Bibrachial amyotrophy as a rare manifestation of intraspinal fluid collection: a case report and systematic review

INTRODUCTION

Intraspinal cerebrospinal fluid (CSF) collection has been reported as a rare cause of lower motor neuron (LMN) disorder. We report a case of bibrachial diplegia associated with intraspinal CSF collection and perform a systematic literature review.

PATIENT AND METHODS

A 52-year-old man developed a bibrachial amyotrophy over 6 years, confirmed by the presence of cervical subacute neurogenic changes at electromyography (EMG). Brain magnetic resonance imaging (MRI) revealed cerebral siderosis, while spine MRI showed a ventral longitudinal intraspinal fluid collection (VLISFC) from C2 to L2. No CSF leakage was localized at myelography; a conservative treatment was chosen. We searched for all published cases until 30th April 2023 and extrapolated data of 44 patients reported in 27 publications.

RESULTS

We observed a male predominance, a younger disease onset compared to amyotrophic lateral sclerosis, and a quite long disease duration, highlighting a slow disease progression. LMN signs were more frequently bilateral, mostly involving C5-C6 myotomes. Around 61% of patients presented additional symptoms, but only three referred to a history of headache. Accordingly, CSF opening pressure was mostly normal. Spinal MRI revealed the presence of VLISFC and in some cases myelomalacia. EMG patterns displayed both chronic and subacute neurogenic change in the cervical region. The disease course mainly depended on the treatment choice, which was mostly represented by a surgical approach when a specific dural defect was detected by imaging.

CONCLUSION

Bibrachial diplegia due to VLISFC can be a treatable cause of focal amyotrophy and presents some clinical and radiological "red flags" which cannot be missed by a clinical neurologist.

Favorable effects of open surgery on patients with extensive skull base osteoradionecrosis through a personalized sequential approach: A case series

The present study aimed to investigate outcomes following open surgery for extensive skull base ORN. Open surgery through a personalized sequential approach was employed to deal with five cases of extensive skull base ORN. Two patients with mild cases underwent regional debridement and sequestrectomy, and three patients with severe cases underwent extensive resection with reconstruction using free anterolateral thigh (ALT) flap. Biological glues and vascularized flaps were used for obturation of the skull base bony defect to prevent postoperative cerebrospinal fluid (CSF) leakage. The infections were controlled by antibiotic administrations which strictly followed the principles of antimicrobial stewardship (AMS). As results, both regional debridement plus sequestrectomy and extensive resection achieved satisfied outcomes in all patients. No severe complications and delayed hospitalization occurred. During the follow-up period (8-19 months), all patients were alive, pain free, without crusting or purulent discharge, and no sequestration or CSF leakage occurred. In conclusion, a personalized sequential approach including open surgery, pedicled/vascularized free flap reconstruction and AMS was advocated for patients with extensive skull base ORN.

Leukocyte- and platelet-rich fibrin in cranial surgery: study protocol for a prospective, parallel-group, single-blinded randomized controlled non-inferiority trial {1}

BACKGROUND

CSF leakage is a major complication after cranial surgery, thus, adequate dural closure must be performed. Commercially available fibrin sealants are currently considered the gold standard for dural closure, but problems have been reported regarding safety, efficacy, and costs. This trial aims to investigate autologous leukocyte- and platelet-rich fibrin (L-PRF) as an alternative to commercially available fibrin sealants.

METHODS/DESIGN

This single-blinded, prospective randomized controlled interventional trial aims to demonstrate the non-inferiority of L-PRF compared to commercially available fibrin sealants for dural closure. This trial will include patients undergoing cranial neurosurgery (supratentorial and infratentorial) with intentional opening of the dura. Patients are randomized in a 1:1 fashion comparing L-PRF to commercially available fibrin sealants. The primary endpoint is postoperative CSF leakage within 12 weeks after surgery. Secondary endpoints are complications such as bleeding or wound infections. Additionally, a cost-effectiveness analysis is performed.

DISCUSSION

With this trial, we will evaluate the safety and efficiency of L-PRF compared to commercially available fibrin sealants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03812120. Registered on 22 January 2019.

Clinical Applicability of the Sellar Barrier Concept in Patients with Pituitary Apoplexy: Is It Possible?

There is evidence of association between sellar barrier thickness and intraoperative cerebrospinal fluid (CSF) leakage, impacting the postoperative prognosis of the patients. The aim of this study is to analyze the clinical applicability of the sellar barrier concept in a series of operated patients with pituitary apoplexy (PA). A retrospective study was conducted including 47 patients diagnosed with PA who underwent surgical treatment through a transsphenoidal approach. Brain magnetic resonance imaging (MRI) of the patients were evaluated and classified utilizing the following criteria: strong barrier (greater than 1 mm), weak barrier (less than 1 mm), and mixed barrier (less than 1 mm in one area and greater than 1 mm in another). The association between sellar barrier types and CSF leakage was analyzed, both pre- and intraoperatively. The preoperative MRI classification identified 10 (21.28%) patients presenting a weak sellar barrier, 20 patients (42.55%) with a mixed sellar barrier, and 17 patients (36.17%) exhibiting a strong sellar barrier. Preoperative weak and strong sellar barrier subtypes were associated with weak (p ≤ 0.001) and strong (p = 0.009) intraoperative sellar barriers, respectively. Strong intraoperative sellar barrier subtypes reduced the odds of CSF leakage by 86% (p = 0.01). A correlation between preoperative imaging and intraoperative findings in the setting of pituitary apoplexy has been observed.

Thunderclap headache revealing dural tears with symptomatic intracranial hypotension: Report of two cases

Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4-T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.

Spontaneous Intracranial Hypotension: Controversies in Treatment

Spontaneous intracranial hypotension (SIH) is a disorder of low cerebrospinal fluid (CSF) volume secondary to CSF leakage through a dural defect along the neuraxis with an estimated incidence of 5 people per 100,000.Great debate persists on the optimal treatment of this pathology, and clinical results are often contradictory. SIH may be initially approached via conservative measures, such as bed rest that is often supplemented with hydration, caffeine, and theophylline, which overall relieve symptoms in a small subset of patients at 6 months. Epidural blood patching (EBP) is generally the next consideration in symptom management. It is the most commonly performed intervention for spinal CSF leaks, as the first option or following the failure of conservative treatment. Further procedures may be performed in the case of EBP partial or temporary response and if the spinal CSF leak has been definitively localized (Beck et al., Neurology 87:1220-26, 2016). In those cases, if the CSF leak is well localized, the surgical closure of the spinal CSF leak may be considered.SIH is a complex but treatable CSF disorder. Despite recent advances in the field of neuroimaging and the different therapeutic options available, the appropriate management remains controversial and should be tailored to the patient.

[Surgical tactic of cochlear implantation in patients with intraoperative CSF leakage]

Cochlear implantation (CI) is currently the recognized and most promising method of rehabilitation of patients suffering from profound hearing loss and deafness. During the surgical stage of CI, one of the most unpleasant intraoperative features is CSF leakage from the cochlea opening. Most often it occurs in patients with malformations of the inner ear, with temporal bone fractures and with cochlear otosclerosis. The difficulty of choosing the tactics of surgical intervention in these patients is caused by the large variability of the anatomical structures of the inner ear. In the period from 2017 to 2021, 1954 patients underwent CI, of which 83 were patients with cochlea malformations (65 intraoperative CSF leakages), 14 with the temporal bones fractures (2 intraoperative CSF leakage), 12 with cochlear otosclerosis (1 CSF leakage), while 3 spontaneous intraoperative CSF leakages were noted in patients with normal cochlea anatomy and hyperpnumotized temporal bone pyramid and enlarged vestibular aqueduct. The highest risk of intraoperative CSF leakage was observed in patients with inner ear malformations (common cavity - 10, incomplete partition type III - 15) and anomalies of the internal auditory canal - 5 (dilated IAC - more than 8.5 mm in diameter). Moderate risk of intraoperative CSF leakage was typical for patients with incomplete partition type I (15 patients) and type II (25 patients).

Evaluate the safety and efficacy of dura sealant patch in reducing cerebrospinal fluid leakage following elective cranial surgery (ENCASE II): study protocol for a randomized, two-arm, multicenter trial

BACKGROUND

Cerebrospinal fluid (CSF) leakage is a frequent and challenging complication in neurosurgery, especially in the posterior fossa, with a prevalence of 8%. It is associated with substantial morbidity and increased healthcare costs. A novel dural sealant patch (LIQOSEAL) was developed for watertight dural closure. The objective of this study is to clinically assess the safety and effectiveness of LIQOSEAL as a means of reducing intra- as well as postoperative CSF leakage in patients undergoing elective posterior fossa intradural surgery with a dural closure procedure compared to the best currently available dural sealants.

METHODS

We will conduct a two-arm, randomized controlled, multicenter study with a 90-day follow-up. A total of 228 patients will be enrolled in 19 sites, of which 114 will receive LIQOSEAL and 114 an FDA-approved PEG sealant. The composite primary endpoint is defined as intraoperative CSF leakage at PEEP 20 cm H₂O, percutaneous CSF leakage within 90 days of, wound infection within 90 days of or pseudomeningocele of more than 20cc on MRI or requiring intervention. We hypothesize that the primary endpoint will not be reached by more than 10 patients (9%) in the investigational arm, which will demonstrate non-inferiority of LIQOSEAL compared to control.

DISCUSSION

This trial will evaluate whether LIQOSEAL is non-inferior to control as a means of reducing CSF leakage and safety TRIAL REGISTRATION: ClinicalTrials.gov NCT04086550 . Registered on 11 September 2019.

Radiological evolution of autograft fat used for skull base reconstruction after transsphenoidal surgery for pituitary adenomas

PURPOSE

Cerebro-spinal fluid leak after transsphenoidal surgery for pituitary adenomas may be prevented by skull base reconstruction with fat autograft. However, graft changes may interfere with the interpretation of postoperative images. Our aim is to describe the radiological evolution of the fat autograft.

METHODS

A retrospective analysis was performed, including patients undergoing a transsphenoidal surgery for pituitary adenomas with a fat autograft for skull base reconstruction. Clinical and radiological data were collected, with assessment of fat autograft and extent of resection. Statistical analysis was performed using Kruskal-Wallis and Wilcoxon signed-rank test while Spearman's Rho was used to analyze the relationship between variables.

RESULTS

Seventy-two patients were included. Macroadenomas were diagnosed in 62 cases (86.1%) and in 21 cases an invasion of the cavernous sinus was described (29%). Gross total resection was achieved in 84.7% of cases. The volume of the fat graft significantly decreased between 3 months and 1 year after surgery (p = 0.01) and between 1 year and the last follow-up (mean 4.63 years, p < 0.01). Fat signal ratio significantly diminished between 3 months and 1 year in unenhanced and enhanced T1-weighted sequences (p = 0.04 and p = 0.02 respectively). Volume reduction was related to the decrease in signal ratio in unenhanced T1 sequences (p = 0.008).

CONCLUSION

Fat resorbs with time: almost 50% of the fat volume is lost during the first year after surgery and 60% is resorbed at 4.6 years. T1-signal, before and after gadolinium injection, also decreases during the first year, probably because of the progressive fibrosis of the graft. This information will contribute to the interpretation of postoperative images.

Risk Factors for Postoperative Cerebrospinal Fluid Leakage After Intradural Spine Surgery

OBJECTIVE

Well-defined risk factors for cerebrospinal fluid leakage (CSFL) after intradural spine surgery are scarce in the literature. The aim of the present study was to identify patient- and surgery-related risk factors and the incidence of CSFL.

METHODS

For the present retrospective cohort study, we identified consecutive patients who had undergone intradural spine surgery between 2009 and 2021 at our department. The primary endpoint was the incidence of clinically or radiologically proven CSFL. The effects of the clinical and surgical factors on the occurrence of CSFL were analyzed.

RESULTS

A total of 375 patients (60.3% women; mean age, 54 ± 16.5 years) were included. Of the 375 patients, 30 (8%) had experienced postoperative CSFL and, thus, a significantly greater risk of wound healing disorders (odds ratio [OR], 24.9; 95% confidence interval [CI], 9.3-66.7) and surgical site infections (OR, 8.4; 95% CI, 2.6-27.7; P < 0.01 for each). No patient-related factors were associated with the development of CSFL. Previous surgery at the index level correlated significantly with the occurrence of postoperative CSFL (OR, 2.76; 95% CI, 1.1-6.8; P = 0.03) on multivariate analysis. Furthermore, patients with intradural tumors tended to have a greater risk of CSFL (OR, 2.3; 95% CI, 0.9-5.8; P = 0.07). Surgery-related factors did not influence the occurrence of CSFL. Surgery on the thoracic spine had resulted in a significantly lower postoperative CSFL rate compared with surgery on the cervical or lumbar spine (OR, -2.5; 95% CI, 1.3-4.9; P = 0.02).

CONCLUSIONS

Our study found no modifiable risk factors for preventing CSFL after intradural spine surgery. Patients with previous surgery at the index level had a greater risk of CSFL. The occurrence of CSFL resulted in significantly more wound healing disorders and surgical site infections, necessitating further therapy.

Gorham-Stout disease of skull base leading to cranial settling and rhinorrhea: a case-based review

PURPOSE

Gorham-Stout disease (GSD) is a rare progressive osteolytic disorder, theoretically caused by lymphovascular endothelial proliferation. Spinal involvement carries a dismal prognosis because of neurological consequences. Lesions of the skull base are extremely rare and entail even more devastating prognosis due to cervical instability and cerebrospinal fluid (CSF) leakage. Due to scarcity of this condition, the aim of this study was to give an overview of skull base GSD and review the cases with such condition reported in the literature.

METHODS

In this case-based review, different aspects of skull base GSD are discussed, and a sample clinical case of GSD leading to cranial settling and rhinorrhea is presented. The characteristics, symptoms, and managements of all English-language PubMed-reported cases were reviewed, and different features of presentation and methods of treatments were analyzed.

RESULTS

Based on the literature review, most of the cases encountered serious problems in the course of the disease. Meningitis/CSF leakage was detected in 12 of 26 collected cases, followed by hearing loss/tinnitus/otitis media in 10 cases, headache in 8, and neck pain/stiffness in 8 patients. Despite a variety of treatments, improvement was only observed in 8 of 26 collected cases. The reminders showed either stable condition or worsening and death.

CONCLUSION

All cases of GSD of the skull base should be evaluated for rhinorrhea/otorrhea and cranial settling, both of them being among the most life-threatening conditions. Since definite treatment, in order to stop disease progression, is sometimes impossible, symptomatic and supportive treatment should be started as possible.

[On the tactics of management and treatment of patients with congenital cerebral hernias in their localization in the maxillofacial region]

The analysis of the state of two patients with congenital cerebral hernias was carried out, which made it possible to establish differences in the effect of hernias on the state of the body. In the first case, the hernia is localized in the nasal cavity, and after its removal, the postoperative cerebrospinal fluid (CSF) leakage was stopped by a flap of the mucous membrane from the opposite side of the nasal septum. In the second case clinical analysis and computed tomography made it possible to state that the hernia was in the retromaxillary space and did not affect the patient's condition. Computed tomography shows signs of moderate blood pressure on the adjacent formations, and removal of the hernia and stopping the subsequent CSF leakage were impossible. The presented observations demonstrate an ambiguous approach to resolving the issue of surgical intervention in such cases.

[Nosocomial meningitis in endoscopic transsphenoidal surgery]

One of the main problems of transsphenoidal surgery is the risk of infectious complications. Nosocomial meningitis (NCM) can lead to increased length of hospital stay and financial costs, poor treatment outcomes and even mortality. This complication is an indicator of the quality of medical care for patients with neurosurgical diseases. The purpose of the review was to study the main risk factors of NCM, modern schemes for antibiotic prophylaxis and treatment of this complication after endoscopic transsphenoidal surgery. The main risk factors of meningitis are intra- and postoperative CSF leakage, overweight, diabetes mellitus, previous transsphenoidal surgeries and radiotherapy. To date, there are no generally accepted periods for antibiotic prophylaxis in nasal CSF leakage, installed external ventricular / lumbar drains or tampons in nasal cavity. Antibiotic prophylaxis should not exceed 3 postoperative days due to the risk of cultivating the drug-resistant organisms. If NCM is detected, treatment should be initiated immediately with a broad spectrum of antibiotics.

Comparison of Efficacy of an Epidural Blood Patch in Patients with Spinal Leakage of Cerebrospinal Fluid

BACKGROUND

The leakage of cerebrospinal fluid (CSF) can be encountered spontaneously or after procedures such as epidural or spinal anesthesia, intrathecal chemotherapy, CSF tapping, or other various spinal procedures. The leakage of CSF can lead to intracranial hypotension, which is associated with an orthostatic headache. For such patients with this type of headache, an epidural blood patch is the treatment of choice.

OBJECTIVE

The purpose of this study is to compare the clinical features and efficacy of an epidural blood patch for patients with spinal leakage of CSF.

STUDY DESIGN

Retrospective study.

SETTING

University hospital inpatients referred for consultation to the pain clinic.

METHODS

Identification of patients with orthostatic headache was performed using the program Clinical Data Warehouse (CDW) v 2.5. Search word in CDW for analysis was "epidural blood patch." We carefully evaluated the demographics, etiology, clinical features of headache, associated phenomena other than headache, level and types of CSF leakage, and frequencies and outcomes of epidural blood patches. We allocated patients into 2 groups according to the cause of headache: spontaneous intracranial hypotension (group SIH) and post-dural puncture headache (group PDPH).

RESULTS

The number of patients needing repeated epidural blood patches was significantly higher in the SIH group SIH in the PDPH group (P = 0.007). In the PDPH group, a targeted epidural blood patch was possible in 100% of the cases, whereas it was possible in only 66.7% of the patients in the SIH group, indicated by previous examination (P < 0.001). Forty patients (90.9%) and 17 patients (70.8%) achieved complete recovery from headache after a single epidural blood patch in the PDPH group and SIH group, respectively (P < 0.001).

LIMITATION

The number of patients allocated to each group was not balanced because of the retrospective design.

CONCLUSION

Most patients in the PDPH group required a single epidural blood patch to achieve complete recovery from headache. However, patients in the SIH group required repeated epidural blood patches for complete pain relief.

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.

High efficacy of tetra-PEG hydrogel sealants for sutureless dural closure

Advances in meticulous dural closure technique remain a great challenge for watertight dural closure in the aged society, because the cerebrospinal fluid (CSF) leakage after spinal surgery is often accompanied with the disgusting wound infection, meningitis and pseudomeningocele. Here, a tetra-poly (ethylene glycol) (PEG)-based hydrogel sealant is developed with collective advantages of facile operation, high safety, quick set time, easy injectability, favorable mechanical strength and powerful tissue adhesion for effective sutureless dural closure during the surgery procedure. Impressively, this tetra-PEG sealant can instantaneously adhere to the irregular tissue surfaces even in a liquid environment, and effectively prevent or block off the intraoperative CSF leakage for sutureless dural closure and dura regeneration. Together, this sutureless tetra-PEG adhesive can be utilized as a very promising alternative for high-efficient watertight dural closure of the clinical patients who incidentally or deliberately undergo the durotomy during the spinal surgery.

Anterior Dural Tear in Thoracic and Lumbar Spinal Fractures: Single-Center Experience with Coating Technique and Literature Review of the Available Strategies

Differently from the posterior, the anterior dural tears associated with spinal fractures are rarely reported and debated. We document our experience with a coating technique for repairing ventral dural lacerations, providing an associated literature review on the available strategies to seal off such dural defects. A PubMed search on watertight repair techniques of anterior dural lacerations focused on their association with spinal fractures was performed. Studies on animal or cadaveric models, on cervical spine, or based on seal/gelfoam or “not suturing” strategies were excluded. 10 studies were finally selected and our experience of three patients with thoracic/lumbar spinal fractures with associated ventral dural tear was integrated into the analysis of the surgical techniques. Among the described repair techniques for ventral dural lacerations a preference for primary suturing, mostly trans-dural, was noted (n = 6/10 papers). Other documented strategies were the plugging of the dural opening with a fat graft sutured to its margins, or stitched to the dura adjacent to the defect, and the closure of the dural tear with two patches, both trans-dural and epidural. Our coating techniques of the whole dural sac with the heterologous patch were revealed as safe and effective alternatives strategies, even when patch flaps wrapping nerve roots have to be cut and a fat graft has to be stitched in the patch respectively for sealing off antero-lateral and wide anterior dural tears. Compared to all the documented strategies for obtaining a watertight closure of an anterior dural laceration, the coating techniques revealed advantages of preserving neural structures, being adaptable to anterior and antero-lateral dural tears of any size.

Tension Pneumocephalus Following Balloon Sinuplasty

Balloon sinus dilation (BSD) is a common method of relieving sinus outflow obstruction. With the rising utilization of BSD, increasing numbers of BSD-related complications have also been reported. Here, we report a case of pneumocephalus and cerebrospinal fluid leak following BSD of the frontal sinus. Additionally, a review of the literature regarding BSD complications was performed.

Comparison of Transthecal Approach With Traditional Conservative Approach for Primary Closure After Incidental Durotomy in Anterior Lumbar Tear

BACKGROUND

Incidental durotomies (IDs) are frequent complications of spinal surgeries which are mostly posterior or lateral. Anterior IDs are rare; however, they may lead to severe complications. We compared the transthecal approach with the conservative approach for primary closure after durotomy in anterior lumbar dural tear to assess the efficacy of these approaches to decrease postsurgical complications and clinical outcomes.

METHODS

A total of 21 patients undergoing L2-S1 laminectomy with anterior ID were randomly divided into a transthecal group (n = 9) and a conservative group (n = 12) based on the surgical dural closure technique. Postoperative pseudomeningocele, wound infection, rootlet herniation, pneumocephalus, cerebrospinal fluid (CSF) leakage, headache, meningitis, in addition to surgery duration and length of hospitalization were examined and compared in both groups.

RESULTS

The frequency of pseudomeningocele and CSF leakage in patients undergoing the transthecal approach was significantly lower than those undergoing the conservative approach (P = .045 and .008, respectively). Furthermore, although the differences in the frequency of meningitis, pneumocephalus, headache, and wound infection were not statistically significant between the 2 groups, the effect sizes of the comparison were obtained as 49.4, 19.8, 7.1, and 2.6, respectively. This indicated that the differences were clinically significant between the 2 groups.

CONCLUSIONS

We found that the transthecal approach was significantly more successful in managing CSF leakage as well as its complications and clinical outcomes. However, further clinical trials with bigger sample sizes are needed to substantiate this claim.

A systematic review and meta-analysis of factors affecting the outcome of the epidural blood patching in spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is an often misdiagnosed condition resulting from non-iatrogenic cerebrospinal fluid (CSF) hypovolemia, typically secondary to spinal CSF leakage. Patients commonly present with posture-related headache, nausea, and vomiting. Following failure of conservative measures, epidural blood patching (EBP) is the most commonly performed intervention for spinal CSF leaks. The authors performed a systematic review and meta-analysis of existing literature to evaluate the role of different factors possibly affecting the efficacy of the EBP procedure. In accordance with the PRISMA guidelines, PubMed/Medline and SCOPUS databases were searched. Six eligible articles were retrieved. Five hundred patients were treated for SIH with EBP, of which 300 reported good response defined as complete remission of symptoms within 48 h after the first EBP requiring no further invasive treatment. Among the factors available for meta-analysis, none was found to be statistically significant in affecting the efficacy of the EBP procedure. A largely symmetrical funnel plot is reported for all the variables evaluated, indicating that publication bias did not play a significant role in the observed effects. The current knowledge about SIH and the EBP is scarce. The existing literature is contradictory and insufficient to aid in clinical practice. More studies are needed to draw significant conclusions that may help in the identification of patients at higher risk of EBP failure, who may benefit from different approaches.

Four-Year Treatment Outcomes of Children Operated for Neural Tube Defect in Addis Ababa, Ethiopia: A Retrospective Study

BACKGROUND

Closure of neural tube defects (NTDs) in children is a common neurosurgical procedure in Ethiopia, but we know little about the outcomes. The aim of this study was to study outcomes and to identify predictors of mortality and morbidity of surgically treated NTDs.

METHODS

Between July 2013 and August 2014, all patients operated for NTDs were prospectively registered in a database and followed for a minimum of 4 years after the initial surgery.

RESULTS

A total of 88 children primary operated for NTD closure in the period between July 2013 to August 2014 were included in the study. The median age at primary NTD closure was 29 days. The commonest site of defect was lumbar (60.2%) followed by lumbosacral (11.4%). There was no perioperative mortality, however, 23 (26.1%) of the children developed wound-related complications including cerebrospinal fluid leak and infection. Preoperative cerebrospinal fluid leakage (P = 0.013) was associated with risk of postoperative complications. We acquired 4-years follow-up data for 61 (69%) of the cases. At 4 years, 25 (41%) of these children had died. Presence of hydrocephalus and reduced motor function were found to be negative predictors for survival.

CONCLUSIONS

Overall, the prognosis was poor. The study provides a basis for identifying patients at risk to improve the standard of care.

The sellar barrier on preoperative imaging predicts intraoperative cerebrospinal fluid leak: a prospective multicenter cohort study

BACKGROUND

The type of sellar barrier observed between a pituitary tumor and cerebrospinal fluid (CSF) on preoperative magnetic resonance imaging (MRI) may predict intraoperative CSF leak during endonasal pituitary surgery. This is the first multicentric prospective cohort trial to study the sellar barrier concept and CSF leak rate during endoscopic pituitary surgery.

METHODS

This multi-center, international study enrolled patients operated for pituitary adenomas via fully endoscopic endonasal surgery over a period of 4 months. The independent variable was the subtype of sellar barrier observed on preoperative MRI (strong, mixed or weak); the dependent variable was the presence of an intraoperative CSF leak. The primary goal was to determine the association between a particular type of sellar barrier and the risk of intraoperative CSF leak. Appropriate statistical methods were then applied for data analysis.

RESULTS

Over the study period, 310 patients underwent endoscopic endonasal surgery for pituitary tumor. Preoperative imaging revealed a weak sellar barrier in 73 (23.55%), a mixed sellar barrier in 75 (24.19%), and a strong sellar barrier in 162 (52.26%) patients. The overall rate of intraoperative CSF leak among all patients was 69 (22.26%). A strong sellar-type barrier was associated with significantly reduced rate of intraoperative CSF leak (RR = 0.08; 95% CI 0.03-0.19; p < 0.0001), while a weak sellar barrier associated with higher rates of CSF leak (RR = 8.54; 95% CI 5.4-13.5; p < 0.0001).

CONCLUSIONS

The preoperative MRI of pituitary patients can suggest intraoperative CSF leak rates, utilizing the concept of the sellar barrier. Patients with a weak sellar barrier carry a higher risk for an intraoperative CSF leak, whereas a strong sellar barrier on MRI seems to mitigate intraoperative CSF leak. We propose that preoperatively assessment of the sellar barrier can prepare surgeons for intraoperative CSF leak repair.

Unplanned hospital readmission after surgical treatment for thoracic spinal stenosis: incidence and causative factors

BACKGROUND

To assess the incidence and causative factors of unplanned hospital readmission within 90 days after surgical treatment of thoracic spinal stenosis (TSS).

METHODS

Hospital administrative database was queried to identify patients who underwent surgical treatment of TSS from July 2010 through December 2017. All unplanned readmissions within 90 days of discharge were reviewed for causes and the rate of unplanned readmissions was calculated. Patients of unplanned readmission were matched 1:3 to a control cohort without readmission.

RESULTS

Twenty-one patients (incidence of 1.7 % in 1239 patients) presented unplanned hospital readmission within a 90-day period and enrolled as the study group, 63 non-readmission patients (a proportion of 1: 3) were randomly selected as the control group. Causes of readmission include pseudomeningocele (8 patients; 38 %), CSF leakage combined with poor incision healing (6 patients; 29 %), wound dehiscence (2 patient; 9 %), surgical site infection (2 patients; 9 %), spinal epidural hematoma (1 patient; 5 %), inadequate original surgical decompression (2 patients; 9 %). Mean duration from re-admission to the first surgery was 39.6 ± 28.2 days, most of the patients readmitted at the first 40 days (66.7 %, 14/21 patients). When compared to the non-readmitted patients, diagnosis of OPLL + OFL, circumferential decompression, dural injury, long hospital stay were more to be seen in readmitted patients.

CONCLUSIONS

The incidence of 90-day unplanned readmission after surgical treatment for TSS is 1.7 %, CSF leakage and pseudomeningocele were the most common causes of readmission, the peak period of readmission occurred from 10 to 40 days after surgery, patients should be closely followed up within this period.

Acute-Phase Intraoperative Findings of Traumatic Spinal Cerebrospinal Fluid Leakage

The acute-stage intraoperative findings of the spinal dural laceration in patients with traumatic cerebrospinal fluid (CSF) leakage have not been clearly revealed so far. Herein, we report an interesting case of traumatic CSF leakage in a patient who underwent acute-stage direct closure for a dural laceration similar to a stab at the C1/2 level. Because a 41-year-old man strongly twisted his neck, he had a typical orthostatic headache. Whole-spine T2 fat-saturated magnetic resonance imaging and computed tomographic myelography were examined, and fluid collection between the intrathecal site and epidural dorsal space, including soft tissue, was confirmed as a direct CSF leakage at the C1/2 level. Direct surgical closure was performed 13 days after the onset of symptoms, and dural laceration with sharp edges was detected on the right side at the C1/2 level. The laceration was sutured and coated with dural sealant. Finally, the patient's orthostatic headache was relieved completely after the operation.

Exclusion of Ossified Ligaments Behind C2 Vertebra Combined with Anterior Controllable Antedisplacement and Fusion for Cervical Ossification of the Posterior Longitudinal Ligament Extending to C2 Segment

OBJECTIVE

We sought to introduce an anterior surgical technique for cervical ossification of posterior longitudinal ligament (OPLL) extending to C2.

METHODS

A total of 29 patients with multilevel OPLL extending to C2 underwent surgery from January 2016 to January 2019. The rationale of our surgical technique is to transect the ossified ligament at the level of C2/3, dividing OPLL into 2 parts. OPLL behind the C2 vertebra is reserved as "focus exclusion," and OPLL below C2 is performed anterior controllable antedisplacement and fusion. Neurologic condition was evaluated using the Japanese Orthopaedic Association scoring system and its improvement ratio. Radiologic assessment included type and extent of OPLL, occupying rate, thickness and length of ossified mass, and curvature of spinal cord. Surgery- and implant-related complications were recorded.

RESULTS

The mean Japanese Orthopaedic Association score increased from 9.4 to 15.8 points at last follow-up, with a significant improvement (P < 0.01). The mean preoperative length of the ossified mass behind C2 was 15.4 mm, and its thickness was 2.2 mm, with no significant progression at last follow-up (15.3 mm and 2.2 mm, P > 0.05). There was also no statistical difference in OPLL thickness at the largest occupying rate level between preoperation and last follow-up (7.4 mm vs. 7.3 mm, P > 0.05). Four patients presented with cerebrospinal fluid leakage, 1 with screw displacement, and 1 with dysphagia.

CONCLUSIONS

For patients with cervical OPLL extending to C2, exclusion of ossified ligaments behind C2 combined with anterior controllable antedisplacement and fusion below C2 is an effective and alternative technique.

Cervical myelomeningocele with CSF leakage: a case-based review

BACKGROUND

The cystic spinal dysraphism of the cervical and upper thoracic region (CDCT) accounts for only 3.9 to 8% of spina bifida cystica lesions. The presence of external cerebrospinal fluid (CSF) leakage is infrequent and very few authors have reported about surgical complications.

CASE REPORT

We present the case of a new born diagnosed of CDCT C1-C3 with a stalk of fibrovascular tissue, CSF leakage, hydrocephalus, and type Chiari II malformation, discuss about the chosen surgical technique and the associated complications, and make a review of the literature focusing on the main aspects of CDCT.

CONCLUSIONS

The CDCT with a stalk of neuroglial and/or fibrovascular tissue originates from the dorsal surface of the spinal cord and penetrates into a cervical cystic sac. The presence of CSF leakage, hydrocephalus, and/or type Chiari II malformation can influence to decide the most appropriate surgical technique.

Pedicled Multifidus Muscle Flap To Treat Inaccessible Dural Tear In Spine Surgery: Technical Note And Preliminary Experience

OBJECTIVE

To assess the usefulness, feasibility, and limitations of pedicled multifidus muscle flaps (PMMFs) for the treatment of inaccessible dural tears during spine surgery.

METHODS

The technique of PMMF harvesting was investigated together with relevant anatomy. We prospectively evaluated 8 patients treated with the PMMF technique between January 2017 and December 2019. Results were compared with a retrospective series of 9 patients treated with a standard technique between January 2014 and December 2016. Inclusion criteria were inaccessible dural tear or dural tear judged not amenable to direct repair because of tissue loosening. Exclusion criteria were surgical treatment of intradural disease. Clinical and demographic data of all patients were collected. Clinical evaluations were performed according to American Spinal Injury Association criteria and Oswestry Disability Index. Preoperative and postoperative computed tomography was performed in all patients. The primary end point was wound healing (cerebrospinal fluid leakage, infection, and fluid collection); secondary end points were neurologic outcome and complications.

RESULTS

Control group: 1 death as a result of wound infection secondary to cerebrospinal fluid fistula and 2 patients needed lumbar subarachnoid drain; neurologic outcome: 3 patients improved and 6 were unchanged. Flap group: no wound-related complications were observed; neurologic outcome: 3 patients improved and 5 were unchanged. No flap-related complications were described. Flap harvesting was feasible in all cases, with an average 20 minutes adjunctive surgical time.

CONCLUSIONS

The PMMF technique was feasible and safe; in this preliminary experience, its use is associated with lower complications as a result of dural tears but larger series are needed to confirm its effectiveness.

Is the Postoperative Horizontal Decubitus Position Following Transection of a Tight Filum Terminale in Pediatric Patients Necessary? - A Retrospective Cohort Study

After untethering surgery of a tethered spinal cord of a tight filum terminale, patients are usually kept in the horizontal decubitus position to prevent cerebrospinal fluid (CSF) leakage. However, the optimal period for keeping these patients in this position has not been established yet. Surgical results in two groups of pediatric patients with a tight filum terminale were retrospectively analyzed. Group A was maintained in the horizontal decubitus position for 72 h and group B was managed without being kept in this position postoperatively. A total of 313 patients underwent sectioning of a tight filum terminale. Of these patients, 144 were maintained horizontally for 72 h postoperatively (group A) and 169 were managed without this position (group B). Among the patients who were maintained horizontally for 72 h, one (0.7%) developed pseudomeningocele. No patients experienced CSF leakage in this group. Among the patients who were not horizontal, one (0.6%) developed CSF leakage and one (0.6%) developed pseudomeningocele. Maintaining patients without restriction of their position does not appear to change the rate of postoperative CSF leakage or pseudomeningocele. This suggests that maintaining patients horizontally after transection of a tight filum terminale is not necessary for preventing CSF leakage.

Safe Discharge of Patients From an Ambulatory Care Center After Incidental Durotomy During Minimally Invasive Spine Surgery

Background

Incidental durotomy is a well-known complication of spinal surgery that may occur occasionally. Increasingly, minimally invasive techniques are being used for spinal decompressions in an ambulatory surgical center (ASC) setting. The management of this complication in an ASC setting has not been reported.

Methods

A total of 832 consecutive minimally invasive decompressive spinal surgeries were performed by a single surgeon in an ASC during the course of 1 year. Incidental durotomies with cerebrospinal fluid leakage were repaired and patients were discharged to home. Patients with a watertight suture dural repair did not receive any modifications to the usual discharge activities allowed. All other patients were treated with bed rest overnight and head of bed restrictions. A protocol for close patient follow-up after discharge was followed. The complications were collected prospectively and analyzed retrospectively.

Results

There were 30 incidental durotomies (3.6%), with all occurring in the lumbar spine. Suture repair was accomplished in 28 patients (93%). Patch repair was performed in 2 patients (7%). All patients were discharged to home from the ASC. There were 2 short-term complications noted after discharge. The patient safety protocols in place identified the complications and allowed timely interventions.

Conclusions

Incidental durotomy occurring during minimally invasive spinal decompressive surgery is an occasional event. Suture repair of the laceration is feasible in most instances. Lumbar spine patients may be safely discharged to home from the ASC. Patients can be stratified into those with, or without, a watertight suture dural closure. Those with such a closure, who are without symptoms of intracranial hypotension, do not require modification of their activities. A short period of bedrest with head of bed modification successfully treated the remainder. Hospitalization or routine prolonged bed rest is not necessary. Protocols must be put in place to identify and timely manage potentially serious sequelae.

Sellar Diaphragm Reconstruction with Tachosil During Endoscopic Endonasal Surgery: Technical Note

This report introduces a new closure technique for the management of intraoperative cerebrospinal fluid (CSF) leakage during endoscopic endonasal surgery. The procedure is based on the combination of a traditional autologous tissue flap with a heterologous fibrin graft (TachoSil). We performed a retrospective analysis on 121 patients with pituitary adenomas treated in our center by the senior neurosurgeon (author V.R.B) in the previous 4 years. Only one patient (0.8%) developed a CSF leakage and no adverse events were found related to the use of TachoSil. Compared with other techniques used previously, sellar diaphragm reconstruction with TachoSil seems to be an effective and inexpensive alternative.

The 3F (Fat, Flap, and Flash) Technique For Skull Base Reconstruction After Endoscopic Endonasal Suprasellar Approach

BACKGROUND

Endoscopic endonasal surgery is a rapidly evolving field that offers the possibility of treating a wide variety of skull base lesions. Reconstruction of the osteodural defect is of utmost importance, as an effective and watertight closure is mandatory. Over the years, various techniques and materials have been adopted in an effort of providing a resilient and reliable method of closure.

MATERIALS AND METHODS

We retrospectively analyzed data from a series of 25 patients who underwent skull base reconstruction according to a novel paradigm following endoscopic endonasal transtuberculum-transplanum approaches for tumor removal between June 2017 and June 2018. The 3F strategy involves autologous fat grafting, nasoseptal flap coverage, and flash mobilization out of the bed following the operation.

RESULTS

The 3F technique achieved successful watertight closure in 24 of 25 cases (96%). One case of postoperative cerebrospinal fluid rhinorrhea developed on postoperative day 10, which did not require reoperation. No perioperative complications related to the 3F strategy (e.g., overpacking, infections, or hematomas) occurred. No donor graft site infections or hematomas developed.

CONCLUSIONS

The 3F skull base reconstruction is a safe and effective method in achieving watertight closure after extended endoscopic endonasal approaches. Despite this study reporting a preliminary experience in a small series of patients, it seems that the 3F technique can be considered as a viable solution among the wide kaleidoscope of available skull base reconstruction methods.

Intracranial hypotension and hypertension: reversible Chiari malformation due to dynamic cerebrospinal fluid abnormalities in Gorham-Stout disease. Case report

Gorham-Stout disease (GSD) is an intractable disease characterized by massive osteolysis caused by abnormal lymphangiogenesis in bone. In rare cases of GSD, CSF abnormalities develop. The authors present the case of a 19-year-old woman with GSD presenting with orthostatic headache due to intracranial hypotension (5 cm H2O). The clinical course of this case was very unusual. Orthostatic headache was associated with a CSF leak from the thigh after pathological fractures of the femur and pelvis. The chronic CSF leak led to acquired Chiari malformation (CM) with syringomyelia. After an epidural blood patch, her neurological status improved; however, after the complete arrest of the CSF leak from the thigh, she presented with severe nonpostural headache and progressive visual acuity loss with optic papilledema. A ventriculoperitoneal shunt was placed to treat intracranial hypertension (50 cm H2O). Headache improved and optic papilledema decreased after shunt surgery. This case shows that dynamic CSF abnormalities may lead to reversible CM in patients with GSD. Sealing a CSF leak rather than performing suboccipital decompression is recommended for acquired CM resulting from a CSF leak.

Pitfalls of skull base reconstruction in endoscopic endonasal approach

Various skull base reconstruction techniques have been developed in endoscopic endonasal approach (EEA) for skull base lesions to prevent postoperative cerebrospinal fluid (CSF) leakage. This study was performed to evaluate the efficacy and pitfalls of our method of skull base reconstruction after EEA. A total of 123 patients who underwent EEA (127 surgeries) between October 2014 and May 2017 were reviewed. Our algorithm for skull base reconstruction in EEA was categorized based on intraoperative CSF leakage graded as follows: grade 0 was excluded from this study; grade 1, dural suturing with abdominal fat graft or packing of gelatin sponge into the cavity; grade 2, method for grade 1 with addition of mucosal flap or nasoseptal flap (NSF); and grade 3, duraplasty in fascia patchwork closure with NSF. Bony reconstruction was not mandatory, and there was no postoperative bed rest or initial lumbar drainage (LD) insertion in any of the cases. Postoperative CSF leakage after EEA was mostly prevented (96.3%) by our algorithm without postoperative initial LD or bed rest. On the other hand, reconstruction surgery was required for postoperative CSF leakage in two cases-one with prior multitranssphenoidal surgery and radiotherapy and another patient with poor compliance due to communication difficulties. Both of the latter patients were obese. Greater care with regard to postoperative CSF leakage is required in patients with prior EEA with radiotherapy and obesity. In such high-risk patients, initial LD or bed rest may be required to prevent postoperative CSF leakage. It is also important to restrict activities that result in increased intracranial pressure.

Repair of Cerebrospinal Fluid Leakage Using a Transfrontal, Radial Adipofascial Flap: An Individual Approach Supported by Three-Dimensional Printing for Surgical Planning

BACKGROUND

Leakage of cerebrospinal fluid (CSF) because of large prolactinomas represents a complex issue. Because of limited anatomic space, multiple leakage sites, and scarce locally available tissue for repair, surgical possibilities are limited. We report an initial case of using a radial fasciocutaneous flap applied subfrontally to cover a large skull base defect, supported by preoperative three-dimensional (3D) printing for surgical planning.

CASE DESCRIPTION

A 29-year-old woman developed severe nuchal pain that was caused by destruction of large parts of her skull base by a prolactinoma. After occipitocervical fusion, medical treatment showed good tumor response but led to CSF leakage after 12 months. An endoscopic approach and ventriculoperitoneal shunt implantation failed to stop the leakage. A 3D model of the skull improved the understanding of the expanded osseous destruction and multiple CSF leakage sites and supported surgical planning. For an extensive coverage of the former clivus and sella region, an intracranially applied radial flap was planned. Dopamine-agonist medication was increased before the operation. Intraoperatively, the flap was brought into position subchiasmatically and wound around the pituitary stalk. CSF leakage was not observed on follow-up (10 weeks). Long-term follow-up will determine the effectiveness of this method.

Targeted Epidural Blood Patch Treatment for Refractory Spontaneous Intracranial Hypotension in China

Objective  An epidural blood patch (EBP) is the mainstay of treatment for refractory spontaneous intracranial hypotension (SIH). We evaluated the treatment efficacy of targeted EBP in refractory SIH. Methods  All patients underwent brain magnetic resonance imaging (MRI) with contrast and heavily T2-weighted spine MRI. Whole spine computed tomography (CT) myelography with non-ionic contrast was performed in 46 patients, and whole spine MR myelography with intrathecal gadolinium was performed in 119 patients. Targeted EBPs were placed in the prone position one or two vertebral levels below the cerebrospinal fluid (CSF) leaks. Repeat EBPs were offered at 1-week intervals to patients with persistent symptoms, continued CSF leakage, or with multiple leakage sites. Results  Brain MRIs showed pachymeningeal enhancement in 127 patients and subdural hematomas in 32 patients. One hundred fifty-two patients had CSF leakages on heavily T2-weighted spine MRIs. CSF leaks were also detected on CT and MR myelography in 43 and 111 patients, respectively. Good recovery was achieved in all patients after targeted EBP. No serious complications occurred in patients treated with targeted EBP during the 1 to 7 years of follow-up. Conclusions  Targeted and repeat EBPs are rational choices for treatment of refractory SIH caused by CSF leakage.

Is the Keros classification alone enough to identify patients with the 'dangerous ethmoid'? An anatomical study

CONCLUSION

By means of three-dimensional display of the critical measurements, the authors suggest a novel definition of 'dangerous ethmoid'. Parallel to Keros type III, the proposed determining factors include: olfactory fossa width >6 mm, its distance to the medial nasal concha (turbinate) <20 mm and to the orbit interval of <10 mm. Clinical evaluation of these preliminary criteria based only on radiological data is required and underway.

OBJECTIVES

Detailed pre-operative assessment of sinus computer tomography (CT) scans reduces the frequency of severe complications in patients undergoing endoscopic sinus surgery (ESS). The authors aimed to identify a sub-set of anatomical features pre-disposing to major post-operative complications.

METHOD

Sinus computer tomography (CT) scans of patients of a single institution qualified for ESS were examined. Besides the Keros classification, authors focused on the anatomic measurements as follows: the olfactory fossa depth, width, and its distance from the medial nasal concha and the medial wall of the orbit (referred to as 'critical measurements'). The sample comprised 120 consecutive CT exams, without clinical validation.

RESULTS

Keros type I, II, and III was noted in 9.2%, 75.8%, and 15.0% of cases, respectively. Despite some statistically significant correlations, it was not possible to identify the patient age, sex, and side of body clearly correlating with the critical measurements.

The Effect of l-Arginine on Dural Healing After Experimentally Induced Dural Defect in a Rat Model

BACKGROUND

Incomplete repair of the dura mater may result in numerous complications such as cerebrospinal fluid leakage and meningitis. For this reason, accurate repair of the dura mater is essential. In this study, the effect of systemic and local supplementation of l-arginine on dural healing was evaluated.

METHODS

Thirty male Wistar rats were used and divided into control, local, and systemic l-arginine groups, with 10 rats in each. In each group, a 5-mm experimental incision was made at the lumbar segment of the dura mater and cerebrospinal fluid leakage was induced. Each group was divided into 2 subgroups and at the end of the first and sixth weeks, the rats were killed and the damaged segments of the dura were separated, histologically evaluated and the dural healing indicators including cell types, granulation tissue formation, collagen deposit, and vascularization were compared between groups.

RESULTS

The systematic supplementation of l-arginine showed a significant effect in dural healing compared with the control group. After the first week, granulation formation increased considerably (P < 0.031), and after 6 weeks, collagen deposition and neovascularization were significantly different compared with the control group (P < 0.030; P < 0.009). In comparison between different groups at the end of the first and sixth weeks, maximum changes in healing indicators were observed in the systemic group and the least variations were related to the control group.

CONCLUSIONS

The systemic supplementation of l-arginine may accelerate dural healing by increasing the level of granulation tissue formation, collagen deposition, and vascularization.

Sellar reconstruction without intrasellar packing after endoscopic surgery of pituitary macroadenomas is better than its reputation

Objectives: Sellar reconstruction with intrasellar packing following endoscopic resection of pituitary macroadenomas remains a subject of clinical and radiological discussion particularly, when an intraoperative cerebrospinal fluid (CSF) leakage is absent. This study was conducted to contribute our experience with sellar reconstruction after a standard endoscopic surgery of pituitary macroadenomas without intraoperative CSF leakage to the ongoing discussion between techniques with and without intrasellar packing.

Methods: A consecutive series of 47 pituitary macroadenomas undergoing excision via a standard endoscopic endonasal transsphenoidal surgery (EETS) without evident intraoperative CSF leakage were retrospectively evaluated over a 10-months mean follow-up period. According to the sellar reconstruction technique, three groups could be identified: Group A – with no intrasellar packing, Group B – with haemostatic materials packing, and Group C – with abdominal fat packing. Postoperative clinical and radiological assessments of the three groups were documented and analyzed for differences in outcome.

Results: Postoperative clinical assessment did not differ significantly between the three groups. In group A, postoperative CSF leakage, sphenoid sinusitis and empty sella syndrome were not observed. However, a significant difference in radiological assessment could be identified; the interpretation of sellar contents in postoperative MRI of group A succeeded earlier and more reliably than in other groups with intrasellar packing.

Conclusions: There is no difference in the incidence of postoperative CSF leakage and empty sella syndrome among the various reconstructive techniques with and without intrasellar packing, irrespective of size and extension of the pituitary adenoma. Sellar reconstruction without intrasellar packing following a standard EETS is not inferior to other techniques with packing and even shows more radiological advantages, which made it our preferred technique, at least if no intraoperative CSF leakage is evident.

Cerebrospinal fluid rhinorrhea: evaluation with 3D-SPACE sequence and management with navigation-assisted endonasal endoscopic surgery

BACKGROUND

This study aimed to assess the efficacy of MR images with three-dimensional sampling perfection with application optimised contrast using different flip-angle evolution (3D-SPACE) sequence for detecting cerebrospinal fluid (CSF) rhinorrhea and image-guided surgery for the management of CSF rhinorrhea.

MATERIALS AND METHODS

This study included 45 consecutive patients with suspected CSF rhinorrhea from 2010 to 2015. Patients underwent preoperative MRI scan including 3D-SPACE and conventional T2-weighted (T2W) protocol. Two-blinded neuroradiologists determined the presence and location of CSF leakage. Imaging results were compared with surgical findings and/or β-2 transferrin testing. Intraoperative navigation was used during endonasal endoscopic surgery for repairing CSF rhinorrhea.

RESULTS

3D-SPACE sequence correctly described 27 cases (93.1%) and conventional T2W sequence described only 20 (69.0%) of the total 29 patients with truly positive CSF leakage. The sensitivity, specificity, positive predictive value and negative predictive value for detecting CSF leakages were 93.1%, 87.5%, 93.1%, and 87.5% for 3D-SPACE, and 69.0%, 81.3%, 87.0% and 59.1% for T2W, respectively. To repair the leakage, 3D-SPACE image-guided navigation was used to locate the CSF leakage sites intraoperatively. Only two CSF leakage sites proved by surgery were missed by navigation. Successful endoscopic repairs were achieved in 25 of 26 (96.2%) patients during the first attempt. During the follow-up, there were no major postoperative complications or recurrences encountered.

CONCLUSION

MR imaging with 3D-SPACE sequence is an effective and reliable method with higher sensitivity and specificity than T2W for detecting CSF leakage. Intraoperative 3D-SPACE image-guided navigation is helpful in locating the sites of the CSF leakage during endonasal endoscopic surgery.

The usefulness of MDCT-myelography for patients with spontaneous intracranial hypotension

Purpose

The detection and localization of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH) is important. The aim of this study was to evaluate the usefulness of multidetector CT (MDCT)-myelography in patients with SIH.

Methods

A radiologist retrospectively searched the electronic database to find the patients who had undergone MDCT-myelography for SIH between October 2010 and September 2014. In the MDCT-myelographic treatment, the patient’s whole spine was scanned by 64 or 256 channel MDCT scanners after being injected with 20 ml of contrast agent via L3/4 interlaminar space under fluoroscopic guidance. Three radiologists in consensus determined the presence, pattern (“pseudodiverticular sign” or “gray-rim sign”) and level of contrast leakage outside the dural sac.

Results

Eighteen patients (M:F = 9:9; mean age, 36.2; age range 17–56) were finally included in this study. CSF leakage was detected in 17 of 18 patients. CSF leakage pattern was described as a “pseudodiverticular sign” in five and “gray-rim sign” in ten patients. Leakage level could be determined in ten patients based on MDCT-myelography.

Conclusions

MDCT-myelography was useful to detect CSF leakage and to guess the leakage level in patients with SIH.

Primary Endoscopic Transnasal Transsphenoidal Surgery for Giant Pituitary Adenoma

OBJECTIVES

Giant pituitary adenoma (>4 cm) remains challenging because the optimal surgical approach is uncertain.

METHODS

Consecutive patients with giant pituitary adenoma who underwent endoscopic transnasal transsphenoidal surgery (ETTS) as the first and primary treatment were retrospectively reviewed. Inclusion criteria were tumor diameter ≥4 cm in at least 1 direction, and tumor volume ≥10 cm(3). Exclusion criteria were follow-ups <2 years and diseases other than pituitary adenoma. All the clinical and radiologic outcomes were evaluated.

RESULTS

A total of 38 patients, average age 50.8 years, were analyzed with a mean follow-up of 72.9 months. All patients underwent ETTS as the first and primary treatment, and 8 (21.1%) had complete resection without any evidence of recurrence at the latest follow-up. Overall, mean tumor volume decreased from 29.7 to 3.2 cm(3) after surgery. Residual and recurrent tumors (n = 30) were managed with 1 of the following: Gamma Knife radiosurgery (GKRS), reoperation (redo ETTS), both GKRS and ETTS, medication, conventional radiotherapy, or none. At last follow-up, most of the patients had favorable outcomes, including 8 (21.1%) who were cured and 29 (76.3%) who had a stable residual condition without progression. Only 1 (2.6%) had late recurrence at 66 months after GKRS. The overall progression-free rate was 97.4%, with few complications.

CONCLUSIONS

In this series of giant pituitary adenoma, primary (ie, the first) ETTS yielded complete resection and cure in 21.1%. Along with adjuvant therapies, including GKRS, most patients (97.4%) were stable and free of disease progression. Therefore, primary ETTS appeared to be an effective surgical approach for giant pituitary adenoma.

How I do it: shoelace watertight dural closure in extended transsphenoidal surgery

BACKGROUND

Skull base reconstruction after extended transsphenoidal surgery is essential to prevent postoperative cerebrospinal fluid leakage.

METHODS

A novel and simple technique for skull base reconstruction termed "shoelace dural closure" was devised. The dura mater was closed with a fat graft using a continuous running suture with both ends of a double-armed suture.

CONCLUSIONS

The shoelace dural closure is an effective method for achieving watertight closure of the anterior skull base without the use of lumbar drains, fascia lata grafts, or nasoseptal flaps.

Subarachnoidal-pleural fistula (SAPF) as an unusual cause of persistent pleural effusion. Beta-trace protein as a marker for SAPF. Case report and review of the literature

BACKGROUND

We describe a case of a 56-year-old woman who developed a recurrent pleural effusion after a thoracoscopic resection of an anterior bulging thoracic disc hernia (level D9-D10). Despite several evacuating pleural punctions, dyspnea reoccurred due to recurrent pleural effusion, the same side as the disc resection. Because of increasing headache after each punction, a subarachnoidal pleural fistula (SAPF) was suspected. Although magnetic resonance imaging (MRI) showed features suggestive of SAPF, there was not enough evidence to justify a new thorascopy.

METHODS

Cerebrospinal fluid (CSF) leakage into the thoracic and abdominal cavity has been described as a result of trauma or surgery. Detection of beta-trace protein (BTP, a brain-specific protein) has been described to detect CSF fistulae causing rhino- and otoliquorrhea. Similarly, BTP determination could be used to identify the presence of CSF at other anatomical sites such as the thoracic cavity. Therefore, we decided to determine the concentration of BTP in the pleural effusion of this patient. BTP was assayed using immunonephelometry.

RESULTS

The patient's BTP pleural fluid concentration was 14·0 mg/l, which was a 25-fold increase compared with the BTP serum concentration. After insertion of a subarachnoidal lumbal catheter, a video-assisted thorascopy was performed. Leakage of liquor through the parietal pleura into the thoracic cavity was observed. The SAPF was closed using a durasis patch and DuraSeal®. Postoperatively, there was no reoccurrence of pleural fluid.

CONCLUSIONS

SAPF has to be included to the differential diagnosis of patients with persistent pleural effusion after spinal surgery. This case illustrates the importance of BTP in diagnosing SAPF, especially in cases where major therapeutic consequences may need to be drawn.

Subtotal petrosectomy and cerebrospinal fluid leakage in unilateral anacusis

Objective This study presents a group of patients experiencing recurrent cerebrospinal fluid (CSF) leakage associated with ipsilateral anacusis who underwent subtotal petrosectomies with the goal of stopping the CSF leak and preventing meningitis. Materials and Methods Eight patients with CSF leakage were enrolled: three patients with giant vestibular schwannomas had CSF leakage after gamma knife failure and subsequent removal via a retrosigmoid approach; two patients had malformations at the level of the inner ear with consequent translabyrinthine fistulas; two had posttraumatic CSF leakages; and one had a CSF leakage coexisting with an encephalocele. Two patients developed meningitis that resolved with antibiotic therapy. Each patient had preoperative anacusis and vestibular nerve areflexia on the affected side. Results The patients with congenital or posttraumatic CSF leaks had undergone at least one unsuccessful endaural approach to treat the fistula. All eight patients were treated successfully with a subtotal petrosectomy. The symptoms disappeared within 2 months postoperatively. No meningitis, signs of fistula, or other symptoms occurred during the follow-up. Conclusion A subtotal petrosectomy should be the first choice of treatment in patients with recurrent CSF leakage whenever there is associated unilateral anacusis.

Cerebrospinal fluid leakage in Gorham-Stout disease due to dura mater involvement after progression of an osteolytic lesion in the thoracic spine

Patients with Gorham-Stout disease (GSD), a rare disease of poorly understood etiopathophysiology, suffer from progressive osteolysis. Destruction of bone matrix is caused by lymphatic vessels, which can lead to CSF leakage if parts of bony structures adjacent to CSF spaces are involved. So far, fewer than 200 patients have been reported in the literature; only 4 of these patients presented with CSF leakage. The authors report the case of a 30-year-old man with GSD and CSF leakage due to dura mater involvement after progression of an osteolytic lesion in the thoracic spine. Neurosurgical intervention, including dura repair, was needed. Experimental medical therapy with rapamycin was started, leading to disease control for more than 12 months. Progression of GSD can lead to destruction of the meninges, causing CSF leakage. The authors review 4 other cases reported in the literature and discuss therapeutic options.

T2-weighted vs. intrathecal contrast-enhanced MR cisternography in the evaluation of CSF rhinorrhea

BACKGROUND

Endoscopic surgical approach is being more widely used in the treatment of cerebrospinal fluid (CSF) rhinorrhea. Accurate localization of CSF fistulas prior to surgery is essential in increasing the success of dural repair and in decreasing negative or recurrent explorations.

PURPOSE

To evaluate and compare intrathecal contrast medium-enhanced magnetic resonance cisternography (CEMRC) with T2-weighted MR cisternography (T2MRC) in identifying the presence and site of CSF rhinorrhea.

MATERIAL AND METHODS

Sixty patients with suspected CSF rhinorrhea underwent MR cisternography including intrathecally enhanced fat-suppressed T1WI in three orthogonal planes and T2WI in the coronal plane. Both set of images were reviewed by two blinded radiologists for the presence and location of CSF leakage. Imaging data were compared with surgical findings and/or beta-2 transferrin testing.

RESULTS

With surgery proven CSF leakage in 20 instances as reference, CEMRC detected 18 (90%), whereas T2MRC reported only 13 (65%) correctly. Overall, sensitivity, specificity, positive predictive value, and negative predictive value in detecting CSF fistulas were 92%, 80%, 76%, and 93% for CEMRC, and 56%, 77%, 64%, and 71% for T2MRC, respectively.

CONCLUSION

The minimally invasive CEMRC is an effective method with higher sensitivity and specificity than T2MRC in the evaluation of CSF fistulas.

Postoperative Cervical Cord Compression Induced by Hydrogel Dural Sealant (DuraSeal®)

Cerebrospinal fluid (CSF) leakage is a potential complication of cranial and spinal surgery. Postoperative CSF leakage can induce delayed healing, wound infection and meningitis. DuraSeal® (Covidien, Waltham, MA, USA) is a synthetic product which has been increasingly used to facilitate watertight repair of dural defects after cranial and spinal surgery. Despite some advantages of Duraseal®, the authors report a patient who developed cord compression following the use of DuraSeal® in cervical spine surgery in which the expansion of the DuraSeal® was believed to be the causative factor.

Primary closure of a cerebrospinal fluid fistula by nonpenetrating titanium clips in endoscopic endonasal transsphenoidal surgery: technical note

Postoperative cerebrospinal fluid (CSF) leakage is one of the most common and aggravating complications in transsphenoidal surgery. Although primary closure of the fistula would be the most desirable solution for an intraoperatively encountered CSF leak, it is difficult to achieve in such a deep and narrow operative field. In this article, the authors report endonasal endoscopic applications of no-penetrating titanium clips to repair a CSF fistula following tumor removal. The AnastoClip Vessel Closure System (VCS; LeMaitre Vascular, Boston, MA) was used for closure of a CSF fistula in endonasal transsphenoidal surgery. In all four patients, CSF leakage was successfully obliterated primarily with two to five clips. There was no postoperative CSF rhinorrhea or complications related to the use of the VCS. Metal artifact by the clips on postoperative images was tolerable. Primary closure of the fistula using the VCS was an effective strategy to prevent postoperative CSF leakage in transsphenoidal surgery. Future application can be expanded to reconstruction of the skull base dura via endonasal skull base approaches.

Intracranial subdural hematoma as a cause of postoperative delirium and headache in cervical laminoplasty: A case report and review of the literature

Objectives

To describe a rare case of acute intracranial subdural hematoma as a cause of postoperative delirium and headache following cervical spine surgery.

Summary of Background Data

Headache is uncommon following spinal surgery, but can be observed in cases of accidental tearing of the dura during surgery. The causes of headache after surgery are thought to include dural tear and CSF leakage. On the other hand, intracranial subdural hematoma can be a cause of headache and cognitive dysfunction. However, only 4 cases as a postoperative complication of spinal surgery have been reported in the literature.

Methods

A 55-year-old man underwent re-explorative surgery due to postoperative hematoma causing hemiplegia following cervical laminoplasty. During this operation, accidental dural tear occurred and induced CSF leakage. On the following day, headache and delirium were noted. CSF leakage continued despite intraoperative repair of the dural laceration. Cranial CT at that time clearly demonstrated subdural hematoma.

Results

We reexplored the surgical site and attempted to stop the CSF leakage with meticulous suturing of the dural sac under microscopic observation. The intracranial subdural hematoma was carefully observed under consultation with a specialist neurosurgeon. Following this reexploration, the headache and delirium gradually improved, with spontaneous resolution of intracranial hematoma over a two-month period of observation.

Conclusions

We have reported a rare case of acute intracranial subdural hematoma caused by CSF leakage following cervical spine surgery. This report demonstrates the possibility of intracranial hematoma as a cause of postoperative cognitive dysfunction or headache, especially when accidental tearing of the dura has occurred in spinal surgery.