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1/54. Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst.

    CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required.
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2/54. Transnasal endoscopic repair of congenital defects of the skull base in children.

    OBJECTIVE: To examine imaging findings and methods of endoscopic treatment of congenital skull base defects in children. DESIGN: Retrospective study and case series. SETTING: Academic tertiary care center. patients: Four patients (aged 12 and 14 months and 8 and 13 years) were included from 1995 to 1997. Three presented with a nasal glioma, which was recurrent in 1 case. The fourth patient presented with bacterial meningitis due to a spontaneous cerebrospinal fluid leak. Computed tomography and magnetic resonance imaging were used to locate the defect of the skull base. INTERVENTION: Transnasal endoscopic resection of the glioma or the meningocele, with immediate repair of the skull base defects using free mucosal flaps and/or pediculized mucosal flaps and/or conchal cartilage together with fibrin glue and nasal packing during a 3-week period. RESULTS: None of the 4 patients has experienced recurrent cerebrospinal fluid leaks or postoperative meningitis. CONCLUSIONS: The transnasal endoscopic repair of congenital meningoceles is a reliable technique in select pediatric patients. Computed tomography and magnetic resonance imaging provide information that can be used to help the surgical procedure.
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ranking = 0.125
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3/54. Spontaneous cerebrospinal fluid leakage detected by magnetic resonance cisternography--case report.

    A 49-year-old male with no history of head trauma suffered cerebrospinal fluid (CSF) discharge from the left nostril for one month. Coronal computed tomography (CT) showed lateral extension of the sphenoid sinus on both sides and CSF collection on the left side. CT cisternography could not identify the site of CSF leakage. Heavily T2-weighted magnetic resonance (MR) imaging (MR cisternography) in the coronal plane clearly delineated a fistulous tract through the sphenoid bone into the sphenoid sinus. Patch graft with muscle fragment completely relieved the CSF rhinorrhea. Postoperative three-dimensional CT showed the two bone defects identified during surgery. Small bony dehiscences in the sphenoid bone and lateral extension of the sphenoid sinus predisposed the present patient to CSF fistula formation. MR cisternography in the coronal and sagittal planes is superior to CT scanning or CT cisternography for detection of the site of active CSF leakage.
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ranking = 0.125
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4/54. Intracranial mucocele as a complication of endoscopic repair of cerebrospinal fluid rhinorrhea: case report.

    OBJECTIVE AND IMPORTANCE: Endoscopic repair of an anterior cranial fossa cerebrospinal fluid (CSF) fistula has gained widespread acceptance. We report a case of mucocele development at the site of an endoscopic CSF leak repair. CLINICAL PRESENTATION: A 46-year-old woman underwent functional endoscopic sinus surgery for nasal obstructive symptoms. The surgery was complicated by an intraoperative CSF leak from the posterior cribriform plate/anterior sphenoid, which was repaired immediately using bone and mucosa grafts. Two years postoperatively, a 13-mm anterior cranial base mass was found incidentally. This mass increased to 20 mm over the next year. INTERVENTION: The anterior cranial base mass was excised via a right frontal craniotomy and confirmed histologically to be a mucocele. CONCLUSION: Endoscopic repair of an anterior cranial base CSF fistula with mucosal grafts may lead to formation of a mucocele.
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5/54. Identification of intranasal cerebrospinal fluid leaks by topical application with fluorescein dye.

    The purpose of this paper is to describe a safe new technique for intraoperative identification of the site of cerebrospinal fluid rhinorrhea. Cerebrospinal fluid (CSF) rhinorrhea after intracranial or intranasal surgery is a known potential complication with significant morbidity and mortality. It is currently accepted that endoscopic intranasal management of CSF rhinorrhea is the preferred method of surgical repair, with higher success rates and less morbidity than intracranial surgical repair in selected cases. Accurate identification of the site of CSF leakage is necessary for a successful endoscopic surgical repair. Computer tomography (CT) with or without intrathecal contrast and preoperative nasal endoscopy are frequently used to preoperatively localize the site of the leak. Intrathecal fluorescein administered immediately before surgery has aided in the intraoperative identification of the site of CSF leak in 25-64% of patients undergoing endoscopic repair of CSF rhinorrhea in whom preoperative CT scanning and nasal endoscopy had not identified the site of CSF leak. Intrathecal fluorescein, however, has been associated with severe complications, such as lower extremity weakness, numbness, generalized seizures, opisthotonus, and cranial nerve deficits. We present three cases of CSF rhinorrhea in which fluorescein was applied intranasally during the endoscopic surgical repair. Ten percent fluorescein was applied to the nose with a cotton swab. Under endoscopic visualization the fluorescein changed its fluorescent color from amber/yellow to a dark green and was found streaming from high in the nasal cavity, which led to accurate identification of the site of the CSF leak.
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ranking = 0.625
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6/54. Delayed cerebrospinal fluid rhinorrhea seven months after transsphenoidal surgery for pituitary adenoma--case report.

    A 51-year-old female had undergone transsphenoidal surgery for pituitary adenoma producing growth hormone. Cerebrospinal fluid (CSF) leakage occurred during surgery. The sella turcica and sphenoid sinus were packed with abdominal fat and fibrin glue, buttressing the closure with a fragment of sphenoid bone. No CSF rhinorrhea occurred postoperatively. Severe meningitis developed 7 months later. CSF rhinorrhea occurred 10 days after readmission. Exploration through the transsphenoidal approach identified a small hole at the floor of the sella and CSF leaking into the sphenoid sinus through the hole. The CSF leakage stopped after the second surgery. Delayed CSF rhinorrhea without bromocriptine administration is very rare. The cause of delayed CSF rhinorrhea remains unclear. CSF rhinorrhea should be suspected if meningitis develops even months after transsphenoidal surgery.
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ranking = 0.125
keywords = operative
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7/54. Subdural and intraventricular traumatic tension pneumocephalus: case report.

    Simple pneumocephalus most frequently arises as a complication of a head injury in which a compound basal skull fracture with tearing of the meninges allows entry of air into the cranial cavity. It can also follow a neurosurgical operation. Tension traumatic pneumocephalus with intraventricular extension is an extremely rare, potentially lethal condition that requires prompt diagnosis and treatment. We report the case of subdural and intraventricular accidental tension pneumocephalus occurring in a 26-year-old man as a result of skull fracture. This case is combined with rhinorrhea and meningitis that suggest some difficulties to treat. The operative procedure associated with medical treatment was performed and a good result was obtained.
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ranking = 0.125
keywords = operative
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8/54. Spontaneous postoperative cerebrospinal fluid leaks following application of anti-adhesion barrier gel: case report and review of the literature.

    STUDY DESIGN: This report documents cerebrospinal fluid leakage after application of anti-adhesion barrier gel in a single-surgeon clinical series of 27 patients treated with ADCON-L (Gliatech, Cleveland, OH) during surgery. OBJECTIVE: To discuss a heretofore unreported postoperative complication when using an anti-adhesion barrier gel for lumbar spinal surgery. SUMMARY OF BACKGROUND DATA: Anti-adhesion barrier gel has been touted as a beneficial adjunct to lumbar surgery. No previous report has been identified that documents the complication encountered in this series. methods: During the time that ADCON-L was used, in a 9-month period, all spinal surgeries were reviewed, and those cases where ADCON-L was used were documented. The reports of all surgeries then were reviewed for complications during surgery, and clinical follow-up information was obtained. RESULTS: Five of 27 cases receiving ADCON-L during surgery developed cerebrospinal fluid leakage. Three of these patients required reoperation. CONCLUSION: The excessive rate of cerebrospinal fluid leakage after the use of ADCON-L is significant, and the morbidity associated with its use outweighs the potential benefit of the product.
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ranking = 0.625
keywords = operative
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9/54. 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.
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ranking = 0.25
keywords = operative
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10/54. Extended transsphenoidal approach with submucosal posterior ethmoidectomy for parasellar tumors. Technical note.

    The authors have developed an extended transsphenoidal approach with submucosal posterior ethmoidectomy for resection of tumors located in the cavernous sinus or the suprasellar region that are difficult to remove via the conventional transsphenoidal approach. Surgery was performed using this approach in 14 patients with large pituitary adenomas, three patients with craniopharyngiomas, and one patient with a meningioma of the tuberculum sellae. The submucosal dissection of the nasal septum used in the conventional transsphenoidal approach was extended to the superior lateral wall of the nasal cavity to expose the bony surface of the superior turbinate lying under the nasal mucosa. Submucosal posterior ethmoidectomy widened the area visualized through the conventional transsphenoidal approach both superiorly and laterally. This provided a safer and less invasive access to lesions in the cavernous sinus or the suprasellar region through the sphenoid sinus. Using this approach the authors encountered no postoperative complications, such as olfactory disturbance, cranial nerve palsy, or arterial injury. In this article the authors present the surgical methods used in this approach.
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ranking = 0.125
keywords = operative
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