Endoscopic Duraplasty for Cerebrospinal Fluid (CSF) Leak

Abstract

OBJECTIVE: 1) Review all cases of CSF leaks of the anterior and middle skull base treated through an endoscopic approach; 2) Assess the outcome; 3) Discuss key points to improve success rate. METHOD: Sixty-five patients endoscopically treated for CSF leak of the anterior and middle skull base (October 1996 -December 2009) were retrospectively evaluated. The etiology of the leak was spontaneous (48%), traumatic (30%), and iatrogenic (22%). The site of the fistula was localized at the cribriform plate (60%), fovea etmoidalis (29%), and sphenoid sinus (11%). Associated meningo (encephalo)cele was detectable in 57% of cases. Endoscopic transnasal multilayer duraplasty involved 3 different techniques: underlay (73%), overlay (24%), and tobacco pouch (3%). Autologous grafts were preferably employed (iliotibial tract, fat tissue, cartilage). Fischer and Chi-square tests were employed to statistically correlate postoperative complications with patient age, gender, site and etiology of the leak, and period in which the procedure was performed. RESULTS: Mean follow-up was 65 months. Mean hospitalization time was 8.8 days. Postoperative complications occurred in 11% of the patients (3 CSF-leak, 4 meningitis) but no statistical correlation was found between complications and the above-mentioned variables, even if no complications were recorded during the last 2 years. Two patients required a revision duraplasty for recurrent CSF leak after 3.5 and 7 years. The success rate after primary treatment was 92.3%. CONCLUSION: Transnasal endoscopic multilayer duraplasty is a safe and effective technique in the treatment of the majority of anterior and middle skull base defects. Standardization of the surgical technique and the selection of autologous materials for the plasty are key points for success.

Management of cerebrospinal fluid leak: the importance of multidisciplinary approach

“…In this population, even after repair intervention, permanence of underlying risk factors involves a chronic increase of intracranial pressure itself with a remodeling and a thinning of basicranium at the level of the thinnest bone limiting. That process favors meninges' bulging through orifices [36][37][38] . Careful monitoring methods allow early recognition of complications and make it possible to make a second surgical exploration.…”

“…Regarding large ventral skull leaks (over 2 cm), comprising bone and dura, but even smaller leaks associated with high intracranial pressure, multilayer technique is recommended. This multilayer technique should consist of an intradural collagen graft between dura and brain, a second onlay graft in contact with the dura and bone and as a third layer a vascularized or mucosa flap 36,37 . In a further step, some defects might be supplemented with adipose tissue.…”