scholarly journals Repair of the sellar floor using bioresorbable polydioxanone foils after endoscopic endonasal pituitary surgery

2020 ◽  
Vol 48 (6) ◽  
pp. E16 ◽  
Author(s):  
Jan-Philip Zeden ◽  
Jörg Baldauf ◽  
Henry W. S. Schroeder
Keyword(s):  
Case Series ◽  
Pituitary Surgery ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Recent Developments ◽  
The Individual ◽  
Sellar Reconstruction ◽  
Sellar Floor

OBJECTIVEPostoperative CSF leakage is the most common unwanted sequela of transnasal pituitary surgery. The individual anatomy, the extent of the sellar opening, and the occurrence of an intraoperative CSF leak add to the risk of postoperative rhinorrhea. Despite the current sophistication and recent developments in pituitary surgery, watertight closure of the sellar floor remains a matter of concern. Improvements and additions to the technical armamentarium of sellar reconstruction are therefore still desirable.METHODSThe authors present a closure technique of the sellar floor using a bioresorbable polydioxanone foil, which is placed between the dura and the bony margins of the open sellar floor to keep the intrasellar implants in place and to withstand the pressure arising from the intracranial compartment.RESULTSThe technique was used in a technical case series of 30 patients, and in all patients the floor could be sufficiently reconstructed. CSF flow intraoperatively was documented in 10 cases (33.3%). Postoperative CSF rhinorrhea was detected in one patient (3.3%). No complications could be attributed to the technique or the material during a mean follow-up period of 477 days. The foils can easily be identified on MR images and CT scans and therefore do not affect the postoperative radiological assessment.CONCLUSIONSThe described technique is an easy, inexpensive, and reliable method for sellar floor reconstruction and has a low CSF leakage rate. It is recommended when the risk of a postoperative CSF leak is high and there is still enough bony margin of the sellar floor left that enables a sufficient fixation of the foil.

scholarly journals Iatrogenic cerebrospinal fluid leak after repeated nasal swab tests for COVID-19: illustrative case

2021 ◽  
Vol 2 (17) ◽  
Author(s):  
Johnson Ku ◽  
Chieh-Yi Chen ◽  
Jason Ku ◽  
Hsuan-Kan Chang ◽  
Jau-Ching Wu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Nasal Cavity ◽  
Nasal Swab ◽  
Cerebrospinal Fluid Leak ◽  
Cribriform Plate ◽  
Csf Leak ◽  
Illustrative Case ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Csf Leakage

BACKGROUND Nasal swab tests are one of the most essential tools for screening coronavirus disease 2019 (COVID-19). The authors report a rare case of iatrogenic cerebrospinal fluid (CSF) leak from the anterior skull base after repeated nasal swab tests for COVID-19, which was treated with endoscopic endonasal repair. OBSERVATIONS A 41-year-old man presented with clear continuous rhinorrhea through his left nostril for 5 days after repeated nasal swabbing for COVID-19. There were no obvious risk factors for spontaneous CSF leak. Computed tomography cisternography showed contrast accumulation in the left olfactory fossa and along the left nasal cavity. Such findings aligned with a preliminary diagnosis of CSF leakage through the left cribriform plate. Magnetic resonance imaging confirmed the presence of a CSF fistula between his left cribriform plate and superior nasal concha. The patient underwent endoscopic endonasal repair. CSF rhinorrhea ceased after the surgery, and no recurrence was noted during the 12-week postoperative follow-up period. LESSONS Although rare, iatrogenic CSF leakage can be a serious complication following COVID-19 nasal swab tests, especially when infection may cause significant neurological sequelae. Healthcare providers should become familiar with nasal cavity anatomy and be well trained in performing nasal swab tests.

Universal Sellar Anatomical Reconstruction Using the Sellar Floor Flap after Endoscopic Pituitary Adenoma Surgery

2018 ◽  
Vol 158 (4) ◽  
pp. 774-776 ◽  
Author(s):  
Zixiang Cong ◽  
Kaidong Liu ◽  
Guodao Wen ◽  
Liang Qiao ◽  
Handong Wang ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenoma ◽  
Csf Leak ◽  
Anatomical Reconstruction ◽  
Endoscopic Endonasal ◽  
Reconstructive Technique ◽  
Sellar Reconstruction ◽  
Sellar Floor ◽  
Csf Leaks

Postoperative cerebrospinal fluid (CSF) leaks still occur in patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery. We propose a reconstructive technique, the sellar floor flap (SFF), for universal sellar anatomical reconstruction. A total of 113 patients without intraoperative CSF leaks after endoscopic endonasal pituitary adenoma surgery from July 2013 to June 2016 were reviewed: 43 underwent sellar reconstruction with the SFF (the SFF group) and 70 underwent sellar packing only (the nonreconstruction group). No case of postoperative CSF leak was reported in the SFF group, whereas 7 cases were reported in the nonreconstruction group ( P < .05). The SFF is suitable for universal reconstruction after endoscopic endonasal pituitary adenoma surgery and may decrease postoperative CSF leak.

Surgical Experience in Prevention of Postoperative CSF Leaks Using Abdominal Fat Grafts in Endoscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas

2020 ◽  
Author(s):  
Stephen Ahn ◽  
Jae-Sung Park ◽  
Do H. Kim ◽  
Sung W. Kim ◽  
Sin-Soo Jeun
Keyword(s):  
Pituitary Adenomas ◽  
Case Series ◽  
Abdominal Fat ◽  
Fat Graft ◽  
Csf Leak ◽  
Endoscopic Endonasal ◽  
Tertiary Referral Center ◽  
Fat Grafts ◽  
Sellar Floor ◽  
Csf Leaks

Abstract Objective Cerebrospinal fluid (CSF) leaks are the most common complication during endonasal endoscopic transsphenoidal approach (EETSA) and prevention of postoperative CSF leaks is critical. In this study, we report a single surgeon's experience of sellar floor reconstruction using abdominal fat grafts for prevention of postoperative CSF leaks in EETSA for pituitary adenomas. Design This study is presented as case series with retrospective chart review. Setting Present study was conducted at tertiary referral center. Participants A total of 216 patients who underwent surgery via EETSA for pituitary adenomas between 2008 and 2018 at our institution were evaluated. When an intraoperative CSF leak occurred, sellar floor reconstruction was performed using a fat graft harvested from the abdomen via a 2-cm skin incision. Main Outcome Measures Primary outcome and measures of this study was postoperative CSF leaks. Results A total of 53 patients showed intraoperative CSF leaks (24.5%) and 2 patients showed postoperative CSF leaks (0.93%). There were no postoperative CSF leaks in any patients who showed intraoperative CSF leaks and received sellar floor reconstruction using fat grafts. There were also no postoperative CSF leaks in 12 patients who received preventative sellar floor reconstruction using fat grafts due to extensive arachnoid herniation without intraoperative CSF leaks. However, there were two postoperative CSF leaks in patients who did not show intraoperative CSF leaks and did not receive sellar floor reconstruction. Conclusion The effectiveness of sellar floor reconstruction using abdominal fat grafts in patients receiving EETSA for pituitary adenoma was reported. We suggest that identification of intraoperative CSF leaks is important and preventive sellar floor reconstruction without evidence of intraoperative CSF leaks can also be beneficial.

Prevention of Cerebrospinal Fluid Rhinorrhea After Transsphenoidal Surgery by Collagen Fleece Coated With Fibrin Sealant Without Autologous Tissue Graft or Postoperative Lumbar Drainage

2011 ◽  
Vol 68 (suppl_1) ◽  
pp. ons130-ons137 ◽  
Author(s):  
Jin Mo Cho ◽  
Jung Yong Ahn ◽  
Jong Hee Chang ◽  
Sun Ho Kim
Keyword(s):  
Cerebrospinal Fluid ◽  
Fibrin Sealant ◽  
Transsphenoidal Surgery ◽  
Csf Leak ◽  
Autologous Tissue ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Tissue Graft ◽  
Csf Leakage ◽  
Sellar Floor

Abstract BACKGROUND: Autologous tissue grafting and postoperative lumbar cerebrospinal fluid (CSF) drainage (PLD) have been used to prevent CSF rhinorrhea after transsphenoidal surgery. OBJECTIVE: To describe the technical details and efficacy of our techniques of using collagen fleece coated with fibrin sealant (TachoComb, Nycomed, Linz, Austria) instead of an autologous tissue graft and refraining from the use of PLD. METHODS: We retrospectively reviewed 307 consecutive patients who underwent a transsphenoidal surgery for pituitary adenoma from November 2005 to February 2008. Among them, 90 cases of intraoperative CSF leaks were repaired with TachoComb without an autologous tissue graft or PLD. The repair procedures were tailored according to CSF leakage type, and we used only Bioglue (Cryolife Inc, Atlanta, Georgia) for sellar floor reconstruction. RESULTS: The overall rate of CSF rhinorrhea was 2.2% (2 of 90 cases). The 2 cases of CSF rhinorrhea resulted from large arachnoid defects, and there were no adverse effects from TachoComb such as transmission of viral disease or infection. CONCLUSION: Our technique is an alternative method to the traditional autologous tissue graft technique. PLD is not an essential procedure for the prevention of CSF rhinorrhea if the intraoperative CSF leak is completely sealed off during the transsphenoidal surgery. However, in cases of large arachnoid defects, aggressive repair of the arachnoid defect and sellar floor reconstruction with bone or bony substitutes should be considered in conjunction with our methods.

scholarly journals A study assessing the outcome of endoscopic endonasal transsphenoidal excision of pituitary adenoma at a tertiary care institutions- An Initial experience of 30 cases

2018 ◽  
Vol 10 (1) ◽  
pp. 53-60 ◽  
Author(s):  
Sourabh Dixit ◽  
Nirmalya Samanta ◽  
Suniti Kumar Saha ◽  
Kaushik Roy ◽  
Partha Ghosh ◽  
...  
Keyword(s):  
Tertiary Care ◽  
Case Series ◽  
Pituitary Tumors ◽  
Pituitary Surgery ◽  
Tumor Removal ◽  
Single Centre ◽  
Endoscopic Endonasal ◽  
Csf Rhinorrhea ◽  
Growth Hormone Secreting Adenomas ◽  
Cost Economic

Background: Endoscopic Endonasal Transphenoidal Pituitary Surgery (EETS), has been proved to be a preferred alternative to conventional surgery because of its salient features like wider, more panoramic field of visualization, improved illumination and mobility of instruments, and an ability to look around anatomical corners using angled lens and minimal invasiveness.The current study was done to analyse the effectiveness and morbidity in the patients operated in our centre by Endoscopic Endonasal Transphenoidal Pituitary Surgery (EETS) done by single team in single centre in15 months. Aims and Objective: To describe a case series of patients with pituitary adenomas with endoscopic endonasaltranssphenoidal approach, the technique performed and complications in our centre. Materials and Methods: The technique performed in a series of 30 consecutive patients, and description of their complications and the protocol followed to treat these complications. Results: The tumor removal was gross total in 18 (60.0%) patients, subtotal in 8 (30.7%), and partial in 4 (7.7%) patient. Two patients with growth hormone-secreting adenomas had normalization of hormonal status. Four patients developed temporary diabetes insipidus. Four patients developed post-operative CSF rhinorrhea and were managed conservatively.Two patient had recurrence of tumor.one patient had meningitis and one patient expired in perioperative periods. Conclusions: Our experience suggests that the Endoscopic transsphenoidal approach offers a potentially viable and cost economic treatment option in pituitary tumors which are difficult to remove by the standard microscopic approaches. In past one and half year we have witnessed encouraging results without much of the anticipated complications.

The Use of Methylene Blue Staining Test in Determining the CSF Leaks Location of the Anterior Skull Base

2018 ◽  
Vol 69 (6) ◽  
pp. 1376-1377
Author(s):  
Razvan Hainarosie ◽  
Teodora Ghindea ◽  
Irina Gabriela Ionita ◽  
Mura Hainarosie ◽  
Cristian Dragos Stefanescu ◽  
...  
Keyword(s):  
Methylene Blue ◽  
Cerebrospinal Fluid ◽  
Intrathecal Injection ◽  
Diagnostic Procedures ◽  
Blue Staining ◽  
Csf Leak ◽  
Glucose Content ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Csf Leakage

Cerebrospinal fluid rhinorrhea represents drainage of cerebrospinal fluid into the nasal cavity. The first steps in diagnosing CSF rhinorrhea are a thorough history and physical examination of the patient. Other diagnostic procedures are the double ring sign, glucose content of the nasal fluid, Beta-trace protein test or beta 2-transferrin. To establish the exact location of the defect imagistic examinations are necessary. However, the gold standard CSF leakage diagnostic method is an intrathecal injection of fluorescein with the endoscopic identification of the defect. In this paper we analyze a staining test, using Methylene Blue solution, to identify the CSF leak�s location.

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

2012 ◽  
Vol 116 (4) ◽  
pp. 749-754 ◽  
Author(s):  
Wouter I. Schievink ◽  
Marc S. Schwartz ◽  
M. Marcel Maya ◽  
Franklin G. Moser ◽  
Todd D. Rozen
Keyword(s):  
Skull Base ◽  
Intracranial Hypotension ◽  
Spontaneous Intracranial Hypotension ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Spinal Imaging ◽  
Radiological Data ◽  
Single Instance ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Methods Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Results Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. Conclusions There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

Spontaneous and medically induced cerebrospinal fluid leakage in the setting of pituitary adenomas: review of the literature

2012 ◽  
Vol 32 (6) ◽  
pp. E2 ◽  
Author(s):  
Grace Lam ◽  
Vivek Mehta ◽  
Gabriel Zada
Keyword(s):  
Pituitary Adenoma ◽  
Pituitary Adenomas ◽  
Somatostatin Analogs ◽  
Csf Leak ◽  
Cerebrospinal Fluid Leakage ◽  
Review Of The Literature ◽  
Csf Rhinorrhea ◽  
Clinical Scenarios ◽  
Csf Leakage ◽  
Csf Leaks

Object Spontaneous and medically induced CSF leaks are uncommonly associated with pituitary adenomas. The aim of this study was to further characterize the clinical scenarios most closely associated with this phenomenon. Methods A review of the literature was conducted to identify all cases of nonsurgical CSF leaks associated with pituitary adenomas. The authors aimed to identify associated risk factors and management strategies used to treat these tumors and repair the CSF leak site. Results Fifty-two patients with spontaneous or medically induced CSF leaks in the setting of a pituitary adenoma were identified from 29 articles published from 1980 through 2011. In 38 patients (73%), CSF rhinorrhea developed following initiation of medical therapy, whereas spontaneous CSF leakage developed as the presenting symptom in 14 patients (27%). The patients' mean age was 42.8 years (range 23–68 years). There were 35 males and 17 females. Forty-two patients (81%) had a prolactinoma, with the remaining patients having the following tumors: nonfunctioning pituitary adenoma (6 patients), growth hormone–secreting adenoma (2 patients), mammosomatotroph cell adenoma (1 patient), and ACTH-secreting adenoma (1 patient). Infrasellar tumor invasion into the paranasal sinuses was specifically reported in 56% of patients. The medical agents associated with CSF leakage were dopamine agonists (97%) and somatostatin analogs (3%). The average time from initialization of medical treatment to onset of rhinorrhea was 3.3 months (range 3 days–17 months). Nonsurgical management was successful in 4 patients, including 1 who had successful resolution with a temporary lumbar drain. Forty-six patients (88%) underwent surgical intervention to treat the CSF leak and/or resect the tumor. In 2 patients, surgery was not performed due to medical contraindications or patient preference. Conclusions Nonsurgical development of CSF rhinorrhea may occur in the setting of pituitary adenomas, especially following favorable response of invasive prolactinomas to initiation of dopamine agonist therapy. Additional cases have been reported as the presenting symptom of a pituitary adenoma and are likely to be related to decreased tumor volume due to intrinsic infarction or hemorrhage, ongoing invasion, and/or increases in intracranial pressure. Surgical repair, preferentially via a transsphenoidal approach, is the recommended initial treatment for definitive repair of the CSF leak and achievement of maximal tumor resection.

scholarly journals Snare technique for the remodeling of the redundant arachnoid pouch to prevent cerebrospinal fluid rhinorrhea and hematoma collection during transsphenoidal surgery for suprasellar-extended pituitary tumors

2016 ◽  
Vol 125 (6) ◽  
pp. 1443-1450 ◽  
Author(s):  
Ju Hyung Moon ◽  
Eui Hyun Kim ◽  
Sun Ho Kim
Keyword(s):  
Transsphenoidal Surgery ◽  
Tumor Resection ◽  
Pituitary Tumors ◽  
Csf Leak ◽  
Arachnoid Membrane ◽  
Csf Rhinorrhea ◽  
Resection Cavity ◽  
Postoperative Hematoma ◽  
Csf Leakage ◽  
Suprasellar Extension

OBJECTIVE Transsphenoidal surgery (TSS) is considered a most effective treatment for pituitary tumors with huge suprasellar extension. However, the chance of developing CSF leakage is relatively high, because tearing of the arachnoid membrane is common and there could be multiple tear points during the dissection of suprasellar tumors from the overlying arachnoid membrane. If there are multiple leaking points in the arachnoid membrane packing methods such as using fat or multilayered fascia graft may not be sufficient to seal off the leaking points. Moreover, the packing material may not provide sufficient tamponade to stop bleeding, and thus generates postoperative hematoma formation in the tumor resection cavity. To prevent these complications, the authors have developed a new technique for remodeling the redundant arachnoid pouch (the so-called snare technique) to reconstruct the diaphragm, seal off the CSF leak points completely, and reduce the dead space in the tumor resection cavity. METHODS In 9 patients with huge macroadenomas (> 2.5 cm in diameter) with suprasellar extension, the snare technique was used to remodel the arachnoid pouch after tumor removal via standard TSS between July 2009 and August 2014. Complications were investigated, including postoperative CSF rhinorrhea, postoperative hematoma collection, and visual compromise. RESULTS During the resection of the tumor, CSF leakage was encountered in 8 cases, all of which were sealed off using the snare technique. In 1 case without intraoperative CSF leakage, the snare technique was also applied after intentional puncturing of the arachnoid membrane to reduce the volume and tension of the arachnoid pouch. None of the 9 patients experienced postoperative CSF rhinorrhea. Lumbar CSF drainage was not required in any case. Magnetic resonance imaging studies performed 24 hours after surgery revealed a remarkable reduction in the height of the diaphragm in all cases. Visual deficits improved in all patients immediately after surgery. CONCLUSIONS Remodeling of the arachnoid pouch using the snare technique is simple and effective for completely sealing off the CSF leak point and preventing hematoma collection in the tumor resection cavity after TSS for huge pituitary tumors with suprasellar extension.

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