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Alattar AA, Hirshman BR, McCutcheon BA, Chen CC, Alexander T, Harris J, Carter BS. Risk Factors for Readmission with Cerebrospinal Fluid Leakage Within 30 Days of Vestibular Schwannoma Surgery. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx197] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Cerebrospinal fluid (CSF) leak is a well-recognized complication after surgical resection of vestibular schwannomas and is associated with a number of secondary complications, including readmission and meningitis.
OBJECTIVE
To identify risk factors for and timing of 30-d readmission with CSF leak.
METHODS
Patients who had undergone surgical resection of a vestibular schwannoma from 1995 to 2010 were identified in the California Office of Statewide Health Planning and Development database. The most common admission diagnoses were identified by International Classification of Disease, ninth Revision, diagnosis codes, and predictors of readmission with CSF leak were determined using logistic regression.
RESULTS
A total of 6820 patients were identified. CSF leak, though a relatively uncommon cause of admission after discharge (3.52% of all patients), was implicated in nearly half of 490 readmissions (48.98%). Significant independent predictors of readmission with CSF leak were male sex (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.32-2.25), first admission at a teaching hospital (OR 3.32, 95% CI 1.06-10.39), CSF leak during first admission (OR 1.84, 95% CI 1.33-2.55), obesity during first admission (OR 2.10, 95% CI 1.20-3.66), and case volume of first admission hospital (OR of log case volume 0.82, 95% CI 0.70-0.95). Median time to readmission was 6 d from hospital discharge.
CONCLUSION
This study has quantified CSF leak as an important contributor to nearly half of all readmissions following vestibular schwannoma surgery. We propose that surgeons should focus on technical factors that may reduce CSF leakage and take advantage of potential screening strategies for the detection of CSF leakage prior to first admission discharge.
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Affiliation(s)
- Ali A Alattar
- School of Medicine, University of California San Diego, La Jolla, California
| | - Brian R Hirshman
- Division of Neurological Surgery, University of California San Diego, San Diego, California
- Computation, Organization, and Society Program, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | | | - Clark C Chen
- Division of Neurological Surgery, University of California San Diego, San Diego, California
| | - Thomas Alexander
- Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
| | - Jeffrey Harris
- Division of Otolaryngology-Head and Neck Surgery, University of California San Diego, San Diego, California
| | - Bob S Carter
- Division of Neurological Surgery, University of California San Diego, San Diego, California
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Massive Cerebrospinal Fluid Leak of the Temporal Bone. Case Rep Otolaryngol 2016; 2016:7521798. [PMID: 27597915 PMCID: PMC4997066 DOI: 10.1155/2016/7521798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022] Open
Abstract
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.
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Arístegui Ruiz MÁ, González-Orús Álvarez-Morujo RJ, Oviedo CM, Ruiz-Juretschke F, García Leal R, Scola Yurrita B. Surgical treatment of vestibular schwannoma. Review of 420 cases. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2015; 67:201-11. [PMID: 26679233 DOI: 10.1016/j.otorri.2015.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/24/2015] [Accepted: 09/01/2015] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES Vestibular schwannoma is the most frequent cerebellopontine angle tumor. The aim of our study is to reflect our experience in the surgical treatment of this tumor MATERIAL AND METHODS Retrospective study of 420 vestibular schwannomas operated in our hospital between 1994-2014. We include tumor size, preoperative hearing, surgical approaches, definitive facial and hearing functional results, and complications due to surgery. RESULTS A total of 417 patients with 420 tumors were analyzed, 209 female (50.1%) and 208 male (49.9%). Mean age at diagnosis was 49.8±13.2 years. The majority of the tumors were resected through a translabyrinthine approach (80.2%). Total tumor removal was achieved in 411 tumors (98.3%), and anatomic preservation of facial nerve in 404 (96.2%). Definitive facial nerve outcome was House-Brackmann grade I and II in 69.9%, and was significantly better in tumors under 20mm. Surgical complications included cerebrospinal fluid leakage in 3 patients (0.7%) and retroauricular subcutaneous collection in 16 (3.8%), 5 cases of meningitis (1.2%), 4 patients with intracraneal bleeding (0.9%), and death in 3 patients (0.7%). CONCLUSIONS Surgery is the treatment of choice for vestibular schwannoma in the majority of patients. In our experience, the complication rate is very low and tumor size is the main factor influencing postoperative facial nerve function.
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Affiliation(s)
| | | | - Carlos Martín Oviedo
- Servicio de ORL, Hospital General Universitario Gregorio Marañón, Madrid, España
| | | | - Roberto García Leal
- Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, España
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Ammar MB, Piccirillo E, Topsakal V, Taibah A, Sanna M. Surgical Results and Technical Refinements in Translabyrinthine Excision of Vestibular Schwannomas. Neurosurgery 2012; 70:1481-91; discussion 1491. [DOI: 10.1227/neu.0b013e31824c010f] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Vestibular schwannomas (VSs) are the most common cerebellopontine angle tumors, accounting for 75% of all lesions in this location.
OBJECTIVE:
To evaluate the results after removal of VS through the enlarged translabyrinthine approach, which is a widening of the classic translabyrinthine approach that gives larger access and provides more room to facilitate tumor removal and to minimize surgery-related morbidities.
METHODS:
This was a retrospective study of 1865 patients who underwent VS excision through the enlarged translabyrinthine approach between 1987 and 2009. Mean age was 50.39 years. Mean tumor size was 1.8 cm. Median follow-up was 5.7 years.
RESULTS:
Total removal was achieved in 92.33% of cases; 143 patients had incomplete resection with evidence of regrowth in 8. In the 1742 previously untreated patients, anatomic preservation of facial nerve was achieved in 1661 cases (95.35%), and House-Brackmann grade I or II was reached in 1047 patients (59.87%). Facial nerve outcome was significantly better in tumors ⩽ 20 mm. Surgical complications included cerebrospinal fluid leakage in 0.85%, meningitis in 0.10%, intracranial bleeding in 0.80%, non--VII/VIII cranial nerve palsy in 0.96%, cerebellar ataxia in 0.69%, and death in 0.10%. The technical modifications that evolved with increasing experience are described.
CONCLUSION:
The enlarged translabyrinthine approach is a safe and effective approach for the removal of VS. In our experience, the complication rate is very low and tumor size is still the main factor influencing postoperative facial nerve function with a cutoff point at around 20 mm.
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Affiliation(s)
- Mehdi Ben Ammar
- Department of Neurosurgery, Military Hospital of Tunis, University of Tunis El Manar, Tunis, Tunisia
| | | | - Vedat Topsakal
- Department of Otorhinolaryngology, University Medical Center of Utrecht, Utrecht, the Netherlands
| | | | - Mario Sanna
- Gruppo Otologico, Piacenza and Rome, Italy
- Department of Otorhinolaryngology, University Medical Center of Utrecht, Utrecht, the Netherlands
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Angeli RD, Ben Ammar M, Sanna M. Perioperative complications after translabyrinthine removal of large or giant vestibular schwannoma: outcomes for 123 patients. Acta Otolaryngol 2011; 131:1237-8. [PMID: 21728749 DOI: 10.3109/00016489.2011.596161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Jayashankar N, Morwani KP, Sankhla SK, Agrawal R. The enlarged translabyrinthine and transapical extension type I approach for large vestibular schwannomas. Indian J Otolaryngol Head Neck Surg 2011; 62:360-4. [PMID: 22319693 DOI: 10.1007/s12070-010-0057-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 10/10/2010] [Indexed: 10/18/2022] Open
Abstract
To evaluate the results obtained by performing the enlarged translabyrinthine and transapical extension type I approaches for removal of large vestibular schwannomas and those with anterior extensions. An academic tertiary referral centre at Mumbai, India. Retrospective case review. 35 patients of vestibular schwannomas having size greater than 3 cm in extrameatal diameter with extension anterior to the internal auditory canal who underwent the enlarged translabyrinthine or transapical extension type I approach and with a minimum follow up of 1 year are considered. Other subjects who underwent translabyrinthine approach but did not fulfill the above criteria were excluded. Tumor was removed completely in 34 subjects (97.1%). Anatomic interruption of facial nerve occured in 4 cases (11.4%); 3 subjects underwent end to end anastomosis and 1 subject required a cable graft, these were done during the primary procedure itself. At 1 year follow up 28 subjects (80%) had good facial function (Grade I and II, House Brackmann Grading). Postoperative cerebrospinal fluid leak was encountered in 1 subject (2.9%). 34 subjects (97.1%) had a normal albeit slow gait by the sixth post-operative day. Complete tumor removal with a very low morbidity in our series suggest that the enlarged translabyrinthine and transapical extension type I approach offers excellent control of the neurovascular structures in the cerebellopontine angle as also of the large vestibular schwannoma itself aiding complete removal. It also offers the advantage of management of the interrupted facial nerve at the primary procedure itself since the proximal and distal segments are in the operative field.
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Yuen HW, Thompson AL, Symons SP, Pirouzmand F, Chen JM. Vascularized mastoid bone flap cranioplasty after translabyrinthine vestibular schwannoma surgery. Skull Base 2009; 19:193-201. [PMID: 19881899 DOI: 10.1055/s-0028-1096204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE We describe a novel technique of cranioplasty using a vascularized mastoid bone flap in patients after translabyrinthine excision of vestibular schwannomas (VS). Postoperative outcomes in terms of pinna and postauricular deformity are evaluated. STUDY DESIGN Retrospective study. SETTING Tertiary referral center. RESULTS Seventeen patients underwent cranioplasty with bone flap after translabyrinthine VS excision. At minimum follow-up of 12 months, none had a cerebrospinal fluid (CSF) leak. The measured pinna projections between the operated and non-operated sides had a mean difference of 0.80 mm (+/-1.70), which is not statistically significant (p > 0.05). The mean depth of the postauricular depressions was 1.38 mm (+/-0.93). Over the same period, 10 patients underwent translabyrinthine VS surgery without cranioplasty. In this group, there was a significant difference of 4.71 mm (+/-1.53) in mean pinna underprojections on the operated sides compared with the non-operated sides. Compared with patients who have undergone cranioplasty, the retroauricular depressions were significantly deeper (p < 0.05) with a mean depth of 2.92 mm (+/-1.21). CONCLUSIONS Vascularized mastoid cortical bone flap cranioplasty is a simple and effective technique to ameliorate the pinna and retroauricular deformities after translabyrinthine VS excision without increased surgical cost or the use of alloplastic materials.
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Affiliation(s)
- Heng-Wai Yuen
- Department of Otolaryngology-Head and Neck Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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Fístulas de LCR tras la cirugía de tumores del ángulo pontocerebeloso y su relación con el índice de masa corporal. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2009; 60:318-24. [DOI: 10.1016/j.otorri.2009.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Accepted: 03/24/2009] [Indexed: 11/21/2022]
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Díaz Anadon Á, Lassaletta L, María Roda J, Gavilán Bouzas J. CSF fistulae following surgery for cerebellopontine angle tumours and their relationship with the body mass index. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s2173-5735(09)70151-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Reconstructive options for skull defects following translabyrinthine surgery for vestibular schwannomas. Curr Opin Otolaryngol Head Neck Surg 2008; 16:318-24. [DOI: 10.1097/moo.0b013e32830139b8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jacob A, Bortman JS, Robinson LL, Yu L, Dodson EE, Welling DB. Does Packing the Eustachian Tube Impact Cerebrospin al Fluid Rhinorrhea Rates in Translabyrinthine Vestibular Schwannoma Resections? Otol Neurotol 2007; 28:934-8. [PMID: 17704723 DOI: 10.1097/mao.0b013e31814619bd] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To calculate cerebrospinal fluid (CSF) leak rates for translabyrinthine (TL), middle cranial fossa (MCF), and retrosigmoid/suboccipital (SO) craniotomies performed for removal of vestibular schwannoma (VS) and analyze whether packing the eustachian tube (ET) in TL VS resections impacts CSF rhinorrhea rates. STUDY DESIGN Retrospective. SETTING Tertiary care center. METHODS Chart review. RESULTS Three hundred fifty-nine VS resections were reviewed in 356 patients ranging from 10 to 86 years of age. Two hundred thirty-one TL, 70 MCF, 53 SO, and 5 combined TL/SO procedures were analyzed. Total CSF leak rates (incisional, otorrhea, and rhinorrhea) were 14.2% for TL, 11.4% for MCF, and 13.2% for SO approaches. Differences in overall CSF leak rates were not statistically significant. For those who underwent TL craniotomies, 2 groups of patients were identified based on whether their ETs were packed during surgery. In 1 group, the incus was removed, the aditus enlarged, the ET packed, and the middle ear filled with muscle. In the second group, the aditus, epitympanum and middle ear were packed without removing the incus, and the ET was not packed. Of 148 patients who had their ET packed, 12 developed CSF rhinorrhea (8.1%). The CSF rhinorrhea rate for patients who did not have ET packing was 5.9% (3 of 51 patients). This difference was not statistically significant (p = 0.80). When Proplast was used to pack the ET (121 patients), the CSF rhinorrhea rate was 5.8%. Unfortunately, this material extruded in 4 of 121 patients (3.3%) and presented clinically as delayed purulent otorrhea. CONCLUSION Cerebrospinal fluid leak rates were similar in patients undergoing TL, SO, and MCF approaches, and CSF rhinorrhea was not decreased by ET packing. Patients whose ETs are packed with Proplast are at risk for extrusion and otorrhea years after their initial VS resection.
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Affiliation(s)
- Abraham Jacob
- Department of Otolaryngology-Head & Neck Surgery, The Ohio State University, Columbus, Ohio 43210, USA.
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Park JS, Kong DS, Lee JA, Park K. Intraoperative management to prevent cerebrospinal fluid leakage after microvascular decompression: dural closure with a “plugging muscle” method. Neurosurg Rev 2007; 30:139-42; discussion 142. [PMID: 17221266 DOI: 10.1007/s10143-006-0060-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Revised: 10/02/2006] [Accepted: 10/06/2006] [Indexed: 10/23/2022]
Abstract
Our objective is to present surgical techniques used for the prevention of cerebrospinal fluid leakage after microvascular decompression (MVD). From January 1996 to February 2006, microvascular decompression for hemifacial spasm or trigeminal neuralgia was performed in 678 consecutive patients. In order to achieve watertight dural closure, several pieces of muscle were interposed between the dura when the dura was sutured; the dura was stitched with the addition of muscle pieces to plug the dural defect. In cases where the mastoid air cell system was opened, bone wax was used to seal the opened surface of the cavity, and a muscle patch was applied for the secondary sealing. The cranioplasty was performed using polymethylmethacrylate (PMMA) bone cement. Only 2 (0.29%) of 678 patients, who underwent MVD followed by dural closure using several muscle pieces to plug the potential dural defect, suffered from CSF leaks. Both were treated with lumbar subarachnoid drainage; neither patient required a lumbar peritoneal shunt or a revision operation. A watertight dural closure with the addition of muscle pieces in a "plugging" fashion, along with sealing the opened surface of the mastoid cavity using bone wax and cranioplasty using bone cement, provides a simple and effective technique for the prevention of CSF leakage after MVD.
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Affiliation(s)
- Jae Sung Park
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu, Seoul 135-710, South Korea
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