Impact of Chemoradiotherapy on CSF Leak Repair after Skull Base Surgery

Very delayed CSF leak in patients after craniotomy for resection of skull base tumors

OBJECTIVE

Cerebrospinal fluid (CSF) leak is a potentially dangerous neurosurgical complication. Delayed CSF leak has already been described after trauma, radiation therapy and endonasal transsphenoidal surgery for Sella turcica pathologies. Still, very few reported cases describe delayed CSF leak after craniotomy for tumors. We present our experience with patients showing delayed CSF leak after skull base tumor resection.

METHODS

Data for all tumors resected from the skull base region from January 2004 to December 2018 was retrieved from the surgeon's prospective database and supplemented with a retrospective file review. Patients who presented CSF leak within the first 12 months after surgery and those with a history of trauma or radiation-based treatment to the skull base region were excluded from the study. Epidemiology, clinical presentation, previous surgical approach, pathology, interval between craniotomy and CSF leak and proposed treatment were analyzed.

RESULTS

Overall, more than two thousand patients underwent surgery for resection of skull base tumors during the study period. Six patients (two male, four female; mean age 57.5 years, range 30-80) presented with delayed CSF leak, including five (83%) who presented with bacterial meningitis. After skull base tumor resection, CSF leak developed in a mean of 72 months (range 12-132). Three patients underwent retrosigmoid craniotomy, two for resection of cerebellopontine angle epidermoid cyst and one for resection of a petro tentorial meningioma; one had trans petrosal retrolabyrinthine craniotomy for resection of a petroclival epidermoid cyst; one had far lateral craniotomy for resection of a foramen magnum meningioma; and one had pterional craniotomy for resection of a cavernous sinus meningioma. All patients underwent surgical re-exploration and repair. CSF leak was managed with mastoid obliteration in five patients and skull base reconstruction with fat graft in one.

CONCLUSION

Recognition of very delayed CSF leak as a potential complication after resection of skull base tumors may be useful tool in long-term patient management. In our experience, these patients usually present with bacterial meningitis. Surgical options should be considered as a definitive treatment.

Precision Postoperative Radiotherapy in Sinonasal Carcinomas after Endonasal Endoscopic Surgery

Simple Summary

Sinonasal cancers are rare and heterogeneous tumors, mainly carcinomas, with essentially local evolution and a severe vital and functional prognosis. These tumors are more and more being treated in first intent by a mini-morbid endoscopic approach rather than open surgery as the cornerstone of curative treatment. Adjuvant radiotherapy remains necessary owing to non-optimal local control. This article describes the requirements of radiotherapy to ensure adequate delays, the potential of postoperative radiotherapy to increase local and distant disease control and to decrease morbidity further after mini morbid surgery and dose painting techniques, and reviews the criteria that lead to the choice of one technique over another.

Abstract

Radiotherapy plays an important role in the treatment of sinonasal cancer, mainly in the adjuvant setting after surgical resection. Many technological approaches have been described, including intensity-modulated radiotherapy, concomitant chemoradiotherapy, charged particle therapy or combined approaches. The choice is based on general criteria related to the oncological results and morbidity of each technique and their availability, as well as specific criteria related to the tumor (tumor extensions, pathology and quality of margins). The aims of this review are: (i) to provide an overview of the radiotherapy techniques available for the management of sinonasal malignant tumors and (ii) to describe the constraints and opportunities of radiotherapy owing to the recent developments of endonasal endoscopic surgery. The indication and morbidity of the different techniques will be discussed based on a critical literature review.

The effect of prior radiation on the success of ventral skull base reconstruction: A systematic review and meta-analysis

The incidence of cerebrospinal fluid leak after ventral skull base reconstruction is a primary outcome of interest to skull base surgeons. Exposure to pre-operative radiation may put patients at an increased risk of skull base reconstructive failure. A systematic search identified studies which included patients receiving ventral skull base reconstruction in the setting of pre-operative radiation. A meta-analysis using a random effects model was conducted to estimate an odds ratio of cerebrospinal fluid (CSF) leak in patients exposed to pre-operative radiation. A meta-analysis of 13 studies demonstrated that the odds ratio of CSF leak was 1.73 (95% CI 0.98-3.05). The majority of studies (77%) used vascularized tissue grafts for reconstruction. We identified an increased incidence of CSF leak among patients undergoing ventral skull base reconstruction after prior radiation therapy, although not of statistical significance. Skull base surgeons should exercise caution when planning reconstruction in this population.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

Massive Cerebrospinal Fluid Leak of the Temporal Bone

Cerebrospinal fluid (CSF) leakage of the temporal bone region is defined as abnormal communications between the subarachnoidal space and the air-containing spaces of the temporal bone. CSF leak remains one of the most frequent complications after VS surgery. Radiotherapy is considered a predisposing factor for development of temporal bone CSF leak because it may impair dural repair mechanisms, thus causing inadequate dural sealing. The authors describe the case of a 47-year-old man with a massive effusion of CSF which extended from the posterior and lateral skull base to the first cervical vertebrae; this complication appeared after a partial enucleation of a vestibular schwannoma (VS) with subsequent radiation treatment and second operation with total VS resection.