The Association Between Obesity and Spontaneous Temporal Bone CSF Leak Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVE

We undertook a systematic review of the literature with meta-analysis to identify the role of obesity (BMI ≥30) in the patient characteristics presenting with spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base and the outcomes of their repair.

DATA SOURCES

A Systematic Review of English Articles using MEDLINE, EMBASE, and Cochrane Library.

REVIEW METHODS

The research algorithm included the following keywords: "spontaneous CSF leak," "lateral skull base," "temporal bone," "meningocele," "encephalocele," and "otorrhea." We also manually searched the references of included studies, to identify possible studies missed during our literature search.

RESULTS

More than two-thirds of the patients were female (69.2%) and often were obese (mean BMI 36.5 kg/m2) with a mean age of 57. Most common presenting symptoms were otorrhea and hearing loss. Most authors did not report a routine use of a post-operative lumbar drain. Most patients had a single skull base defect and encephaloceles prolapsing through, across obese and non-obese groups. Median length of stay in hospital was 3.2 days, and the majority of patients did not have any recurrence during their follow-up (89.6%), which was not affected by obesity.

CONCLUSION

Obesity does not affect length of hospital stay or recurrence rate following surgical repair of lateral skull base sCSF leaks. Surgical repair is a safe and viable approach in the management of obese patients with sCSF leaks in the temporal bone.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2012-2018, 2024.

Sellar Reconstruction With a Bioabsorbable Plate After Endoscopic Transsphenoidal Pituitary Adenoma Resection: Safe and Efficacious

OBJECTIVE

To report outcomes of a large cohort of patients who underwent endoscopic endonasal transsphenoidal surgery (EETS) for resection of a pituitary adenoma with subsequent Resorb-X plate (RXP) sellar reconstruction.

METHODS

A retrospective review of 620 EETS operations performed at a single academic center between 2005 and 2020 was conducted.

RESULTS

A total of 215 EETS operations of 208 patients were identified between 2012 and 2020 who underwent reconstruction with the RXP after EETS for pituitary tumor resection with a final pathologic diagnosis of pituitary adenoma. Analysis of pooled data revealed a mean preoperative tumor volume of 6.8 cm3 (range: 0.038-51.03 cm3). Postoperative cerebrospinal fluid leak occurred in 2 patients (0.93%). Postoperative meningitis occurred in 1 patient (0.47%). There were no cases of RXP extrusion.

CONCLUSIONS

The rate of postoperative CSF leak and meningitis after use of the RXP for sellar reconstruction compares favorably to other methods, including use of autologous grafts and flaps. Use of RXP during EETS is a safe and efficacious method of sellar reconstruction and may obviate the need for autologous tissue reconstruction after pituitary adenoma resection.

Endoscopic Repair of Anterior Skull Base Cerebrospinal Fluid Leaks is Successful in Frail Patients

OBJECTIVE

Surgical frailty estimates a patient's ability to withstand the physiologic stress of an intervention. There is limited data regarding the impact of frailty on endoscopic cerebrospinal fluid (CSF) leak repair.

METHODS

Patients undergoing CSF leak repair at two tertiary academic skull base programs were retrospectively reviewed. Demographic, treatment, and postoperative outcomes data were recorded. Frailty was calculated using validated indices, including the American Society of Anesthesiologists (ASA) classification, Charlson Comorbidity Index (CCI), and the Modified 5-Item Frailty Index (mFI-5). Outcomes included 30-day medical and surgical complications and readmission.

RESULTS

A total of 185 patients were included with 128 (69.2%) female patients and average age of 54 ± 14 years. The average body mass index was 34.6 ± 8.5. The most common identified etiology was idiopathic intracranial hypertension (IIH) in 64 patients (34.6%). A total of 125 patients (68%) underwent perioperative lumbar drain placement (primarily to measure intracranial pressures and diagnose IIH). Most patients were ASA class 3 (48.6%) with mean CCI 2.14 ± 2.23 and mFI-5 0.97 ± 0.90. Three patients had postoperative CSF leaks, with an overall repair success rate of 98.4%. There was no association between increased frailty and 30-day medical outcomes, surgical outcomes, or readmission (all p > 0.05).

CONCLUSIONS

Endoscopic CSF leak repair in a frail population, including lumbar drain placement and bed rest, was not associated with an increased rate of complications. Previous data suggests increased complications in open craniotomy procedures in patients with significant comorbidities. This study suggests that the endoscopic approach to CSF leak repair is well tolerated in the frail population.

LEVEL OF EVIDENCE

IV Laryngoscope, 2024.

Progressive superficial siderosis despite complete remission of intracranial hypotension symptoms following epidural patching: Case report

Spontaneous intracranial hypotension (SIH) commonly results from ventral spinal cerebrospinal fluid (CSF) leaks and epidural patches are advocated as first-line treatment. Complications such as superficial siderosis can arise but have previously been reported only in the context of long-term persistent, ongoing, CSF leak and SIH. We report a case of a patient with SIH from a ventral spinal CSF leak that was treated with epidural patching and experienced complete resolution of SIH. Four years later SIH symptoms recurred, and brain magnetic resonance imaging unexpectedly showed the interval accumulation of hemosiderin pigmentation on the cerebellum and brainstem during the period when the patient was without symptoms of SIH. This case uniquely demonstrates the progression of superficial siderosis despite the apparent resolution of SIH. Our findings suggest two divergent pathophysiological outcomes from spinal ventral dural tear: (1) CSF loss causing SIH; and (2) persistent low-level bleeding arising from the spinal dural tear leading to superficial siderosis. These divergent pathophysiologies had a discordant response to epidural patching. Epidural patching successfully treated the SIH but did not prevent the progression of superficial siderosis, indicating that some patients may require more than epidural patching despite symptom resolution. This case highlights the need for post-treatment monitoring protocols in patients with ventral spinal CSF leaks and SIH and raises important questions about the adequacy of epidural patching in certain SIH cases arising from ventral spinal CSF leak.

Side-door temporoparietal fascia flap: First experience with a novel technique for anterior skull base reconstruction

BACKGROUND

Modern achievements in transnasal endoscopic skull base (SB) surgery have led to complex resections that render reconstruction a challenge. Temporoparietal fascia flap (TPFF) is a suitable option for SB reconstruction. The side-door TPFF technique for anterior SB reconstruction is described here for the first time in a real-life surgical setting.

METHODS

Patients affected by a SB malignancy who underwent cranioendoscopic resection were included. For reconstruction, a multilayer reconstruction technique including side-door TPFF transposition was employed.

RESULTS

TPFF transposition was performed in five patients. The TPFF could be easily transposed via a side-door approach. It adequately covered the edges of the defect and supported optimal healing of the surgical site. During follow-up, vitality and integration of the TPFF were assessed endoscopically and radiologically.

CONCLUSIONS

The TPFF side-door transposition technique is a valuable option in anterior SB reconstruction that can provide fast and effective healing, especially in patients needing adjuvant radiotherapy.

Short Postoperative Length of Stay After Lateral Cerebrospinal Fluid Leak Repair

OBJECTIVE

To characterize the short-term outcomes of patients undergoing surgical repair of lateral skull base cerebrospinal fluid (CSF) leaks followed by a shortened length of stay (LOS) protocol.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary medical center.

METHODS

A total of 156 adult patients from July 2016 to December 2022 who underwent repair of CSF leaks via transmastoid (TM), middle cranial fossa (MCF), or combined (TM/MCF) approaches were included. Data collected included: LOS, presentation to the emergency department (ED), need for readmission, major neurologic complications (stroke, seizure, and meningitis), and CSF leak recurrence.

RESULTS

Approximately half of patients underwent a TM repair (49.4%), whereas the other half underwent either an MCF (3.8%) or combined TM/MCF repair (46.8%). No peri-/postoperative lumbar drains were used and only 2 (1.3%) patients were admitted to the intensive care unit after surgery. Mean LOS for the cohort was 1.1 ± 0.7 days and was longer for surgeries involving MCF (1.3 ± 0.6) compared to TM (0.8 ± 0.7). Ninety-two percent of TM cases were discharged within 24 hours (32% on the same day) while for cases involving an MCF approach, 72.2% of patients were discharged within 24 hours. Of the patients in the study, 6 (3.8%) presented to an ED for minor complications and no patient required readmission. Revision surgery was required for 3 (1.9%) patients for recurrent CSF leak.

CONCLUSION

Our findings suggest that short LOS after surgical repair of lateral skull base defects in the treatment of CSF leak is safe and effective.

Anatomic Relationship Between the Head of the Middle Turbinate and First Olfactory Filum: A Radiographic Assessment

BACKGROUND

The endoscopic modified Lothrop procedure (EMLP) has become a frequently utilized procedure in rhinologic surgery. One of the most serious complications of the procedure is cerebrospinal fluid leak, which may occur due to lack of recognition of the anterior skull base in the region of the first olfactory filum (FOF), or direct injury to the FOF itself.

OBJECTIVES

To evaluate the position of the head of the middle turbinate (MT) relative to the FOF, which is an important landmark in the EMLP.

METHODS

A series of previously obtained patient computed tomography scans of the sinus were reviewed. A reproducible process was implemented to obtain the measurements. First, the FOF was identified on an axial series. Using a localization feature of the radiographic software, this anteroposterior (AP) position could be visualized in a coronal plane. Subsequently, the MT was viewed in a sagittal plane, where a measurement between the head of the MT and the AP position of the FOF could be performed.

RESULTS

The AP distance between the head of the MT and the FOF was measured in 92 patients. The head of the MT was either at or anterior to the FOF in all measured subjects. The mean anterior distance of the head of the MT to FOF was 3.6 mm (±2.4 mm) on the right, and 3.8 mm (±2.2 mm) on the left. The range in AP distance was 0 to 12 mm. There was no significant difference in AP distance between the head of the MT and FOF based on gender (P = .413) or diagnosis (P = .254).

CONCLUSIONS

In our study, the head of the MT was reliably at or anterior to the FOF in all subjects, suggesting its utility as a fixed landmark in endoscopic sinus surgery, particularly in the EMLP.

LEVEL OF EVIDENCE

N/A.

Intracranial findings in spontaneous intracranial hypotension: Does the severity of abnormalities correspond with certainty and/or multifocality of cerebrospinal fluid leaks?

BACKGROUND AND PURPOSE

Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leaks. This study assessed whether the certainty and/or multifocality of CSF leaks is associated with the severity of intracranial sequelae of SIH.

MATERIALS AND METHODS

A retrospective review was completed of patients with suspected SIH that underwent digital subtraction myelogram (DSM) preceded by brain MRI. DSMs were evaluated for the presence or absence of a CSF leak, categorized both as positive/negative/indeterminate and single versus multifocal. Brain MRIs were assessed for intracranial sequelae of SIH based on two probabilistic scoring systems (Dobrocky and Mayo methods). For each system, both an absolute "numerical" score (based on tabulation of findings) and "categorized" score (classification of probability) were tabulated.

RESULTS

174 patients were included; 113 (64.9%) were female, average age 52.0 ± 14.3 years. One or more definite leaks were noted in 76 (43.7%) patients; an indeterminate leak was noted in 22 (12.6%) patients. 16 (16.3%) had multiple leaks. There was no significant difference in the severity of intracranial findings between patients with a single versus multiple leaks (p values ranged from .36 to .70 using categorized scores and 0.22-0.99 for numerical scores). Definite leaks were more likely to have both higher categorized intracranial scores (Mayo p = .0008, Dobrocky p = .006) and numerical scores (p = .0002 for Mayo and p = .006 for Dobrocky).

CONCLUSIONS

Certainty of a CSF leak on diagnostic imaging is associated with severity of intracranial sequelae of SIH, with definite leaks having significantly more intracranial findings than indeterminate leaks. Multifocal leaks do not cause greater intracranial abnormalities.

Intrathecal hematoma following epidural blood patch: An alternative mechanism to intrathecal puncture

Intrathecal blood after a percutaneous epidural blood patch is a known complication, one that has been previously attributed to inadvertent needle tip position in the subarachnoid space. We present two cases with imaging confirmation of an alternative mechanism, one that includes blood transferring from the epidural space to the subarachnoid space through a pre-existing dural defect.

Tissue Sealant Impact on Skull Base Reconstruction Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVE

Despite significant advances in understanding of skull base reconstruction principles, the role of tissue sealants in modifying postoperative cerebrospinal fluid (CSF) leak outcomes remains controversial. We evaluate postoperative CSF leak incidence associated with tissue sealant use in skull base defect repair during endoscopic skull base surgery (ESBS).

DATA SOURCES

Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library.

REVIEW METHODS

Systematic review and meta-analysis of risk differences (RD). A search strategy identified original studies reporting CSF leakage following ESBS with disaggregation by tissue sealant use and/or type.

RESULTS

27 non-randomized studies (n = 2,403) were included for qualitative and meta-analysis. Reconstruction with a tissue sealant did not significantly reduce postoperative CSF leak risk compared with reconstruction without sealant (RD[95% CI] = 0.02[-0.01, 0.05]). Sub-analyses of dural sealant (-0.02[-0.11, 0.07]) and fibrin glue (0.00[-0.07, 0.07]) compared with no sealant were similarly unremarkable. Postoperative CSF leakage was not significantly modulated in further sub-analyses of DuraSeal (0.02[-0.02, 0.05]), Adherus (-0.03[-0.08, 0.03]), or Bioglue (-0.06[-0.23, 0.12]) versus no dural sealant use, or Tisseel/Tissucol versus fibrin glue nonuse (0.00[-0.05, 0.05]). No significant association was seen comparing dural sealant use versus fibrin glue use on pairwise (0.01[-0.03, 0.05]) or network meta-analysis (-0.01[-0.05, 0.04]). Limitations in source literature prevented sub-analyses stratified by leak characteristics, defect size and location, and accompanying reconstruction materials.

CONCLUSION

Tissue sealant use did not appear to impact postoperative CSF leak incidence when compared with nonuse. Higher quality studies are warranted to thoroughly elucidate the clinical value of adjunct sealant use in endoscopic skull base reconstruction.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2024.

Cranial Nerve Six Palsy After Vaginal Delivery with Epidural Anesthesia: A Case Report

BACKGROUND

This case report describes a 34-year-old woman who developed diplopia and strabismus 2 weeks after a vaginal delivery and epidural anesthesia.

CASE REPORT

A 34-year-old women presented to the emergency department (ED) with continued headache and new-onset diplopia after having undergone epidural anesthesia for a vaginal delivery 2 weeks prior. During that time, she underwent two blood patches, rested supine, drank additional fluids, and consumed caffeinated products for her spinal headache. When she developed double vision from a cranial nerve VI palsy, she returned to the ED. At that time, she had a third blood patch performed, and she was evaluated by a neurologist. The medical team felt the cranial nerve VI palsy was due to the downward pull of the brain and stretching of the nerve. Magnetic resonance imaging and neurosurgical closure of the dura were considered as the next steps in treatment; however, they were not performed after being declined by the patient. All symptoms were resolved over the next 3 weeks. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case illustrates the uncommon complication of a cranial nerve VI palsy from a persistent cerebrospinal fluid leak after a dural puncture. Emergency physicians must be aware that diplopia can be a rare presenting symptom after patients undergo a lumbar puncture. Furthermore, emergency physicians should be aware of the multiple treatment options available. Knowledge of the timeline of resolution of the diplopia is necessary to make shared decisions with our patients about escalating care.

Impact of collagen matrix on reconstructive material selection and postoperative complications in endoscopic endonasal skull base surgery

OBJECTIVE

The aim of this study was to investigate the impact of collagen matrix on reconstructive material selection and postoperative complications in endoscopic endonasal skull base surgery.

METHODS

The authors retrospectively reviewed the data of consecutive patients who underwent purely endoscopic endonasal skull base surgery from January 2015 to March 2023. Intraoperative CSF leakage was classified according to the Esposito grade, and skull base repair was tailored to the leakage grade. The patients were divided into two groups: before (group A) and after (group B) collagen matrix implementation. The rates of autologous graft harvesting (fat, fascia, and nasoseptal flap), postoperative CSF leakage, and donor-site complications were compared between the two groups.

RESULTS

In total, 270 patients were included. Group A included 159 patients and group B included 111 patients. There were no differences in patient characteristics, including age, pathology, and Esposito grade, between the two groups. The overall fat usage rate was significantly higher in group A (63.5%) than in group B (39.6%) (p = 0.0001), and the fascia usage rate was also significantly higher in group A (25.8%) than in group B (4.5%) (p < 0.0001). The nasoseptal flap usage rate did not differ between group A (32.7%) and group B (30.6%) (p = 0.79). Postoperative CSF leakage was similar between the two groups (0.63% in group A vs 1.8% in group B, p = 0.57), and the overall rate of CSF leakage was 1.1%. Donor-site complications occurred in 3 patients in group A, including 1 abdominal hematoma, 1 delayed abdominal infection, and 1 fluid collection after fascia lata harvesting.

CONCLUSIONS

Collagen matrix implementation significantly decreased autologous graft harvesting without increasing postoperative CSF leakage, contributing to less invasive surgery.

Predictors and Complications of Cerebrospinal Fluid Leak after Endoscopic Endonasal Surgery: A Single Institution Retrospective Review

Background  The endoscopic endonasal approach (EEA) is a commonly used technique for resection of sellar, suprasellar, and anterior fossa masses. One of the most troublesome complications of this technique is cerebrospinal fluid (CSF) leak. In this study, we evaluate the risk factors and consequences of CSF leak on surgical outcomes. Methods  The current study is a retrospective single-institution cohort study evaluating patients who underwent EEA for sellar and/or suprasellar masses from July 2017 to March of 2020. Risk factors for intraoperative and postoperative CSF leak were evaluated, including sellar defect size, tumor volume and pathology, age, body mass index, prior endoscopic endonasal surgery, lumbar drain placement, nasoseptal and mucosal graft use, year of surgery, and cavernous sinus invasion. Postoperative infection, perioperative antibiotic use, and length of stay were also evaluated. Results  Our study included 175 patients. Sellar defect size ( p  = 0.015) and intraoperative CSF leak ( p  < 0.001) were significantly associated with an increased risk of postoperative CSF leak. Patients with nasoseptal flaps were more likely to have a postoperative CSF leak than those with free mucosal grafts ( p  = 0.025). Intraoperative CSF leak, Cushing's disease, and lumbar drain placement were associated with an increased length of stay. Conclusion  Sellar defect size, intraoperative CSF leak, and nasoseptal flap use were associated with an increased risk of postoperative CSF leak. Intraoperative CSF leak, Cushing's disease, and lumbar drain placement are all associated with an increased length of stay.

Risk Factors Associated with Postoperative CSF Leak in Extrasellar Tumors

Objective  While postoperative cerebrospinal fluid (CSF) leak rates of pituitary tumors have been frequently studied, there are fewer studies examining postoperative CSF leak rates for extrasellar tumors. The purpose of this study was to identify risk factors for the development of postoperative CSF leak in patients undergoing endoscopic surgery for extrasellar tumors. Methods  A retrospective chart review was done for patients who underwent endoscopic resection for extrasellar tumors between 2008 and 2020. Age, gender, tumor type, tumor location, tumor size, reconstruction technique, medical comorbidities, and other potential risk factors were identified. Data was analyzed to identify significant risk factors for development of postoperative CSF leak. Results  There were 100 patients with extrasellar tumors who developed intraoperative CSF leaks. Seventeen patients (17%) developed postoperative CSF leaks. Leaks occurred at a median of 2 days following surgery (range 0-34 days). Clival tumors had a significantly higher incidence of postoperative leak than those in other sites ( p  < 0.05). There were no significant differences in other locations, body mass index, tumor size, reconstruction technique, medical comorbidities, or other factors. There were nearly twice as many intraoperative grade III leaks in those who developed postoperative CSF leak, but this was not statistically significant ( p  = 0.12). Conclusion  Extrasellar tumors, particularly clival tumors, have a higher rate of postoperative CSF leak than pituitary tumors. Prophylactic lumbar drains can be considered for patients at high risk for developing postoperative CSF leak.

Sphenoid Meningoencephalocele Correction Through a Transpterygoid Approach

Sphenoid meningoencephaloceles are rare, and their treatment is challenging. In this report, we describe two clinical cases of sphenoid meningoencephalocele, in which one patient presented with a cerebrospinal fluid leak after repeated head trauma, while in the other, sphenoid meningoencephalocele was detected during the study of memory impairment as the patient was otherwise asymptomatic. The CT scans showed bony dehiscence on the lateral wall of the sphenoid sinus filled with soft tissue that was confirmed by MRI as being herniated brain tissue. A transpterygoid endoscopic endonasal approach was performed with a multilayer reconstruction of the defect with success in both cases without perioperative complications. Imaging techniques are fundamental for diagnosis and surgical planning. Treatment using an endoscopic endonasal approach is efficient with very low morbidity.

Risk factors for cerebrospinal fluid leak after extended endoscopic endonasal surgery for adult patients with craniopharyngiomas: a multivariate analysis of 364 cases

OBJECTIVE

Over the last decade, the extended endoscopic endonasal approach (EEEA) has evolved as a credible surgical alternative for removing craniopharyngiomas. However, postoperative cerebrospinal fluid (CSF) leak remains one of the most pressing concerns. Craniopharyngiomas often invade the third ventricle, resulting in a higher rate of third ventricle opening after surgery and potentially increasing the risk of postoperative CSF leak. Identifying the risk factors associated with CSF leak after EEEA for craniopharyngiomas may have more clinical value. Nevertheless, there is a lack of systematic studies on the topic. Previous studies yielded inconsistent results, probably due to heterogeneous pathologies or small sample sizes. Hence, the authors present the largest known single-institution case series of the use of purely EEEA for craniopharyngiomas to systematically study the risk factors for postoperative CSF leak.

METHODS

The authors retrospectively reviewed 364 cases of adult patients with craniopharyngiomas who were treated at their institution from January 2019 to August 2022, and they analyzed the risk factors for postoperative CSF leak.

RESULTS

The overall rate of postoperative CSF leak was 4.7%. In the univariate analysis, larger dural defect size (OR 8.293, 95% CI 3.711-18.534, p < 0.001) and lower preoperative serum albumin level (OR 0.812, 95% CI 0.710-0.928, p = 0.002) were associated with higher rates of postoperative CSF leak. Predominantly cystic tumors (OR 0.325, 95% CI 0.122-0.869, p = 0.025) were linked to decreased risk of postoperative CSF leak. However, postoperative lumbar drainage (OR 2.587, 95% CI 0.580-11.537, p = 0.213) and third ventricle opening (OR 1.718, 95% CI 0.548-5.384, p = 0.353) were not related to postoperative CSF leak. In the multivariate analysis, larger dural defect size (OR 8.545, 95% CI 3.684-19.821, p < 0.001) and lower preoperative serum albumin level (OR 0.787, 95% CI 0.673-0.919, p = 0.002) were identified as independent risk factors for postoperative CSF leak.

CONCLUSIONS

The authors' repair technique yielded a reliable reconstructive outcome for high-flow CSF leak in EEEA for craniopharyngioma. Lower preoperative serum albumin level and larger dural defect size were identified as independent risk factors for postoperative CSF leak, potentially providing new insights into minimizing the risk of postoperative CSF leak. Third ventricle opening was not associated with postoperative CSF leak. Lumbar drainage may not be necessary for high-flow intraoperative leak, but this finding may require validation with a prospective randomized controlled trial in the future.

Transverse Venous Sinus Stenosis in Patients With Nasal Cerebrospinal Fluid Leak and Idiopathic Intracranial Hypertension

OBJECTIVE

Spontaneous nasal cerebrospinal fluid (CSF) leaks are frequently linked to idiopathic intracranial hypertension (IIH). The objectives of our study were: (1) to determine the rate of transverse venous sinus stenosis (TVSS) in patients with spontaneous nasal CSF leak and in patients with IIH without CSF (controls), and (2) to study the correlation between spontaneous nasal CSF leak and brain imaging features.

STUDY DESIGN

A multicenter retrospective case-control study.

SETTING

Six French tertiary hospitals.

METHODS

Patients with spontaneous nasal CSF leaks and patients with IIH without nasal CSF leaks (controls) were included. The transverse venous sinus patency was analyzed by magnetic resonance imaging to identify possible stenosis or hypoplasia.

RESULTS

Thirty-two patients with spontaneous nasal CSF leaks and 32 controls were included. TVSS was significantly more frequent in patients with spontaneous nasal CSF leaks than in controls (p = .029). Univariate analysis indicated that TVSS (odds ratio, OR: 4.2; 95% confidence interval, CI [1.352-14.915]; p = .017) and arachnoid granulations (OR: 3; 95% CI [1.065-8.994]; p = .042) were risk factors for spontaneous nasal CSF leak. In multivariate analysis, TVSS and arachnoid granulations were independent risk factors of nasal CSF leak (OR: 5.577, 95% CI [1.485-25.837], p = .016; and OR: 4.35, 95% CI [1.234-17.756], p = .029, respectively).

CONCLUSION

This multicenter case-control study shows that TVSS is an independent risk factor for CSF leak in patients with IIH. Stenosis management by interventional radiology may be proposed postoperatively to increase the success of IIH surgical treatment or preoperatively to reduce the need for surgery.

Risk Factors for Anterior Skull Base Injury in Endoscopic Sinus Surgery

Objectives This retrospective study aimed to investigate the relationships between the Keros classification, the Gera classification, the vertical height of the posterior ethmoid roof (ER), and anterior ethmoidal artery (AEA) types in Japanese patients. Methods We investigated the computed tomography (CT) slices of paranasal sinuses (120 sides) of 60 patients; measured the cribriform plate (CP) depth, lateral lamella CP angle (LLCPA), and vertical height of the lateral ER from the hard palate (LERHP) at the coronal plane of the posterior ethmoidal artery (PEA); and reviewed the AEA types, whether floating or non-floating. Results CP depth was positively correlated with LLCPA (r=0.63; p<0.01) and the height of LERHP (r=0.19; p<0.05). The height of the LERHP in females was significantly lower than that in males. With increased CP depth, floating AEAs became prevalent (p<0.001). Conclusion In females, low height of the posterior ethmoid sinus roof, where cerebrospinal fluid (CSF) leaks occurred while penetrating the basal lamella, often existed; the heights positively correlated with the Keros classification in Japanese patients. The Keros and Gera classifications, AEA type, and posterior ER height do not individually constitute a complete risk assessment but may correlate, preventing major complications, such as CSF leak and orbital hemorrhage.

Predictors of extent of resection and recurrence following endoscopic endonasal resection of craniopharyngioma

OBJECTIVE

Craniopharyngioma is a benign but surgically challenging brain tumor. Controversies exist regarding its ideal treatment strategy, goals of surgery, efficacy of radiation, and the long-term outcomes of these decisions. The authors of this study performed a detailed analysis of factors predictive of the extent of resection and recurrence in large series of craniopharyngiomas removed via an endoscopic endonasal approach (EEA) with long-term follow-up.

METHODS

From a prospective database of all EEAs done at Weill Cornell Medical College by the senior author from 2004 to 2022, a consecutive series of histologically proven craniopharyngiomas were identified. Gross-total resection (GTR) was generally the goal of surgery. Radiation was often given if GTR had not been achieved. The stalk was preserved if not infiltrated with tumor but was sacrificed to achieve GTR. Intentional subtotal resection (STR) was performed in select cases to avoid hypothalamic injury.

RESULTS

Among the 111 identified cases were 88 adults and 23 children. Newly diagnosed cases comprised 58.6% of the series. GTR was attempted in 77.5% of the patients and among those cases was achieved in 89.5% of treatment-naive tumors and 72.4% of recurrent tumors. An inability to achieve GTR was predicted by prior surgical treatment (OR 0.13, 95% CI 0.03-0.6, p = 0.009), tumor diameter ≥ 3.5 cm (OR 0.11, 95% CI 0.02-0.53, p = 0.006), and encasement of the optic nerve or a major artery (OR 0.11, 95% CI 0.01-0.8, p = 0.03). GTR with stalk preservation maintained some anterior pituitary function in 64.5% of cases and prevented diabetes insipidus in 25.8%. After a median follow-up of 51 months (IQR 17-80 months), the recurrence rate after GTR was 12.5% compared with 38.5% after non-GTR. The median recurrence-free survival was 5.5 years after STR, 8.3 years after near-total resection (≥ 98%), and not reached after GTR (p = 0.004, log-rank test). GTR was the strongest predictor of recurrence-free survival (OR 0.09, 95% CI 0.02-0.42, p = 0.002), whereas radiation did not show a statistically significant impact (OR 1.17, 95% CI 0.45-3.08). In GTR cases, the recurrence rate was higher if the stalk had been preserved (22.6%) as opposed to a sacrificed stalk (4.9%; OR 5.69, 95% CI 1.09-29.67).

CONCLUSIONS

The study data show that GTR should be the goal of surgery in craniopharyngiomas if it can be achieved safely. Although stalk preservation can maintain some endocrine function, the risk of recurrence is higher in such cases. Radiation may not be as effective as previously reported.

Systematic review of errors on beta-2 transferrin gel electrophoresis testing of rhinorrhea and otorrhea

BACKGROUND

Beta-2 transferrin (B2-Tf) gel electrophoresis (GE) is the preferred non-invasive diagnostic modality for confirming cerebrospinal fluid (CSF) in body fluids. While B2-Tf GE testing is highly sensitive and specific for CSF, false-positive (FP) and false-negative (FN) results can lead to diagnostic and therapeutic dilemmas. Several series have demonstrated potential causes of false B2-Tf GE results, but few studies have reported reasons for these errors. The purpose of this systematic review was to describe sources of B2-Tf GE errors.

METHODS

A systematic review was performed by searching OVID, EMBASE, and Web of Science databases for B2-Tf GE studies. After applying exclusion criteria, original research studies directly addressing erroneous B2-Tf GE results underwent qualitative analysis.

RESULTS

Of the 243 abstracts screened, 71 underwent full-text review and 18 studies reporting B2-Tf GE errors were included for analysis. There were 15 potential FPs, 12 actual FPs, 12 potential FNs, 19 actual FNs, and 14 indeterminate results. There were also 246 potentially indeterminate results from in vitro studies. Reasons for B2-Tf GE errors included serum transferrin alterations (n = 17; all potential), infection related (n = 13; 9 potential), orbital or salivary contamination (n = 2; 1 potential), and collection related (n = 255; 246 potential). There were 31 false or indeterminate results with unspecified reasons. There were no reported errors due to laboratory processing.

CONCLUSIONS

Multiple potential or actual reasons for false or indeterminate results have been reported for B2-Tf GE testing of rhinorrhea and otorrhea. Future studies should explore reasons for B2-Tf testing errors and how these may affect clinical decision making.

Tension pneumocephalus following bariatric surgery: case report

Bariatric surgery is an effective treatment for patients with idiopathic intracranial hypertension (IIH), a condition that is associated with skull base defects. A 55-year-old woman presented with symptoms of intractable nausea and vomiting, followed by headache and confusion two weeks after an elective laparoscopic vertical sleeve gastrectomy procedure. She had a presumed diagnosis of IIH and a remote history of CSF oto/rhinorrhea treated with a lumbar peritoneal (LP) shunt. Computed tomography (CT) scan of the head revealed tension pneumocephalus with midline shift and dehiscence of the tegmen. The patient underwent emergent craniotomy for decompression of the air-filled temporal lobe, clamping of the LP shunt, and repair of the skull base defect. Caution should be exercised in obese patients with a history of CSF leak secondary to a middle fossa skull base defect when being evaluated for bariatric surgery.

Airway Complications After Anterior Cervical Spine Surgery: Etiology and Risk Factors

STUDY DESIGN

Narrative Review.

OBJECTIVE

To provide an overview of etiology and risk factors of airway complications after anterior cervical spine surgery (ACSS).

METHODS

A search was performed in PubMed and adapted for use in other databases, including Embase, Cochrane Library, Cochrane Register of Controlled Trials, Health Technology Assessment database, and NHS Economic Evaluation Database.

RESULTS

81 full-text studies were reviewed. A total of 53 papers were included were included in the review and an additional four references were extracted from other references. 39 papers were categorized as etiology and 42 as risk factors.

CONCLUSIONS

Most of the literature on airway compromise after ACSS is level III or IV evidence. Currently, there are no systems in place to risk-stratify patients undergoing ACSS regarding airway compromise or guidelines on how to manage patients when these complications do occur. This review focused on theory, primarily etiology and risk factors.

Radionuclide Cisternography with [64Cu]Cu-DOTA

Radionuclide cisternography (RNC) is a method for conducting imaging of the cerebrospinal system and can be used to identify cerebrospinal fluid leaks. So far, RNC has commonly employed radiopharmaceutical agents suitable only for single-photon emission tomography techniques, which are thus lacking in terms of image resolution and can potentially lead to false-negative results. Therefore, [64Cu]Cu-DOTA was investigated as an alternative radiopharmaceutical for RNC, employing positron emission tomography (PET) instead of single-photon emission tomography. A formulation of [64Cu]Cu-DOTA was produced according to the guidelines for good manufacturing practice. The product met the requirements of agents suitable for intrathecal application. [64Cu]Cu-DOTA was administered to a patient and compared to the approved scintigraphic RNC agent, [111In]In-DTPA. While no cerebrospinal fluid leak was detected with [111In]In-DTPA, [64Cu]Cu-DOTA RNC exhibited a posterolateral leak between the vertebral bodies C1 and C2. Thus, in this patient, PET RNC with [64Cu]Cu-DOTA was superior to RNC with [111In]In-DTPA. Since radiopharmaceuticals have a very good safety profile regarding the occurrence of adverse events, PET RNC with [64Cu]Cu-DOTA may become an attractive alternative to scintigraphic methods, and also to computed tomography or magnetic resonance imaging, which often require contrast agents, causing adverse events to occur much more frequently.

Development of a shortwave infrared sinuscope for the detection of cerebrospinal fluid leaks

Significance

Cerebrospinal fluid (CSF) rhinorrhea (leakage of brain fluid from the nose) can be difficult to identify and currently requires invasive procedures, such as intrathecal fluorescein, which requires a lumbar drain placement. Fluorescein is also known to have rare but significant side effects including seizures and death. As the number of endonasal skull base cases increases, the number of CSF leaks has also increased for which an alternative diagnostic method would be highly advantageous to patients.

Aim

We aim to develop an instrument to identify CSF leaks based on water absorption in the shortwave infrared (SWIR) without the need of intrathecal contrast agents. This device needed to be adapted to the anatomy of the human nasal cavity while maintaining low weight and ergonomic characteristics of current surgical instruments.

Approach

Absorption spectra of CSF and artificial CSF were obtained to characterize the absorption peaks that could be targeted with SWIR light. Different illumination systems were tested and refined prior to adapting them into a portable endoscope for testing in 3D-printed models and cadavers for feasibility.

Results

We identified CSF to have an identical absorption profile as water. In our testing, a narrowband laser source at 1480 nm proved superior to using a broad 1450 nm LED. Using a SWIR enabling endoscope set up, we tested the ability to detect artificial CSF in a cadaver model.

Conclusions

An endoscopic system based on SWIR narrowband imaging can provide an alternative in the future to invasive methods of CSF leak detection.

Anterior and Lateral Skull Base Spontaneous CSF Leaks: Evaluation of Comorbidities and Treatment Outcomes

OBJECTIVES

To evaluate clinical characteristics and outcomes of patients diagnosed with anterior (ASB) or lateral skull base (LSB) spontaneous cerebrospinal fluid (sCSF) leak.

METHODS

Single center retrospective review of patients diagnosed with sCSF leaks of ASB or LSB between 1/1/2009 and 11/1/2019 (n = 69). Body mass index (BMI), gender, age at diagnosis, origin of CSF leak (ASB vs LSB), surgical approach, lumbar drain use, recurrence, pre-operative diagnosis of diabetes mellitus (DM), and obstructive sleep apnea (OSA) were collected.

RESULTS

69 patients included in this study met criteria for sCSF leak without a traumatic or iatrogenic cause (Female: 51 (74%); average BMI: 37.0 ± 7.9). Forty-eight (70.0%) presented with sCSF leaks of the lateral skull base. All ASB leaks were treated with an endoscopic transnasal approach. Eleven (22.9%) LSB leak patients were treated using transmastoid approaches and 35 (72.9%) patients with a middle cranial fossa approach. Eleven patients (15.9%) reported sCSF leak recurrence. Two patients (9.5%) with anterior skull base and 9 patients (18.8%) with lateral skull base leaks had recurrence. LSB sCSF leaks had a relative risk of 2.192 of recurrence compared to ASB leaks (95% CI: 0.431-11.157, P = .483). A 5.017 times increased risk (95% CI: 1.285-19.583, P = .020) was reported for patients with OSA, while the risks for DM and BMI were 1.351 (95% CI: 0.67-9.105, P = .177) and 1.026 (95% CI: 0.963-1.094, P = .426) respectively. Patients with sCSF leak recurrence had significantly lower lumbar drain use (33.3%) than those without recurrence (72.7%) (P = .049).

CONCLUSION

Spontaneous CSF leak recurrence is complex and multifactorial, and while patients with both DM and OSA had the higher risk of recurrence, OSA is likely an independent clinical risk factor for sCSF leak recurrence in this patient population.

A causative role for remote dural puncture and resultant arachnoid bleb in new daily persistent headache: A case report

A 24-year-old woman experienced a postdural puncture headache following a labor epidural, recovered following bedrest, and was then without headache for 12 years. She then experienced sudden onset of daily, holocephalic headache persisting for 6 years prior to presentation. Pain reduced with prolonged recumbency. MRI brain, MRI myelography, and later bilateral decubitus digital subtraction myelography showed no cerebrospinal fluid (CSF) leak or CSF venous fistula, and normal opening pressure. Review of an initial noncontrast MRI myelogram revealed a subcentimeter dural outpouching at L3-L4, suspicious for a posttraumatic arachnoid bleb. Targeted epidural fibrin patch at the bleb resulted in profound but temporary symptom relief, and the patient was offered surgical repair. Intraoperatively, an arachnoid bleb was discovered and repaired followed by remission of headache. We report that a distant dural puncture can play a causative role in the long delayed onset of new daily persistent headache.

Intracranial Hypotension Syndrome: The Importance of Neurointensive Care

Surgical procedures involving the spine can result in various complications, including vascular, nerve root and dura mater injury, surgical wound infection, and hematoma formation. Unintentional durotomy is a frequent complication of these procedures (up to 17%). Two clinical cases are reported in which the occurrence of epileptiform activity in the form of generalized tonic-clonic seizures after instrumentation of the dorsal and lumbar spine raised suspicion of cerebrospinal fluid (CSF) fistula. In both cases, the diagnostic suspicion and early approach allowed for the adoption of a timely medical and surgical plan, with the aim of reducing the volume of lost CSF as well as the potential neurological dysfunction resulting from this surgical complication.

Acute Bacterial Meningitis and Petrous Apicitis in a Child with Aplasia Cutis Congenita: A Case Report

Petrous apicitis and acute bacterial meningitis are uncommon in the present antibiotic era. The diagnosis of petrous apicitis is seldom considered unless there is cranial nerve palsy. A young child with aplasia cutis congenita presented with acute bacterial meningitis and an incidental opacified left mastoid in brain imaging. During the course, fever persisted, and high-resolution temporal bone imaging showed rapid progression to coalescent mastoiditis, petrous apicitis with erosions of tegmen tympani, and petrous apex. Other findings included bony dehiscences and thinning of left calvaria. Tympanomastoid exploration showed herniated brain and cerebrospinal fluid leak through tegmen tympani, which was closed with temporalis fascia graft. Herein, we report a rare presentation of petrous and tegmen erosion along with aplasia cutis congenita and discuss the challenges in diagnosis and management.

Case report: Post-traumatic Tourette syndrome resolving with treatment of jugular venous narrowing; reconciling organic brain dysfunction following whiplash trauma with the absence of direct brain injury

We describe a man aged 33 years who developed multiple symptoms, personality change, and a severe tic disorder following a road traffic accident, which were undiminished for 3 years until jugular venous narrowing between the styloid process of the skull and the transverse process of the C1 vertebra was treated by surgical decompression. Immediately following surgery, his abnormal movements almost completely resolved, with no regression in 5 years of follow-up. Vigorously debated at the time was whether or not his condition represented a functional disorder. Unrecognized throughout his illness, however, was a complaint of intermittent, profuse discharge of clear fluid from his nose that began on the day of the accident and continued up to the time of surgery, after which it was substantially reduced. This outcome reinforces the idea that jugular venous narrowing can cause or perpetuate a cerebrospinal fluid leak. It suggests that the interaction between these two pathological defects may have a profound effect on brain function in the absence of any demonstrable brain lesion. It invites a reevaluation of normal head and neck venous anatomy. It should strike a cautionary note in the diagnosis of functional illness. It invites exploration of a remediable structural cause for Tourette syndrome.

Comparing two techniques of performing an epidural catheter-assisted epidural blood patch using a 20 ml syringe versus a 5 ml syringe and its effect on clotting time, the strength of clot retraction and haemolysis - A prospective in vitro study (EC-EBP study)

Background and Aims

Epidural blood patch (EBP) is performed by injecting autologous blood into the epidural space using a Tuohy needle. Certain clinical scenarios mandate an epidural catheter (EC)-assisted EBP. Collecting blood in a 20-ml versus 5-ml syringe appears to influence the quality of the clot. This in vitro study compared the techniques of performing the EC-assisted EBP using 20-ml versus 5-ml syringe on clotting time (CT), clot retraction (CR) and haemolysis.

Methods

This in vitro study was performed in a haematology laboratory. Five consented adult healthy male volunteers donated blood. In the 5-ml syringe technique, blood was injected through an EC, and as it flowed out of the tip, it was collected at the beginning and the end of 1 min. With the 20-ml technique, blood was collected at the beginning and end of the first, second and third minute. The samples were tested for CT, CR and haemolysis by measuring the plasma-free haemoglobin (PFHb).

Results

Five injections were made using a 5-ml syringe, and another five with a 20-ml syringe. Injection time was shorter in the 5-ml technique (80.80 ± 5.89 vs. 272 ± 28.4 s, P < 0.0001). With the 20-ml technique, CT progressively increased (>15 min), whereas, with the 5-ml syringe, the CT was normal. Both techniques caused mild, insignificant haemolysis (PFHb >0.005 g/dl), without affecting the quality of CR.

Conclusion

EC-assisted EBP using a 5-ml syringe technique shortens the injection time and deposits fresh blood quickly without affecting CT and CR.

Complications of endoscopic sinus surgery for chronic rhinosinusitis in a tertiary care teaching hospital in Saudi Arabia

OBJECTIVES

To aimed to determine the incidence of complications of endoscopic sinus surgery (ESS) and to investigate the factors associated with the occurrence of complications.

METHODS

In this retrospective study, we reviewed the medical records of all patients who had undergone ESS at King Saud University Medical City (KSUMC) between January 2015 and March 2022. Patients who underwent ESS for complicated acute sinusitis, sinonasal malignancy, and cerebrospinal fluid leak repair, and those who underwent extended ESS for indications other than chronic rhinosinusitis were excluded. This study was approved by the KSUMC Institutional Review Board.

RESULTS

We included 1395 patients, 3 of whom had major complications and 28 had minor complications, resulting in an overall major complication rate of 0.2% and a minor complication rate of 2%. The most common major complication was orbital hematoma, and the most common minor complication was synechia. Moreover, the duration of surgery and laterality increased the risk of complications, whereas the use of image guidance had no effect.

CONCLUSION

The ESS is a safe procedure. The operative start time and laterality were associated with an increased risk of complications and warrant further investigation.

Cerebrospinal Fluid Leakage from Scrotum Secondary to Ventriculoperitoneal Shunt Migration

Ventriculoperitoneal (VP) shunts are a common neurosurgical procedure used to treat hydrocephalus. Despite their efficacy, many shunts fail and require revisions. The most common causes of shunt failure include obstruction, infection, migration, and perforation. Extraperitoneal migrations require urgent attention. We present a case of migration to the scrotum, a unique complication that may be present in young patients due to the presence of a patent processus vaginalis. Here, we discuss a case of a 16-month-old male patient with a VP shunt presenting with cerebrospinal fluid (CSF) drainage from his scrotum after an indirect hernia repair. This case represents an important reminder for physicians about the sequelae associated with VP shunt complications, particularly extraperitoneal migration, and brings awareness to the underlying factors that may increase this risk.

Bipolar high frequency electric welding in radical resection of frontal sinus tumors

The aim of study is to develop a new method of connecting the dura mater defects in frontal sinus tumors with intracranial spread using high-frequency bipolar coagulation for welding of living tissues. Depending on the method of dura mater defect repair, patients were divided into 2 groups. The 1st group (control) included patients whose dura mater defect was connected according to the conventional method (suturing with polypropylene threads), in the 2nd group - the dura mater defect was connected by high-frequency bipolar electric welding using EKVZ-300, Patonmed. As a result of the study, the authors proposed an effective method of connecting the dura mater defects after the removal of frontal sinus tumors spreading intracranially. Such methods include a high-frequency bipolar electric welding method, the use of which contributed to a minimal destructive effect on adjacent tissues, but at the same time hermetically connected the dura mater. This was possible due to the supply of current with certain wave characteristics in a certain modulation at a temperature of 40-48°C, resulting in the connection of tissues without the formation of a coagulation scab due to the mechanism of protein-associated electrothermal adhesion of tissues. Presented data indicate significant advantages of using high-frequency bipolar electric welding the dura mater defects and fascia lata to restore the closed physiological circuit of cerebrospinal fluid circulation, compared to the traditional suture method. This approach has reduced intra- and postoperative complications, the time of surgery, and the length of the postoperative period.

A Comparison of Outcomes Using Combined Intra- and Extradural versus Extradural-Only Repair of Tegmen Defects

Objective  Tegmen tympani or tegmen mastoideum defects involve dehiscence of the temporal bone that can be a source of cerebrospinal fluid (CSF) otorrhea. Herein, we compare a combined intra-/extradural repair strategy with an extradural-only repair as it pertains to surgical and clinical outcomes. Design  A retrospective review from our institution was performed of patients with tegmen defects requiring surgical intervention. Participants  Patients with tegmen defects who underwent surgery (combined transmastoid and middle fossa craniotomy) for repair of tegmen defects between 2010 and 2020 were inclined in this study. Results  A total of 60 patients with 40 intra-/extradural (mean follow-up time: 1,060 ± 1,103 days) and 20 extradural-only (mean follow-up time: 519 ± 369 days) repairs were identified. No major differences in demographic factors or presenting symptoms were identified between the two cohorts. There was no difference in hospital length of stay between the two patient cohorts (mean: 4.15 vs. 4.35 days, p  = 0.8). In the extradural-only repair technique, synthetic bone cement was more frequently used (100 vs. 7.5%, p  < 0.01), whereas in the combined intra-/extradural repair, synthetic dural substitute was used more often (80 vs. 35%, p  < 0.01), with similar successful surgical outcomes achieved. Despite disparities in the techniques and materials used for repair, there were no differences in complication rates (wound infection, seizures, and ossicular fixation), 30-day readmission rates, or persistent CSF leak between the two treatment cohorts. Conclusion  The results of this study suggest no difference in clinical outcomes between combined intra-/extradural versus extradural-only repair of tegmen defects. A simplified extradural-only repair strategy can be effective, and may reduce the morbidity of intradural reconstruction (seizures, stroke, and intraparenchymal hemorrhage).

Association of Postoperative Sigmoid Sinus Occlusion and Cerebrospinal Fluid Leak in Translabyrinthine Surgery

OBJECTIVE

To characterize the incidence of sigmoid sinus occlusion (SSO) following translabyrinthine (TL) surgery for posterior fossa tumor resection and determine the association with cerebrospinal fluid (CSF) leak.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

METHODS

Patients undergoing TL surgery for vestibular schwannoma from 2012 to 2020 were included. Demographic data, medical history, preoperative tumor length and volume, and postoperative complications including CSF leak were recorded. Neuroradiology review of postoperative magnetic resonance imaging was used to determine the presence or absence of flow through the sigmoid sinus.

RESULTS

Of 205 patients undergoing TL, 21 (10.2%) experienced CSF leak postoperatively. Overall 56 (27%) demonstrated SSO on immediate postoperative magnetic resonance imaging. CSF leaks were more likely in those with SSO (19.6%) than those without SSO (6.7%; odds ratio, 3.54 [95% CI, 1.25-10.17]). Tumor volume and body mass index were not significantly associated with CSF leak. In total, 105 (51%) patients had some degree of sigmoid sinus thrombosis, but nonocclusive thrombosis was not associated with CSF leak.

CONCLUSION

SSO after TL approaches is common and appears to be significantly associated with postoperative CSF leak development. Minimizing manipulation of the sigmoid sinus during TL surgery and compression after surgery may have a role in preventing CSF leak.

Incidence and management of postoperative pseudomeningocele and cerebrospinal fluid leak after Chiari malformation type I decompression

OBJECTIVE

The optimal surgical management of Chiari malformation type I (CM-I) remains controversial and heterogeneous. The authors sought to investigate patient-specific, technical, and perioperative features that may affect the incidence of CSF-related complications including pseudomeningocele and CSF leak at their institution.

METHODS

The authors performed a single-center, retrospective review of all adult patients with CM-I who underwent posterior fossa decompression. Patient demographics, operative details, and perioperative factors were collected via electronic medical record review. The authors performed Fisher's exact test and independent Student t-tests for categorical and continuous variables, respectively. Univariate regression analysis was performed to determine odds ratios. A multivariable regression analysis was performed for those factors with p < 0.10 or large effect sizes (OR ≥ 2.0 or ≤ 0.50) by univariate analysis. The STROBE guidelines for observational studies were followed.

RESULTS

A total of 59 adult patients were included. Most patients were female (78.0%), and the mean body mass index was 32.2 (± 9.0). Almost one-third (30.5%) of patients had a syrinx on preoperative imaging. All patients underwent expansile duraplasty, of which 47 (79.7%) were from autologous pericranium. Arachnoid opening for fourth ventricular inspection was performed in 26 (44.1%) cases. CSF-related complications were identified in 18 (30.5%) of cases. Thirteen (22.0%) patients required readmission and 11 (18.6%) required intervention such as wound revision (n = 5), wound revision with CSF diversion (n = 4), CSF diversion alone (n = 1), or blood patch (n = 1). Three (5.1%) patients required permanent CSF diversion. Male sex (OR 3.495), diabetes mellitus (OR 0.249), tobacco use (OR 2.53), body mass index more than 30 (OR 2.45), preoperative syrinx (OR 1.733), autologous duraplasty (OR 0.331), and postoperative steroids (OR 2.825) were included in the multivariable analysis. No factors achieved significance by univariate or multivariable analysis (all p > 0.05).

CONCLUSIONS

The authors report a single-center, retrospective experience of posterior fossa decompression for 59 adults with CM-I. No perioperative or technical features were found to affect the CSF-related complication rate. More standardized practices within centers are necessary to better delineate the true risk factors and potential protective factors against CSF-related complications.

Risk Factors for Postoperative Cerebrospinal Fluid Leak after Graded Multilayer Cranial Base Repair with Suturing via the Endoscopic Endonasal Approach

This study analyzed risk factors for postoperative cerebrospinal fluid (CSF) leak after graded multilayer cranial base repair method with dural suturing. We performed surgery via the endoscopic endonasal approach (EEA) from 2012.6 to 2018.4, and those consecutive clinical data were prospectively accumulated and retrospectively analyzed. We tailored the repair method according to the intraoperative CSF leak grade. Among 388 surgeries via the EEA, there were 10 (2.6%) cases of postoperative CSF leak after graded repair with suturing. Postoperative CSF leak occurred in two of the 150 cases without intraoperative CSF leak (grade 0), one of the 104 cases with small (grade 1) intraoperative CSF leak, two of the 60 cases with moderate (grade 2) leak, and five of the 74 cases with large (grade 3) leak. Univariate analysis indicated that chordoma (P = 0.023), estimated tumor volume ≥ 7400 mm³ (P = 0.003), and maximum tumor diameter ≥ 32.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Additionally, among cases with intraoperative grade 3 CSF leak, chordoma (P = 0.021), estimated tumor volume ≥ 23000 mm³ (P = 0.003), and maximum tumor diameter ≥ 45.5 mm (P = 0.001) were significant risk factors for postoperative CSF leak. Maximum tumor diameter, estimated tumor volume, and chordoma tumor pathology are related to a higher risk of postoperative CSF leak.

Does an Epidural Blood Patch (EBP) for Postdural Puncture Headache (PDPH) From a Lumbar Spinal Drain Necessitate a Distinct Approach?

An intentional or unintentional dural puncture puts patients at significant risk for a postdural puncture headache (PDPH). When conservative treatments fail, an epidural blood patch (EBP) is offered cautiously due to rare but devastating complications. The literature is abundant with reviews on the management of PDPH in obstetric patients, but there is a paucity of data on the management of PDPH and complications of EBP in patients post spinal drain placement. In this case report, we address the specific concerns that vascular patients may have about the outcomes of large needle sizes and suggest alternative approaches for non-obstetric patients.

CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study

Objective

Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors.

Methods

A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis.

Results

A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely - such as previous endonasal surgery and the presence of intraoperative CSF leak.

Conclusions

There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.

Minimally invasive surgery for spinal cerebrospinal fluid leaks in spontaneous intracranial hypotension

OBJECTIVE

Spinal CSF leaks cause spontaneous intracranial hypotension (SIH). Surgical closure of spinal CSF leaks is the treatment of choice for persisting leaks. Surgical approaches vary, and there are no studies in which minimally invasive techniques were used. In this study, the authors aimed to detail the safety and feasibility of minimally invasive microsurgical sealing of spinal CSF leaks using nonexpandable tubular retractors.

METHODS

Consecutive patients with SIH and a confirmed spinal CSF leak treated at a single institution between April 2019 and December 2020 were included in the study. Surgery was performed via a dorsal 2.5-cm skin incision using nonexpandable tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach. The primary outcome was successful sealing of the dura, and the secondary outcome was the occurrence of complications.

RESULTS

Fifty-eight patients, 65.5% of whom were female (median age 46 years [IQR 36-55 years]), with 38 ventral leaks, 17 lateral leaks, and 2 CSF venous fistulas were included. In 56 (96.6%) patients, the leak could be closed, and in 2 (3.4%) patients the leak was missed because of misinterpretation of the imaging studies. One of these patients underwent successful reoperation, and the other patient decided to undergo surgery at another institution. Two other patients had to undergo reoperation because of insufficient closure and a persisting leak. The rate of permanent neurological deficit was 1.7%, the revision rate for a persisting or recurring leak was 3.4%, and the overall revision rate was 10.3%. The rate of successful sealing during the primary closure attempt was 96.6% and 3.4% patients needed a secondary attempt. Clinical short-term outcome at discharge was unchanged in 14 patients and improved in 25 patients, and 19 patients had signs of rebound intracranial hypertension.

CONCLUSIONS

Minimally invasive surgery with tubular retractors and a tailored interlaminar fenestration and, if needed, a transdural approach is safe and effective for the treatment of spinal CSF leaks. The authors suggest performing a minimally invasive closure of spinal CSF leaks in specialized centers.

Late Airway Compromise Secondary to Dural Tear and Cerebrospinal Fluid Leak

Background: While dysphagia after anterior cervical spine surgery is common, a dural tear is a rare complication. Airway compromise resulting from cerebrospinal fluid collection is an even rarer complication that has only been described to occur in the first few days postoperatively. Case Report: A 55-year-old male presented with progressive dysphagia and respiratory compromise 3 weeks after anterior cervical discectomy and fusion surgery at C3-C6. Imaging demonstrated extensive fluid collection in the retropharyngeal space and lateral neck, resulting in displacement of the cricoid cartilage rightward and anteriorly while also narrowing the pharyngeal space. After the patient's airway was secured by awake fiberoptic intubation, the fluid was determined to be cerebrospinal fluid (CSF) from a cervical dural tear. The tear was identified and repaired. The patient was extubated the next day, and a lumbar drain was placed to reduce the strain on the repair. After 11 days in the hospital, the patient made a full recovery. Conclusion: Dural tears following cervical disc surgery are rare and almost always identified in the immediate postoperative period; however, a dural tear should still be considered when a patient presents with a fluid collection at a later date. While techniques for securing the airway would not be different based on the type of fluid, knowing that the fluid collection is CSF could prompt the anesthesia team to place a lumbar drain.

Machine learning driven prediction of cerebrospinal fluid rhinorrhoea following endonasal skull base surgery: A multicentre prospective observational study

Background

Cerebrospinal fluid rhinorrhoea (CSFR) is a common complication following endonasal skull base surgery, a technique that is fundamental to the treatment of pituitary adenomas and many other skull base tumours. The CRANIAL study explored CSFR incidence and related risk factors, particularly skull base repair techniques, via a multicentre prospective observational study. We sought to use machine learning to leverage this complex multicentre dataset for CSFR prediction and risk factor analysis.

Methods

A dataset of 865 cases - 725 transsphenoidal approach (TSA) and 140 expanded endonasal approach (EEA) - with cerebrospinal fluid rhinorrhoea as the primary outcome, was used. Relevant variables were extracted from the data, and prediction variables were divided into two categories, preoperative risk factors; and repair techniques, with 6 and 11 variables respectively. Three types of machine learning models were developed in order to predict CSFR: logistic regression (LR); decision tree (DT); and neural network (NN). Models were validated using 5-fold cross-validation, compared via their area under the curve (AUC) evaluation metric, and key prediction variables were identified using their Shapley additive explanations (SHAP) score.

Results

CSFR rates were 3.9% (28/725) for the transsphenoidal approach and 7.1% (10/140) for the expanded endonasal approach. NNs outperformed LR and DT for CSFR prediction, with a mean AUC of 0.80 (0.70-0.90) for TSA and 0.78 (0.60-0.96) for EEA, when all risk factor and intraoperative repair data were integrated into the model. The presence of intraoperative CSF leak was the most prominent risk factor for CSFR. Elevated BMI and revision surgery were also associated with CSFR for the transsphenoidal approach. CSF diversion and gasket sealing appear to be strong predictors of the absence of CSFR for both approaches.

Conclusion

Neural networks are effective at predicting CSFR and uncovering key CSFR predictors in patients following endonasal skull base surgery, outperforming traditional statistical methods. These models will be improved further with larger and more granular datasets, improved NN architecture, and external validation. In the future, such predictive models could be used to assist surgical decision-making and support more individualised patient counselling.

The reversible impairment of behavioral variant frontotemporal brain sagging syndrome: Challenges and opportunities

Introduction

Due to loss of brain buoyancy, spontaneous spinal cerebrospinal fluid (CSF) leaks cause orthostatic headaches but also can cause symptoms indistinguishable from behavioral variant frontotemporal dementia (bvFTD) due to severe brain sagging (including the frontal and temporal lobes), as visualized on brain magnetic resonance imaging. However, the detection of these CSF leaks may require specialized spinal imaging techniques, such as digital subtraction myelography (DSM).

Methods

We performed DSM in the lateral decubitus position under general anesthesia in 21 consecutive patients with frontotemporal dementia brain sagging syndrome (4 women and 17 men; mean age 56.2 years [range: 31-70 years]).

Results

Nine patients (42.8%) were found to have a CSF-venous fistula, a recently discovered type of CSF leak that cannot be detected on conventional spinal imaging. All nine patients underwent uneventful surgical ligation of the fistula. Complete or near-complete and sustained resolution of bvFTD symptoms was obtained by all nine patients, accompanied by reversal of brain sagging, but in only three (25.0%) of the twelve patients in whom no CSF-venous fistula could be detected (P = 0.0011), and who were treated with non-targeted therapies.

Discussion

Concerns about a spinal CSF leak should not be dismissed in patients with frontotemporal brain sagging syndrome, even when conventional spinal imaging is normal. However, even with this specialized imaging the source of the loss of spinal CSF remains elusive in more than half of patients.

Comparison of Graft Materials in Multilayer Reconstruction with Nasoseptal Flap for High-Flow CSF Leak during Endoscopic Skull Base Surgery

Cerebrospinal fluid (CSF) leak is a crucial complication after endoscopic skull base surgery. Therefore, multilayer reconstruction with grafts is as essential as a reconstruction with pedicled flaps. Although widely used, the multilayer technique with autologous fascia lata has drawbacks, such as additional wound and donor site complications. We compared acellular dermal graft and banked homologous fascia lata graft (alternative grafts) with autologous fascia lata graft for high-flow CSF leak repair. We retrospectively enrolled 193 subjects who underwent endoscopic skull base reconstruction with multilayer fascial grafts and nasoseptal flap for high-flow CSF leaks from November 2014 to February 2020 at a single institution. Acellular dermal matrix (ADM), banked homologous fascia lata, and autologous fascia lata were used in 48 (24.9%), 102 (52.8%), and 43 (22.3%) patients, respectively. Postoperative CSF leaks occurred in 23 (11.9%) patients and meningitis in 8 (4.1%). There was no significant difference in postoperative CSF leak (p = 0.36) and meningitis (p = 0.17) across the graft groups. Additionally, we could not find out contributing risk factors for postoperative CSF leak and meningitis. ADM and banked homologous fascia lata are non-inferior to autologous fascia lata for endoscopic skull base reconstruction in water-tight reconstruction or safety without additional donor site morbidities.

Treatment Patterns and Health Care Resource Utilization of Iatrogenic Spinal Cerebrospinal Fluid Leaks in the United States

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

We aimed to characterize the treatment patterns and the associated costs in patients with cerebrospinal fluid (CSF) leak after spine procedures in the United States.

BACKGROUND

CSF leak is a common complication after spinal procedures. However, there is a little data regarding the national patterns of treatment choice and the associated health care resource utilization.

METHODS

We utilized the IBM MarketScan Research databases to retrospectively analyze adult US patients diagnosed with CSF leak within 30 days of spine procedures between 2001 and 2018. Treatment prevalence, treatment failure, and health care resource utilization data within 30 days of the CSF leak were collected. A subanalysis was performed on patients who received epidural blood patches (EBP) to better understand health care utilization attributable to this treatment modality.

RESULTS

Twenty one thousand four hundred fourteen patients were identified. The most common causes of CSF leak were diagnostic spinal tap (59.2%) and laminectomy/discectomy (18.7%). With regard to treatment prevalence, 40.4% of the patients (n=8651) had conservative medical management, 46.6% (n=9987) received epidural blood patch repair, 9.6% required surgical repair (n=2066), and 3.3% (n=710) had lumbar drain/puncture. Nine hundred sixty-seven (9.7%), 150 (21.1%), and 280 (13.5%) patients failed initial EBP, lumbar drain, and surgery, respectively, and the overall failure rate was 10.9% (n=1397). The median 30-day total cost across all groups was $5,101. Patients who received lumbar drain ($22,341) and surgical repair ($30,199) had higher 30-day median total costs than EBP ($8,140) or conservative management ($17,012). The median 30-day total cost for patients whose EBP failed ($8,179) was substantially greater than those with a successful EBP repair ($3,439).

CONCLUSIONS

National treatment patterns and costs for CSF leaks were described. When used in the correct patient cohort, EBP has the lower failure rates and costs than comparable alternatives. EBP may be considered more often in situations where conservative management or lumbar drains are currently being used.

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries

BACKGROUND

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea.

METHODS

A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes.

RESULTS

A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days.

CONCLUSIONS

Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores

Objective  This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design  This study is a retrospective review. Setting  This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants  A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures  The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results  Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p  = 0.01, R ²  = 0.97) and ASA ( p  = 0.04., R ²  = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p  = 0.03, R ²  = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p  < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion  Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.

Efficacy of Imaging Methods in the Detection and Diagnosis of Cerebrospinal Fluid Rhinorrhea

OBJECTIVE

To assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea.

DATA SOURCES

The PubMed, EMBASE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar databases were searched up to December 2021.

REVIEW METHODS

Diagnostic accuracy was compared among seven radiological methods: computed tomography (CT), CT cisternography (CTC), magnetic resonance imaging (MRI), magnetic resonance cisternography (MRC), CT + MRI, radionuclide cisternography, and intrathecal gadolinium (Gd)-MRC. Sensitivity, specificity, and accuracy were used as outcomes of the analysis. Both a traditional pairwise meta-analysis and a network meta-analysis were performed.

RESULTS

Twenty-three trials were included in the analysis. The results of a network meta-analysis performed on a network consisting of seven diagnostic methods showed that all imaging modalities had greater diagnostic accuracy than CT, with the exception of CTC, which had lower sensitivity. Only intrathecal Gd-MRC was significantly superior to other imaging methods with regard to sensitivity and accuracy. Gd-MRC also showed the greatest surface under the cumulative ranking curve values for all of the outcomes (sensitivity: 0.9200; specificity: 0.8364; accuracy: 0.8920).

CONCLUSION

This network meta-analysis demonstrates that intrathecal Gd-MRC is the most useful diagnostic method to detect CSF rhinorrhea. Laryngoscope, 2022.