Rhinorrhea and pneumocephalus after cerebrospinal fluid shunting. The role of lateral extensions of the sphenoid sinus

Tension pneumocephalus in a patient with NF1 following ventriculoperitoneal shunt-deciphering the cause and proposed management strategy

INTRODUCTION

Spontaneous pneumocephalus following ventriculoperitoneal shunting is a very unique complication, seen in a handful of patients. Small bony defects form as a result of chronically raised intracranial pressure, which can later lead to pneumocephalus once intracranial pressure decreases following ventriculoperitoneal shunting.

CASE REPORT

Here, we present a case of a 15-year-old girl with NF1 who presented to us with pneumocephalus 10 months following shunting and our management strategy along with a literature review of this condition.

CONCLUSION

NF1 & hydrocephalus can lead to skull base erosion, which needs to be looked up before proceeding with VP shunting to avoid delayed onset pneumocephalus. SOKHA with the opening of LT is a minimally invasive approach suitable to tackle both problems simultaneously.

Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study

OBJECTIVE

Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

METHODS

From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting.

RESULTS

Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3-9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6-63 months).

CONCLUSIONS

According to the authors' results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

OBJECTIVE AND IMPORTANCE

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect.

CLINICAL PRESENTATION

A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus.

INTERVENTION

The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure.

CONCLUSION

In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

Difficulties in treatment of CSF leakage associated with a temporal meningocele

Temporal meningocele is a rarely encountered pathology. It is caused by communication between the subarachnoid space of the middle fossa and lateral extension of the sphenoid sinus. Cerebrospinal fluid (CSF) pressures and the hydrostatic pulsatile forces may lead to the development of pitholes on the middle fossa at the sites of arachnoid villi with herniation of dura/arachnoid or brain tissue into the sinus. We describe an adult patient who presented with spontaneous CSF rhinorrhea due to a temporal meningocele. She was first operated on transsphenoidally, but the CSF rhinorrea did not cessate, therefore she was operated transcranially five days after the first operation. There has been no CSF rhinorrhea for three and a half years. Transcranial temporal encephalocele repairment is more effective than transsphenoidal surgery. Recurrent CSF leaks can occur due to both the increased CSF pressure and the insufficient operation technique.

Arachnoid diverticula associated with anterior cranial base tumors: technical case report

INTRODUCTION

Cerebrospinal fluid (CSF) diverticula are uncommonly associated with anterior cranial base tumors. When they occur, they often complicate the surgical management of these tumors via a transsphenoidal approach. This report examines the effectiveness of transsphenoidal surgery in the treatment of these rare entities.

METHODS

We performed a review of four sellar and parasellar tumors (three pituitary adenomas and one chordoma) that contained an arachnoid diverticulum communicating with the intracranial subarachnoid space.

RESULTS

One of these tumors (a prolactinoma) was successfully treated medically and regressed dramatically in size; the remaining three were treated by transsphenoidal resection. In all of the operative cases, the tumor was successfully resected with no endocrinological or neurological deficit. An intraoperative CSF leak was encountered in each operative case and was treated by packing the sella with an abdominal fat graft. One patient returned to the operating room for a CSF leak repair. No instances of infection, meningitis, or other major complications occurred. Sellar and parasellar tumors associated with arachnoid diverticula can be successfully treated using transsphenoidal surgery.

CONCLUSION

Preoperative anatomic localization of the CSF diverticulum, as well as anticipatory planning for an intraoperative CSF leak are essential. Whenever possible, it is probably wise to preserve the arachnoidocele rather than to rupture it intentionally, obliterating the dead space within the sella in either situation.

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea

Cerebrospinal fluid rhinorrhea and meningoencephaloceles extending into the nasal cavity from the anterior, middle, and posterior cranial fossae often are managed by otolaryngologists. A thorough understanding of the underlying pathophysiology, management principles, and treatment options is essential to achieve optimal outcomes. Surgical and medical management is highly individualized and depends on many factors, including etiology, anatomic site, and underlying intracranial pressure. This article highlights the history, physiology, pathophysiology, diagnosis, surgical techniques, and postoperative care relevant to nasal cerebrospinal fluid leaks and encephaloceles.

[Spontaneous posterior sphenoid sinus fistula]

OBJECTIVE

Describe a rare localization of spontaneous cerebrospinal fistula.

CASE REPORT

A 75-year-old women was admitted for bacterial meningitis arising from a sinus infection. She had not experienced facial or head trauma. The CT-scan revealed pneumocephaly and a defect in the posterior part of the sphenoid sinus.

DISCUSSION

Spontaneous cerebrospinal fistula is uncommon. The exact etiology remains unknown.

Endoscopic transnasal transpterygopalatine fossa approach to the lateral recess of the sphenoid sinus

OBJECTIVES

Lesions affecting the lateral recess of the sphenoid sinus are rarely discussed in the literature as a separate entity. This region is difficult to visualize and manipulate through the transnasal routes, especially when extensive pneumatization is present. External approaches to this area involve extensive surgery and are associated with significant morbidity. The objectives of this study are to present our experience with the endoscopic transpterygopalatine fossa approach as a method for exposing and manipulating lesions of the lateral recess of the sphenoid and to illustrate the detailed surgical steps of the procedure.

STUDY DESIGN

Retrospective review.

METHODS

Clinical charts of patients who had lesions originating from or extending into the lateral recess of the sphenoid sinus and who were treated at our institutions from September 1995 to June 2002 were retrospectively reviewed. All these patients were managed by the endoscopic transpterygopalatine fossa approach.

RESULTS

Twelve patients (7 males and 5 females) were included in the study. Lesions included seven cerebrospinal fluid (CSF) leaks and five tumors. One patient with squamous cell carcinoma (SCC) of the sphenoid died of his disease. All CSF leaks were successfully repaired, and benign tumors were removed with good local control through the follow-up period.

CONCLUSION

The endoscopic transpterygopalatine fossa approach is an excellent approach for dealing with lesions of the sphenoid lateral recess.

Nasal cerebrospinal fluid leaks: critical review and surgical considerations

Otolaryngologists have assumed a major role in the evaluation and management of anterior skull base defects that result in cerebrospinal fluid (CSF) leaks and meningoencephaloceles. To achieve the best possible results for patients with CSF leaks, a thorough understanding of the underlying pathophysiology and a critical analysis of management principles and treatment options is essential. Surgical and medical management of these patients is highly individualized and depends on a number of factors, including etiology, anatomic site, patient age, and underlying intracranial pressure. This review article will highlight the history, physiology, pathophysiology, diagnosis, surgical techniques, and postoperative care relevant to nasal CSF leaks and encephaloceles.

Surgical treatment of cerebrospinal fluid fistulae involving lateral extension of the sphenoid sinus

OBJECTIVE AND IMPORTANCE

Four cases of spontaneous cerebrospinal fluid rhinorrhea caused by communication between the subarachnoid space of the middle cranial fossa and a lateral extension of the sphenoid sinus are presented. The cause and management of this unique type of cranial base defect are discussed.

CLINICAL PRESENTATION

During the past 10 years, four patients referred to our institution with atraumatic cerebrospinal fluid fistulae were observed to have temporal encephaloceles (encephalomeningoceles) traversing the floor of the middle cranial fossa. Three of the patients had previously undergone unsuccessful transnasal attempts to repair their fistulae by obliteration of the sphenoid sinus. The fourth patient presented before undergoing any treatment. No patient had associated hydrocephalus or tumor. Preoperative computed tomographic cisternograms revealed that all fistulae involved a lateral extension of the sphenoid sinus into the floor of the middle cranial fossa.

INTERVENTION

After definitive localization, each patient was operated on transcranially through an anterior middle cranial fossa approach with extradural and/or intradural exploration. The associated temporal encephalocele was amputated or disconnected, and the dehiscent dura and middle cranial fossa floor defect were oversewn and packed with autogenous tissue, respectively.

CONCLUSION

The surgical treatment of cerebrospinal fluid rhinorrhea secondary to middle fossa encephalocele associated with lateral extension of the sphenoidal sinus differs from the surgical strategy for more medial sphenoidal fistulae. Fistulae involving a lateral extension of the sphenoid sinus require a transcranial approach for direct visualization and obliteration of the defect, whereas fistulae involving the central portion of the sinus may be successfully obliterated transsphenoidally.

The endoscopic approach to the lateral accessory sphenoid sinus

In summary, an interesting case of an accessory parasphenoid sinus mucocele in a 10-year-old girl is reported. By choosing an endoscopic approach, hearing and balance were preserved, and an external sinus or neurosurgical procedure avoided. The surgery was done on an outpatient basis, with minimal postoperative discomfort and no complications. The mucocele was adequately drained and there has been no recurrence over the following 12 months.

Delayed pneumocephalus in patients with CSF shunts

Cerebrospinal fluid (CSF) shunting has been associated with a significant number of complications, the commonest being shunt malfunction, infection and subdural haematomas. Delayed pneumocephalus following CSF diversion is a rare complication. Two cases are presented and the literature is reviewed with respect to the aetiology and management of this problem.

Spontaneous trigemino-pontine pneumocephalus

A case of a spontaneous trigemino-pontine pneumocephalus in a 25-year-old man without any known risk factors is described. Other cases of spontaneous pneumocephalus in the literature are briefly reviewed.