[Diagnosis and treatment of spontaneous meningoencephalocele in lateral recess of sphenoid sinus and analysis of its influencing factors]

Objective:To explore the influencing factors of adult spontaneous meningoencephalocele, which occurs in the lateral recess of sphenoid sinus, in order to improve the level of clinical diagnosis and treatment. Methods:The clinical data of 27 adults with spontaneous meningoencephalocele in lateral recess of sphenoid sinus in Department of the Otorhinolaryngology, the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2022 were retrospectively analyzed. Preoperative sinus CT and MRI were performed to confirm the diagnosis and location of meningoencephalocele. Results:①There were 0 cases of lateral recess of sphenoid sinus type Ⅰ, 8 cases of lateral recess of sphenoid sinus type Ⅱ and 19 cases of lateral recess of sphenoid sinus type Ⅲ. ②Among the 27 adult patients with spontaneous meningoencephalocele, 9 were male and 18 were female, and the onset age was 19-72 years old, with an average age of（50.7±12.4） years old. 18 cases were complicated with cerebrospinal fluid leakage, 11 cases with headache and dizziness, 3 cases with recurrent meningitis（complicated with cerebrospinal fluid leakage）, and 2 cases with epilepsy. ③There were 20 patients with intracranial hypertension, 17 patients with body mass index（BMI） ≥25 kg/m², and 8 patients with empty sella. Conclusion:Type Ⅲ of lateral recess of sphenoid sinus is the most common type in adult spontaneous meningoencephalocele, and intracranial hypertension and obesity are the influencing factors of this disease. Puncture, biopsy or operation should not be performed for patients suspected of spontaneous meningoencephalocele, and imaging examination should be performed to identify the source of the tumor.

Profiles of central nervous system surgical site infections in endoscopic transnasal surgery exposing the intradural space

OBJECTIVE

Despite its efficacy and minimal invasiveness, the clean-contaminated nature of endoscopic transnasal surgery (ETS) may be susceptible to central nervous system surgical site infections (CNS-SSIs), especially when involving intradural exposure. However, the profiles of ETS-associated CNS-SSIs are not fully elucidated.

METHODS

The institutional ETS cases performed between May 2017 and March 2023 were retrospectively analysed. The incidences of CNS-SSIs were calculated, and their risk factors examined.

RESULTS

The incidence of CNS-SSIs was 2.3% (7/305) in the entire cohort and 5.0% (7/140) in ETSs with intradural exposure. All the CNS-SSIs were meningitis and developed following ETS with intradural exposure. The incidences were 0%, 5.6% and 5.8% in ETSs with Esposito grade 1, 2 and 3 intraoperative cerebrospinal fluid leakage, respectively. Among the pre- and intra-operative factors, body mass index (unit odds ratio (OR), 0.62; 95% confidence interval (CI), 0.44-0.89; P<0.01), serum albumin (unit OR, 0.03; 95% CI, 0.0007-0.92; P=0.02), and American Society of Anesthesiologists physical status score (unit OR, 20.7; 95% CI, 1.65-259; P<0.01) were significantly associated with CNS-SSIs. Moreover, postoperative cerebrospinal fluid leakage was also significantly associated with CNS-SSIs (OR, 18.4; 95% CI, 3.55-95.0; P<0.01).

CONCLUSIONS

The incidence of ETS-associated CNS-SSIs is acceptably low. Intradural exposure was a prerequisite for CNS-SSIs. Malnutrition and poor comorbidity status should be recognized as important risks for CNS-SSIs in ETS.

Enhanced Dural Repair Using Biodegradable Sealants Based on Photocurable Hyaluronic Acid

Cerebrospinal fluid (CSF) leakage is a common complication of intradural surgery or incidental durotomy in neurosurgery. Dural suturing is a common method for durotomy repair, but this technique requires a long operation time and includes the risk of CSF leakage by incomplete sealing. Glue-type sealants are effective for watertight dural closure. However, unresolved shortcomings include insufficient sealing performance, poor biocompatibility, and excessive swelling. Here, a dural sealant using light-activated hyaluronic acid (HA) with multi-networks (HA photosealant) that provides fast sealing performance and high biocompatibility is reported. The HA photosealants form a watertight hydrogel barrier with multilength networks under low-energy visible light exposure (405 nm, <1 J cm-2) for 5 s and allow firm tissue adhesion on the wet dural surface. In a rabbit model of craniectomy and durotomy, HA photosealants exhibit the faster sealing performance of dural tears and enhance dural repair with accelerated bone formation compared to commercial surgical glues, with no degenerative changes, such as inflammation or necrosis, in histopathological evaluation. This biocompatible HA photosealant can be applied in a variety of clinical settings that require fast wound closure as a promising potential.

Posterior cranial vault distraction in children with syndromic craniosynostosis: the era of biodegradable materials-a comprehensive review of the literature and proposed novel global application

Distraction osteogenesis is utilized to increase intracranial volume in the treatment of restrictive pathologies, most commonly syndromic synostosis. Children too young for open calvarial vault expansion or other systemic or local contraindications to a direct reconstructive approach benefit greatly from distraction osteogenesis, typically addressing posterior vault expansion. Wound infection, cerebrospinal fluid (CSF) leak, device failure, need for a second surgery for removal, and cost, are issues that can limit the use of this approach. These challenges are more pronounced in low- and middle-income countries (LMICs) due to lack of access to the device, the financial burden of the need for a second surgery, and the severity of the implications of infection and CSF leak. Over the last five decades, there has been an increased acceptance of bioresorbable instrumentation in craniofacial surgery. Poly L-lactic acid, polyglycolic acid, and polydioxanone are the most commonly used polymers. New resorbable fixation tools such as ultrasound-activated pins and heat-activated pins are superior to conventional bioresorbable screws in allowing attachment to thinner bone plates. In this paper, we present a review of the literature on cranial vault distraction and the use of bioresorbable materials and propose a novel design of a fully absorbable cranial distractor system using external magnetic distraction control, eliminating the need for external activation ports and a second surgery to remove the hardware. The application of this technology in LMIC settings could advance access to care and treatment options for patients with syndromic synostosis.

Marsupialization as an alternative to reconstruction in endoscopic skull base surgery. How I do it

BACKGROUND

To treat extradural solid-cystic lesions of the ventral skull base, a pedicled nasoseptal flap (NSF) maintains patency of the marsupialized cavity and prevents restenosis and cyst recurrence.

METHODS

The authors provide a step-by-step description of the surgical technique valid in different lesions of the skull base, all treated via the endoscopic endonasal approach (EEA). The application is demonstrated by an operative video.

CONCLUSION

In selected lesions, endoscopic marsupialization using an NSF ensures drainage and ventilation of the surgical cavity. Re-epithelialization provided by a pedicled flap is a viable alternative to multilayer skull base reconstruction.

Unintended dural tears during unilateral biportal endoscopic lumbar surgery: incidence and risk factors

BACKGROUND

An unintended dural tear (DT) is the most common intraoperative complication of lumbar spine surgery. The unilateral biportal endoscopic technique (UBE) has become increasingly popular for treating various degenerative diseases of the lumbar spine; however, the DT incidence and risk factors specific to UBE remain undetermined. Therefore, this study aimed to evaluate the incidence and risk factors of DTs in UBE.

METHOD

Data from all patients who underwent UBE for degenerative lumbar spinal diseases from November 2018 to December 2021 at our institution were used to assess the effects of demographics, diagnosis, and type of surgery on unintended DT risk.

RESULTS

Overall, 24/608 patients (3.95%) experienced DTs and were treated with primary suture repair or bed rest. Although several patients experienced mild symptoms of cerebrospinal fluid (CSF) leaks, no serious postoperative sequelae such as nerve root entrapment, meningitis, or intracranial hemorrhage occurred. Additionally, no significant correlations were identified between DT and sex (P = 0.882), body mass index (BMI) (P = 0.758), smoking status (P = 0.506), diabetes (P = 0.672), hypertension (P = 0.187), or surgeon experience (P = 0.442). However, older patients were more likely to experience DT than younger patients (P = 0.034), and patients with lumbar spinal stenosis (LSS) were more likely to experience DT than patients with lumbar disc herniation (LDH) (P = 0.035). Additionally, DT was more common in revision versus primary surgery (P < 0.0001) and in unilateral laminotomy with bilateral decompression (ULBD) versus unilateral decompression (P = 0.031). Univariate logistic regression analysis revealed that age, LSS, ULBD, and revision surgery were significant risk factors for DT.

CONCLUSIONS

In this UBE cohort, we found that the incidence of DT was 3.95%. Additionally, older age, LSS, ULBD, and revision surgery significantly increased the risk of DT in UBE surgery.

Long-term outcomes and potential predictive recurrence factors after endonasal endoscopic surgical treatment of symptomatic Rathke's cleft cysts

Although patients with symptomatic Rathke's cleft cysts (RCCs) receive surgical treatment, recurrence sometimes occurs after surgery. However, the mechanism underlying recurrence remains unclear. We evaluated the outcomes of RCC decompression over a long-term follow-up period. We retrospectively reviewed the medical records of 35 patients with symptomatic RCC who underwent endonasal endoscopic surgery (EES) at our institution between 2008 and 2023. Patients' characteristics, intraoperative findings, and postoperative follow-up outcomes were evaluated. A univariate regression model was used to identify the predictors of recurrence. The median patient age was 48.0 years, and 74.2% of the patients were female. The mean follow-up duration was 94.7 ± 47.6 months. Cyst content recurrence was observed in 15 patients (42.8%). Five patients (14.2%) with symptomatic recurrence underwent reoperation. Postoperative vision improved in all 23 patients (100%); headaches improved in 20 patients (90.9%). A new hormonal deficit occurred in two patients (5.7%). Complications included intraoperative cerebrospinal fluid (CSF) leak in 10 patients (28.5%), postoperative CSF leak in two patients (5.7%), permanent diabetes insipidus in two patients (5.7%), and postoperative infection in three patients (8.5%). Univariate analyses revealed that the position of the anterior pituitary lobe (p = 0.019) and preoperative visual disturbances (p = 0.008) significantly affected recurrence after surgery. Although EES was efficient, the recurrence rate was relatively high over a long-term period. The anterior pituitary lobe position and preoperative visual disturbances were significantly associated with recurrence. The anterior-inferior position can predict a high risk of recurrence before surgery.

Ten-Year Analysis of Complications Related to Simple Basilar Skull Fractures in Children Presenting to a Trauma Center

OBJECTIVES

Head trauma is a common presenting complaint among children requiring urgent medical attention, accounting for more than 600,000 emergency department (ED) visits annually, 4% to 30% of which identify skull fractures among the patient's injuries. Previous literature shows that children with basilar skull fractures (BSFs) are usually admitted for observation. We studied whether children with an isolated BSF have complications precluding them from safe discharge home from the ED.

METHODS

We performed a retrospective review of ED patients aged 0 to 18 years given a simple BSF diagnosis (defined by nondisplaced fracture, with normal neurologic examination, Glasgow Coma Score of 15, no intracranial hemorrhage, no pneumocephalus) during a 10-year period to identify complications associated with their injury. Complications were defined as death, vascular injury, delayed intracranial hemorrhage, sinus thrombosis, or meningitis. We also considered hospital length of stay (LOS) longer than 24 hours or any return visit within 3 weeks of the original injury.

RESULTS

Of the 174 patients included in the analysis, there were no deaths, cases of meningitis, vascular injury, nor delayed bleeding events. Thirty (17.2%) patients required a hospital LOS longer than 24 hours and 9 (5.2%) returned to the hospital within 3 weeks of discharge. Of those with LOS longer than 24 hours, 22 (12.6%) patients needed subspecialty consultation or intravenous fluids, 3 (1.7%) had cerebrospinal fluid leak, and 2 (1.2%) had a concern for facial nerve abnormality. On the return visits, only 1 (0.6%) patient required readmission for intravenous fluids because of nausea and vomiting.

CONCLUSIONS

Our findings suggest that patients with uncomplicated BSFs can be safely discharged from the ED if the patient has reliable follow-up, is tolerating oral fluids, has no evidence of cerebrospinal fluid leak, and has been evaluated by appropriate subspecialists before discharge.

Management of cervical CSF-venous fistula causing acute cognitive impairment and coma

CSF-venous fistulas (CVFs) are increasingly recognised as a cause of spontaneous intracranial hypotension. They may present atypically including with brain sagging pseudo-dementia. Cervical CVFs are rare and their management can be difficult due to associated eloquent nerve roots. We report the case of a 49-year-old woman who presented with cognitive decline progressing to coma. Brain imaging showed features of spontaneous intracranial hypotension and a right C7 CVF was identified at digital subtraction and CT myelography. Initial treatment with CT-guided injection of fibrin sealant produced temporary improvement in symptoms before surgical treatment resulted in total clinical remission and radiological resolution.

Initial experience of 3-dimensional exoscope in decompression of massive lumbar disc herniation

OBJECTIVES

To investigate the effect of a three-dimensional (3D) exoscope for decompression of single-segment massive lumbar disc herniation (LDH).

METHODS

The study included 56 consecutive patients with single segment massive LDH who underwent decompression assisted by a 3D exoscope from October 2019 to October 2022 at a university hospital. The analysis was based on comparison of perioperative metrics including decompression time, estimated blood loss (EBL) during decompression and postoperative length of stay (PLS); clinical outcomes including assessment using the visual analogue scale (VAS) and the Oswestry disability index (ODI); and incidence of reoperation and complications.

RESULTS

The mean decompression time was 28.35 ± 8.93 min (lumbar interbody fusion (LIF)) and 15.50 ± 5.84 min (fenestration discectomy (LOVE surgery)), the mean EBL during decompression was 42.65 ± 12.42 ml (LIF) and 24.32 ± 8.61 ml (LOVE surgery), and the mean PLS was 4.56 ± 0.82 days (LIF) and 2.00 ± 0.65 days (LOVE surgery). There were no complications such as cerebrospinal fluid leakage, nerve root injury and epidural hematoma. All patients who underwent decompression assisted by a 3D exoscope were followed up for 6 months. At the last follow-up, the VAS and ODI scores were significantly improved from the preoperative period to the last follow-up (P < 0.05).

CONCLUSIONS

A 3D exoscope provides a visually detailed, deep and clear surgical field, which makes decompression safer and more effective and reduces short-term complications. A 3D exoscope may be a good assistance tool during decompression for single-segment massive LDH.

Using Ipratropium Bromide Nasal Spray Response as a Screening Tool in the Diagnostic Workup of Cerebrospinal Fluid Rhinorrhea

OBJECTIVES

Unilateral clear thin rhinorrhea (UCTR) can be concerning for a nasal cerebrospinal fluid (CSF) leak. Beta-2 transferrin electrophoresis has been the gold standard for initial non-invasive confirmatory testing for CSF rhinorrhea, but there can be issues with fluid collection and testing errors. Ipratropium bromide nasal spray (IBNS) is highly effective at reducing rhinitis-related rhinorrhea, and should presumably not resolve CSF rhinorrhea. This study assessed whether different clinical features and IBNS response helped predict presence or absence of CSF rhinorrhea.

METHODS

A prospective cohort study was conducted where all patients with UCTR had nasal fluid tested for beta-2 transferrin, and were prescribed 0.06% IBNS. Patients were diagnosed with CSF rhinorrhea or other rhinologic conditions. Clinical variables like IBNS response (rhinorrhea reduction), positional worsening, salty taste, postoperative state, female gender, and body-mass index were assessed for their ability to predict CSF rhinorrhea. Sensitivity, specificity, and predictive values and odds ratios were calculated for all clinical variables.

RESULTS

Twenty patients had CSF rhinorrhea, and 53 had non-CSF etiologies. Amongst clinical variables assessed for predicting CSF absence or presence, significant associations were shown for IBNS response (OR = 844.66, p = 0.001), positional rhinorrhea worsening (OR = 8.22, p = 0.049), and body-mass index ≥30 (OR = 2.92, p = 0.048). IBNS response demonstrated 96% sensitivity and 100% specificity, and 100% positive and 91% negative predictive values for predicting CSF rhinorrhea.

CONCLUSIONS

In patients with UCTR, 0.06% IBNS response is an excellent screening tool for excluding CSF rhinorrhea, and should be considered in the diagnostic workup of CSF rhinorrhea.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:56-61, 2024.

Postoperative Intracranial Hypotension-Associated Venous Congestion after Spinal Surgery Managed with Multiple Blood Patches: Case Report

BACKGROUND

 Postoperative intracranial hypotension-associated venous congestion (PIHV) is a rare event. The authors report the case of a patient presenting with PIHV after spinal surgery following the sudden loss of cerebrospinal fluid (CSF) induced by suction drainage.

METHODS

 A 69-year-old patient underwent uneventful revision surgery for wound dehiscence after lumbar surgery with placement of a subfascial suction drain.

RESULTS

 Postoperatively, the patient presented with fluctuating consciousness and a generalized tonic-clonic seizure. Computed tomography (CT) and serial magnetic resonance imaging (MRI) were performed showing convexity subarachnoid hemorrhages (SAHs), diffuse swelling of the brain and thalami and striatum bilaterally without diffusion restriction, and signs of intracranial hypertension resulting in pseudohypoxic brain swelling in PIHV. A dural leak at L3-L4 was treated with several CT-guided patches combining autologous blood and fibrin glue injections. The patient recovered without neurologic deficit and follow-up MRI revealed progressive complete reversal of brain swelling, and re-expansion of CSF spaces.

CONCLUSION

 PIHV is a rare but potentially fatal entity. Awareness of PIHV after cranial or spinal surgery leads to early treatment of CSF hypovolemia and possibly better clinical outcome. Following acute CSF volume loss, an acute elevation of cerebral blood volume overcoming autoregulatory mechanisms seems a likely explanation for diffuse cerebral vasogenic edema and SAH in PIHV.

Temporal Characteristics of CSF-Venous Fistulas on Dynamic Decubitus CT Myelography: A Retrospective Multi-Institution Cohort Study

BACKGROUND AND PURPOSE

CSF-venous fistula can be diagnosed with dynamic decubitus CT myelography. This study aimed to analyze the temporal characteristics of CSF-venous fistula visualization on multiphase decubitus CT myelography.

MATERIALS AND METHODS

A retrospective, multisite study was conducted on patients diagnosed with CSF-venous fistula at 2 institutions between June 2017 and February 2023. Both institutions perform decubitus CT myelography with imaging immediately following injection and usually with at least 1 delayed scan. The conspicuity of CSF-venous fistula was assessed on each phase of imaging.

RESULTS

Forty-eight patients with CSF-venous fistula were analyzed. CSF-venous fistulas were better visualized on the early pass in 25/48 cases (52.1%), the delayed pass in 6/48 cases (12.5%) and were seen equally on both passes in 15/48 cases (31.3%). Of 25 cases in which the CSF-venous fistula was better visualized on the early pass, 21/25 (84%) fistulas were still at least partially visible on a delayed pass. Of 6 cases in which the CSF-venous fistula was better visualized on a delayed pass, 4/6 (67%) were partially visible on the earlier pass. Six of 48 (12.5%) CSF-venous fistulas were visible only on a single pass. Of these, 4/6 (66.7%) were seen only on the first pass, and 2/6 (33.3%) were seen only on a delayed pass. One fistula was found with one pass only, and one fistula was discovered upon contralateral decubitus imaging without a dedicated second injection.

CONCLUSIONS

A dynamic decubitus CT myelography imaging protocol that includes an early and delayed phase, likely increases the sensitivity for CSF-venous fistula detection. Further studies are needed to ascertain the optimal timing and technique for CSF-venous fistula visualization on dynamic decubitus CT myelography and its impact on patient outcomes.

A Novel Intraoperative Posture-Adjustment Apparatus for Correction of Cervical Lordosis in Anterior Cervical Surgery

OBJECTIVE

Cervical alignment is a crucial factor related to the success of anterior cervical surgical procedures. In patients with severe spinal cord compression, a traditional neck pillow (TNP) may not adequately correct cervical position during surgery. Therefore, the aim of this study was to introduce this innovative intraoperative posture-adjustment apparatus (IPAA), and explored its clinical and radiological results in cervical angle correction against TNP in patients who had undergone anterior cervical surgery.

METHODS

The clinical and radiological data of 86 patients who underwent anterior cervical surgery with a minimum follow-up period of 1 year were retrospectively reviewed. Of these, 58 patients underwent IPAA, whereas 28 underwent TNP. Radiological parameters such as the degree of C2-C7 lordosis (CL), functional spinal unit angle (FSUA), C7 slope (C7S), fusion rate, and adjacent segment disease (ASD) were recorded and compared between the groups. Clinical outcomes including the Japanese Orthopaedic Association (JOA), neck disability index (NDI), visual analogue scale (VAS) for neck and arm were recorded. Complications such as kyphosis, dysphagia, Braden Scale score, revision surgery, hematoma, cerebrospinal fluid leakage, wound infection, and deep venous thrombosis were also recorded. The independent t-test or Mann-Whitney U test was used to compare continuous data, and categorical variables were assessed using the Pearson's chi-square test or Fisher's exact test.

RESULTS

Compared with the pre-operative data, the post-operative CL, FSUA, and C7S were significantly increased in both groups. CL, FSUA, and C7S in the IPAA group (14.44 ± 4.94°, 7.36 ± 2.91°, 16.54 ± 4.63°) were significantly higher than those in the TNP group (7.17 ± 8.19°, 4.99 ± 5.36°, 14.19 ± 4.48°; P < 0.05). Although there were no significant differences between the groups in terms of VAS arm and JOA scores, the post-operative and final follow-up NDI and VAS neck scores in the IPAA group were significantly lower than those in the TNP group (p < 0.05). At the last follow-up, the TNP group had significantly more kyphotic patients than the IPAA group (2 vs. 0, p = 0,041). There was no significant difference between the groups in terms of fusion rate, ASD, or complications such as dysphagia, Braden's Scale score, revision surgery, hematoma, cerebrospinal fluid leakage, wound infection, or deep venous thrombosis.

CONCLUSION

IPAA was shown to be more effective than TNP in adjusting cervical alignment (CL, FSUA, and C7S). These findings suggest that IPAA could be used as an alternative way to TNP in neck setting and cervical alignment adjustment and IPAA could potentially improve clinical outcomes after anterior cervical surgery.

Prevalence of SLEC-negative spontaneous intracranial hypotension in patients with spinal nerve root sleeve diverticula on MRI

PURPOSE

While there is thought to be an association between spinal nerve root diverticula (NRD) and spontaneous intracranial hypotension (SIH) without a spinal longitudinal epidural collection (SLEC), it remains unclear what the overall prevalence of SLEC-negative SIH is in patients with NRD on MRI.

METHODS

Spine MRI imaging reports from our single institution were electronically screened for instances of NRD over a 9-year period (2016-2023). From these cases, patients with brain MRIs consistent with SIH were also identified. Subsequently, the overall proportion of SLEC-negative SIH was determined as a function of total cases with NRD based on spinal level.

RESULTS

In total, 83,843 patients with spinal MRIs were screened which identified 4174 (4.97%) with NRD. From these, there were 1203 cervical, 622 thoracic, and 2979 lumbosacral spine MRIs. In total, 16 patients (0.38%; Standard Error [SE]: 0.48%-0.28%) had a brain MRI compatible with SLEC-negative SIH and met ICHD-3 criteria. Patients with cervical NRD had SIH in 2 cases (0.16%; SE: 0.27%-0.05%). SLEC-negative SIH was present in 11 patients with lumbosacral NRD (0.34%; SE: 0.44%-0.24%). In patients with diverticula in the thoracic spine, 14 (2.3%; SE: 2.8%-1.8%) had SLEC-negative SIH. SLEC-negative SIH was significantly more prevalent in patients with thoracic diverticula compared to those with cervical (p<.0001) or lumbosacral NRD (p<.0001).

CONCLUSION

In patients with spinal NRD, concurrent SLEC-negative SIH is present in approximately 0.38% of patients, suggesting that in the vast majority of cases, they are an incidental finding. However, SIH is present in approximately 2.3% of patients with thoracic NRD and may be more specific for leak localization.

Dynamic interaction between cerebrospinal fluid and sinovenous pressure in idiopathic intracranial hypertension: a case report

BACKGROUND

Idiopathic intracranial hypertension (IIH) is a common neurosurgical condition, and the exact pathophysiology remains elusive. Cerebral sinovenous stenosis (CSS) and the resultant decreased venous outflow have been labelled as a potential contributors to the pathophysiology of IIH. We describe the effect of cerebrospinal fluid (CSF) drainage on sinovenous pressure in a patient with IIH and a radiographic evidence of CSS.

CASE DESCRIPTION

A patient in their 40s with a diagnoses of IIH and imaging finding of focal stenosis of the distal left transverse sinus. To assess the nature of the stenosis, we performed venous sinus pressure monitoring with concurrent CSF drainage (5 ml at one minute intervals) through a lumbar drain with continuous mean sinovenous pressures recording. We observed a progressive decline in the pressure recording while draining CSF, after draining 40 ml of CSF, the final pressure gradient recording of the TS-SS trans-stenotic was (7 mm Hg from 27 mm Hg), mean SSS pressure (37 mm Hg from 60 mm Hg), and mean TS pressure (35 mm Hg from 56 mm Hg). The mean SS pressure remained relatively unperturbed.

CONCLUSION

Our findings indicate that the cerebral sinovenous pressure response to CSF removal generally conforms to a monophasic exponential decay model.

[Application of analgesia and sedation under BIS monitoring combined with hydraulic coupling intracranial pressure monitoring in severe craniocerebral injury]

OBJECTIVE

To investigate the clinical value of analgesia and sedation under bispectral index (BIS) monitoring combined with hydraulic coupled intracranial pressure (ICP) monitoring in severe craniocerebral injury (sTBI).

METHODS

(1) A prospective self-controlled parallel control study was conducted. A total of 32 patients with sTBI after craniotomy admitted to the intensive care unit (ICU) of the First People's Hospital of Huzhou from December 2020 to July 2021 were selected as the research objects. ICP was monitored by Codman monitoring system and hydraulically coupled monitoring system, and the difference and correlation between them were compared. (2) A prospective randomized controlled study was conducted. A total of 108 sTBI patients admitted to the ICU of the First People's Hospital of Huzhou from August 2021 to August 2022 were selected patients were divided into 3 groups according to the random number table method. All patients were given routine treatment after brain surgery. On this basis, the ICP values of the patients in group A (35 cases) were monitored by Codman monitoring system, the ICP values of the patients in group B (40 cases) were monitored by hydraulic coupling monitoring system, and the ICP values of the patients in group C (33 cases) were monitored combined with hydraulic coupling monitoring system, and the analgesia and sedation were guided by BIS. The ICP after treatment, cerebrospinal fluid drainage time, ICP monitoring time, ICU stay time, complications and Glasgow outcome score (GOS) at 6 months after surgery were compared among the 3 groups. In addition, patients in group B and group C were further grouped according to the waveforms. If P1 = P2 wave or P2 and P3 wave were low, they were classified as compensatory group. If the round wave or P2 > P1 wave was defined as decompensated group, the GOS scores of the two groups at 6 months after operation were compared.

RESULTS

(1) There was no significant difference in ICP values measured by Codman monitoring system and hydraulic coupling monitoring system in the same patient (mmHg: 11.94±1.76 vs. 11.88±1.90, t = 0.150, P = 0.882; 1 mmHg≈0.133 kPa). Blan-altman analysis showed that the 95% consistency limit (95%LoA) of ICP values measured by the two methods was -4.55 to 4.68 mmHg, and all points fell within 95%LoA, indicating that the two methods had a good correlation. (2) There were no significant differences in cerebrospinal fluid drainage time, ICP monitoring time, ICU stay time, and incidence of complications such as intracranial infection, intracranial rebleeding, traumatic hydrocephalus, cerebrospinal fluid leakage, and accidental extubation among the 3 groups of sTBI patients (P > 0.05 or P > 0.017). The ICP value of group C after treatment was significantly lower than that of group A and group B (mmHg: 20.94±2.37 vs. 25.86±3.15, 26.40±3.09, all P < 0.05), the incidence of pulmonary infection (9.1% vs. 45.7%, 42.5%), seizure (3.0% vs. 31.4%, 30.0%), reoperation (3.0% vs. 31.4%, 40.0%), and poor prognosis 6 months after operation (33.3% vs. 65.7%, 65.0%) were significantly lower than those in group A and group B (all P < 0.017). According to the hydraulic coupling waveform, GOS scores of 35 patients in the compensated group were significantly higher than those of 38 patients in the decompensated group 6 months after operation (4.03±1.18 vs. 2.39±1.50, t = 5.153, P < 0.001).

CONCLUSIONS

The hydraulic coupled intracranial pressure monitoring system has good accuracy and consistency in measuring ICP value, and it can better display ICP waveform changes than the traditional ICP monitoring method, and has better prediction value for prognosis evaluation, which can replace Codman monitoring to accurately guide clinical work. In addition, analgesia and sedation under BIS monitoring combined with hydraulic coupled ICP monitoring can effectively reduce ICP, reduce the incidence of complications, and improve the prognosis, which has high clinical application value.

Surgical Approach to Frontal and Ethmoid Sinus Osteomas: The Experience of 2 Metropolitan Italian Hospitals

OBJECTIVES

The aim of this study was to report the surgical management experience of patients with osteomas of the frontal and ethmoid sinuses performed in 2 metropolitan Italian hospitals between 2012 and 2019.

METHODS

A retrospective chart review of cases of frontal and ethmoid osteomas from the Ca' Granda Niguarda Hospital of Milan and the Policlinico Umberto I University Hospital of Rome was performed. All patients underwent preoperative computed tomography and, when orbital or intracranial extension was suspected, magnetic resonance imaging. Surgical treatment was performed according to Chiu classification.

RESULTS

A total of 38 cases of frontal and ethmoid sinus osteomas were included in the study; 22 patients were men and 16 were women. The mean age at diagnosis was 49 years. Seven (18.4%) patients were treated using an open approach; 3 (7.9%) patients underwent open and endoscopic approach; the remaining 28 (73.7%) patients were treated with endoscopic approach. Seven (18.4%) patients had a cerebrospinal fluid leak intraoperatively and were treated with the placement of tissue graft through the defect. The mean follow-up time was 18 months; no recurrence was observed at 12-month follow-up.

CONCLUSION

Osteomas of the frontal and ethmoid sinuses can be treated using different techniques, mostly endoscopically. The choice of surgical approach (endoscopic vs open) depends on the location and size of the osteoma, anatomical size, characteristic of the sinus, surgeon's experience, and available existing technical facilities. Cerebrospinal fluid leak is a possible complication of surgery.

Congenital Retrosigmoid Cholesteatoma: Case Series and Literature Review

BACKGROUND

This study aimed to discuss 3 cases of congenital cholesteatoma located posterior to the sigmoid sinus, with no/minimal involvement of mastoid, and compare them with cases presented in the literature to better define this rare entity.

METHODS

Retrospective chart analysis of 3 congenital cholesteatomas located posterior to the sigmoid sinus treated surgically in 2 skull-base centers and literature review. Though congenital cholesteatoma can arise outside the middle ear, only a few cases presenting in the retrosigmoid occipital bone have been described earlier.

RESULTS

In all 3 patients, there was a delay in the presentation, as symptoms were nonspecific or lacking, leading in 1 case to severe complications. Computed tomography and magnetic resonance imaging, especially diffusion-weighted imaging scans, allowed accurate diagnosis and surgical planning. Surgery happened to be challenging due to the tight adherence of the cholesteatoma to the thinned dural surface. Complete excision was achieved in all the cases.

CONCLUSION

Congenital cholesteatoma located posterior to the sigmoid sinus is a rare entity and is even more exceptional after a critical review of the literature. Complete excision is quintessential to prevent intradural extension or infection. The most important surgical issue is the management of the posterior fossa dura and the sigmoid sinus. We recommend meticulous dissection with slow peeling of the epithelial lining from the dura. Bipolar coagulation of the dura may help in avoiding recidivism. Moreover, cerebrospinal fluid (CSF) leak during dissection has to be avoided as long as possible, because the loss of tension of the already thinned dura makes its peeling particularly difficult.

Delayed approach to postdural puncture headache

A postpartum female in her mid-20s presented with atypical symptoms of postdural puncture headache. However, on initial presentation, the patient reported no headache. Primary symptoms of acute, severe interscapular pain and upper extremity radiculopathy at the time of epidural placement were observed. The absence of a positional headache and the severity of pain at presentation prompted MRI analysis to establish a clinical diagnosis.MRI findings revealed a significant cerebrospinal fluid (CSF) leak causing a mass effect on the cervicothoracic spinal cord and severe stenosis at the cauda equina. An epidural blood patch (EBP) was considered; however, it was postulated that the narrow epidural space would not be sufficient to accommodate the volume associated with an EBP. She was managed conservatively until subsequent imaging revealed CSF resorption. She received an epidural blood patch on day 7. Thereafter, her symptoms improved, allowing her to nurse her infant and be discharged home.

Study of β1-transferrin and β2-transferrin using microprobe-capture in-emitter elution and high-resolution mass spectrometry

Cerebrospinal fluid (CSF) leak can be diagnosed in clinical laboratories by detecting a diagnostic marker β2-transferrin (β2-Tf) in secretion samples. β2-Tf and the typical transferrin (Tf) proteoform in serum, β1-transferrin (β1-Tf), are Tf glycoforms. An innovative affinity capture technique for sample preparation, called microprobe-capture in-emitter elution (MPIE), was incorporated with high-resolution mass spectrometry (HR-MS) to study the Tf glycoforms and the primary structures of β1-Tf and β2-Tf. To implement MPIE, an analyte is first captured on the surface of a microprobe, and subsequently eluted from the microprobe inside an electrospray emitter. The capture process is monitored in real-time via next-generation biolayer interferometry (BLI). When electrospray is established from the emitter to a mass spectrometer, the analyte is immediately ionized via electrospray ionization (ESI) for HR-MS analysis. Serum, CSF, and secretion samples were analyzed using MPIE-ESI-MS. Based on the MPIE-ESI-MS results, the primary structures of β1-Tf and β2-Tf were elucidated. As Tf glycoforms, β1-Tf and β2-Tf share the amino acid sequence but contain varying N-glycans: (1) β1-Tf, the major serum-type Tf, has two G2S2 N-glycans on Asn413 and Asn611; and (2) β2-Tf, the major brain-type Tf, has an M5 N-glycan on Asn413 and a G0FB N-glycan on Asn611. The resolving power of the innovative MPIE-ESI-MS method was demonstrated in the study of β2-Tf as well as β1-Tf. Knowing the N-glycan structures on β2-Tf allows for the design of more novel test methods for β2-Tf in the future.

Efficacy of hydroxyapatite-based skull base reconstruction for intraoperative high-flow cerebrospinal fluid leakage performed by less-experienced surgeons

Cerebrospinal fluid (CSF) leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique. Injectable hydroxyapatite (HXA) has shown promising results to prevent CSF leakage. This study aimed to validate the efficacy of HXA-based skull base reconstruction performed by less-experienced neurosurgeons who had short-term clinical experiences as independent surgeons. Between March 2018 and November 2022, 41 patients who experienced intraoperative high-flow CSF leakage following endoscopic endonasal surgery at two independent tertiary institutions were enrolled. Skull base reconstruction was performed using conventional multilayer techniques combined with or without HXA. The primary outcome was postoperative CSF leakage. The surgical steps and nuances were described in detail. The most common pathology was craniopharyngioma. Injectable HXA was used in 22 patients (HXA group) and conventional techniques were performed in 19 patients (control group). The HXA group achieved a significantly lower incidence of postoperative CSF leakage than the control group (0% vs. 26.3%, p = 0.016). No HXA-related complications were observed. The use of injectable HXA in skull base reconstruction was highly effective and safe. This technique and its favorable results might be readily reproduced by less-experienced neurosurgeons.

Surgical evolution in spinal dural arteriovenous fistula treatment-a 7 years monocentric experience

Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.

Cerebrospinal Fluid Rhinorrhea as the First Symptom of Metastatic Prostate Adenocarcinoma

The most common cause of cerebrospinal fluid (CSF) rhinorrhoea is damage to the skull base with a dura mater's rupture due to an accident or an iatrogenic injury. This applies to over 96% of cases. Other possibilities that can lead to CSF leakage are neoplasms of the nasal cavity, paranasal sinuses, and nasopharynx. Although prostate cancer spreads to bones, cranial metastases to paranasal sinuses are extremely rare. We present a case of an 83-year-old patient with CSF leakage due to infiltrating metastatic prostate cancer. Cerebrospinal fluid rhinorrhea turned out to be the first symptom of prostate cancer metastasis. Diagnostic and treatment strategies are presented in the discussion.

A Case of Left Carotid Artery Injury

Invasive pituitary adenomas can infiltrate the dura mater, sphenoid sinus, or cranial bone. Endoscopic transsphenoidal sinus surgery is considered the standard of care; however, several potential complications must be noted. These complications can include cerebrospinal fluid leaks, infection, bleeding, optic nerve damage, and endocrinological complications such as diabetes insipidus. We present a case of a 69-year-old female with multiple recurrent invasive pituitary adenomas who has previously undergone 5 transsphenoidal procedures. Intraoperatively, the patient suffered from a left-sided carotid artery injury that was repaired with a muscle graft. Management of carotid artery injury during transsphenoidal surgery is optimized in a step-by-step approach which includes early recognition of the injury, briefing the surgical team, immediate control using compression, use of additional tissue graft for wound repair, and postoperative care. Through the use of the approach mentioned above, we were able to control the complication successfully.

Prone Dynamic CT Myelography in Spontaneous Intracranial Hypotension : Diagnostic Need and Radiation Doses

BACKGROUND AND PURPOSE

The diagnostic work-up in patients with spontaneous intracranial hypotension (SIH) and spinal longitudinal extradural CSF collection (SLEC) on magnetic resonance imaging (MRI) comprises dynamic digital subtraction myelography (dDSM) in prone position for leak detection. Dynamic computed tomography (CT) myelography (dCT-M) in prone position follows if the leak is not unequivocally located. A drawback of dCT‑M is a high radiation dose. This study evaluates the diagnostic needs of dCT-M examinations and measures to reduce radiation doses.

METHODS

Frequency, leak sites, length and number of spiral acquisitions, DLP and effective doses of dCT‑M were retrospectively recorded in patients with ventral dural tears.

RESULTS

Of 42 patients with ventral dural tears, 8 underwent 11 dCT‑M when the leak was not unequivocally shown on digital subtraction myelography. The median number of spiral acquisitions was 4 (range 3-7) and the mean effective radiation dose 30.6 mSv (range 13.1-62.16 mSv) mSv. Five of eight leaks were located in the upper thoracic spine (range C7/Th1-Th2/3). Bolus tracking of intrathecal contrast agent in dCT‑M was used to limit the number and length of spiral acquisitions.

DISCUSSION

A dCT‑M in prone position to localize a ventral dural tear is needed in every fifth patient with a SLEC on MRI. It is typically needed when the leak is located in the upper thoracic spine and when patients have broad shoulders. Measures to reduce the radiation dose include bolus tracking or to repeat the DSM with adjusted positioning of patient.

Patient experience of spontaneous intracranial hypotension (SIH): qualitative interviews for concept elicitation

BACKGROUND & OBJECTIVES

Spontaneous intracranial hypotension (SIH) is an underdiagnosed and debilitating condition caused by a spinal cerebrospinal fluid (CSF) leak. Although SIH can lead to substantial morbidity and disability, little data exists about patients' perspectives. Without hearing directly from patients, our understanding of the full experience of having SIH is limited, as is our ability to identify and use appropriate patient-reported outcome measures (PROMs) within clinical care and research. The purpose of this study was to conduct qualitative interviews with confirmed SIH patients to fully describe their experiences and identify relevant concepts to measure.

METHODS

Patients were recruited from an SIH specialty clinic at a large, U.S.-based healthcare center. Patients undergoing an initial consultation who were ≥ 18 years old, English-speaking, met the International Classification of Headache Disorders-3 criteria for SIH, and had a brain MRI with contrast that was positive for SIH were eligible to participate. During semi-structured qualitative interviews with a trained facilitator, participants were asked to describe their current SIH symptoms, how their experiences with SIH had changed over time, and the aspects of SIH that they found most bothersome. Analysts reviewed the data, created text summaries, and wrote analytic reports.

RESULTS

Fifteen participants completed interviews. Common symptoms reported by patients included headache, tinnitus, ear fullness/pressure/pain, and neck or interscapular pain. Patients reported that their symptoms worsened over the course of their day and with activity. The most bothersome aspect of SIH was disruption to daily activities and limits to physical activities/exercise, which were severe. With regard to symptoms, the most bothersome and impactful included physical pain and discomfort (including headache), as well as fatigue.

CONCLUSIONS

Patients reported a diverse set of symptoms that were attributed to SIH, with devastating impacts on functioning and high levels of disability. Researchers considering use of PROMs for SIH should consider inclusion of both symptom scales and aspects of functioning, and future work should focus on evaluating the validity of existing measures for this patient population using rigorous qualitative and quantitative methods in diverse samples. Additionally, these data can be used to assist clinicians in understanding the impacts of SIH on patients.

Cerebrospinal fluid production rate in various pathological conditions: a preliminary study

INTRODUCTION

The cerebrospinal fluid (CSF) production rate in humans is not clearly defined but is estimated to be 18-24 ml/h (Trevisi et al Croat Med J 55(4):377-387 (24); Casey and Vries Childs Nerv Syst 5(5):332-334 (8)). A frequent clinical observation is that patients often drain higher volumes of CSF than can be explained by the assumed 'normal' CSF production rate (PRcsf). In the National Hospital for Neurology and Neurosurgery PRcsf was recorded in a variety of common neurosurgical pathologies using LiquoGuard7, an automated peristaltic pump that accurately controls CSF drainage and maintains a pre-set CSF pressure.

METHODS

A prospective observational study was performed from September 2021 onwards, on all patients in the National Hospital for Neurology and Neurosurgery who required CSF drainage as part of their ongoing treatment. The external drain was connected to a LiquoGuard7 pump (Möller Medical GmbH, Fulda, Germany), and the internal software of LiquoGuard7 was used to measure PRcsf. Statistical analysis used SPSS (version 25.0, IBM) by paired t test, comparing measured rates to hypothetical 'normal' CSF production rates calculated and published by Ekstedt (16-34ml/h) (Ekstedt J Neurol Neurosurg Psychiatry 41(4):345-353 (14)), assuming a similar distribution.

RESULTS

PRcsf was calculated in 164 patients. Suspected normal pressure hydrocephalus (n=41): PRcsf of 79ml/h±20SD (p<0.0001). Post-surgical CSF leak (n=26): PRcsf of 90ml/h±20SD (p<0.0001). Subarachnoid haemorrhage (n=34): PRcsf of 143ml/h±9SD (p<0.0001). Intracerebral haemorrhage (n=22): PRcsf of 137ml/h±20SD (p<0.0001). Spinal lesions (n=7): PRcsf of 130ml/h±20SD (p<0.0032). Pituitary adenomas (n=10): PRcsf of 29 ml/h±9SD (p<0.049). Idiopathic intracranial hypertension (n=15): PRcsf of 86ml/h±10SD (p<0.0001). Decompensated long-standing overt ventriculomegaly (n=4): PRcsf of 65ml/h±10SD (p<0.0001). Cerebral infection (n=5): PRcsf of 90ml/h±20SD (p<0.0001).

CONCLUSION

Net CSF production rate may be higher than expected in many conditions, as measured with new device LiquoGuard7 through the study of net flow rate, which may have implications for clinical decisions on CSF diversion. The conventional understanding of CSF production and circulation does not explain the findings of this study. More extensive studies are needed to validate this technique.

Cerebrospinal Venous Fistula Presenting with Cognitive Decline: Systematic Literature Review and Report of Two Cases

OBJECTIVE

A cerebrospinal fluid (CSF) venous fistula (CVF) is an aberrant connection between the subarachnoid space and a vein resulting in CSF loss. The presentation and management of CVF with cognitive decline is incompletely understood.

METHODS

A systematic review was completed following the PRISMA guidelines. Articles that included at least 1 case of imaging-confirmed CVF with details on patient treatment were included. A separate review of cases of patients with spontaneous intracranial hypotension (SIH) with frontotemporal dementia (FTD) or dementia symptoms was also completed.

RESULTS

Ten CVF articles (69 patients; average age, 51.5 years) and 5 SIH with FTD or dementia articles (n = 41; average age, 55.9 years) were identified. Only 1 patients with CVF with cognitive abnormalities was identified. The most common symptom was headache in both reviews. Brain sag was identified in all patients, whereas CSF leak was identified in only 2 patients with SIH with FTD or dementia (4.9%). An epidural blood or fibrin glue patch was used in all patients with CVF and in 33 patients with SIH with FTD or dementia. Fifty-five patients with CVF (79.7%) and 27 patients with SIH with FTD or dementia (65.9%) had surgery.

CONCLUSIONS

The 2 cases and literature reviews show the difficulty in diagnosis and treatment of CVF with cognitive decline. Novel imaging techniques should be used in patients with cognitive decline in whom a CSF leak is suspected. Transvenous embolization or surgery should be considered before patching for treatment of CVF-induced brain sag and resulting dementia.

The insertion and management of an external ventricular drain in pediatric patients with hydrocephalus associated with medulloblastoma

An external ventricular drain (EVD) is used to facilitate cerebrospinal fluid (CSF) removal in medulloblastoma patients suffering from hydrocephalus. It is essential to recognize that EVD management plays a crucial role in influencing the incidence of drain-related complications. However, the ideal method for EVD management remains undetermined. Our research sought to examine the safety of EVD placement and the impact of EVD on the incidences of intracranial infections, postresection hydrocephalus, and posterior fossa syndrome (PFS). We conducted a single-center observational study involving a cohort of 120 pediatric medulloblastoma patients who were treated from 2017 to 2020. The rates of intracranial infection, postresection hydrocephalus, and PFS were 9.2%, 18.3%, and 16.7%, respectively. EVD did not influence the occurrence of intracranial infection (p = 0.466), postresection hydrocephalus (p = 0.298), or PFS (p = 0.212). A gradual EVD weaning protocol correlated with an elevated incidence of postresection hydrocephalus (p = 0.033), whereas a rapid weaning approach resulted in 4.09 ± 0.44 fewer drainage days (p < 0.001) than the gradual weaning strategy. EVD placement (p = 0.010) and intracranial infection (p = 0.002) were linked to delayed speech return, whereas a longer duration of drainage was conducive to the recovery of language function (p = 0.010). EVD insertion was not correlated with the incidence of intracranial infection, postoperative hydrocephalus, or PFS. The optimal EVD management method should encompass a rapid EVD weaning strategy, followed by prompt drain closure. We have presented additional evidence to improve the safety of EVD insertion and management in neurosurgical patients to ultimately facilitate the establishment of standardized institutional/national implementation and management protocols.

Quantification of Fat Graft Retention in the Translabyrinthine Approach Using Magnetic Resonance Imaging Volumetric Analysis

OBJECTIVE

To characterize the viability and volume of autologous free fat grafts over time, determine clinical/patient factors that may affect free fat graft survival and assess the clinical impact of free fat graft survival on patient outcomes in the translabyrinthine approach for lateral skull base tumor resection.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary neurotologic referral center.

PATIENTS

Forty-two adult patients who underwent translabyrinthine craniotomy for resection of a lateral skull base tumor with the mastoid defect filled by autologous abdominal fat graft and subsequently underwent more than one postoperative magnetic resonance imaging (MRI) scans of the brain.

INTERVENTIONS

Mastoid obliteration with abdominal fat after craniotomy, postoperative MRI.

MAIN OUTCOME MEASURES

Rate of fat graft volume loss, fraction retention of original fat graft volume, initial fat graft volume, time to steady-state fat graft retention, rate of postoperative cerebrospinal fluid (CSF) leak, and/or pseudomeningocele formation.

RESULTS

Patients were followed postoperatively with MRI for a mean of 31.6 months with a mean of 3.2 postoperative MRIs per patient. Initial graft size was a mean of 18.7 cm3 with a steady-state fat graft retention of 35.5%. Steady-state graft retention (<5% loss per year) was achieved at a mean of 24.96 months postoperatively. No significant association was found in multivariate regression analysis of clinical factors impact on fat graft retention and CSF leak/pseudomeningocele formation.

CONCLUSIONS

In the use of autologous abdominal free fat graft for filling mastoid defects after translabyrinthine craniotomy, there is a logarithmic decline in fat graft volume over time, reaching steady state in 2 years. Rates of CSF leak or pseudomeningocele formation were not significantly affected by initial volume of the fat graft, rate of fat graft resorption, nor the fraction of original fat graft volume at steady state. In addition, no analyzed clinical factors significantly influenced fat graft retention over time.

Utility of Photon-Counting Detector CT Myelography for the Detection of CSF-Venous Fistulas

CSF-venous fistulas are an increasingly recognized type of CSF leak that can be particularly challenging to detect, even with recently improved imaging techniques. Currently, most institutions use decubitus digital subtraction myelography or dynamic CT myelography to localize CSF-venous fistulas. Photon-counting detector CT is a relatively recent advancement that has many theoretical benefits, including excellent spatial resolution, high temporal resolution, and spectral imaging capabilities. We describe 6 cases of CSF-venous fistulas detected on decubitus photon-counting detector CT myelography. In 5 of these cases, the CSF-venous fistula was previously occult on decubitus digital subtraction myelography or decubitus dynamic CT myelography using an energy-integrating detector system. All 6 cases exemplify the potential benefits of photon-counting detector CT myelography in identifying CSF-venous fistulas. We suggest that further implementation of this imaging technique will likely be valuable to improve the detection of fistulas that might otherwise be missed with currently used techniques.

Temporal Characteristics of CSF-Venous Fistulas on Digital Subtraction Myelography

BACKGROUND AND PURPOSE

CSF-venous fistula can be diagnosed with multiple myelographic techniques; however, no prior work has characterized the time to contrast opacification and the duration of visualization. The purpose of our study was to evaluate the temporal characteristics of CSF-venous fistula on digital subtraction myelography.

MATERIALS AND METHODS

We reviewed the digital subtraction myelography images of 26 patients with CSF-venous fistulas. We evaluated how long the CSF-venous fistula took to opacify after contrast reached the spinal level of interest and how long it remained opacified. Patient demographics, CSF-venous fistula treatment, brain MR imaging findings, CSF-venous fistula spinal level, and CSF-venous fistula laterality were recorded.

RESULTS

Eight of the 26 CSF-venous fistulas were seen on both the upper- and lower-FOV digital subtraction myelography, for a total of 34 CSF-venous fistula views evaluated on digital subtraction myelography. The mean time to appearance was 9.1 seconds (range, 0-30 seconds). Twenty-two (84.6%) of the CSF-venous fistulas were on the right. The highest fistula level was C7, while the lowest was T13 (13 rib-bearing vertebral bodies). The most common CSF-venous fistula levels were T6 (4 patients) followed by T8, T10, and T11 (3 patients each). The mean age was 58.3 years (range, 31.7-87.6 years). Sixteen patients were women (61.5%).

CONCLUSIONS

This is the first study to report the temporal characteristics of CSF-venous fistulas using digital subtraction myelography. We found that on average, the CSF-venous fistula appeared 9.1 seconds (range, 0-30 seconds) after intrathecal contrast reached the spinal level.

Implementation of an Online External Ventricular Drain Training Module-An Educational Initiative to Improve Proficiency of Perioperative Health Care Providers: Results of a Retrospective Study

BACKGROUND

An external ventricular drain (EVD) training module may improve the knowledge and proficiency of perioperative health care providers (HCPs).

METHODS

We examined knowledge gaps, self-reported comfort in managing EVDs, and improvement in self-assessment scores among HCPs from 7 academic medical centers based on an online EVD training module.

RESULTS

Of the 326 HCPs who completed the module, 207 (70.6%) reported being uncomfortable managing EVDs. The median pretest scores were 6 (interquartile range=2), and posttest scores were 8 (interquartile range=1), out of a maximum possible score of 9. The most frequent incorrectly answered questions were: (a) maximum allowed hourly cerebrospinal fluid volume drainage (51%), (b) the components of a normal intracranial pressure waveform (41%), and (c) identifying the correct position of the stopcock for accurate measurement of intracranial pressure (41%). The overall gain in scores was 2 (interquartile range=2) and highest among HCPs who had managed 1 to 25 EVDs (2.51, 95% confidence interval: 2.23-2.80), and without self-reported comfort in managing EVDs (2.26, 95% confidence interval: 1.96-2.33, P <0.0001). The majority of participants (312, 95.7%) reported that the training module helped them understand how to manage EVDs, and 276 (84.7%) rated the module 8 or more out of 10 in recommending it to their colleagues.

CONCLUSIONS

This online EVD training module was well-received by participants. Overall, improved scores reflect enhanced knowledge among HCPs following completion of the module. The greatest benefit was observed in those reporting less experience and feeling uncomfortable in managing EVDs. The impact on the reduction in EVD-associated adverse events deserves further examination.

Pituitary enlargement in patients with cerebrospinal fluid drainage due to ventricular shunt insertion: know the condition and do not mistake for adenoma

OBJECTIVE

Childhood hydrocephalus patients treated by ventriculo-peritoneal (v.-p.) shunting are sometimes referred years after this therapy for evaluation of suspicious pituitary enlargement. Since pituitary size has been shown to depend on cerebrospinal fluid (CSF) pressure, we assume this phenomenon to be caused by shunt overdrainage. Therefore, we studied pituitary size and morphology in shunted hydrocephalus patients with radiological signs of high CSF drainage.

PATIENTS AND METHODS

Retrospective study of pituitary size and morphology in 15 shunted patients with non-tumoral hydrocephalus and 7 shunted hydrocephalus patients due to childhood brain tumor compared to a population mean. In five brain tumor patients also pre- and postsurgical comparisons were performed.

RESULTS

Pituitary mid-sagittal size and pituitary volume were significantly higher in both hydrocephalus groups, compared to the population mean (midsagittal size t = 5.91; p < 0.001; pituitary volume, t = 3.03; p = 0.006). In patients available for pre- and postoperative comparison, there was also a significant increase in pituitary size and volume postoperatively (mean preoperative midsagittal height 2.54 ± 1.0 mm vs. 6.6 ± 0.7 mm post-surgery; mean pre-operative pituitary volume 120.5 ± 69.2 mm³ vs. 368.9 ± 57.9 mm³ post-surgery).

CONCLUSION

Our results confirmed a significant increase in pituitary size and volume, mimicking pituitary pathology, after v.-p. shunt insertion. This phenomenon can be explained by the Monro-Kellie doctrine, stating that intracranial depletion of CSF-as caused by v.p. shunting-leads to compensatory intracranial hyperemia, especially in the venous system, with the consequence of engorged venous sinuses, most likely responsible for enlargement of the pituitary gland.

Impact of an external ventricular shunt (EVD) handling protocol on secondary meningitis rates: a historical cohort study with propensity score matching

BACKGROUND

External ventricular drainage (EVD) is frequently used in neurosurgical procedures for cerebrospinal fluid (CSF) drainage. It is, however, associated with high infection rates, namely secondary meningitis and ventriculitis. Based on a previous high prevalence of these infections among patients with EVDs, we have proposed and implemented a protocol in an effort to decrease the infection rate. The aim of this study was to measure the effect of hospital-wide implementation of the EVD handling protocol on secondary EVD infections.

PATIENTS AND METHODS

We included 409 consecutive patients who received a new EVD for other indications than infectious pathologies from January 2000 until June 2012. Patients above 18 years of age were divided into pre- (n = 228) and post-protocol (n = 181) groups. Patient and disease demographics, as well as EVD data together with confounders for secondary meningitis were recorded in a database. Propensity score matching was then performed to create groups matched for sex, age, reason for drainage, type of shunt, time in situ and duration of surgery to place the EVD. Binomial logistic regression for confounder adjustment and regression discontinuity analyses were then performed on the matched cohort.

RESULTS

Infections occurred more frequently in the pre-protocol group (23% vs 9%, p <  0.001). The incidence of infection was 33/1000 drain-days pre-protocol and 9/1000 drain-days post-protocol. Regression analysis in a propensity score-matched cohort (n = 103 in the pre- and n = 178 in the post-protocol groups) showed that the pre-protocol period was independently associated with more infections (OR 2.69; 95%-CI 1.22-5.95, p = 0.01).

CONCLUSIONS

The incidence of secondary EVD infections can be reduced significantly by the implementation of a strict hospital-wide EVD handling protocol.

Posterior Surgical Ligation and Cyst Decompression -via Needle Puncture- of a Large Anterior Sacral Pelvic Meningocele Through Posterior Sacral Laminectomy

The first documented description of an anterior sacral meningocele was Bryant's in 1823. Anterior sacral meningocele patients have constipation as a universal symptom; urinary incontinence is also common. All the symptoms are directly related to the pressure from a pelvic mass on adjacent structures. When the patient stands, a headache often develops because the spinal fluid pressure decreases as the meningocele sac fills. Finally, a scimitar-shaped sacrum on a neuroradiological anteroposterior plain assessment is pathognomonic. The coccyx may be absent, and the lower sacral laminae may be absent or incomplete. The surgical options for this rare clinical condition are still matter of debate.Anterior sacral meningocele is a pathology that lacks a current classification and neurosurgical therapeutic standards, even though a similar dynamic has been shown by the related traumatic pseudomeningocele. Anterior approaches (retro- and transperitoneal meningocele neck occlusion with internal cerebrospinal fluid (CSF) cyst drainage) and posterior approaches (posterior sacral laminectomy, dural sac ligation, and CSF cyst drainage) are the available surgical strategies.We now report the case of an adult patient for whom a posterior approach was suggested and performed and report her postoperative surgical follow-up. The surgical rationale is also discussed.

Symptoms Underestimate the Presence of Obstructive Sleep Apnea in Patients with Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone

OBJECTIVE

To determine the severity of symptoms and degree of obstructive sleep apnea (OSA) in patients with spontaneous cerebrospinal fluid (sCSF) leaks of the temporal bone given the known association between sCSF leaks and OSA.

STUDY DESIGN

Retrospective case review.

SETTING

Ambulatory clinics in tertiary referral centers.

PATIENTS

Polysomnogram testing in 34 consecutive patients who had been diagnosed with sCSF leaks of the temporal bone was examined. Diagnosis of sCSF leak was defined as biochemically confirmed CSF from middle ear fluid with no other obvious source.

INTERVENTION

Diagnostic.

MAIN OUTCOMES MEASURES

Patient characteristics (age, sex, body mass index, Epworth Sleepiness Scale score, presence of hypoxia, overnight change in blood pressure, and apnea hypopnea index [AHI]) were recorded. Diagnosis of OSA was defined as mild when AHI ≥5 and <15/h, moderate when AHI ≥15 and <30/h, and severe when AHI ≥30/h.

RESULTS

Of the 34 patients, 28 (82%) had a confirmed diagnosis of OSA. There was a male predisposition in those with OSA, and 17 of 28 (61%) were male. A majority were overweight, and the mean body mass index was 30.1 (SD, 4.8; range, 23.2-40) kg/m2. The mean severity of OSA was moderate, and the mean AHI was 28.7 (SD, 21.9; range, 5.4-92.8). Of the 28 patients, 13 with OSA (46%) had Epworth Sleepiness Scale scores higher than 8, suggesting that many were asymptomatic for excessive daytime sleepiness at the time of presentation.

CONCLUSION

OSA is highly prevalent among patients with sCSF leaks of the temporal bone. Patients with sCSF leaks irrespective of symptoms of OSA should undergo formal polysomnogram testing.

Predicting Shunt Dependency from the Effect of Cerebrospinal Fluid Drainage on Ventricular Size

BACKGROUND

Prolonged external ventricular drainage (EVD) in patients with subarachnoid hemorrhage (SAH) leads to morbidity, whereas early removal can have untoward effects related to recurrent hydrocephalus. A metric to help determine the optimal time for EVD removal or ventriculoperitoneal shunt (VPS) placement would be beneficial in preventing the prolonged, unnecessary use of EVD. This study aimed to identify whether dynamics of cerebrospinal fluid (CSF) biometrics can temporally predict VPS dependency after SAH.

METHODS

This was a retrospective analysis of a prospective, single-center, observational study of patients with aneurysmal SAH who required EVD placement for hydrocephalus. Patients were divided into VPS-dependent (VPS+) and non-VPS dependent groups. We measured the bicaudate index (BCI) on all available computed tomography scans and calculated the change over time (ΔBCI). We analyzed the relationship of ΔBCI with CSF output by using Pearson's correlation. A k-nearest neighbor model of the relationship between ΔBCI and CSF output was computed to classify VPS.

RESULTS

Fifty-eight patients met inclusion criteria. CSF output was significantly higher in the VPS+ group in the 7 days post EVD placement. There was a negative correlation between delta BCI and CSF output in the VPS+ group (negative delta BCI means ventricles become smaller) and a positive correlation in the VPS- group starting from days four to six after EVD placement (p < 0.05). A weighted k-nearest neighbor model for classification had a sensitivity of 0.75, a specificity of 0.70, and an area under the receiver operating characteristic curve of 0.80.

CONCLUSIONS

The correlation of ΔBCI and CSF output is a reliable intraindividual biometric for VPS dependency after SAH as early as days four to six after EVD placement. Our machine learning model leverages this relationship between ΔBCI and cumulative CSF output to predict VPS dependency. Early knowledge of VPS dependency could be studied to reduce EVD duration in many centers (intensive care unit length of stay).

Wound closure with a mesh and liquid tissue adhesive (Dermabond Prineo) system in pediatric spine surgery: a prospective single-center cohort study incorporating parent-reported outcome measures

OBJECTIVE

Wound healing can be challenging in children undergoing spine surgery for neurological conditions due to a high risk of cerebrospinal fluid (CSF) leakage and wound infection. In adults, use of the Dermabond Prineo (DP) skin closure system, which consists of both tissue adhesive glue and a self-adhesive mesh, for wound closure of medium-length surgical incisions has been reported. The aim of this study was to investigate the efficiency and cosmetic outcome of DP for wound closure in extra- and intradural pediatric neurological spine surgery.

METHODS

In this prospective cohort study, 47 children underwent 50 spine procedures using DP for wound closure between 2018 and 2022 at a single institution. Patient demographic and surgical data were collected. The primary outcome was revision surgery for wound healing disorders, while secondary outcomes were infections, minor wound healing disorders, and both physician and parental satisfaction (parent-reported outcome measures [PROMs]) at last follow-up.

RESULTS

Among 50 spinal (45 intra- and 5 extradural) interventions, 1 patient (2%) underwent revision surgery for a cutaneous CSF fistula and pseudomeningocele. Minor wound healing disorders occurred after 16 surgeries, which did not require surgical wound revision and resolved completely. No allergic reactions to DP or surgical site infections within 30 days were observed. The parents and the medical team described wound care as significantly facilitated since wound dressing changes were not needed. Three families (6.4%) encountered difficulties in wound care, and 46 (97.9%) were satisfied with DP. The cosmetic outcome based on PROMs was excellent, with a mean score of 8 (IQR 2) on a scale from 1 to 10. At long-term follow-up, a mean of 11.3 ± 10.7 months after surgery, physicians rated the cosmetic outcome on the visual analog scale (median score 9, IQR 1) and Hollander scale (median score 6, IQR 1). The outcomes were similar among the different pathologies and age groups and did not differ in patients with and without syndromic malformations.

CONCLUSIONS

The application of DP is simple, enables good patient comfort, facilitates both professional and parental wound care, and leads to excellent cosmetic results. DP possibly aids in the reduction of postoperative CSF leakage and infections after pediatric neurological spine surgery.

[Ommaya Reservoir and the External Ventricular Drainage]

Childhood hydrocephalus is a highly diverse disease caused by various factors, and most surgical treatments are performed during infancy. Despite the diversity of hydrocephalus pathologies, treatment options are limited. It is difficult for pediatric neurosurgeons to select and perform appropriate surgical procedures for neonates and infants. Treatment options for hydrocephalus are broadly divided into permanent and temporary. Permanent treatments include cerebrospinal fluid shunt and endoscopic third ventriculostomy; temporary treatment entails cerebrospinal fluid drainage using lumbar puncture and intermittent cerebrospinal fluid drainage with an Ommaya reservoir, ventricular drainage, and ventriculosubgaleal shunt. This article describes in detail Ommaya reservoir placement and ventricular drainage as representative procedures for temporarily treating hydrocephalus.

[The surgical management of benign tumors of the lateral skull base with intracranial invasion: experience from a single centre over ten years]

Objective: To investigate the clinical features, pathological types, imaging features, and surgical strategies of lateral skull base benign tumors with intracranial invasion. Methods: From January 2011 to March 2021, 36 patients of lateral skull base benign tumors with intracranial invasion were included in this retrospective study. Among the 36 patients, 14 cases were male, 22 cases were female, the aged range from 20-67, with the median age of 48. The clinical manifestations, characteristic imaging findings, pathological types, surgical approach selection, and prognosis were analyzed. Results: 36 cases of lateral skull base tumors with intracranial invasion were all accepted surgeries. 23 cases were neurogenic tumors, facial nerve tumors (n=8), neurogenic tumors in jugular foramen with unknown origin(n=6), hypoglossal schwannoma (n=3), transotic intralabyrinthine schwannoma (n=3), vestibular schwannoma involving the middle ear(n=2), vagal nerve schwannoma(n=1). Other types of tumors included meningioma (n=10) and paraganglioma (Di 1 or 2,n=3). Different pathological types of tumors had different clinical manifestations and imaging manifestations. Sixteen cases were subjected to primary resection, while, other 20 cases underwent staged operation. Among the patients with staged operation, 10 patients had completed the second stage operation, five patients were waiting for the second stage operation, the other five patient's residual intracranial tumor were significantly reduced and the space between tumor and brain tissues widened after the first stage operation, so, the following up with "wait and scan"policy was suggested. The total resection rate of tumors was related to the pathological nature, in which neurogenic tumors were 15/17, and meningiomas were 5/8. The main postoperative complications were cerebrospinal fluid leakage and infection in the operation area. There were two cases of postoperative intracranial infection, and three cases of cerebrospinal fluid leakage occurred in non staged operation cases. Conclusions: Lateral skull base tumors with intracranial invasion are rare. The most common pathological type is schwannoma, followed by meningioma and paraganglioma. For this type of tumor, if there is infection in the operation area and neck invasion is large, it is suggested to choose staged surgery, which can reduce the risk of intracranial infection and the incidence of cerebrospinal fluid leakage. Staged surgery strategy can also reduce the difficulty of second stage surgery, so the operation is much safer than non staged surgery.

[Analysis and management of delayed cerebrospinal fluid rhinorrhea after invasive pituitary adenoma surgery]

Objective: To investigate the related factors and treatments of delayed cerebrospinal fluid rhinorrhea (CFR) after invasive pituitary adenoma (IPA) surgery. Methods: One hundred and forty-two patients with IPA treated in Tianjin Huanhu Hospital from January 2014 to January 2019 were analyzed retrospectively, including 62 males and 80 females, aging from 38 to 67 years. The clinical data of patients before and after operation were collected. All patients with postoperative CFR underwent endoscopic CFR repair. During the operation, residual or recurrent pituitary adenomas were resected, the dura around the leak was enlarged and the necrotic tissue was removed. For those who still had fluid leakage after repair, the necrotic tissue was cleaned up, the leakage was filled and reinforced under endoscopy. Endoscopic rhinorrhea repair was performed if necessary. The cerebrospinal fluid leak was repaired with multi-layer materials. The related risk factors of delayed CFR after operation were analyzed. SPSS 19.0 software was used for statistical analysis. Results: Among the 142 patients in this group, 64 cases underwent total tumor resection and 78 cases underwent non-total tumor resection. They were followed up for 6 to 72 months. Thirty-one cases had delayed CFR, with an incidence of 21.83%, and occurred between 1 and 5 years postoperatively, with an average of 2.4 years. All 31 patients with delayed CFR underwent endoscopic CFR repair. The nasal endoscopy was rechecked at 2 weeks, 1 month, 3 months and 6 months after operation. Twenty-eight patients were repaired successfully after 1 operation, while 2 patients after 2 operations and 1 patient after 3 operations. These patients were followed up for 6 to 60 months, and no CFR occurred again. Univariate analysis showed that the degree of tumor resection, recurrence, size, texture, postoperative radiotherapy and operator experience were the risk factors of delayed CFR (all P<0.05). Multivariate analysis showed that the degree of tumor resection and recurrence were the highest independent risk factors for postoperative CFR, and tumor size, texture, postoperative radiotherapy and operator experience were the independent risk factors in this study. Conclusions: Delayed CFR after IPA is related to the degree of tumor resection, recurrence, size, texture, postoperative radiotherapy and the operator experience. It is necessary to completely remove the tumor under endoscope, to expand resection of the dura and necrotic tissue around the leak, to repair the defect with multi-layer materials, to follow-up closely and to repair timely after operation.

Fully endoscopic endonasal approach for the treatment of intrasellar arachnoid cysts

PURPOSE

To report our experience of endoscopic endonasal obliteration of symptomatic sellar arachnoid cyst (SAC).

METHODS

From 2002 to 2019, we retrospectively reported the data of 17 cases of SAC operated in Timone University Hospital, Marseille, France. Preoperative clinical findings were collected including main symptoms, visual function and endocrinological assessment. Surgical procedure was homogeneous and consisted in endonasal fully endoscopic surgical obliteration of the cyst cavity with fat graft. Post-operative outcomes, complication and follow-up was reported.

RESULTS

Visual disorders and/or headaches were the main symptoms. Our technique provided improvement for 83.3% of the patients suffering from visual disturbance and for 87.5% of those suffering from headaches. We reported 2 cases of cerebrospinal fluid (CSF) leakage (11.8%), but no meningitis. One case of definitive diabetes insipidus occurred and one case of postoperative syndrome of inappropriate antidiuretic hormone secretion was temporary. There was one case of recurrence reported. The mean follow-up was 39 months.

CONCLUSION

Patients with symptomatic SAC can be treated successfully by endoscopic endonasal obliteration of the cyst. This simple technique offers true benefits for the patients without craniotomy, but the complication rate remains high especially with the risk of CSF leakage. Special attention to skull base opening and closing could reduce this risk.

Keyhole surgery for giant basal brain tumors. Theoretical explanation with an example of trans-eyebrow subraorbital approach

BACKGROUND

Improvement of modern neurosurgical technology has given rise to keyhole surgery for a wide range of pathologies. Supraorbital trans-eyebrow approach has been described in detail for small tumors of anterior cranial fossa and suprasellar neoplasms. Can we use this small and less traumatic approach for a more complex tumor extending beyond the suprasellar region?

OBJECTIVE

To analyze own experience of surgical treatment of large and giant parasellar tumors via supraorbital approach, to identify the principles of such operations, indications and possible limitations.

MATERIAL AND METHODS

There were 58 resections of parasellar tumors via mini-supraorbital approach had been performed between 2016 and 2021 at the 2nd pediatric neurosurgical department. We selected 42 patients with large and giant tumors extending beyond the chiasmal-sellar zone and causing occlusive hydrocephalus (mean volume 44.2 cm³). Preoperative status of patients, postoperative clinical data and logistics of in-hospital treatment were analyzed.

RESULTS

Total resection was performed in all cases. No redo surgeries or revisions were required. There were no cases of wound infection, CSF leakage and damage to large vessels.

CONCLUSION

We standardized planning of surgeries for large neoplasms considering available knowledge about the nature of diseases, analysis of clinical and X-ray data, goals and objectives of surgery. The reader is offered a theoretical substantiation of applicability of keyhole surgery for chiasmal-sellar tumors on the example of well-known mini-supraorbital approach. We gave certain advices on planning such operations and illustrated clinical examples.