Cerebrospinal fluid fistula after endoscopic skull base surgery prevention

• Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial
• Avoiding complications in endoscopic skull base surgery
• CLOSURE OF NASOCRANIAL FISTULAS WITH "BATH-PLUG" TECHNIQUE AND MULTILAYER RECONSTRUCTION
• Double flap technique for reconstruction of anterior skull base defects after craniofacial tumor resection: technical note
• Vascularised local and free flaps in anterior skull base reconstruction
• Pericranial flap for endoscopic anterior skull-base reconstruction: clinical outcomes and radioanatomic analysis of preoperative planning
• Natura abhorret a vacuo--use of fibrin glue as a filler and sealant in neurosurgical "dead spaces". Technical note
• Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches

Monitoring of complications after endoscopic skull base surgery is necessary in order to standardize protocols of management and improve our surgical techniques. The presence of late-onset complications underlines the need of a special focus in postoperative care and follow-up ¹⁾

With a suitable technical background and appropriate endoscopic skills, the surgeries of the anterior skull base cerebrospinal fluid fistulas can be performed efficiently and with a low complication rate ²⁾.

Cerebrospinal fluid leakage after endoscopic skull base surgery remains a challenge despite multilayer reconstruction including nasoseptal flap (NSF) has become a standard technique.

Techniques to prevent postoperative cerebrospinal fluid fistula remain controversial in transsphenoidal surgery. Although direct repair of cerebrospinal fluid fistula by primary suture or patch grafting is the most desirable management, conventional stitching is extremely difficult, particularly through an endonasal route with a deep and narrow surgical corridor. To obliterate a CSF fistula, packing of autologous grafts and/or bioabsorbable materials into the sella turcica and the sphenoid sinus has generally been employed with or without postoperative CSF lumbar drainage.

Kassam et al indicated that one of the most common causes of failure in reconstruction for CSF leakage is migration of the graft by stretching under pressure of neighboring tissue or CSF, and this event might occur early in the wound-healing phase before generating a biological seal. They reported that use of the balloon to apply pressure on the graft within the sphenoid sinus was highly effective to prevent graft migration ³⁾.

The U-clip anastomotic device (Medtronic, Minneapolis, MN) has been used for endoscopic suturing to fix a graft patch through an endonasal route ⁴⁾.

The AnastoClip Vessel Closure System (VCS; LeMaitre Vascular, Boston, MA) is an automatic suture device originally invented for microsurgical vascular reconstruction ⁵⁾. It was used for closure of a CSF fistula in endonasal transsphenoidal surgery. In all four patients, CSF leakage was successfully obliterated primarily with two to five clips. There was no postoperative CSF rhinorrhea or complications related to the use of the VCS. Metal artifact by the clips on postoperative images was tolerable. Primary closure of the fistula using the VCS was an effective strategy to prevent postoperative CSF leakage in transsphenoidal surgery. Future application can be expanded to reconstruction of the skull base dura via endonasal skull base approaches ⁶⁾.

Jamshidi et al. demonstrated that a high-volume LP, followed by acetazolamide therapy for 10 days, can be considered in the management of post-operative CSF leaks ⁷⁾.

Hadad-Bassagasteguy flap

Cruciate embedding fascia-bone flap.

Among patients undergoing intradural EES judged to be at high risk for CSF leak as defined by the study's inclusion criteria, perioperative lumbar drainage used in the context of vascularized nasoseptal flap closure significantly reduced the rate of postoperative CSF leaks. Clinical trial registration no.: NCT03163134 (clinicaltrials.gov) ⁸⁾.

Injectable hydroxyapatite (HXA) has shown promising results in preventing CSF leakage.

Hong et al. 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 ⁹⁾.