Neurocirugía, Hospital Zambrano Hellion TecSalud, San Pedro Garza García, MEX
- Medicine, Tecnológico de Monterrey, Monterrey, MEX
| | | | | | | |
Collapse
|
4
|
张 婷, 卢 醒, 翟 翔. [The value of magnetic resonance hydrography in the localization of fistula in patients with cerebrospinal fluid rhinorrhea]. LIN CHUANG ER BI YAN HOU TOU JING WAI KE ZA ZHI = JOURNAL OF CLINICAL OTORHINOLARYNGOLOGY, HEAD, AND NECK SURGERY 2022; 36:300-303. [PMID: 35511625 PMCID: PMC10128177 DOI: 10.13201/j.issn.2096-7993.2022.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Indexed: 06/14/2023]
Abstract
Objective:To evaluate the application value of magnetic resonance hydrography in determine the leak location of patients with cerebrospinal fluid rhinorrhea. Methods:Clinical data of 58 patients with cerebrospinal fluid rhinorrhea treated in Tianjin Huanhu Hospital from February 2015 to February 2021 were analyzed retrospectively. The leak position was judged by three methods: nasal sinus coronal CT, magnetic resonance hydrography and magnetic resonance hydrography combined with nasal sinus coronal CT. The consistency of the leak position among groups determined by different imageological examination pre-operation was compared with the real leak position found during the operation. Results:The positive rate of magnetic resonance hydrography combined with coronal CT in paranasal sinuses(91.4%) was significantly higher than that of magnetic resonance hydrography(74.1%)(P>0.05). The positive rate of magnetic resonance hydrography(74.1%) was higher than that of CT(43.1%)(P>0.01). Conclusion:The comprehensive application of imaging examination technology has important clinical guiding significance for the correct diagnosis of cerebrospinal fluid rhinorrhea. Magnetic resonance hydrography combined with coronal CT of paranasal sinus can effectively find the leak location, which was suggested as the first choice for preoperative localization of cerebrospinal fluid rhinorrhea.
Collapse
Affiliation(s)
- 婷 张
- 天津市环湖医院影像科(天津, 300350)Department of Imaging, Tianjin Huanhu Hospital, Tianjin, 300350, China
| | - 醒 卢
- 天津市环湖医院耳鼻咽喉头颈外科Department of Otolaryngology Head and Neck Surgery, Tianjin Huanhu Hospital
| | - 翔 翟
- 天津市环湖医院耳鼻咽喉头颈外科Department of Otolaryngology Head and Neck Surgery, Tianjin Huanhu Hospital
| |
Collapse
|
5
|
Shafiei M, Aminmansour B, Mahmoodkhani M, Seyedmoalemi M, Tehrani DS. Basilar Skull Fractures and Their Complications in Patients With Traumatic Brain Injury. Korean J Neurotrauma 2022; 19:63-69. [PMID: 37051043 PMCID: PMC10083455 DOI: 10.13004/kjnt.2022.18.e49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/20/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Since traumatic brain injury is more common in young people, who are the main workforce and builders of society, it is important to consider the effects caused by brain injury on them. In this study, we investigated the clinical manifestations, complications, and prognosis of patients with basilar skull fractures. Methods This cross-sectional study was conducted from March 2021 to March 2022 at the Kashani Hospital, Esfahan, Iran. Patients with basilar skull fractures were included in this study by census for one year. Recorded patient information was divided into two parts: demographic information, including age and sex, and disease information including loss of consciousness, signs of meningitis, need for surgery, and neurologic examination. Results In this study, 100 patients were included, of whom 89 were men. The most common complication was pain at the site of the trauma, followed by bruising and bleeding from the site of the trauma. Raccoon eyes and cerebrospinal fluid leakage were observed in 19% and 32% of the patients, respectively. Conclusion As the occurrence of trauma has an economic burden on the country's health system, we must identify its consequences and problems and prevent its occurrence as much as possible by implementing educational measures.
Collapse
Affiliation(s)
- Mehdi Shafiei
- Department of Neurosurgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bahram Aminmansour
- Department of Neurosurgery, School of Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehdi Mahmoodkhani
- Department of Neurosurgery, School of Medicine, Kashani Hospital, Isfahan University of Medical Sciences, Isfahan, Iran
| | | | | |
Collapse
|
6
|
Abstract
CLINICAL ISSUE Basilar skull fractures are fractures of the lower part of the skull. They make up about 20% of all skull fractures and are mainly caused by high-velocity blunt trauma and falls from high heights. Depending on their precise location, they can be divided into frontobasal, laterobasal and frontolateral fractures. Possible clinical signs are the presence of cerebrospinal fluid rhinorrhea or otorrhea, periorbital ecchymosis (raccoon eyes), retroauricular ecchymosis (battle sign) and cranial nerve injuries. Furthermore, fractures of the petrous bone can lead to a conductive hearing loss, sensorineural hearing loss as well as dizziness and nausea due to a failure of the labyrinth. PRACTICAL RECOMMENDATIONS If there are any clinical signs of a basilar skull fracture, neurological deficits or limited consciousness (GCS < 15), a CT should be performed to rule out a basilar skull fracture and accompanying pathologies. In addition, if vascular injury is suspected, a CT angiography should be performed. Treatment is usually interdisciplinary and depends mainly on the accompanying injuries and possible complications. A purely conservative approach with close controls (with imaging) is often sufficient. The surgical approach is primarily used to treat possible complications, for example intracerebral bleeding.
Collapse
|
7
|
Milton CK, Andrews BJ, Baker CM, O'Connor KP, Conner AK, Sughrue ME, McKinney KA, El Rassi ET, Sanclement JA, Glenn CA. Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma. J Neurol Surg B Skull Base 2020; 83:116-124. [DOI: 10.1055/s-0040-1718765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/19/2020] [Indexed: 10/22/2022] Open
Abstract
Abstract
Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae.
Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported.
Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation.
Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.
Collapse
Affiliation(s)
- Camille K. Milton
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Bethany J. Andrews
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Cordell M. Baker
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Kyle P. O'Connor
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Andrew K. Conner
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Michael E. Sughrue
- Department of Neurosurgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Kibwei A. McKinney
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Edward T. El Rassi
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Jose A. Sanclement
- Department of Otorhinolaryngology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| | - Chad A. Glenn
- Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
| |
Collapse
|
8
|
Mokolane NS, Minne C, Dehnavi A. Prevalence and pattern of basal skull fracture in head injury patients in an academic hospital. SA J Radiol 2019; 23:1677. [PMID: 31754528 PMCID: PMC6837784 DOI: 10.4102/sajr.v23i1.1677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background Basal skull fractures (BSFs) have been reported to be a major cause of morbidity and mortality in the literature, particularly in young male patients. However, there are limited data available on the aetiology, prevalence and patterns of such observed in South Africa. Objectives To evaluate the prevalence and pattern of BSF in head injury patients referred to Dr George Mukhari Academic Hospital, Gauteng, South Africa. Methods Patients of all ages with head injuries were considered for the study, and those who met the inclusion criteria were scanned using a 128-slice multidetector helical computed tomography (CT) machine after obtaining consent. Data were prospectively obtained over a 6-month period, interpreted on an advanced workstation by two readers and statistically analysed. Results The prevalence of BSF in this study was found to be 15.2%. The majority of patients (80.5%) were under 40 years old, with a male to female ratio of 3:1. The most common aetiology of BSF was assault, which accounted for 46% of cases. The middle cranial fossa was the most frequently fractured compartment, while the petrous bone was the most commonly fractured bone. There was a statistically significant association between head injury severity and BSF, and between the number of fracture lines and associated signs of BSF (p < 0.001). The sensitivity of clinical signs in predicting BSF was 31%, while specificity was 89.3% (p = 0.004). Conclusion The prevalence and pattern of BSF found were consistent with data from previously published studies, although, dissimilarly, assault was found to be the most common aetiology in this study.
Collapse
Affiliation(s)
- Ntjeke S Mokolane
- Department of Radiology, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa.,Department of Radiology, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
| | - Cornelia Minne
- Clinical Unit, Dr George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa
| | - Alireza Dehnavi
- Clinical Unit, Dr George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa
| |
Collapse
|
9
|
Varshneya K, Rodrigues AJ, Medress ZA, Stienen MN, Grant GA, Ratliff JK, Veeravagu A. Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.8.focus19543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVESkull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.METHODSThe authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.RESULTSThe authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).CONCLUSIONSThe authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.
Collapse
|