Incidence and Significance of Intraoperative Cerebrospinal Fluid Leak in Endoscopic Pituitary Surgery Using Intrathecal Fluorescein

Jakimovski, Dejan; Bonci, Gregory; Attia, Moshe; Shao, Huibo; Hofstetter, Christoph P.; Tsiouris, Apostolos John; Anand, Vijay K.; Schwartz, Theodore H.

doi:10.1016/j.wneu.2013.06.005

Cited by 88 publications

(99 citation statements)

References 44 publications

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“…Otherwise, a lumbar puncture was performed to administer 0.25 ml of 10% fluorescein (AKFluor, Akorn) with 10 ml of CSF to help visualize CSF leaks and to ensure there was no leak after reconstruction of the skull base. 23,44,47 Glucocorticoids and antihistamines were given to prevent a hypothetical allergic reaction to fluorescein. Once in rigid head fixation, patients were registered with the frameless stereotactic equipment to preoperatively acquire MRI and/or CT angiography.…”

Section: Operative Approachmentioning

confidence: 99%

Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Khan

Anand

Schwartz

2014

FOC

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Object This paper describes a consecutive series of skull base meningiomas resected using an endoscopic endonasal approach through various corridors at a single institution over 7 years. The impact of case selection and experience, the presence of a cortical cuff between the tumor and surrounding vessels, and brain edema on morbidity and rates of gross-total resection (GTR) were examined. Methods A retrospective review of a series of 46 skull base meningiomas from a prospective database was conducted. The series of cases were divided by location: olfactory groove (n = 15), tuberculum and planum (n = 20), sellar/cavernous (n = 9) and petroclival (n = 2). Gross-total resection was never intended in the sellar/cavernous tumors, which generally invaded the cavernous sinus. Clinical charts, volumetric imaging, and pathology were reviewed to assess the extent of resection and complications. Cases were divided based on a time point in which surgical technique and case selection improved into Group 1 (surgery prior to June 2008; n = 21) and Group 2 (surgery after June 2008; n = 25) and into those with and without a cortical cuff and with and without brain edema. Results Improved case selection had the greatest impact on extent of resection. For the entire cohort, rates of GTR went from 38% to 76% (p = 0.02), and for cases in which GTR was the intent, the rates went from 63% to 84% (not significant), which was mostly driven by the planum and tuberculum meningiomas, which went from 75% to 91.7 % (nonsignificant difference). The presence of a cortical cuff and brain edema had no impact on outcomes. There were 3 CSF leaks (6.5%) but all were in Group 1. Hence, CSF leak improved from 14.2% to 0% with surgical experience. Lessons learned for optimal case selection are discussed. Conclusions Surgical outcome for endonasal endoscopic resection of skull base meningiomas depends mostly on careful case selection and surgical experience. Imaging criteria such as the presence of a cortical cuff or brain edema are less important.

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Section: Operative Approachmentioning

confidence: 99%

Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Khan

Anand

Schwartz

2014

FOC

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“…This patient was operated on in 2005 (earlier period of our series) at the beginning of our learning curve. Our CSF leak rate is now 0.7% for pituitary tumors [23]. For patients with visual disturbances, only 33.3% of patients had improvement in their visual field deficits.…”

Section: Discussionmentioning

confidence: 78%

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients

Yang¹,

Anand²,

Schwartz³

2013

J Neurol Surg B

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“…2,3,6,[9][10][11]13,[21][22][23] In this prospective study, we define the sensitivity, specificity, NPV, and PPV of using 25 mg ITF with white light excitation to detect CSF leaks, which we have already shown in prior studies to be safe. 1,8,17,22 In contrast to lower dosages of ITF, the 25-mg dose is much more specific and has a lower false-negative rate. Seth et al performed a retrospective study of 10 mg ITF and reported sensitivity and specificity values of 73.8% and 100%, respectively, and a false-negative rate of 26.2%.…”

Section: Discussionmentioning

confidence: 99%

“…21 We routinely use a slightly higher dose (25 mg) and have previously reported the safety of this technique. 1,8,16,17,22 Although safe, there are no data on the sensitivity and specificity of using 25 mg ITF to detect intraoperative CSF leaks. Thus, a prospective study was initiated to address this issue.…”

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confidence: 99%

Sensitivity and specificity of intrathecal fluorescein and white light excitation for detecting intraoperative cerebrospinal fluid leak in endoscopic skull base surgery: a prospective study

Raza

Banu²,

Donaldson³

et al. 2016

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E ndoscopic endonasal approaches provide a minimal access corridor to the ventral skull base. Although anatomically appealing, the success and applicability of these approaches has hinged upon the surgeon's ability to successfully close the resulting defects in the skull base in order to prevent a postoperative CSF leak. The complications of an inadequate closure can also include meningitis and tension pneumocephalus. As such, a variety of closure methods have been developed, ranging from free tissue grafts and rigid buttresses to vascularized pedicled flaps and gasket seal closure; however, these techniques are not without morbidity and hence are used in a tailored fashion. The primary indication for utilizing a closure technique is the successful identification of intraoperative CSF leaks. 16 Hence, any method that increases the surgeon's ability to detect intraoperative CSF leaks would be potentially advantageous.Because CSF is translucent and the surgical cavity can contain small pools of blood and irrigation, it may be difficult to recognize small, low-flow CSF leaks. Using intrathecal fluorescein (ITF) injection to highlight CSF was described over 40 years ago. 10,11,15 The green fluorescence (peak emission wavelength 519 nm) can be detected with endoscopic white light illumination and is thought to easaBBreViatiONS ITF = intrathecal fluorescein; NPV = negative predictive value; PPV = positive predictive value. OBJectiVe The intraoperative detection of CSF leaks during endonasal endoscopic skull base surgery is critical to preventing postoperative CSF leaks. Intrathecal fluorescein (ITF) has been used at varying doses to aid in the detection of intraoperative CSF leaks. However, the sensitivity and specificity of ITF at certain dosages is unknown. methOdS A prospective database of all endoscopic endonasal procedures was reviewed. All patients received 25 mg ITF diluted in 10 ml CSF and were pretreated with dexamethasone and Benadryl. Immediately after surgery, the operating surgeon prospectively noted if there was an intraoperative CSF leak and fluorescein was identified. The sensitivity, specificity, and positive and negative predictive power of ITF for detecting intraoperative CSF leak were calculated. Factors correlating with postoperative CSF leak were determined. reSultS Of 419 patients, 35.8% of patients did not show a CSF leak. Fluorescein-tinted CSF (true positive) was noted in 59.7% of patients and 0 false positives were encountered. CSF without fluorescein staining (false negative) was noted in 4.5% of patients. The sensitivity and specificity of ITF were 92.9% and 100%, respectively. The negative and positive predictive values were 88.8% and 100%, respectively. Postoperative CSF leaks only occurred in true positives at a rate of 2.8%. cONcluSiONS ITF is extremely specific and very sensitive for detecting intraoperative CSF leaks. Although false negatives can occur, these patients do not appear to be at risk for postoperative CSF leak. The use of ITF may help surgeons prevent postoperative CSF le...

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Incidence and Significance of Intraoperative Cerebrospinal Fluid Leak in Endoscopic Pituitary Surgery Using Intrathecal Fluorescein

Cited by 88 publications

References 44 publications

Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Endoscopic endonasal resection of skull base meningiomas: the significance of a “cortical cuff” and brain edema compared with careful case selection and surgical experience in predicting morbidity and extent of resection

Endoscopic Endonasal Transsphenoidal Treatment of Pituitary Apoplexy: Outcomes in a Series of 20 Patients

Sensitivity and specificity of intrathecal fluorescein and white light excitation for detecting intraoperative cerebrospinal fluid leak in endoscopic skull base surgery: a prospective study

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