RESUMEN

We report a challenging and uncommon case involving a 53-year-old Japanese man with cerebrospinal fluid (CSF) leakage caused by a meningocele in the lateral recess of the sphenoid sinus. Our innovative treatment approach involved a combination of transpterygoid and endoscopic modified medial maxillectomy techniques, with special emphasis on the preservation of the sphenopalatine artery. This strategic preservation was pivotal to the successful use of the ipsilateral nasoseptal flap for reconstruction, which played a crucial role in the prevention of postoperative CSF leakage. Otolaryngologists and neurosurgeons collaborated to perform the bath-plugging technique; effective collaboration was instrumental to the success of the procedure. This report highlights significant advancement from conventional frontal craniotomy to a more sophisticated endoscopic technique, shows the importance of meticulous surgical planning and execution, emphasizes careful preservation of critical anatomical structures during complex neurosurgical and otolaryngological procedures, and underscores the evolving landscape of surgical approaches for managing complex medical conditions.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Endoscopía , Meningocele , Seno Esfenoidal , Humanos , Seno Esfenoidal/cirugía , Seno Esfenoidal/diagnóstico por imagen , Masculino , Meningocele/cirugía , Meningocele/diagnóstico por imagen , Persona de Mediana Edad , Endoscopía/métodos , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Rinorrea de Líquido Cefalorraquídeo/cirugía , Rinorrea de Líquido Cefalorraquídeo/etiología , Colgajos Quirúrgicos , Enfermedades de los Senos Paranasales/cirugía , Enfermedades de los Senos Paranasales/diagnóstico por imagen , Tomografía Computarizada por Rayos X

RESUMEN

Meningomyelocele is a common congenital condition and its reconstruction poses a challenge for surgeons. The dorsal intercostal artery (DICA) flap offers a one-stage tension-free closure with adequate results. This study, spanning from January 2019 to September 2022, analyses the outcome of nine DICA flaps for meningomyelocele reconstruction, where the average size of the DICA flap was 6.8 x 4.6 cm for an average defect of 6.33 x 4 cm. Notably, no post-operative blood transfusion was required, nor any complications occurred except for one patient's septic shock-related death. Two had post-operative cerebrospinal fluid (CSF) leak, repaired primarily with one requiring VP shunt. Based on our experience, the DICA flap, with its consistent anatomy, is a reliable option for the reconstruction of meningomyelocele defects.

Asunto(s)

Meningomielocele , Procedimientos de Cirugía Plástica , Colgajos Quirúrgicos , Humanos , Meningomielocele/cirugía , Masculino , Femenino , Procedimientos de Cirugía Plástica/métodos , Lactante , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Complicaciones Posoperatorias

RESUMEN

OBJECTIVES: Various nonvascularized or vascularized techniques have been adopted in endoscopic endonasal surgery (EES) for repairing intraoperative cerebrospinal fluid (CSF) leaks after tumor resection. Vascularized nasoseptal flaps, free nasoseptal grafts, free turbinate grafts, and fascia lata and mashed muscle are frequently used. Outcomes of those grafts applied in the defects of different regions need to be clarified. METHODS: The data from a series of 162 patients with skull base tumor who underwent EES that had intraoperative CSF leak between Jan 2012 and Jan 2021 were retrospectively analyzed. The regions included anterior skull base, sellar region, clivus and infratemporal fossa. Repair failure rate (RFR), meningitis rate, and associated risk factors were assessed. RESULTS: In total, 172 reconstructions were performed in 162 patients for the 4 sites of the skull base. There were 7 cases (4.3%) that had postoperative CSF leaks, which required second repair. The RFR for anterior skull base, sellar region, clivus, and infratemporal fossawas 2.6%, 2.2%, 16.7%, and 0%, respectively. The clivus defect was an independent risk factor for repair failure (P < 0.01). The postoperative meningitis rate was 5.6%. Repair failure was an independent risk factor for meningitis (P < 0.01). CONCLUSIONS: Vascularized nasoseptal flap, free nasoseptal graft, free turbinate graft, and fascia lata and mashed muscle are reliable autologous materials for repairing the dural defects in different regions during EES. Clivus reconstruction remains a great challenge, which had a higher RFR and meningitis rate. Repair failure is significantly associated with postoperative meningitis.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Meningitis , Procedimientos de Cirugía Plástica , Neoplasias de la Base del Cráneo , Base del Cráneo , Humanos , Masculino , Femenino , Persona de Mediana Edad , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/epidemiología , Pérdida de Líquido Cefalorraquídeo/cirugía , Meningitis/epidemiología , Meningitis/etiología , Adulto , Factores de Riesgo , Estudios Retrospectivos , Anciano , Procedimientos de Cirugía Plástica/métodos , Neoplasias de la Base del Cráneo/cirugía , Base del Cráneo/cirugía , Neuroendoscopía/métodos , Adulto Joven , Adolescente , Resultado del Tratamiento , Complicaciones Intraoperatorias/etiología , Colgajos Quirúrgicos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Cavidad Nasal/cirugía , Niño

RESUMEN

INTRODUCTION: Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. METHODS: Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves 2 critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. RESULTS: Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. CONCLUSIONS: In the authors' preliminary experience, the linear dural incision described herein was effective for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Duramadre , Humanos , Duramadre/cirugía , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Anciano , Adulto , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/cirugía , Complicaciones Posoperatorias , Adulto Joven , Anciano de 80 o más Años , Craneotomía/métodos , Procedimientos Neuroquirúrgicos/métodos , Adolescente , Resultado del Tratamiento

RESUMEN

OBJECTIVE: To evaluate the efficacy of a nonabsorbable, synthetic graft for the reconstruction of spontaneous middle fossa (sMF) cerebrospinal fluid (CSF) leaks. PATIENTS: Six adult patients (age ≥16 yr) who had sMF CSF leaks surgically repaired within an 18-month period at a single university hospital using synthetic, nonbiological, nonabsorbable graft (Neuro-Patch) and a retrospective control group of five patients undergoing multilayer MF repair with autologous grafts. INTERVENTIONS: MF repair through a combined transmastoid/MF approach using Neuro-Patch or multilayer autologous grafts. MAIN OUTCOME MEASURES: The incidence of postoperative leak within 6 months postoperatively was the main outcome measure; we also recorded the need for lumbar drain, additional hearing loss, length of inpatient stay, body mass index, previous meningitis, preoperative increased intracranial pressure, and age. RESULTS: In the Neuro-Patch group, there was no postoperative CSF leak without the need for lumbar drain. We observed no additional hearing loss; patients were monitored for 2 days without any readmissions. Increased intracranial pressure (four of six), previous episodes of meningitis (two of six) or obesity (five of six) did not affect patient outcomes. Demographic and prognostic factors were the same for the control group. However, one patient needed lumbar drain postoperatively because of residual leak; lumbar drain was used in one more case (two of five cases), whereas three of five patients had to stay for longer than 2 days (5 d). CONCLUSIONS: Our pilot study suggests the use of Neuro-Patch via combined transmastoid/MF approach as an effective technique with minimum, if any morbidity; it could be of particular benefit for patients with larger MF dura defects. A larger number of patients are required to strengthen the evidence.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Fosa Craneal Media , Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Proyectos Piloto , Pérdida de Líquido Cefalorraquídeo/cirugía , Fosa Craneal Media/cirugía , Resultado del Tratamiento , Estudios Prospectivos , Anciano , Complicaciones Posoperatorias/epidemiología , Rinorrea de Líquido Cefalorraquídeo/cirugía , Estudios Retrospectivos , Procedimientos de Cirugía Plástica/métodos

RESUMEN

OBJECTIVE: To suggest a comprehensive algorithm for the surgical approach for correcting of sources of temporal bone CSF leaks. METHODS: A case series for patients operated in a single academic tertiary referral center between 2011 and 4.2022. Included in the study were 46 patients, 5 of whom had a bilateral problem, resulting in 51 pathologic temporal bones. The presentation was an active CSF leak (38 patients) or bacterial otogenic meningitis (8 patients). Follow up ranged from 8 months to 5 years. RESULTS: Of the 42 ears operated via the default middle fossa approach, 37 were successful (88 %) in controlling CSF leak. None had intracranial complications or sensorineural hearing loss. Location, number and size of the defects, hearing status, associated superior semicircular canal dehiscence, additional intra-temporal or intra-cranial pathologies may indicate a transmastoid approach. Of the six ears that had a canal wall up mastoidectomy as a primary procedure, one required revision due to ongoing CSF leak. Five revision cases and three primary cases were effectively sealed with a subtotal petrosectomy and obliteration. One was lost to follow-up. Hearing was reconstructed with bone-anchored hearing implants in 6 out of these 8 ears. CONCLUSIONS: The middle fossa approach could be used as a default approach for sealing TD. There are a number of indications for transmastoid approaches in both primary and revision cases. Obliteration of the ear was used in all revision cases. The suggested algorithm can help in planning surgery for temporal bone CSF leaks or a history of otogenic meningitis.

Asunto(s)

Algoritmos , Pérdida de Líquido Cefalorraquídeo , Hueso Temporal , Humanos , Hueso Temporal/cirugía , Masculino , Femenino , Persona de Mediana Edad , Adulto , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Resultado del Tratamiento , Anciano , Estudios de Seguimiento , Adulto Joven , Meningitis Bacterianas/cirugía , Mastoidectomía/métodos , Estudios Retrospectivos , Adolescente , Procedimientos Quirúrgicos Otológicos/métodos

RESUMEN

Cerebrospinal fluid (CSF) leaks may occur at the skull base or along the spinal column and can cause a variety of debilitating neurological symptoms for patients. Recognizing the potential presence of a CSF leak and then identifying its source are necessary for accurate diagnosis and definitive treatment. A standardized workflow can be followed for successful leak localization, which often requires several diagnostic studies, and for definitive leak treatment, which can range from minimally invasive, needle-based approaches to a variety of surgical corrections. This review paper provides an overview of epidemiology, pathophysiology, and diagnostic workup for CSF leaks and introduces available treatment options. An illustrative case of a skull base CSF leak demonstrating diagnosis and surgical correction is provided.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Humanos , Pérdida de Líquido Cefalorraquídeo/terapia , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/diagnóstico , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Base del Cráneo/cirugía , Base del Cráneo/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos

RESUMEN

Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Humanos , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/terapia , Embolización Terapéutica/métodos , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Endovasculares/métodos

RESUMEN

The confirmation of cerebrospinal fluid (CSF) leaks in the setting of spontaneous intracranial hypotension (SIH) by imaging involves a growing toolset of multimodal advanced spinal and skull base imaging techniques, for which exists a unique set of challenges for each CSF leak type. Furthermore, the repertoire of minimally invasive CSF leak treatment beyond nontargeted epidural blood patch administration has grown widely, with varied practices across institutions. This review describes current diagnostic imaging and treatment modalities as they apply to the challenges of CSF leak localization and management.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Hipotensión Intracraneal , Procedimientos Quirúrgicos Mínimamente Invasivos , Humanos , Pérdida de Líquido Cefalorraquídeo/terapia , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Pérdida de Líquido Cefalorraquídeo/cirugía , Hipotensión Intracraneal/terapia , Hipotensión Intracraneal/diagnóstico por imagen , Hipotensión Intracraneal/etiología , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , Parche de Sangre Epidural/métodos , Imagen por Resonancia Magnética

RESUMEN

INTRODUCTION: Penetrating neck trauma (PNT) due to gunshot injuries is one of the challenging conditions with the potential for both significant morbidities and mortality. RESEARCH QUESTION: There are significant concerns in the approach to patients with spinal gunshot injuries. Surgery indications, methods of surgery, and management of CSF leaks are the main concerns of these patients. METHODS AND MATERIALS: An 11-year-old boy was referred to our center with a single gunshot wound to the left side of the posterior cervical region 2 days ago with cerebrospinal fluid leakage and left arm weakness. RESULTS: The patient underwent surgery, and the pellet was removed. His left arm weakness fully recovered after the operation, and no new symptoms developed during the 1-year follow-up. CONCLUSION: Timely surgery could dramatically improve outcomes in PNT patients with mild symptoms and prevent worsening neurological defects.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Heridas por Arma de Fuego , Humanos , Masculino , Heridas por Arma de Fuego/cirugía , Heridas por Arma de Fuego/complicaciones , Niño , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Paresia/etiología , Paresia/cirugía , Extremidad Superior/cirugía , Extremidad Superior/lesiones , Traumatismos del Cuello/cirugía , Traumatismos del Cuello/complicaciones

RESUMEN

OBJECTIVE: Spontaneous intracranial hypotension (SIH) is an important cause of orthostatic headaches caused by spinal CSF leaks. It has a strong negative impact on patients' socioeconomic status and health-related quality of life (HRQOL). This study aimed to analyze the impact of surgical and endovascular treatments on patients' HRQOL. METHODS: The authors conducted a prospective, observational cohort study that included all patients treated for SIH with microsurgery or embolization, depending on the type of CSF leak, at their institution between April 2022 and May 2023. Patients were asked to complete a specifically designed questionnaire, as well as the 15D HRQOL questionnaire, before and 3 months after treatment. RESULTS: A total of 21 patients (14 female; mean age 51.7 years) were treated in the study period. There were 12 (57%) type 1 leaks, 3 (14%) type 2, and 6 (29%) type 3. While 20 (95.2%) leaks were localized in the thoracic spine, only 1 (4.8%) was found in the lumbar spine. All patients completed the questionnaires. Fifteen (71.4%) patients underwent microsurgery and 6 (28.6%) endovascular embolization. The mean 15D score improved from 0.802 before to 0.889 after treatment (p = 0.013). Compared with an age- and sex-matched general population, HRQOL was significantly impaired in patients with SIH before treatment. After treatment, the authors found no significant difference in the overall HRQOL between patients and the healthy population. Mean headache intensity on a numeric rating scale improved from 8.1 before treatment to 2.3 after treatment (p = 0.003). Patients reported that SIH had a notable impact on their social and working life. CONCLUSIONS: SIH has a considerable negative impact on HRQOL. Microsurgery or embolization can dramatically improve HRQOL, subjective perception of health, and headache intensity. Therefore, surgical or endovascular treatment should be considered given the improvement observed in HRQOL for patients with SIH.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Hipotensión Intracraneal , Calidad de Vida , Humanos , Femenino , Masculino , Persona de Mediana Edad , Hipotensión Intracraneal/etiología , Hipotensión Intracraneal/terapia , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Estudios Prospectivos , Adulto , Embolización Terapéutica , Encuestas y Cuestionarios , Resultado del Tratamiento , Anciano , Microcirugia , Cefalea/etiología , Cefalea/terapia , Procedimientos Endovasculares/métodos

RESUMEN

BACKGROUND: During pituitary surgery, CSF leaks are often treated by intrasellar packing, using muscle or fat grafts. However, this strategy may interfere with the interpretation of postoperative MRI and may impact the quality of resection in cases of second surgery, due to the existence of additional fibrous tissue. We present an alternative technique, using a diaphragm reconstruction with a heterologous sponge combining fibrinogen and thrombin (TachoSil), applied in selected patients with low-flow CSF leaks. This study investigates the surgical outcome of patients treated with this strategy. METHODS: From a cohort of 2231 patients treated from June 2011 to June 2023 by endoscopic endonasal approach for pituitary surgery, the surgical technique of diaphragm repair with TachoSil patch performed in 55 patients (2.6%) was detailed, and the rate of closure failure was analyzed at 6 months postoperatively. No intrasellar packing was used and sellar floor reconstruction was performed whenever possible. The rate of postoperative CSF leak was compared with that reported in three previous publications that also used the TachoSil patch technique. RESULTS: Patients were mostly women (F/M ratio: 1.2) with a median age of 53.6 years. Surgery was indicated for non-functioning adenomas, Cushing's disease, acromegaly, and Rathke's cleft cysts in 38/55 (69.1%), 6/55 (10.9%), 5/55 (9.1%) and 6/55 (10.9%) patients respectively. The rate of postoperative CSF leak was 1.8% (n = 1/55), which was not significantly different from that reported in the three cohorts from the literature (2.8%, p > 0.05). No postoperative meningitis was recorded. CONCLUSIONS: In highly selected patients with low-flow CSF leaks related to small focal diaphragm defects, diaphragm reconstruction using a TachoSil patch can be a safe and valuable alternative to intrasellar packing.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Combinación de Medicamentos , Fibrinógeno , Procedimientos de Cirugía Plástica , Trombina , Humanos , Femenino , Persona de Mediana Edad , Trombina/uso terapéutico , Masculino , Fibrinógeno/uso terapéutico , Adulto , Pérdida de Líquido Cefalorraquídeo/cirugía , Anciano , Procedimientos de Cirugía Plástica/métodos , Estudios de Cohortes , Diafragma/cirugía , Complicaciones Posoperatorias , Neoplasias Hipofisarias/cirugía , Resultado del Tratamiento , Rinorrea de Líquido Cefalorraquídeo/cirugía , Hipófisis/cirugía , Tapones Quirúrgicos de Gaza

RESUMEN

BACKGROUND: Cerebrospinal fluid leak after endoscopic skull base surgery remains a significant complication. Several investigators have suggested Hydroset cranioplasty to reduce leak rates. We investigated our early experience with Hydroset and compared the rate of nasal complications and CSF leak rates with case-controlled historic controls. METHODS: We queried a prospective database of patients undergoing first time endoscopic, endonasal resection of suprasellar meningiomas and craniopharyngiomas from 2015 to 2023. We compared cases closed with a gasket seal, Hydroset, and a nasoseptal flap with those closed with only a gasket seal and nasoseptal flap. Demographics, technical considerations and postoperative outcomes (SNOT-22) were compared. RESULTS: Seventy patients met inclusion criteria, twenty patients in the Hydroset group (meningioma n = 12; craniopharyngioma n = 8) and 50 control patients (meningioma n = 25; craniopharyngioma n = 25). CSF diversion was used in fewer Hydroset patients (75%, 15/20) compared with control group (94%, 47/50; p = 0.02). CSF leak was less frequent in the Hydroset than the control group (5% versus 12%, p = 0.38). One Hydroset patient required delayed nasal debridement. SNOT-22 responses demonstrated no significant difference in sinonasal complaints between groups (Hydroset average SNOT-22 score 22.45, control average SNOT-22 score 25.90; p = 0.58). CONCLUSIONS: We demonstrate that hydroxyapatite reconstruction leads to improved CSF leak control above that provided by the gasket-seal and nasoseptal flap, without significant associated morbidity as long as the cement is fully covered with vascularized tissue.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Craneofaringioma , Meningioma , Base del Cráneo , Colgajos Quirúrgicos , Humanos , Masculino , Femenino , Persona de Mediana Edad , Pérdida de Líquido Cefalorraquídeo/prevención & control , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/cirugía , Estudios de Casos y Controles , Base del Cráneo/cirugía , Craneofaringioma/cirugía , Anciano , Meningioma/cirugía , Adulto , Neoplasias Hipofisarias/cirugía , Complicaciones Posoperatorias/prevención & control , Complicaciones Posoperatorias/etiología , Resultado del Tratamiento , Neoplasias de la Base del Cráneo/cirugía , Procedimientos de Cirugía Plástica/métodos , Neoplasias Meníngeas/cirugía , Tabique Nasal/cirugía

RESUMEN

PURPOSE: To assess the audiometric outcomes following surgical repair of spontaneous temporal bone cerebrospinal fluid otorrhea and compare different surgical approaches. MATERIALS AND METHODS: Retrospective review of adults (≥18 years old) who underwent repair of spontaneous CSF leak between 2011 and 2022. Audiometric outcomes were compared across the three surgical groups: transmastoid, middle cranial fossa and combined. RESULTS: Thirty-nine patients (40 ears) met the inclusion criteria (71.8 % females; mean age 59.77 +/- 12.4). Forty-two percent underwent transmastoid, 12.5 % middle cranial fossa and 45 % transmastoid-middle cranial fossa. Four patients (10 %) had recurrence, 3 in the transmastoid group and 1 in the combined approach. The mean change in air-bone gap (ABG) for all patients (postoperative-preoperative) was -7.4 (paired t-test, p-value = 0.0003). The postoperative ABG was closed in 28 (70 %) ears (postoperative ABG ≤ 15). The mean change in pure tone average (PTA) for all patients (postoperative-preoperative) was -4.1 (paired t-test, p-value = 0.13). The mean change in word recognition scores (WRS) for all patients (postoperative-preoperative) was -3 (paired t-test, p-value = 0.35). On multivariable analysis (controlling for site and reconstruction material), there was no significant difference in ABG, PTA and WRS change between surgical groups. CONCLUSIONS: Transmastoid, middle cranial fossa and combined approaches are all effective in treatment of spontaneous CSF leaks and all showed mean decrease in post-operative ABG. Transmastoid approach showed the greatest decrease in ABG and PTA (although middle cranial fossa approach shows the greatest decrease, when excluding profound hearing loss in a patient with superior canal dehiscence). Further studies comparing audiometric outcomes are needed.

Asunto(s)

Otorrea de Líquido Cefalorraquídeo , Hueso Temporal , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Hueso Temporal/cirugía , Otorrea de Líquido Cefalorraquídeo/cirugía , Otorrea de Líquido Cefalorraquídeo/etiología , Resultado del Tratamiento , Anciano , Fosa Craneal Media/cirugía , Audiometría de Tonos Puros , Adulto , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Apófisis Mastoides/cirugía , Audiometría

RESUMEN

OBJECTIVES: Tegmen and superior semicircular canal defects have been well studied, yet the factors contributing to their onset and progression are widely debated. The clinical utility of intraoperative intracranial pressure measurements has yet to be tested. This report aims to use intraoperative opening pressure and concurrent superior semicircular canal dehiscence (SSCD) to analyze factors influencing disease course and clinical outcomes in patients with tegmen dehiscence. METHODS: A retrospective analysis of 61 patients who underwent tegmen defect repair was performed. Multiple variables of interest including body mass index (BMI), presence of SSCD, presence of dural venous sinus stenosis, opening pressure, and acetazolamide therapy use were recorded. The cohort was divided into those with or without concurrent SSCD and those presenting with or without cerebrospinal fluid (CSF) leak for analysis. RESULTS: A linear relationship between opening pressure and BMI (p = 0.009) was noted; however, intraoperative opening pressure was not associated with disease outcome. Concurrent SSCD was present in 25 % of patients, while 62 % presented with CSF leak. The concurrent SSCD group exhibited higher opening pressure, higher likelihood of having dural sinus stenosis, and higher likelihood of being discharged on acetazolamide. The CSF leak group had higher likelihood of obstructive sleep apnea and persistent symptoms. CONCLUSIONS: In patients undergoing tegmen defect repair, concurrent SSCD suggests increased disease severity. The presence of preoperative CSF leak predicts persistent symptoms following repair. BMI is linearly correlated with intracranial pressure in these patients.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Dehiscencia del Canal Semicircular , Canales Semicirculares , Humanos , Masculino , Femenino , Estudios Retrospectivos , Persona de Mediana Edad , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/cirugía , Canales Semicirculares/cirugía , Dehiscencia del Canal Semicircular/cirugía , Dehiscencia del Canal Semicircular/complicaciones , Resultado del Tratamiento , Adulto , Índice de Masa Corporal , Anciano , Presión Intracraneal , Complicaciones Posoperatorias/etiología , Acetazolamida

RESUMEN

A 4-year-old boy was referred to our tertiary hospital after a penetrating adnexal injury by a large-breed dog to the left orbital area. There was an increase in lacrimation, which was thought to be due to an inflammatory reaction. However, it was discovered that the lacrimation increased in the reverse-Trendelenburg position and with the Valsalva maneuver. Halo sign and beta transferrin test were positive, which led to the diagnosis of cerebrospinal fluid (CSF) fistula, and the patient was operated using a supraorbital craniotomy. A dural tear was visualized and sutured appropriately, then fibrin glue and an autologous galeal graft were applied to the tear. The CSF oculorrhea stopped postoperatively, and the patient was discharged after 10 days of follow-up. The patient had no recurrent CSF leakage at 4-year follow-up. Although CSF oculorrhea is rare and may be difficult to discern from lacrimation, the presence of pneumocephalus and halo sign should suggest fistula repair.

Asunto(s)

Mordeduras y Picaduras , Pérdida de Líquido Cefalorraquídeo , Humanos , Masculino , Animales , Preescolar , Perros , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/diagnóstico , Pérdida de Líquido Cefalorraquídeo/cirugía , Mordeduras y Picaduras/complicaciones , Mordeduras y Picaduras/diagnóstico , Tomografía Computarizada por Rayos X , Lesiones Oculares Penetrantes/diagnóstico , Lesiones Oculares Penetrantes/cirugía , Craneotomía/efectos adversos , Órbita/diagnóstico por imagen , Enfermedades Orbitales/etiología , Enfermedades Orbitales/diagnóstico

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Humanos , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Vértebras Torácicas/cirugía , Vértebras Torácicas/diagnóstico por imagen , Procedimientos Neuroquirúrgicos/métodos , Masculino , Femenino , Persona de Mediana Edad

RESUMEN

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, 134:2713-2717, 2024.

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Endoscopía , Fragilidad , Base del Cráneo , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Base del Cráneo/cirugía , Fragilidad/complicaciones , Endoscopía/métodos , Resultado del Tratamiento , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Anciano , Adulto

Asunto(s)

Pérdida de Líquido Cefalorraquídeo , Microcirugia , Vértebras Torácicas , Humanos , Pérdida de Líquido Cefalorraquídeo/cirugía , Pérdida de Líquido Cefalorraquídeo/etiología , Pérdida de Líquido Cefalorraquídeo/diagnóstico por imagen , Vértebras Torácicas/cirugía , Vértebras Torácicas/diagnóstico por imagen , Microcirugia/métodos , Procedimientos Neuroquirúrgicos/métodos

RESUMEN

OBJECTIVE: Chronic subdural hematoma (CSDH) is frequently met in neurosurgical practice and often need urgent surgical treatment in case of neurological deterioration. Different surgical approaches to evacuate CSDH are described in the literature. In our experience, an external drainage system is crucial in order to avoid recurrences. We recently encountered a case of subcutaneous CSF collection after drainage removal. Thus, we developed a simple surgical technique to prevent postoperative CSF leak after subdural drainage system removal. METHOD: We have developed a technique in which the periosteum is harvested during the surgery prior to the evacuation of the hemorrhage and fixed with sutures on the uncut dura mater opposite and laterally to the exit of the catheter exiting the dural hole caused by the passage of the Jackson-Pratt subdural drainage system. When the drainage catheter is removed, the flap, partially held by the sutures, falls over the hole avoiding CSF leakage. By using this technique, the small dural hole will be covered with the periosteum allowing for natural closure and wound healing hence preventing CSF leakage. RESULTS: This technique was successfully employed in 21 patients who didn't develop postoperative CSF leakage following CSDH evacuation and removal of subdural drainage system. CONCLUSION: In this technical note, we describe a safe dura closure technique that we developed to help reduce the risk of postoperative CSF leakage following subdural drainage removal, which can, however, also be applied in all surgeries in which a catheter is placed in the subdural space.

Asunto(s)

Hematoma Subdural Crónico , Humanos , Hematoma Subdural Crónico/cirugía , Drenaje , Pérdida de Líquido Cefalorraquídeo/prevención & control , Pérdida de Líquido Cefalorraquídeo/cirugía , Duramadre/cirugía , Periodo Posoperatorio