Impact of Reconstructing Intercostal Artery on Spinal Cord Circulation During Open Surgery for Thoracoabdominal Aortic Aneurysm

ABSTRACT Introduction: We evaluated the outcomes of the selective intercostal artery reconstruction for preventing spinal cord injury during thoracoabdominal aortic aneurysm repair. Methods: We retrospectively assessed 84 consecutive patients who underwent thoracoabdominal aortic aneurysm repairs between 2004 and 2016. The mean age of the patients was 57.3 years. We performed preoperative multidetector computed tomography in 74 patients (88.0%) to identify the Adamkiewicz artery. Spinal cord injury preventive measures included motor evoked potential monitoring, hypothermia induction, Adamkiewicz artery or other intercostal artery reconstruction, and cerebrospinal fluid drainage. Results: The hospital death rate was 5.9%, and paraplegia occurred in four patients (4.7%). The Adamkiewicz artery or other intercostal arteries were reconstructed selectively in 46 patients (54.7%). Of these patients, 41 underwent postoperative multidetector computed tomography, which revealed occlusion of the reconstructed grafts in 23 patients (56.0%). There was no paraplegia in the patients who underwent reconstruction of the Adamkiewicz artery, which was patent on postoperative multidetector computed tomography. Univariate analysis showed no significant effect of various risk factors on the development of spinal cord injury. Conclusion: Outcome of open surgery for thoracoabdominal aortic aneurysm in our institution regarding spinal cord injury was satisfactory. The benefits of Adamkiewicz artery reconstruction remain inconclusive, and further larger studies are required to identify its validation for spinal cord protection in thoracoabdominal aortic aneurysm repair.

Apport de l'imagerie dans les brèches ostéoméningées de l'étage antérieur de la base du crâne / Role of imaging in the osteo-dural defects of the anterior base of the skull

Décrire les caractéristiques radiologiques de la brèche ostéo-méningée (BOM) de l'étage antérieur de la base du crâne. Méthodes: Etude rétrospective, descriptive, monocentrique, colligeant les patients hospitalisés pour prise en charge d'une brèche ostéoméningée (BOM) et explorés par le couple TDM/IRM, du 1er janvier 2012 au 31 Décembre 2021. Résultats: Ont été retenu 23 patients avec un âge moyen de 48 ans et un sex ratio de 0,3. Des antécédents de chirurgie nasosinusienne ou de neurochirurgie ont été notés chez deux patients (9 %). Treize patients (57 %) étaient victimes de traumatisme crânien. Une rhinoliquorrhée était retrouvée dans 21 cas (persistante dans trois cas (12%) et intermittente dans 18 cas (76%)). La découverte de la BOM a été faite suite à une méningite dans quatre cas. Le dosage de la bêta trace a confirmé la présence de LCR chez deux patients. La TDM a confirmé le diagnostic chez 12 patients dont deux patients qui ne présentaient pas de rhinoliquorrhée à l'examen clinique. Elle a aussi permis d'établir le bilan topographique dans ces cas. Elle a suspecté une BOM dans 9 cas et était négative dans deux cas. L'IRM a confirmé le diagnostic dans tous les cas et a permis de: localiser le siège de la fuite de LCR dans les brèches multiples, confirmer le diagnostic deméningoencéphalocèle (trois cas) et objectiver des signes indirects d'hypertension intra-crânienne (HTIC) (quatre cas). Conclusion: L'imagerie en coupes permet de localiser la BOM mais nécessite souvent, une approche par étapes et son interprétation exige une connaissance approfondie de l'anatomie normale et des variantes de la base du crâne. Mots-clés: Liquorrhée, Brèche Ostéoméningée, Chirurgie, TDM, IRM

Endoscopic management of frontal sinus CSF leaks / Manejo endoscópic de fístulas liquóricas do seio frontal

Abstract Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 - 41 months). Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Resumo Introdução: O manejo endoscópico das fístulas liquóricas do seio frontal tornou-se o padrão-ouro, com altas taxas de sucesso e baixa morbidade. Objetivo: Revisar nossa experiência no tratamento de fístulas liquóricas do seio frontal por meio de uma abordagem endoscópica endonasal. Método: Foi feita uma avaliação retrospectiva de pacientes submetidos à cirurgia endoscópica para fístulas liquóricas do seio frontal. Dados demográficos, localização e etiologia do defeito, técnica cirúrgica e reconstrutiva, complicações e seguimento pós-operatório foram analisados. Resultados: Foram tratados cirurgicamente pelo autor principal 22 pacientes com média de 40,4 anos entre 2015 e 2019. A fístula liquórica foi traumática (17) ou espontânea (5). O reparo endoscópico foi feito com sucesso na primeira tentativa em todos os casos. Uma abordagem combinada de trefinação e endoscopia foi necessária em 5 pacientes (22,8%). Nenhuma complicação grave foi relatada e a via de drenagem do seio frontal estava patente em todos os nossos casos. A cirurgia de revisão foi necessária em apenas 2 pacientes devido à formação de sinéquia. O seguimento médio dos pacientes foi de 22,7 meses (variação: 7 a 41). Conclusão: O progresso no campo da cirurgia endoscópica mudou o paradigma, estabeleceu o reparo endoscópico de fístulas liquóricas do seio frontal como o padrão de tratamento. Alguns poucos limites remanescentes dessa abordagem podem ser resolvidos pela combinação da endoscopia com a trefinação frontal.

Fístula de líquido cefalorraquídeo después de hisopado nasofaríngeo en pandemia COVID-19. A propósito de dos casos

Resumen Uno de los pilares fundamentales en el manejo de la pandemia por SARS-CoV2 es la detección temprana de la presencia del virus en pacientes. El método más utilizado es mediante hisopado nasofaríngeo para amplificar ácidos nucleicos mediante reacción en cadena de polimerasa (PCR). Las complicaciones asociadas a la técnica de hisopado aún no están completamente caracterizadas. Hasta ahora hay un caso reportado internacionalmente de fístula de líquido cefalorraquídeo poshisopado nasofaríngeo. Presentamos dos casos de fístula posterior a dicho examen: el primer caso un paciente de género femenino con sospecha de hipertensión intracraneal idiopática, cuya brecha se reparó quirúrgicamente; el segundo caso un paciente de género masculino con antecedente de hidrocefalia y meningitis neonatal que, al estudio por rinorraquia, se encuentra un meningoencefalocele en el receso frontal derecho, también reparado quirúrgicamente.

Abstract One of the cornerstones in the management of coronavirus pandemic is the early identification of virus presence in patients. The most used test is the nasopharyngeal swab, used to amplify nucleic acids through polymerase chain reaction. Complications with this test have not been completely characterized. Until now, only one international report of cerebrospinal fluid leak has been reported. We present two cases of leak after nasopharyngeal swab test: the first case corresponded to an adult feminine gender patient with suspected idiopathic intracranial hypertension, whose gap was surgically repaired; the second case adult male patient with medical history of hydrocephalus and neonatal meningitis who was further studied for rhinoliquorrhea that showed a meningoencephalocele occupying the right frontal recess.

Fístula liquórica espontânea: relato de caso / Spontaneous cerebrospinal fluid leaks: case report

As fistulas liquóricas rinogênicas são definidas como comunicações entre as fossas nasais e o espaço subaracnóideo. A origem dessas falhas pode ser de origem traumática ou não traumática, e o quadro clínico cursa com rinorréia ou otorréia citrina, geralmente unilateral. As fístulas não traumáticas espontâneas são menos comuns de ocorrer do que as traumáticas. O paciente relatado apresentava um quadro de rinoliquorreia através de fossa nasal direita, com aumento de fluxo ao se inclinar para frente e/ou realizar flexão anterior do pescoço. Realizando investigação diagnóstica por imagem a tomografia computadorizada de seios da face evidenciou a fístula localizada em recesso lateral de seio esfenoidal direito. Nesse caso o paciente foi submetido a correção cirúrgica, sendo escolhida uma abordagem endoscópica endonasal transpitrigoide para acessar a região do defeito. Realizado o fechamento da fístula o paciente evoluiu sem sinais de recidiva e sem outras sintomatologias.

Rhinogenic cerebrospinal fluid (CSF) leaks are communications between the nasal cavities and the subarachnoid space. The etiology of these leaks could be traumatic or non-traumatic, citrus rhinorrhea or otorrhea are the most common symptoms. The spontaneous non-traumatic leaks are less common to occur than the traumatic ones. The reported patient had CSF rhinorrhea through the right nostril, with an increased flow when leaning forward and/or perform anterior neck flexion. Imaging diagnostic by computed tomography cisternography showed the leak located in the lateral recess of the right sphenoid sinus. In this case the patient underwent a surgical procedure, the choice was an endoscopic endonasal traspterygoid approach to access the defect. A robust reconstruction of the defect was performed and the patient evolved without signs of recurrence or any other symptoms.

Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach / 中华创伤杂志(英文版)

OBJECTIVE@#To describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach.@*METHODS@#This was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent.@*RESULTS@#Thirty-five patients were included in this series. The patients' mean age was 33 years (range 11-71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3-65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus.@*CONCLUSION@#Traumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Clinical efficacy of CT-guided epidural autogenous blood patch in treatment of spontaneous refractory intracranial hypotension headache / 中国介入影像与治疗学

Objective: To observe the efficacy and safety of CT-guided epidural blood patch (EBP) in treatment of spontaneous refractory intracranial hypotension headache. Methods: Clinical and imaging data of 12 patients with spontaneous intracranial hypotension headache treated with CT-guided EBP were retrospectively analyzed, and visual analogue scale (VAS) and complications were calculated before and after procedures. Results: A total of 12 patients received 19 CT-guided EBP therapy, among which 7 patients received secondary EBP therapy. Five patients had postoperatively localized neck pain unrelated to body position, and then healed spontaneously within 1 week. No serious complication occurred. VAS of all patients at each time point after operation was lower than that before operation (all P<0.01), and the clinical symptoms relieved or disappeared after operation. No recurrence was detected during 3 months' follow-up. Conclusion: CT-guided EBP is effective and safe in treatment of spontaneous refractory intracranial hypotension headache.

Endoscopic endonasal double flap technique for reconstruction of large anterior skull base defects: technical note / Técnica endoscópica endonasal utilizando duplo retalho para reconstrução de grandes defeitos da base anterior do crânio: nota técnica

Abstract Introduction: One of the main concerns in endoscopic endonasal approaches to the skull base has been the high incidence and morbidity associated with cerebrospinal fluid leaks. The introduction and routine use of vascularized flaps allowed a marked decrease in this complication followed by a great expansion in the indications and techniques used in endoscopic endonasal approaches, extending to defects from huge tumours and previously inaccessible areas of the skull base. Objective: Describe the technique of performing endoscopic double flap multi-layered reconstruction of the anterior skull base without craniotomy. Methods: Step by step description of the endoscopic double flap technique (nasoseptal and pericranial vascularized flaps and fascia lata free graft) as used and illustrated in two patients with an olfactory groove meningioma who underwent an endoscopic approach. Results: Both patients achieved a gross total resection: subsequent reconstruction of the anterior skull base was performed with the nasoseptal and pericranial flaps onlay and a fascia lata free graft inlay. Both patients showed an excellent recovery, no signs of cerebrospinal fluid leak, meningitis, flap necrosis, chronic meningeal or sinonasal inflammation or cerebral herniation having developed. Conclusion: This endoscopic double flap technique we have described is a viable, versatile and safe option for anterior skull base reconstructions, decreasing the incidence of complications in endoscopic endonasal approaches.

Resumo Introdução: Uma das principais preocupações em abordagens endoscópicas endonasais da base do crânio tem sido a alta incidência e morbidade associada a fístulas liquóricas. A introdução e o uso rotineiro de retalhos vascularizados permitiram uma acentuada redução dessa complicação, seguida por uma grande expansão nas indicações e técnicas utilizadas nas abordagens endoscópicas endonasais, incluindo grandes tumores e áreas anteriormente inacessíveis da base do crânio. Objetivo: Descrever a técnica cirúrgica realizando uma reconstrução endoscópica multicamadas da base anterior do crânio com duplo retalho, sem craniotomia. Método: Descrição passo a passo da técnica endoscópica com duplo retalho (retalhos vascularizados nasoseptal e pericraniano e enxerto livre de fascia lata), utilizados e ilustrados em dois pacientes com meningioma do sulco olfatório submetidos à cirurgia por via endoscópica endonasal. Resultados: Em ambos os pacientes procedeu-se ressecção total macroscópica seguido de reconstrução da base anterior do crânio com os retalhos nasoseptal e pericraniano onlay e enxerto livre de fáscia lata inlay. Os pacientes apresentaram uma excelente recuperação, sem sinais de fístula liquórica, meningite, necrose do retalho, inflamação meníngea crônica ou sinonasal ou hérnia cerebral. Conclusão: A técnica endoscópica de duplo retalho, como descrita, trata-se de uma opção viável, versátil e segura para as reconstruções da base anterior do crânio, diminuindo a incidência de complicações em abordagens cirúrgicas endoscópicas endonasais.

Neurological Symptoms of Intracranial Hypotension

Intracranial hypotension usually arises in the context of known or suspected leak of cerebrospinal fluid (CSF). This leakage leads to a fall in intracranial CSF pressure and CSF volume. The most common clinical manifestation of intracranial hypotension is orthostatic headache. Post-dural puncture headache and CSF fistula headache are classified along with headache attributed to spontaneous intracranial hypotension as headache attributed to low CSF pressure by the International Classification of Headache Disorders. Headache attributed to low CSF pressure is usually but not always orthostatic. The orthostatic features at its onset can become less prominent over time. Other manifestations of intracranial hypotension are nausea, spine pain, neck stiffness, photophobia, hearing abnormalities, tinnitus, dizziness, gait unsteadiness, cognitive and mental status changes, movement disorders and upper extremity radicular symptoms. There are two presumed pathophysiologic mechanisms behind the development of various manifestations of intracranial hypotension. Firstly, CSF loss leads to downward shift of the brain causing traction on the anchoring and supporting structures of the brain. Secondly, CSF loss results in compensatory meningeal venodilation. Headaches presenting acutely after an intervention or trauma that is known to cause CSF leakage are easy to diagnose. However, a high degree of suspicion is required to make the diagnosis of spontaneous intracranial hypotension and understanding various neurological symptoms of intracranial hypotension may help clinicians.

Parche de sangre epidural torácico, de alto volumen, para el tratamiento del Síndrome de Hipotensión Intracraneana Espontánea secundario a fuga cervical de líquido cefalorraquídeo, ¿mejora el período asintomático?. Reporte de caso / High blood volume thoracic epidural patch for the treatment of spontaneous intracranial hypotension syndrome due to cervical cerebrospinal fluid leak, It prolongs the asymptomatic period?. A case report

Mujer de 50 años, con historia de 3 semanas de cefalea ortostática progresiva y síntomas neurológicos inespecíficos, confirmándose higroma subdural a nivel C5 con fuga de líquido cefalorraquídeo compatible con Síndrome de Hipotensión Intracraneal Espontánea (SHIE). Tratamiento médico inicial sin respuesta. Se realiza parche sanguíneo epidural (PSE) a nivel torácico con 20 ml de sangre directo a través de trocar epidural, observándose respuesta terapéutica completa en seguimiento hasta 8 meses. Creemos que un PSE torácico ofrece las ventajas de uno cervical y lumbar y, por lo tanto, debe considerarse una alternativa terapéutica eficaz en este síndrome especialmente en pacientes anatómicamente complejos.

A 50-year-old woman, with a history of three-week orthostatic headache and nonspecific neurological symptoms, has a subdural hygroma at C5 level with a cerebrospinal fluid leakage compatible with Spontaneous Intracranial Hypotension Syndrome (SIHS). Initial conservative treatment has no response. A thoracic epidural blood patch (EBP) is performed, with a 20ml blood volume spread through an epidural needle, with a complete therapeutic response up-to 8 months. We believe that a higher blood volume patch through a thoracic approach gives the advantages of cervical and lumbar EBP, and, therefore, should be considered as a therapeutic alternative especially in technical anatomically difficult patients.

Manejo endoscópico del meningoencefalocele de base de cráneo anterior / Endoscopic management of anterior skull base meningoencephalocele

RESUMEN La fístula de líquido cefalorraquídeo (LCR) corresponde a una comunicación anormal entre el espacio subaracnoideo y la porción neumatizada de la base de cráneo anterior en relación con las cavidades paranasales. Fístulas persistentes requieren reparación quirúrgica por el riesgo de meningitis, abscesos cerebrales y neumoencéfalo asociado. El gold standard es el abordaje extracraneal endoscópico. Uno de los principales inconvenientes es dañar estructuras intracraneanas nobles. La ayuda de tecnologías como la cirugía guiada por imágenes, contribuye a disminuir este problema. A continuación se presentan dos casos clínicos de fístula de líquido cefalorraquídeo en base de cráneo anterior, asociado a meningoencefalocele, intervenidos por cirugía endonasal guiada por imágenes.

ABSTRACT Endoscopic management of anterior skull base meningoencephalocele. The cerebrospinal fluid leak (CSF) is an abnormal communication between the subaracnoid space and the pneumatic portion of the anterior cranial base which is related to the paranasal cavities. The persistent leak requires surgery due to the potential complications such as meningitis, cerebral abscess or pneumoencephalus. Extracranial endoscopic approach is the gold standard procedure. One of the most important risk of the surgery is to damage noble intracranial structures. This situation can be ameliorated by using image guided surgery. We present two cases of CSF in anterior cranial base associated with meningoencephalocele that were treated in our center using nasal image guided endoscopic surgery.

Abordaje endoscópico endonasal para el manejo de fístula de líquido cefalorraquídeo Serie de casos / Endoscopic endonasal approach for the management of cerebrospinal fluid fistula Case Series

"Introducción: La rinoliquia resulta de una comunicación entre el espacio subarac¬noideo y las barreras de la cavidad nasal, lo que conlleva un riesgo de neuroinfección por paso de bacterias de las cavidades nasales al espacio intracraneal. Para su manejo existen técnicas extra e intracraneales. Sin embargo, las técnicas de cierre endoscó¬pico endonasal han ganado popularidad en los últimos años. Objetivo: Describir las características clínicas y quirúrgicas de una serie de casos con diagnóstico de fístula de líquido cefalorraquídeo manejados con cierre endoscópico endonasal en dos hos¬pitales de III nivel. Diseño: Estudio observacional descriptivo tipo serie de casos. Metodología: Se estudiaron 20 pacientes con diagnóstico de fístula de líquido ce¬falorraquídeo (LCR) llevados a manejo endoscópico endonasal. Se registraron sus antecedentes demográficos, forma de presentación, etiología, técnica quirúrgica, seguimiento, tasa de éxito y complicaciones. Resultados: El 60% de los pacien¬tes presentaba alguna comorbilidad asociada, principalmente meningitis recurrente. Todos los pacientes fueron estudiados mediante alguna imagen radiológica, princi¬palmente tomografía axial computarizada de alta resolución. El cierre endoscópico endonasal tuvo un porcentaje de éxito del 75% en la primera cirugía y una tasa del 100% para la cirugía revisional. La única complicación postoperatoria reportada fue meningitis. Conclusiones: Basados en la presente serie de casos y en la literatura disponible, el abordaje endoscópico endonasal para el cierre de fístulas de líquido cefalorraquídeo es un procedimiento bien tolerado para la mayoría de pacientes, con un porcentaje de cierre primario superior al 75% y secundario mayor del 95% en la mayoría de los casos. "

"Introduction: Cerebrospinal fluid rhinorrhea results from a communication between the subarachnoid space and the barriers of the nasal cavity, which carries a risk of neuroinfectious diseases by passage of bacteria from the nasal cavities to the intra¬cranial space. There are extra and intracranial techniques for its treatment. However, endonasal endoscopic closure techniques have gained popularity in recent years. Objective: To describe the clinical and surgical characteristics of patients with diag¬nosis of cerebrospinal fluid leak, managed with endonasal endoscopic repair in two III level hospitals. Design: Case series study. Methods: 20 patients diagnosed with cerebrospinal fluid leak and treated by endonasal endoscopic management were studied. Their demographic background, presentation, etiology, surgical technique, monitoring, success rate and complications were recorded. Results: 60% of patients had comorbid conditions, especially recurrent meningitis. All patients were studied by a radiological image, mostly high-resolution computed tomography. The endona¬sal endoscopic repair had a success rate of 75% in the first attempt and 100% success for revisional surgery. The only postoperative complication reported was meningitis. Conclusions: Based on this case of series, and the available literature, endonasal en¬doscopic repair of cerebrospinal fluid leak is well tolerated for most patients, with a percentage of primary and secondary closure more than 75% and 95%, respectively, in most case of series."

Body mass index and the risk of postoperative cerebrospinal fluid leak following transsphenoidal surgery in an Asian population

<p><b>INTRODUCTION</b>Postoperative cerebrospinal fluid (CSF) leak is a serious complication following transsphenoidal surgery for which elevated body mass index (BMI) has been implicated as a risk factor, albeit only in two recent North American studies. Given the paucity of evidence, we sought to determine if this association holds true in an Asian population, where the BMI criteria for obesity differ from the international standard.</p><p><b>METHODS</b>A retrospective study of 119 patients who underwent 123 transsphenoidal procedures for sellar lesions between May 2000 and May 2012 was conducted. Univariate and multivariate logistic regression analyses were performed to investigate the impact of elevated BMI and other risk factors on postoperative CSF leak.</p><p><b>RESULTS</b>10 (8.1%) procedures in ten patients were complicated by postoperative CSF leak. The median BMI of patients with postoperative leak following transsphenoidal procedures was significantly higher than that of patients without postoperative CSF leak (27.0 kg/m vs. 24.6 kg/m; p = 0.018). Patients categorised as either moderate or high risk under the Asian BMI classification were more likely to suffer from a postoperative leak (p = 0.030). Repeat procedures were also found to be significantly associated with postoperative CSF leak (p = 0.041).</p><p><b>CONCLUSION</b>Elevated BMI is predictive of postoperative CSF leak following transsphenoidal procedures, even in an Asian population, where the definition of obesity differs from international standards. Thus, BMI should be considered in the clinical decision-making process prior to such procedures.</p>

A Case of Frontoethmoidal Mucopyocele Combined with Cerebrospinal Fluid Leak and Complicated Tension Pneumocephalus after Marsupialization

After the trauma of frontoethmoidal sinus, post-traumatic mucocele may occur. Surgical removal of the lesions rarely produces cerebrospinal fluid (CSF) leakage and even delayed tension pneumocephalus. We experienced a case of fronto-ethmoid mucocele complicated with peri-operative CSF leakage and post-operative tension pneumocephalus which was improved by conservative treatment. It is imperative to take into account the potential for tension pneumocephalus when a patient suffers from severe headache after sinus surgery.

Fístula de líquido cefalorraquídeo del receso lateral de seno esfenoidal: ¿Es el canal de Sternberg un defecto real? / Cerebrospinal fluid leak of the lateral recess of the sphenoid sinus: is Sternberg's channel a real defect?

RESUMEN Las fístulas de líquido cefalorraquídeo (LCR) corresponden a una comunicación anómala entre el espacio subaracnoideo y la cavidad nasal. El origen de las fístulas laterales del seno esfenoidal se encuentra en un defecto congénito de la base del cráneo, con una incompleta o prematura fusión de los componentes óseos implicados en el complejo proceso de osificación del esfenoides. Ello origina un canal sin cobertura ósea, solo cubierto por tejido conectivo, denominado canal craneofaríngeo lateral o de Sternberg. Este es un punto débil donde pueden aparecer encefaloceles y/o fístulas, su ubicación lateral en el seno constituyen una zona de difícil abordaje quirúrgico. La reparación quirúrgica de fístulas de LCR ha progresado drásticamente con el desarrollo de ópticas endoscópicas y la mejora en el conocimiento de la anatomía de la base de cráneo. Los endoscopios permiten una visualización directa, localización del defecto y por ende una reparación precisa que traduce menos recidivas y menor morbilidad asociada a accesos transcraneales realizados previamente. El propósito de este artículo es presentar el caso de paciente con fístula del receso lateral del seno esfenoidal, su reparación endoscópica y discusión del origen de la persistencia del canal de Sternberg como causa del defecto.

ABSTRACT Fístulas liquid cerebrospinal (CSF) correspond to an abnormal communication between the subarachnoid space and the nasal cavity. The origin of lateral fístulas of the sphenoid sinus is a congenital defect of the skull base, with an incomplete or premature fusion of bone components involved in the complex process of ossification of sphenoid. This originates a channel without bone coverage, only covered by connective tissue, called channel craneofaringeo or Sternberg channel. This is a weak point where may appear encephaloceles and/or fístula, the lateral location in sinus is a difficult surgical approach. Surgical repair of fístulas of CSF has progressed dramatically with the development of endoscopic optics and the improvement in the knowledge of the anatomy of the skull base. Endoscopes enable a direct visualization, location of the defect and thus accurate reparation and less morbidity associated with transcraneales accesses made previously. The purpose of this article is to present the case of patient with fístula of the lateral recess of the sphenoid sinus, endoscopic repair and discussion of the origin of the persistence of the channel of Sternberg as a cause of the defect.

Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage / 대한핵의학회잡지

We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.

Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management / 대한신경손상학회지

Cerebrospinal fluid (CSF) leaks are one of the common complications after traumatic brain injuries (TBI). The risks of CSF leaks can be detrimental to the outcomes of the patients. Early diagnosis and proper management is imperative for it is strongly associated with a better long-term prognosis of the patients. Diagnostic tools for CSF leaks are still under debate. Nevertheless, many reports of successful treatments for CSF leaks have been published with introduction of various repair techniques for leakage sites even though it is surgically challenging. Hereby, we review about the pathophysiology, manifestations as well as the update of the clinical diagnosis and current management of CSF leaks.

Proper Management of Posttraumatic Tension Pneumocephalus / 대한신경손상학회지

Pneumocephalus is commonly seen after craniofacial injury. The pathogenesis of pneumocephalus has been debated as to whether it was caused by ball valve effect or combined episodic increased pressure within the nasopharynx on coughing. Discontinuous exchange of air and cerebrospinal fluid due to “inverted bottle” effect is assumed to be the cause of it. Delayed tension pneumocephalus is not common, but it requires an active management in order to prevent serious complication. We represent a clinical case of a 57-year-old male patient who fell down from 3 m height, complicated by tension pneumocephalus on 5 months after trauma. We recommend a surgical intervention, but the patient did not want that so we observe the patient. The patient was underwent seizure and meningitis after 7 months after trauma, he came on emergency room on stupor mentality. Tension pneumocephalus may result in a neurologic disturbance due to continued air entrainment and it significantly the likelihood of intracranial infection caused by continued open channel. Tension pneumocephalus threat a life, so need a neurosurgical emergency surgical intervention.

Estudio comparativo de cierre de cuero cabelludo en neurocirugías supratentoriales: intradérmica vs. surget / Comparative study of scalp closure in supratentorial neurosurgery: intradermal vs. surget

Introducción: El cierre de cuero cabelludo en neurocirugías supratentoriales mediante sutura intradérmica es una técnica poco difundida en la actualidad. En contraste, es común que se efectúen suturas de alta tensión con el fin de evitar dehiscencias, fístula de líquido cefalorraquídeo (LCR) y sangrado durante el período posquirúrgico, pero que no tienen buen resultado estético. Objetivo: Comparar las complicaciones relacionadas al cierre de cuero cabelludo que se presentaron en neurocirugías supratentoriales en un período de 19 meses, para determinar si utilizar un cierre de menor tensión y con mejor resultado estético, es igual de seguro que las técnicas de cierre habituales. Materiales y Métodos: Se incluyeron 84 casos de neurocirugías supratentoriales electivas. En 43 casos (control) se realizó el cierre mediante sutura continua tipo surget y en 41 casos (experimental) el cierre fue mediante sutura intradérmica. Resultados: Se presentaron 2 casos de infecciones, 1 en cada grupo (p= 0,97) y 1 caso de sangrado en el grupo control (p= 0,32). No se presentaron dehiscencias ni casos de fístula de LCR. Conclusiones: El cierre de cuero cabelludo mediante sutura intradérmica fue un método seguro que no generó una mayor incidencia de complicaciones y logró un mejor resultado estético a corto y largo plazo.

Background: Scalp closure by means of intradermal suture in patients who underwent supratentorial neurosurgeries is currently an uncommon technique. In contrast, it is usual to perform high tension sutures to avoid skin dehiscence, cerebrospinal fluid leak (CSF) and postoperative bleeding; however it usually results in unsatisfactory aesthetic results. Aim: Comparing complications, over a two year period, related to scalp closure occurred in supratentorial neurosurgeries. The goal is to establish if the intradermal suture is as safe as the current high tension closure technique.Materials and Methods: Eighty-four patients were included. In forty-three cases (control) continuous high tension suture (surget) was performed. The other forty-one cases (experimental) underwent intradermal suture. Results: Two infection cases occurred, one from each group (p= 0, 97). There was one case of bleeding that took place in the control group (p= 0,32). Neither dehiscence nor CSF leak occurred in any of the trial cases.Conclusions: Intradermal suture performed for scalp closure was as safe as surget in terms of complications occurrence and obtained better cosmetic results in the short and long term.

Endoscopic endonasal management of cerebrospinal fluid rhinorrhea after anterior clinoidectomy for aneurysm surgery: changing the paradigm of complication management / Endoscopia endonasal no tratamento da fístula liquórica após clinoidectomia anterior na cirurgia de aneurisma: mudando o paradigma no manejo desta complicação

ABSTRACT Resection of the anterior clinoid process results in the creation of the clinoid space, an important surgical step in the exposure and clipping of clinoidal and supraclinoidal internal carotid artery aneurysms. Cerebrospinal fluid rhinorrhea is an undesired and potentially serious complication. Conservative measures may be unsuccesful, and there is no consensus on the most appropriate surgical treatment. Two patients with persistent transclinoidal CSF rhinorrhea after aneurysm surgery were successfully treated with a combined endoscopic transnasal/transeptal binostril approach using a fat graft and ipsilateral mucosal nasal septal flap. Anatomical considerations and details of the surgical technique employed are discussed, and a management plan is proposed.

RESUMO A ressecção da clinóide anterior resulta na criação do espaço clinoideo, um passo cirúrgico importante na exposição e clipagem de aneurismas dos segmentos clinoideo e supraclinoideo da artéria carótida interna. Fístula liquórica é uma das complicaçoes mais indesejadas e é potencialmente grave. O manejo com medidas conservadoras pode ser bem sucedido, e não há consenso sobre o tratamento cirúrgico mais adequado. Dois pacientes com rinorréia persistente secundária a fistula liquórica transclinoidal após cirurgia de aneurisma foram tratados com sucesso por uma abordagem endoscópica combinada transnasal/transseptal binostril usando um enxerto de gordura e retalho de mucosa naso-septal ipsilateral. Considerações anatômicas e detalhes da técnica cirúrgica empregada são discutidos, e um plano de manejo destes tipo de fistula líquorica é proposto.