1/21. CSF rhinorrhoea following treatment with dopamine agonists for massive invasive prolactinomas.OBJECTIVE: The management of CSF rhinorrhoea following dopamine agonist (DA) treatment for invasive prolactinomas is difficult and there is no clear consensus for its treatment. Our objective was therefore to investigate the different treatments for this condition. DESIGN AND patients: We examined the case notes of five patients with invasive prolactinomas and CSF rhinorrhoea following DA treatment. The different ways in which this complication had been managed is detailed along with a review of the literature. RESULTS: Five patients aged 24-67 years (3 male) with massive invasive prolactinomas (serum prolactin 95000-500000 mU/l) eroding the skull base were treated with dopamine agonists (3 bromocriptine, 1 cabergoline and 1 both). CSF rhinorrhoea developed in all patients between 1 week and 4 months after commencing dopamine agonist treatment. In two patients (cases 1 and 4), CSF rhinorrhoea ceased within a few days of stopping bromocriptine but restarted when treatment was resumed. One of these (case 4), a 67-year-old woman had no further treatment and CSF leakage stopped completely. She died of unrelated medical problems 3 years later. In one patient staphylococcus aureus meningitis and pneumocephalus developed as a complication of CSF rhinorrhoea. Three patients had endoscopic nasal surgery to repair the fistula using muscle grafts, and to decompress the pituitary tumour, with success in two. One patient had intracranial surgery and dural repair, which was successful in sealing the leak. CONCLUSIONS: We suggest that surgery as soon as is feasible is the treatment of choice for the repair of a CSF leak following dopamine agonist treatment. An additional strategy is the withdrawal of dopamine agonist to allow tumour re-growth to stop the leak.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
2/21. Closure of recurrent frontal skull base defects with vascularized flaps -- a technical case report.Techniques for vascularized reconstruction of the anterior cranial fossa floor defects causing recurrent cerebrospinal fluid fistula are discussed in this report. The closure employs the use of local random- or axial-pattern vascularized flaps in simple cases. In complicated cases (for instance, status after repeated exploration) the tissue of the cranial base is severely compromised and shows low potential for healing. Non-vascularized grafts only add avital scars to the already present ones leading to recurrent fistulas. Free vascularized flaps show more mechanical strength and less scar contraction, resistance to infections and survive better in a compromised surrounding, thus leading to long term sealing in such cases. The technical issues of vascularized closure of defects of the frontal skull base are discussed in this report.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
3/21. Sphenoethmoid cerebrospinal fluid leak repair with hydroxyapatite cement.Despite advances in neurological, reconstructive, and endoscopic sinus surgery, sphenoethmoid cerebrospinal fluid (CSF) fistulae continually pose difficult management problems. Standard surgical techniques for fistulae closure succeed approximately 78% to 90% of the time. To improve this success rate, hydroxyapatite cement (HAC), a food and Drug Administration-approved substance for cranial defect repair, was applied to this problem in a clinical setting. Twenty-one patients with spontaneous, posttraumatic, or postoperative CSF leaks of the sphenoid sinus, cribriform plate, or ethmoid region were treated with HAC. Study participants were prospectively accrued at 5 tertiary care medical centers in the eastern united states. The CSF leaks of all 21 patients treated with HAC were successfully sealed by its initial application. The sites of CSF leakage included the nasal cavity (n = 2) and sphenoid sinus (n = 19). Fifteen of the patients had previously undergone a failed repair by standard methods. There have been no recurrent CSF leaks with a maximum follow-up of 72 months, and an average follow-up of 36 months. All patients have survived to date. The only HAC-related morbidity was the extrusion of the HAC when placed in the nasal cavity. Hydroxyapatite cement is an effective method of repair for postoperative, posttraumatic, and spontaneous sphenoid CSF leaks. The efficacy of HAC in sealing the CSF leak was unaffected by previous attempts at leak closure by standard methods or by its origin. Hydroxyapatite cement should not be applied transnasally for the treatment of an ethmoid region fistula owing to its high probability of extrusion. Correct patient selection and technical familiarity with HAC are necessary for successful application.- - - - - - - - - - ranking = 2keywords = seal (Clic here for more details about this article) |
4/21. recurrence of pneumococcal meningitis due to primary spontaneous cerebrospinal fluid fistulas.The authors report a case of pneumococcal meningitis which recurred 3 times in a Taiwanese boy due to spontaneous cerebrospinal fluid (CSF) fistulas. The first time occurred at the age of 2 years, and the second episode presented as meningoencephalomyelitis at the age of 6 years 10 months. Studies including serum levels of immunoglobulin and complements, brain magnetic resonance imaging, and coronal cranial computed tomography (CT) were negative for a specific etiology. The third episode of meningitis developed 2 months after the second episode. Repeated immunological studies and high-resolution CT of paranasal sinuses and temporal bones were negative. technetium-99m diethylenetriamine pentaacetic acid (Tc-99m-DTPA) radionuclide cisternography revealed abnormal retention of radioactivity over the right mastoid area. neurosurgery was undertaken to seal the dural tear and pack the petrosal fissure. Two years after surgery, he has had no further CSF leak age or meningitis. Tracing back the history, there was no head injury, cranial surgery, brain tumor, or hydrocephalus, which might have created CSF fistulas. Primary spontaneous CSF fistulas constitute the most reasonable diagnosis. In cases of recurrent bacterial meningitis, underlying anatomic defects should be carefully evaluated if there is no immune defect.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
5/21. arachnoid cyst of the fallopian canal: a surgical challenge.OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are exceedingly rare, with only 6 reports appearing in the world literature. We report a seventh case that is unique in that it involves an arachnoid cyst of the fallopian canal and an associated facial nerve palsy. STUDY DESIGN: Case report. SETTING: International tertiary care referral center. CONCLUSION: CSF otorhinorrhea associated with a facial nerve palsy may be indicative of an arachnoid cyst of the fallopian canal. These fistula are extremely rare. Surgical management involves sealing the fistula while preserving facial nerve function and is extremely challenging.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
6/21. The osteo-mucoperiosteal flap in repair of cerebrospinal fluid rhinorrhea.Repair of fistulas producing cerebrospinal fluid rhinorrhea, as with any reconstructive operations, should take into account the basic principles of reconstructive surgery for best results: 1. tissue needing replacement should be replaced by like tissue; and 2. a flap is always superior to a graft. In the case of this disease, the tissue sealing the fistula should be a flap containing not only mucosa or mucoperiosteum, but also pedicled bone. Two kinds of regional flaps are described which successfully closed the fistula in each of three patients. Follow-up is long term.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
7/21. Traumatic tension pneumocephalus--intracerebral pneumatocele: a case report.An 18-year-old Chinese man, suffering from head injury in a motorcycle accident, with right traumatic frontal intracerebral hemorrhage and frontal bone fractures, underwent emergency craniotomy with evacuation of hematoma at a local out-patient clinic and three months later, he suffered from CSF rhinorrhea. headache, nausea and vomiting developed a week prior to admission. Tension pneumocephalus was diagnosed by computed tomography (CT) scan and plain skull X-ray. The fistula tract of the ethmoid sinus was investigated by radioisotope albumin (RISA) cisternography. The patient subsequently underwent emergency craniotomy for decompression. During the operation, we found that the intracerebral pneumatocele in the right frontal lobe communicated with the ipsilateral ethmoidal sinus, through which extracranial air ingressed and CSF egressed. This pneumatocele was unroofed and the fistula was temponaded by pericranial muscles and the Gelfomas sealed by tissue glue. Finally duraplasty was performed. Follow-up CT scan revealed that pneumocephalus subsided and the patient was cured of CSF rhinorrhea on discharge. As a surgical emergency, tension pneumocephalus can be successfully treated only by early diagnosis and early treatment.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
8/21. Subdural patch graft technique for watertight closure of large dural defects in extended transsphenoidal surgery.OBJECTIVE: The most common postoperative complication of the transsphenoidal approach is cerebrospinal fluid (CSF) rhinorrhea. If the dura is widely opened beyond the sellar floor and massive intraoperative CSF leakage is encountered, then the conventional packing method, in which the sella turcica is filled with pieces of fat or muscle, demonstrates a relatively high incidence of CSF rhinorrhea. For more reliable prevention of postoperative CSF leakage, we developed a method for watertight closure of large dural defects. methods: For 34 consecutive patients with suprasellar tumors, we performed tumor resection via an extended transsphenoidal approach, in which the surgical window in the sellar floor was extended to the planum sphenoidale to expose the suprasellar cistern. The patients were retrospectively divided into three groups according to the dural defect closure technique used. Group I consisted of the first two patients, whose large dural openings were closed with a conventional fat-packing method. Group II consisted of the next 10 patients, whose large dural defects were patched with fascia and sutured with 5-0 nylon, in a watertight manner. Group III consisted of the last 22 patients, who underwent watertight dural closure with a new knot-tying technique and a double-layer patch graft, which generously covered the dural defect of the cranial base with subdural placement. In Group III, intracranial CSF compressed the patch graft against the cranial base and sealed the gap between the patch graft and the cranial base in a watertight manner. The double-layer patch graft was composed of autologous fascial membrane and a commercially available, expanded polytetrafluoroethylene dural substitute. RESULTS: Postoperative CSF leakage was noted for 50% of the patients in Group I, 30% of the patients in Group II, and 9% of the patients in Group III. The time required for dural closure for Group III was approximately 50% shorter than that required for Group II (45.9 /- 12.4 min versus 93.5 /- 19.1 min, P < 0.001). CONCLUSION: The subdural double-layer patch graft technique is simple and reliable for the prevention of CSF rhinorrhea after transsphenoidal surgery associated with a widely opened dura.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
9/21. Spontaneous cerebrospinal fluid rhinorrhea as the primary manifestation of maxillary carcinoma--case report.A 66-year-old man presented with a maxillary carcinoma manifesting as unrelenting spontaneous cerebrospinal fluid (CSF) rhinorrhea. Anterior craniofacial resection of the tumor was performed with multilayered repair of the dura mater. Maxillary carcinoma usually manifests as nasal blockage, epistaxis, or a mass lesion. This case highlights the necessity for a high index of suspicion for malignant tumor and the need for meticulous repair of the dura mater to seal off the CSF leakage.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
10/21. Endoscopic closure of the eustachian tube.BACKGROUND: Cerebrospinal fluid (CSF) otorhinorrhea can rarely complicate lateral skull base surgery, necessitating sealing of the eustachian tube. Patulous eustachian tube (pET) can also be an indication for closure of the eustachian tube. methods: Representative cases and the technique will be described. RESULTS: The authors describe a technique used in three cases of CSF otorhinorrhea and one case of pET to successfully close the eustachian tube. CONCLUSIONS: Previous reports have described methods of eustachian tube closure utilizing nasal endoscopic techniques. These techniques have relied on packing of the orifice and/or the nasopharynx for successful closure. The authors describe their experience with an alternative technique. The technique does not rely on any packing, which may become dislodged. It has the added advantage of potential reversibility in cases of pET.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
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