Vivostat®: an autologous fibrin sealant as useful adjunct in endoscopic transnasal CSF-leak repair.

The benefit of fibrin glue for reduction of postoperative CSF-leaks after endoscopic skull base surgery is not clearly evident in literature. However, its use is supposed to be beneficial in fixing grafting material. As of today there is no specific data available for otolaryngological procedures. A retrospective data analysis at a tertiary care referral center on 73 patients treated endoscopically transnasally for CSF-leaks at the ENT-department Graz between 2009 and 2012 was performed. Primary closure rate between conventional fibrin glue and autologous fibrin glue were analyzed. The Vivostat(®) system was used in 33 CSF-leak closures and in 40 cases conventional fibrin glue was used. Comparing the two methods the primary closure rate using the autologous Vivostat(®) system was 75.8 and 85.0 % with conventional fibrin glue. The secondary closure the rates were 90.9 % with Vivostat(®) 92.5 % with conventional fibrin glue. The Vivosat(®) system is a useful adjunct in endoscopic CSF-leak closure. Its advantages over conventional fibrin glue are its application system for fixation of grafting material particularly in underlay techniques. Despite this advantage it cannot replace grafting material or is a substitute for proper endoscopic closure which is reflected by the closure rates.

The utility of calcium phosphate cement in cranioplasty following retromastoid craniectomy for cranial neuralgias.

BACKGROUND: Following retromastoid craniectomy for microvascular decompression of the fifth or seventh cranial nerve, the preferred method and value of cranioplasty remains disputed. METHODS: In this study, we report the functional outcome of calcium phosphate cranioplasty following first-time microvascular decompression in 79 consecutive patients who underwent operations over a one-year period. RESULTS: No patient experienced a deep infection, cerebrospinal fluid leak or undue incisional pain at long-term follow-up. Additionally, all patients stated that they were satisfied with the cosmetic outcome. DISCUSSION: Although this technique is unlikely to affect the rates of infection and postoperative pain, we believe that the low rate of CSF leak provides a unique advantage over other currently used methods of closing retromastoid craniectomies.

Endoscopic endonasal treatment of a spontaneous temporosphenoidal encephalocele with a detachable silicone balloon. Case report.

Temporosphenoidal encephaloceles are rare entities that occur when the temporal lobe herniates into the sphenoid sinus through a skull base defect of the temporal bone. Both an iatrogenic and a traumatic pathogenesis have been proposed. The authors describe a spontaneously occurring temporosphenoidal encephalocele in a 63-year-old woman who had a 4-year history of rhinorrhea. Spiral computerized tomography (CT) scanning revealed a bone defect located inside the ophthalmomaxillary triangle. The intrasphenoidal encephalocele had a heterogeneously hypointense signal compared with cerebrospinal fluid (CSF) on T1-weighted magnetic resonance (MR) images and a hyperintense signal compared with CSF on T2-weighted MR images. Two previous endonasal endoscopic procedures, performed by ear, nose, and throat surgeons, had been unsuccessful. The authors performed an endoscopic endonasal right nostril procedure by using 0 degrees and 45 degrees rigid-lens endoscopes that were 4 mm in diameter and 18 cm long. The encephalocele in the sphenoid sinus was partially removed. DuraGen and fat graft were positioned in the bone defect. Two No. 2 French detachable silicone balloons (1.5 cm3 volume) inflated with surgical glue were introduced into the skull defect and into the sphenoid sinus, respectively. The CSF leakage stopped immediately. No nasal packing or postoperative CSF lumbar drainage was necessary. The patient did well. Postoperative CT and MR imaging, obtained at 24 hours and at 3 months, demonstrated that the balloon and the fat graft filled the bone defect and the sphenoid sinus. Eight months postprocedure no CSF leakage was observed. This appears to be the first case reported in the literature of a temporosphenoidal encephalocele successfully treated by an endoscopic endonasal technique involving packing of the defect with inflated detachable balloons.

Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement.

Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a Food and Drug Administration-approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern United States. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.

Simple management of cerebrospinal fluid rhinorrhea after pituitary surgery.

A simple procedure for managing postoperative cerebrospinal fluid rhinorrhea after pituitary surgery is described. Under local anesthesia, a needle is introduced manually through a nostril toward the sella turcica and EDH adhesive or fibrin glue is injected into the sellar cavity or sphenoid sinus, or both. This procedure is simple and safe to perform, acceptable to the patient, and can be done in a short hospital stay.

Neurosurgical applications of the cyanoacrylate adhesives.

The cyanoacrylate adhesives are a biologically heterogenous group, some of which are potentially valuable additions to the neurosurgical armamentarium. The commercially available cyanoacrylates usually contain the more toxic methyl and ethyl monomers. The safe butyl monomer, isobutyl 2-cyanoacrylate, is approved in the United States by the Food and Drug Administration for investigational use only. Isobutyl 2-cyanoacrylate may prove to be useful for the extravascular reinforcement of intracranial aneurysms and for the intravascular occlusion of carotid-cavernous fistulae. Safe and effective alternatives exist for the management of these two problems. The sealing of certain cerebrospinal fluid fistulae and the intravascular occlusion of certain arteriovenous malformations may be more effectively accomplished with isobutyl 2-cyanoacrylate than with other currently available techniques. The ultimate role of this and of other as yet untested cyanoacrylates in neurosurgery remains to be determined.

Cerebrospinal fluid leaks after planned intradural spine surgery: a single-center analysis of 91 cases.

UNLABELLED: BACKGROUND AND STUDY OBJECT: A leak-proof dura closure after elective surgery for intradural spinal lesions is important to achieve an uncomplicated postoperative course. Because many different closure techniques and dura substitutes exist, we tried to identify the superior material and technique to avoid cerebrospinal fluid leaks (CSFLs). PATIENTS AND METHODS: Between 2004 and 2009, 91 patients underwent surgical treatment of intradural spinal pathologies with primary dura closure with or without the use of dura substitutes at our institution. Pre- and postoperative images and the clinical course were analyzed retrospectively with respect to the occurrence of CSFL. RESULTS: In 34% of the 91 patients, radiological signs of CSFL were observed. A total of 12 patients (13%) were symptomatic for CSFL and required a single puncture, lumbar drain, or surgical revision. No significant relation between CSFL and patient characteristics, underlying diagnosis, localization, or extension was noted. In contrast, the incidence of CSFL was significantly increased if more than one substitute for dura closure was used. The results showed that 41.7% of these patients showed radiological signs of CSFL as compared with 10.4% of patients in which only a single material was used. CONCLUSION: In our study, none of the applied products appeared to be superior to the others. Surgery with the combined use of multiple dura closure substitutes was associated with the enhanced incidence of postoperative CSFL. However, our findings concerning the various dura sealants could not be used to compare those different materials, due to the great variety of combinations of dura sealants and the retrospective analysis of the data.

Complications of hydroxyapatite use for transnasal closure of cerebrospinal fluid leaks.

BACKGROUND: Hydroxyapatite cement (HAC) was first introduced in the 1980s as a new method for bone replacement. However, it has not been recommended for use in areas exposed to air. Despite this, surgeries have been performed using HAC to close nasal/sinus cerebrospinal fluid (CSF) leaks or in the treatment of encephaloceles. METHODS: This study retrospectively documented four patients in whom HAC was used for closure of ethmoid and sphenoid sinus CSF leaks. RESULTS: This study showed that exposed hydroxyapatite could be extremely problematic resulting in scarring, chronic granulation, infection, and prolonged healing. Oftentimes, revision surgery was necessary to help control the reaction to hydroxyapatite. CONCLUSION: Because of the frequent complications occurring with use of hydroxyapatite in the paranasal sinuses, its use should be limited to selected individuals in whom difficulty in achieving closure of the CFS leak could be anticipated and in whom adequate tissue coverage could be provided.

Rinorrea traumática de líquido cefalorraquídeo: nuestra experiencia en su diagnóstico y tratamiento / Traumatic cerebrospinal fluid rhinorrhea: our experience in diagnosing and treating this illness

Se realizó un estudio observacional descriptivo longitudinal en el Hospital Clinicoquirúrgico Provincial Docente Manuel Ascunce Domenech de Camagüey, en el período de enero a diciembre del 2004, para evaluar el manejo diagnóstico y terapéutico de la rinorrea traumática de líquido cefalorraquídeo (LCR). Se seleccionaron previo consentimiento informado 16 pacientes provenientes del Servicio de Urgencias. De estos, 11 fueron hombres y el 32 por ciento se encontraba en las edades comprendidas entre 15 y 29 años. Se determinaron síntomas asociados, estudios complementarios, tratamiento médico-quirúrgico, complicaciones y evolución. Se realizó estadística descriptiva e inferencial. Los síntomas más frecuentes fueron las cefaleas (87,5 por ciento), anosmia y vértigos. Los métodos diagnósticos más efectivos fueron la inspección visual (100,0 por ciento), la TAC simple y la rinoscopia. Los tratamientos más frecuentes fueron la antibioticoterapia y reducción de fracturas Lefort y nasoetmoidales con 62,5 por ciento y 87,5 por ciento, respectivamente. El 81,3 por ciento de los casos evolucionó favorablemente, solo 2 (12,5 por ciento) se complicaron con meningitis(AU)

A longitudinal, descriptive and observational study was undertaken from January to December, 2004 at Manuel Ascunce Domenech clinical and surgical hospital in Camaguey province, for the purpose of evaluating the diagnostic and therapeutic management of traumatic cerebrospinal fluid rhinorrhea. After obtaining their informed consent, 16 patients from the Emergency Dental Service were selected. Eleven of them were males and 32 percent was in the 15-29 years old group. Associated symptoms, supplementary studies, medical & surgical treatment, complications and recovery period were considered. Descriptive and inference statistics were used. The most frequent symptoms were headaches (87,5 percent), anosmia and dizziness. The most effective diagnosing methods were visual survey (100 percent), simple CT and rhinoscopy. The most common treatment regimes were antibiotic therapy and LeFort and nasoethmoidal fracture reduction with 62,5 percent and 87,5 percent of cases respectively. Recovery was satisfactory in 81,3 percent of cases, although two (12,5 percent) suffered complications from meningitis(AU)