Double skull base defects with primary spontaneous cerebrospinal fluid leaks in a single patient: temporal and sphenoid bones.
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ABSTRACT:
SUBMITTER: Schmitt B
PROVIDER: S-EPMC3134820 | biostudies-other | 2010 Nov
REPOSITORIES: biostudies-other
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Project description:ObjectiveTo review the literature and our institutional experience regarding the risk of meningitis in patients with spontaneous lateral skull base cerebrospinal fluid (sCSF) leaks awaiting surgical repair, and the roles of antibiotic prophylaxis and pneumococcal vaccination, if known.MethodsA retrospective chart review and systematic review of the literature was undertaken to identify the incidence of meningitis in patients with sCSF leaks awaiting surgical repair. Adults managed surgically for sCSF leaks at an academic tertiary care center over a 10-year period were included. Data was collected on receipt of prophylactic antibiotics and/or pneumococcal vaccines during the timeframe between diagnosis and surgical repair.ResultsInstitutional review identified 87 patients who underwent surgical repair of spontaneous leaks, with a 0% incidence of meningitis over a median duration of 2 months while awaiting surgery (mean 5.5 months, range 0.5-118 months). Eighty-eight percent of patients did not receive prophylactic antibiotics. No studies in the published literature demonstrated the impact of prophylactic antibiotics or pneumococcal vaccine on meningitis risk.ConclusionsThere appears to be a low risk of meningitis among patients with lateral skull base sCSF leaks awaiting surgery for short durations (≤2 months), even in the absence of prophylactic antibiotics. There is a substantial gap in the published literature assessing the risk of meningitis and roles of antibiotics and vaccination in this patient population, indicating the need for large-scale study to conclusively elucidate the nature of this risk.
| S-EPMC10571388 | biostudies-literature
Project description:We aimed to assess the frequency of connective tissue abnormalities among patients with cerebrospinal fluid (CSF) leaks in a prospective study using a large cohort of patients. We enrolled a consecutive group of 50 patients, referred for consultation because of CSF leak. All patients have been carefully examined for the presence of connective tissue abnormalities, and based on findings, patients underwent genetic testing. Ancillary diagnostic studies included echocardiography, eye exam, and histopathological examinations of skin and dura biopsies in selected patients. We identified nine patients with heritable connective tissue disorders, including Marfan syndrome, Ehlers-Danlos syndrome and other unclassified forms. In seven patients, spontaneous CSF leak was the first noted manifestation of the genetic disorder. We conclude that spontaneous CSF leaks are associated with a spectrum of connective tissue abnormalities and may be the first noted clinical presentation of the genetic disorder. We propose that there is a clinical basis for considering spontaneous CSF leak as a clinical manifestation of heritable connective tissue disorders, and we suggest that patients with CSF leaks should be screened for connective tissue and vascular abnormalities.
| S-EPMC3598315 | biostudies-literature
Project description:Spontaneous cerebrospinal fluid (CSF) rhinorrhea due to a skull base defect requires prompt diagnosis and treatment. Multiple surgical options are available for repairing the fistula, including the two-layer "fascial apposition" method and use of a pedicled nasal-septal flap. A 44-year-old obese woman presented with 4 months of progressive cough, exertional dyspnea, hoarseness, and intermittent fluid drainage from the right nostril. Chest computed tomography (CT) imaging and bronchoscopy showed chronic pneumonitis, which was confirmed by pulmonary wedge resection. CT and magnetic resonance imaging of the skull base, as well as laboratory analysis of the nasal fluid for β2-transferrin, confirmed a skull base defect causing CSF rhinorrhea. During surgery, insertion of a lumbar drain with the intrathecal fluorescein administration was performed, followed by endoscopic endonasal repair using an autologous fascial apposition graft and pedicled nasal-septal flap. Both the CSF leak and the pulmonary complications resolved following the operation with no symptoms at 11-month follow-up. This is the first reported case of spontaneous CSF rhinorrhea complicated by chronic aspiration and pneumonitis. Increased diagnostic complexity due to chronic pulmonary complications resulted in unnecessary interventions and treatment delays. Prompt recognition of spontaneous CSF leaks is essential to prevent potentially harmful complications.
| S-EPMC4870059 | biostudies-other
Project description:The vascularized nasoseptal flap has become a principal reconstructive technique for the closure of endonasal skull base surgery defects. Despite its potential utility, there has been no report describing the use of the modern nasoseptal flap to repair traumatic cerebrospinal fluid (CSF) leaks and documenting the outcomes of this application. Specific concerns in skull base trauma include septal trauma with disruption of the flap pedicle, multiple leak sites, and issues surrounding persistent leaks after traumatic craniotomy. We performed a retrospective case series review of 14 patients who underwent nasoseptal flap closure of traumatic CSF leaks in a tertiary academic hospital. Main outcome measures include analysis of clinical outcome data. Defect etiology was motor vehicle collision in eight patients (57%), prior sinus surgery in four (29%), and assault in two (14%). At the time of nasoseptal flap repair, four patients had failed prior avascular grafts and two had previously undergone craniotomies for repair. Follow-up data were available for all patients (mean, 10 months). The overall success rate was 100% (no leaks), with 100% defect coverage. The nasoseptal flap is a versatile and reliable local reconstructive technique for ventral base traumatic defects, with a 100% CSF leak repair rate in this series.
| S-EPMC3312593 | biostudies-other
Project description:ObjectiveThe skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS.MethodsA total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results.ResultsThe diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke's cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2-38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001).ConclusionThe use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.
| S-EPMC8273777 | biostudies-literature
Project description:Cerebrospinal fluid (CSF) leakage is a rare but severe complication during dacryocystorhinostomy (DCR). Understanding the details of the anatomy of the lacrimal drainage system and skull base is essential to avoid this complication. We examined the positional relationship between the lacrimal sac and skull base using 16 cadavers (22 sides) and using computed tomographic images taken in 81 patients (81 sides). Consequently, the frontal sinus intervened between the lacrimal sac and skull base in 81.8-90.1% of cases. The lacrimal sac fundus and posterior lacrimal crest were far from the skull base/cribriform plate, and the skull base above the lacrimal sac was considerably thick. These results indicate that the risk of skull base injury and consequent CSF leakage during DCR is extremely low. However, surgeons should be cautious of this complication by indirect injury due to a twisting movement of a bone rongeur applied to the maxillary bone during creation of a bony window in patients with no interposition of the frontal and ethmoid sinuses between the lacrimal sac and skull base.
| S-EPMC9402570 | biostudies-literature
Project description:Objective/Hypothesis: Spontaneous rhinoliquorrhea often occurs due to defects of the skull base. It is often misinterpreted as rhinitis and is surgically the most difficult rhinoliquorrhea entity to close. Methods: We conducted a retrospective chart analysis of patients that were diagnosed with spontaneous rhinoliquorrhea at the University Hospital Bonn between 2001 and 2017. Results: Overall, twelve patients were included in this study. On average, the time between occurrence of nasal discharge and diagnoses of rhinoliquorrhea was 123 days. In ten patients, the localization of the skull base defect could be localized by computed tomography or MRI cisternography. Ten patients underwent surgery, of which 9 remained recurrence free. One patient underwent revision surgery and from thereon was recurrence free. Conclusion: Spontaneous rhinoliquorrhea still remains a diagnostic and therapeutic challenge. Whenever persistent watery nasal discharge appears in a patient, rhinoliquorrhea must be considered. Endoscopic surgical reconstruction of the skull base is the therapeutic gold standard and should be attempted as soon as the diagnosis is secured.
| S-EPMC6637698 | biostudies-literature
Project description:ImportanceVarious signs may be observed on brain magnetic resonance imaging (MRI) in patients with spontaneous intracranial hypotension (SIH). However, the lack of a classification system integrating these findings limits decision making in clinical practice.ObjectiveTo develop a probability score based on the most relevant brain MRI findings to assess the likelihood of an underlying spinal cerebrospinal fluid (CSF) leak in patients with SIH.Design, setting, and participantsThis case-control study in consecutive patients investigated for SIH was conducted at a single hospital department from February 2013 to October 2017. Patients with missing brain MRI data were excluded. Three blinded readers retrospectively reviewed the brain MRI scans of patients with SIH and a spinal CSF leak, patients with orthostatic headache without a CSF leak, and healthy control participants, evaluating 9 quantitative and 7 qualitative signs. A predictive diagnostic score based on multivariable backward logistic regression analysis was then derived. Its performance was validated internally in a prospective cohort of patients who had clinical suspicion for SIH.Main outcomes and measuresLikelihood of a spinal CSF leak based on the proposed diagnostic score.ResultsA total of 152 participants (101 female [66.4%]; mean [SD] age, 46.1 [14.3] years) were studied. These included 56 with SIH and a spinal CSF leak, 16 with orthostatic headache without a CSF leak, 60 control participants, and 20 patients in the validation cohort. Six imaging findings were included in the final scoring system. Three were weighted as major (2 points each): pachymeningeal enhancement, engorgement of venous sinus, and effacement of the suprasellar cistern of 4.0 mm or less. Three were considered minor (1 point each): subdural fluid collection, effacement of the prepontine cistern of 5.0 mm or less, and mamillopontine distance of 6.5 mm or less. Patients were classified into groups at low, intermediate, or high probability of having a spinal CSF leak, with total scores of 2 points or fewer, 3 to 4 points, and 5 points or more, respectively, on a scale of 9 points. The discriminatory ability of the proposed score could be demonstrated in the validation cohort.Conclusions and relevanceThis 3-tier predictive scoring system is based on the 6 most relevant brain MRI findings and allows assessment of the likelihood (low, intermediate, or high) of a positive spinal imaging result in patients with SIH. It may be useful in identifying patients with SIH who are leak positive and in whom further invasive myelographic examinations are warranted before considering targeted therapy.
| S-EPMC6515981 | biostudies-literature
Project description:To determine whether the microRNA content of CSF vesicles changes throughout life we performed experiments including miRNA microarrays. Hierarchical clustering analysis indicated that the miRNA content of CSF vesicles changes when patients less than 2 years are compared to those older than 70 years of age. CSF vesicles were fractionated and isolated from patients of different ages, total RNA extracted, and subjected to miRNA microarray analysis
2014-11-24 | E-GEOD-57713 | biostudies-arrayexpress
Project description:Objectives Pseudo-cerebrospinal fluid (CSF) rhinorrhea is a rare phenomenon, presumed to result from aberrant autonomic reinnervation of the paranasal mucosa following injury to the greater superficial petrosal nerve or periarterial plexus. In this report, we discuss the case of a postoperative patient with pseudo-CSF rhinorrhea exacerbated by chewing and propose a novel mechanism of pseudo-CSF rhinorrhea. Case Report A 46-year-old man was found to have mastication-induced unilateral clear rhinorrhea following transtemporal resection of a cerebellopontine angle tumor. Computed tomography cisternogram and β-2 transferrin analysis proved negative for any evidence of CSF leak. Conclusions Pseudo-CSF rhinorrhea exacerbated by mastication has not been previously reported in the literature. We propose aberrant cross-innervation of the trigeminal and facial nerves as the mechanism underlying the patient's condition. Pseudo-CSF rhinorrhea is an important entity to identify following skull base surgery because it may spare patients from the unnecessary invasive procedures and morbidity associated with the management of a presumed CSF leak.
| S-EPMC4520968 | biostudies-other