[Endoscopic endonasal anterior skull base surgery : Presentation of a monocentric entity profile]. / Endonasal-endoskopische anteriore Schädelbasischirurgie : Darstellung eines monozentrischen Entitätenprofils.

BACKGROUND: Extended endoscopic endonasal surgery (EEES) is an essential part of treatment of various pathologies of the anterior skull base. In addition to significant improvements in the quality of life of affected patients and a lower complication profile compared to open skull base surgery, the therapeutic results are comparable if the indications are correct. MATERIALS AND METHODS: Data of all endoscopic endonasal skull base procedures performed at the University Skull Base Center Hamburg under the direction of the Department of Otorhinolaryngology between June 2018 and November 2022 were retrospectively collected. RESULTS: A total of 50 cases were identified. Of these, 56% (28/50) were malignant tumors, 24% (12/50) were benign pathologies with direct skull base involvement, and 20% (10/50) were anterior skull base defects with rhinoliquorrhea. In 96% (48/50) of cases, the preoperatively set goal of surgery (representative biopsy, complete resection, closure of the skull base defect) could be achieved. Complications grade III or higher according to Clavien-Dindo occurred in 4/50 cases. During the observation period, n = 5 olfactory neuroblastomas were diagnosed, all of which were exclusively and successfully operated on endoscopically. CONCLUSION: In recent years, the spectrum of endoscopically resectable pathologies of the anterior skull base has steadily expanded. In particular, midline-related tumors such as olfactory neuroblastoma or iatrogenic/idiopathic skull base defects with cerebrospinal fluid rhinorrhea are treated completely endoscopically with very good results. Nevertheless, there are also limitations to this technique. Due to high variance in the scope of frontobasal surgery, the extent, and the complex anatomy, as well as the overlapping responsibilities of the specialist disciplines, establishment of certified skull base centers and bundling of frontobasal surgery at these centers is highly relevant for quality assurance.

An uncommon etiological factor for aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with cerebrospinal fluid rhinorrhea: a case report.

BACKGROUND: Aspiration pneumonitis is an inflammatory disease of the lungs which is difficult to diagnose accurately. Large-volume aspiration of oropharyngeal or gastric contents is essential for the development of aspiration pneumonitis. The role of cerebrospinal fluid (CSF) rhinorrhea is often underestimated as a rare etiological factor for aspiration in the diagnosis process of aspiration pneumonitis. CASE PRESENTATION: We present a case of a patient with 4 weeks of right-sided watery rhinorrhea accompanied by intermittent postnasal drip and dry cough as the main symptoms. Combined with clinical symptoms, imaging examination of the sinuses, and laboratory examination of nasal secretions, she was initially diagnosed as spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, and intraoperative endoscopic findings and postoperative pathology also confirmed this diagnosis. Her chest computed tomography showed multiple flocculent ground glass density shadows in both lungs on admission. The patient underwent endoscopic resection of meningoencephalocele and repair of skull base defect after she was ruled out of viral pneumonitis. Symptoms of rhinorrhea and dry cough disappeared, and pneumonitis was improved 1 week after surgery and cured 2 months after surgery. Persistent CSF rhinorrhea caused by spontaneous sphenoid sinus meningoencephalocele was eventually found to be a major etiology for aspiration pneumonitis although the absence of typical symptoms and well-defined risk factors for aspiration, such as dysphagia, impaired cough reflex and reflux diseases. CONCLUSIONS: We report a rare case of aspiration pneumonitis caused by spontaneous sphenoid sinus meningoencephalocele with CSF rhinorrhea, which can bring more attention and understanding to the uncommon etiology for aspiration, so as to make more accurate diagnosis of the disease and early surgical treatment.

Cryptococcus neoformans in a child with CSF rhinorrhoea: A cytopathological diagnosis.

Cryptococcosis is caused by Cryptococcus neoformans and is fatal in children. The fungus is known to enter respiratory tract by inhalation and localizes in lungs in immunocompetent host. Patients with immunocompromised state facilitate dissemination of disease. However, disseminated cases have been described in immunocompetent HIV-negative individuals. CSF rhinorrhoea as a predisposing cause of cryptococcal meningitis has been rarely reported. We hereby describe C. neoformans directly spreading to the meninges in 1 year child due to CSF rhinorrhoea and the fungus was detected on fluid cytology.

Idiopathic intracranial hypertension presenting as bilateral spontaneous lateral intrasphenoidal and transethmoidal meningoceles: a case report and review of the literature.

BACKGROUND: Basal meningoceles are rare herniations of the meninges that tend to present unilaterally with cerebrospinal fluid rhinorrhea. Growing evidence suggests that intracranial hypertension contributes considerably to the formation of spontaneous basal meningoceles. CASE PRESENTATION: A 50-year-old man of Middle East ethnicity presented with a 16-week history of cerebrospinal fluid rhinorrhea, short-term memory loss, and slight decline in cognitive function. We present a case of bilateral spontaneous meningoceles with bone defects in the left lateral sphenoid sinus and right anterior cribriform plate, as well as with a remodeled sella. A neuronavigation-assisted expanded endoscopic endonasal surgery was performed to resect the meningoceles. Postoperative imaging demonstrated complete resolution of the bilateral meningoceles. CONCLUSIONS: This case reports the first bilateral basal spontaneous meningoceles in the literature. Furthermore, based on this case's imaging results and the literature reviewed, elevated intracranial pressure may be a determining factor behind the development of spontaneous meningoceles.

Ganglioglioma with Cerebrospinal Fluid Rhinorrhea: A Rare Presentation.

BACKGROUND: Gangliogliomas are low-grade gliomas, and patients generally present with seizures. Gangliogliomas commonly occur in the temporal lobe and predominantly occur in children. Malignant progression is rare. CASE DESCRIPTION: A 26-year-old woman presented with a history of seizures since childhood and cerebrospinal fluid rhinorrhea for the past 6 months. Generally, patients with gangliogliomas seek early medical attention, as they present with dramatic complex partial seizures. This patient experienced seizures for 10 years and never sought medical attention during this time. She did not present for medical evaluation until she developed cerebrospinal fluid rhinorrhea. CONCLUSIONS: This case gave us an opportunity to learn the natural history of ganglioglioma, although clinical presentations vary according to tumor location. This is the first case report to our knowledge of a patient with ganglioglioma presenting with cerebrospinal fluid rhinorrhea.

Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks.

OBJECTIVES/HYPOTHESIS: Spontaneous cerebrospinal fluid (CSF) leaks are associated with increased intracranial pressure (ICP) and considered a manifestation of idiopathic intracranial hypertension. Although postoperative acetazolamide and placement of CSF shunt systems are considered valuable interventions for elevated ICP, the impact on recurrence rate remains unclear. The objective of this study was to systematically review evidence from reported literature to evaluate whether postoperative ICP management reduces recurrence rates after primary endoscopic repair. STUDY DESIGN: Prospective case series and systematic review. METHODS: Demographics, defect location, success rates, and ICP management in spontaneous CSF leak patients were prospectively collected over 8 years. A search was also conducted in PubMed to identify studies reporting cases of spontaneous CSF rhinorrhea. RESULTS: Fifty-six articles with nonduplicated data were identified and combined with a prospective series of 108 patients for a total of 679 patients treated for spontaneous CSF rhinorrhea. Average age was 50.4 years with 77% female. Average body mass index was 35.8 kg/m2 . Defects were most commonly located in the sphenoid sinus (n = 334) followed by the ethmoid (n = 318) and the frontal sinus (n = 46). Successful primary repair was 92.82% in patient cohorts where ICP evaluation and intervention with acetazolamide or CSF shunt systems was performed, but was significantly decreased to 81.87% in series with no active management of elevated ICP (P < .001). CONCLUSIONS: Evaluation and intervention for elevated ICP in spontaneous CSF leaks is associated with significantly improved success rates following primary endoscopic repair. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2011-2016, 2017.

[Related factors analysis of spontaneous cerebrospinal fluid leak recurrence after endoscope operation].

OBJECTIVE: To Summarize and analyze the clinical characteristics and treatment of patients with spontaneous cerebrospinal fluid rhinorrhea, and to explore the related factors of recurrence. METHOD: Retrospective- ly analyze the clinical data of 58 patients of spontaneous cerebrospinal fluid rhinorrhea from July 2002 to July 2012, combined with its clinical characteristics, and statistically analyze the related recurrence factors. RESULT: Fifty-eight cases were accepted the nasal endoscopic repairment of cerebrospinal fluid rhinorrheak, follow-up 3 years, 20 cases (34.5%) recurred, 1 case recurred in half a year after operation. In the first year, there were 10 cases recurred. In the second year there were 9 cases recurred, and 1 case recurred in the third year. Through multiariable analysis it was found that higher BMI, empty sella and skull base bone defect were the independent risk factors influencing the recurrence of spontaneous cerebrospinal fluid rhinorrhea (P < 0.05). CONCLUSION: The recurrence rate of spontaneous cerebrospinal fluid rhinorrhea is high, needing long-term follow-up. Higher BMI, empty sella, skull base bone defect are independent risk factors of recurrence of the disease, and the treatment should be individualized.

Unusual posttraumatic delayed cerebrospinal fluid rhinorrhea due to gunshot wound.

Delayed posttraumatic cerebrospinal fluid rhinorrhea (CSFr) without meningitis is considered to be relatively rare. However, even years after trauma, recurrence or delayed onset of CSFr and meningitis due to CSFr are possible. In this article, a case of delayed CSFr from the sphenoid sinus without meningitis three years after the transfacial gunshot wound is reported. Plain high-resolution computed tomography sections through the sphenoid sinus showed a bone defect at the roof with CSF-density fluid extending into the sphenoid sinus. Arachnoid membrane herniation into the sphenoid sinus was found and site of CSF fistula confirmed during the surgery. Skull base defect was reconstructed through an endoscopic approach without any complications and the patient was followed up for 12 months without recurrence. The cause, timing, clinical course and location of CSFr make this an apparently unique case. Patients with a skull base defect without CSFr should be closely followed up and may need further evaluation or management due to the possibility of CSFr development. The positive diagnosis of a CSFr raises the matter of choosing the adequate surgical approach for its repair. Endoscopic closure of CSFr is both safe and effective.

Differences in skull base thickness in patients with spontaneous cerebrospinal fluid leaks.

BACKGROUND: This study was designed to determine if differences in overall skull base thickness exist in patients with spontaneous cerebrospinal fluid (SCSF) leaks and to compare our institution's 10-year experience with the endoscopic repair of these leaks to the existing literature. A retrospective cohort study was performed in a tertiary rhinologic practice. METHODS: A retrospective study by two blinded independent reviewers compared the skull base thickness on computerized tomography (CT) imaging in our SCSF leak patients to nonleaking controls and patients with traumatic CSF leaks. Surgical outcomes were compared with a pooled analysis of the published literature. RESULTS: SCSF leaks were seen most commonly in obese, middle-aged women of African American descent. SCSF leak patients were shown to have thinner skull bases in the region of the ethmoid roof, lateral lamella, and anterior face of the sella (p < 0.05) compared with patients with traumatic leaks and nonleaking controls. No racial difference in skull base thickness was observed when patients were matched according to leak type. The success rate of primary endoscopic intervention in our patients was high at 94% and comparable with the published literature. CONCLUSION: Differences in skull base thickness exist in SCSF patients, but whether this predisposes to such leaks or is a consequence of the underlying pathophysiology remains unknown. The endoscopic endonasal approach provides a highly effective means of repairing such leaks with success rates comparable with the endoscopic repair of other leak types. Adjuvant measures including weight reduction, lumbar drain, and acetazolamide use may increase success rates and should be considered in their management.

Coma from wall suction-induced CSF leak complicating spinal surgery.

A 72-year-old woman was admitted for elective L4/L5 laminectomy. The operative procedure was extradural, and a Jackson-Pratt (JP) drain was placed in the tissue bed and set to wall suction during skin closure. During closure, the patient developed a 15 s period of asystole. The patient was haemodynamically stable, but was comatose for 3 days postoperatively. Cardiac enzymes and EEG were unrevealing. Head CT showed traces of subarachnoid haemorrhage and signs suggestive of cerebral anoxia. JP drain at the incision produced 170-210 mL/day of fluid, positive for ß-2 transferrin, indicating cerebrospinal fluid (CSF). The patient fully returned to baseline on hospital day 10. MRI on hospital day 8 normalised. The reversible coma and radiographic findings were most consistent with acute intracranial hypotension relating to acute loss of CSF. Because radiographic findings can mimic hypoxic-ischaemic injury, acute intracranial hypotension should be considered in the differential diagnosis of postoperative coma after cranial or spinal surgery.

Brain herniations into the dural venous sinuses or calvarium: MRI of a recently recognized entity.

Brain herniations into dural venous sinuses (DVS) are rare findings recently described and their etiology and clinical significance are controversial. We describe five patients with brain herniations into the DVS or calvarium identified on MRI, and discuss their imaging findings, possible causes, and relationship to the patient's symptoms. All patients were examined with MRI including high resolution pre- and post-contrast T1- and T2-weighted sequences. With respect to brain herniations we documented their locations, signal intensities in different sequences, and size. We then reviewed clinical records in an attempt to establish if any symptoms were related to the presence of these herniations. Three males and two females were examined (age range, 11-68 years). Three patients had unilateral temporal lobe herniations into transverse sinuses, one had a cerebellar herniation into the skull, and one had bilateral temporal lobe herniations into the transverse sinuses as well as a cerebellar herniation into the sigmoid sinus. In all, the herniated brain and surrounding cerebrospinal fluid (CSF) had normal signal intensity on all MRI sequences. When correlated with clinical symptoms, brain herniations were thought to be incidental and asymptomatic in three patients and two patients had histories of headaches. Brain herniations with surrounding CSF into the DVS/skull should be considered potential sources of filling defects in the DVS. We believe that they are probably incidental findings that may be more common than previously recognized and should be not confused with the more common arachnoid granulations, clots, or tumors. Two patients had headaches, but their relation to the presence of herniated brain was uncertain.

Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery.

OBJECTIVE: To describe the effect on postoperative cerebrospinal fluid (CSF) leak after anterior skull base (ASB) surgery and complications associated with the addition of the vascularized nasoseptal flap (NSF) to an existing reconstruction protocol. METHODS: A prospective database of all patients undergoing endoscopic ASB approaches was reviewed. Patients were divided into three groups based on the date the use of the NSF was adopted. Group A included patients with high-volume CSF leak closed using the NSF in addition to a multilayer closure. Group B included patients operated on during the same time period with no high-volume leak and no NSF. Group C included patients operated on before the adoption of the NSF with all types of CSF leak. Rates of intraoperative and postoperative CSF leak were analyzed for statistical significance. RESULTS: Of 415 consecutive patients undergoing endoscopic ASB surgery, there were 96 in group A, 114 in group B, and 205 in group C. CSF leak rates in group A (3.1%) and group B (2.6%) were significantly lower than in group C (5.9%; P < 0.05). Lumbar drains and the gasket seal closure were performed more frequently in group A (75% and 32%) compared with group B (21% and 12%) and group C (28% and 11%). NSF carried a 2% risk of postoperative mucocele. CONCLUSIONS: The addition of NSF to an algorithm for multilayer closure can decrease the rate of postoperative CSF leak.

Idiopathic sphenoid sinus CSF rhinorrhoea.

Cerebrospinal fluid (CSF) rhinorrhoea results from a direct communication between the CSF-containing subarachnoid space and the mucosa-lined space of the nasal cavity and paranasal sinuses. We present a case of 40-year-old woman, presenting with clear, watery discharge through the right nostril spontaneously. The CT cisternography confirmed the diagnosis of sphenoid sinus CSF rhinorrhoea, with no intracranial pathology. The patient was managed by transnasal endoscopic procedure, wherein bath plug technique was followed using temporalis fascia and overlay grafting with fascia lata and fibrin glue. The patient has been symptom free for the last year.

Spontaneous cerebrospinal fluid rhinorrhoea: computed tomography and magnetic resonance imaging findings.

Spontaneous cerebrospinal fluid rhinorrhoea is a rare clinical entity. The accurate localisation of the leakage site is essential for surgical planning. Imaging techniques such as high-resolution computed tomography (CT), CT cisternography and magnetic resonance cisternography in variable combinations are performed for this purpose. This pictorial essay aims to present the spectrum of imaging findings in cases of spontaneous cerebrospinal fluid rhinorrhoea, which may be useful for radiologists in the determination of the site of cerebrospinal fluid leakage.

Histological examination of expanded polytetrafluoroethylene artificial dura mater at 14 years after craniotomy: case report.

Expanded polytetrafluoroethylene (ePTFE) porous material (GORE(®) PRECLUDE(®) Dura Substitute) does not degenerate or deteriorate in vivo, and is currently used as artificial dura mater. This material does not adhere well to the surrounding tissues, but cerebrospinal fluid leakage along the suture line has been observed in several cases. We describe a case of craniotomy for tumor resection performed 14 years after dural repair with ePTFE sheet. Histological examination of the ePTFE sheet revealed that the sheet was structurally intact, with no evidence of tissue adhesion or cellular infiltration. However, collagen deposition was observed around the suture thread. When the suture thread was removed the collagen was also removed, and the original needle hole appeared again. No significant changes were observed in the features of the ePTFE sheet even 14 years postoperatively. The formation of fibrous tissue around the needle hole was important in preventing cerebrospinal fluid leakage.

Cerebral herniation as a complication of chest tube drainage of cerebrospinal fluid after injury to the spine.

BACKGROUND: Patients with concomitant injuries to the thorax and thecal sac requiring chest tube drainage are at risk for cerebral herniation caused by overdrainage of cerebrospinal fluid (CSF). CASE DESCRIPTION: A 40-year-old man presented to the trauma service awake, alert, and oriented with an isolated gunshot wound to the midaxillary line through the tenth intercostal space and a complete spinal cord injury at T12. The patient was stabilized and intubated. A chest tube was placed, and he was transferred to the neurologic intensive care unit. The patient was found to be comatose with complete absence of brainstem reflexes 3 hours after admission. RESULTS: Magnetic resonance imaging (MRI) and autopsy revealed diffuse cerebral edema, occlusion of the bilateral posterior cerebral arteries, and tonsillar herniation extending several centimeters below the foramen magnum, with petechial hemorrhages and absence of gliosis. CONCLUSIONS: To the authors' knowledge, this case represents the first report of cerebral herniation secondary to chest tube drainage of a CSF leak caused by traumatic injury to the thecal sac.

The effectiveness of lumbar drainage in the conservative and surgical treatment of traumatic cerebrospinal fluid rhinorrhea.

CONCLUSIONS: We found no differences in clinicopathologic factors and post-treatment effects between patients who did and did not receive lumbar drains (LDs) in the management of cerebrospinal fluid (CSF) rhinorrhea. Care should be taken in using LDs, after considering their effectiveness and complications, although routine use of an LD is not indicated in the management of traumatic CSF rhinorrhea. OBJECTIVES: We assessed the role and effectiveness of LDs in patients managed conservatively and surgically. METHODS: Of 117 patients treated for CSF rhinorrhea, 61 were managed conservatively and 56 were initially managed surgically. We compared the clinicopathologic features and factors related to treatment outcome between patients who did and did not receive LDs. RESULTS: Of 61 conservatively managed patients, 32 were managed without and 29 with LDs. There were no between-group differences in any clinicopathologic factors, recurrence rate, or incidence of meningitis during/after treatment, but duration of hospitalization differed significantly (15.3 vs 23.2 days, p = 0.03). Of 56 surgically managed patients, 24 were managed without and 32 with postoperative LDs. Except for age, there were no between-group differences in clinicopathologic factors. In terms of treatment outcome-related factors, there was no significant difference in recurrence rate, incidence of meningitis, or duration of hospitalization.

Symptomatic postsurgical cerebrospinal fluid leak treated by aspiration and epidural blood patch under ultrasound guidance in 2 adolescents.

Cerebrospinal fluid leakage causing a pseudomeningocele is a well-recognized complication after spine surgery. The repair of pseudomeningocele in a symptomatic patient is usually accomplished with direct open surgical repair of the durotomy, prolonged lumbar drainage, and/or placement of an epidural blood patch. The authors highlight a unique method of pseudomeningocele repair by presenting 2 cases of adolescent girls with symptomatic lumbar pseudomeningoceles. In both cases ultrasound was used to guide the aspiration of CSF from each pseudomeningocele and to apply the epidural blood patch. Both patients had complete and immediate resolution of symptoms. The authors found ultrasound to be a useful tool to assess the extent of the CSF leakage, to determine the degree of aspiration of the extradural CSF, and to confirm the injection of the blood into the epidural space and the space created by the pseudomeningocele.