Background: Spontaneous CSF leak represents less frequent cause of CSF leak, but cases are more difficult to control, with the highest failure rate and recurrence despite adequate repair. The problems in these cases m...Background: Spontaneous CSF leak represents less frequent cause of CSF leak, but cases are more difficult to control, with the highest failure rate and recurrence despite adequate repair. The problems in these cases might be related to an underlying undiagnosed associated intracranial hyper-tension. Recognition and long-term treatment of elevated ICP is therefore critical to the successful management of these patients. Objective: To evaluate the CSF pressure in cases of spontaneous CSF rhinorrhea and to describe our same setting combined protocol to the repair of the leak, measurement and management of CSF pressure. Patients and Methods: All patients presenting to Ain Shams University Hospitals, Cairo, Egypt, with spontaneous CSF leak were included prospectively in the study. Clinical and radiologic data were collected to suspect elevated intracranial pressure. After CSF repair, CSF pressure was measured and if found to be more than 20 cmH2O, a lumboperitoneal shunt was used. Results: Twenty-seven cases, 23 women and 4 men, presented with spontaneous CSF leak. 23 patients had BMI above 30. All patients had empty sella syndrome (100%), and a meningoencephalocele was found in 13 cases (48%). CSF pressure ranged from 5 to 39 cmH2O (mean = 28.7). A pressure above 21 cmH2O was found in19 patients (70%) and subsequently had lumboperitoneal shunt in the same setting. No recurrence occurred in this subset of patients with 6 - 60 months follow-up period. Conclusion: A selective and specific same setting protocol can result in a better diagnosis and control of the accompanying elevated ICP in cases of spontaneous CSF leak. It avoids a second operative intervention, and shortens the hospital stay, with an increase in the success rate. In the same time, the smaller number of patients with normal ICP can avoid further drainage.展开更多
Intracranial hypotension (ICH) is a benign syndrome which is often under-diagnosed. It is characterized by orthostatic headache which is predominantly occipital. ICH is diagnosed in the presence of a typical history a...Intracranial hypotension (ICH) is a benign syndrome which is often under-diagnosed. It is characterized by orthostatic headache which is predominantly occipital. ICH is diagnosed in the presence of a typical history and characteristic imaging findings. Further confirmation by lumbar puncture to document low CSF pressure might be necessary in some cases. Treatment is mainly conservative in the form of bed rest and intravenous saline infusion. However, surgical intervention may be required if conservative measures fail. In this report we presented a case of 42-year-old male patient who presented with symptoms of orthostatic occipital headache of three-month duration and was subsequently diagnosed with intracranial hypotension based on characteristic MRI findings of pachymeningeal enhancement on gadolinium enhanced MRI of the brain with sagging of the mid-brain.展开更多
Introduction: Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery. The use of an endocranial “gasket” plug has been reported for thi...Introduction: Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery. The use of an endocranial “gasket” plug has been reported for this and is used in our institution. We present a simple refinement of the “gasket” technique using commonly available materials that helps ensure proper size and positioning of the gasket by applying stress on a suture attached on the center of the gasket implant. Materials and Methods: We report a case of massive CSF leak following endonasal transsphenoidal surgery for pitui- tary macroadenoma. The skull base was reconstructed in a multi-layered fashion with fascia lata and bony buttress reinforced with a vascularized nasoseptal flap. In order to avoid implant slippage from too-small size or malpositioning, we performed a “stress test” using traction applied to a suture attached to the center of the implant (Medpor?), which allowed us to confirm intraoperatively that the buttress was positioned securely. Results: The patient did well without recurrence of CSF leak. At two-year follow-up, there has been no recurrence of CSF leak or occurrence local complica- tions. We have not verified whether bony regrowth into the implant has occurred. Conclusion: The suture-pull refinement of the gasket implant technique is a simple, inexpensive and low risk method to assure secure endocranial positioning over the skull base defect, and may prevent CSF leak resulting from too-small sizing or buttress malpositioning.展开更多
Introduction: The exact pathophysiology of spontaneous CSF rhinorrhea is not always understood in some patients. Idiopathic intracranial hypertension (IIH) is now recognized as one of the causes of spontaneous CSF lea...Introduction: The exact pathophysiology of spontaneous CSF rhinorrhea is not always understood in some patients. Idiopathic intracranial hypertension (IIH) is now recognized as one of the causes of spontaneous CSF leak in the neurosurgical and ENT literature. Our aim was to set a management protocol for such cases according to the same setting intracranial tension (ICT). Methods: We prospectively managed patients with spontaneous CSF rhinorrhea who were admitted to our hospital between 1st of January 2014 and 31st of December 2017 with a prespecified treatment algorithm. Patients with a history of previous cranial or nasal surgery, trauma, skull base congenital malformations were excluded from the study. The patient’s demographics, clinical data, comorbidities, body mass index (BMI), first time or recurrent leakage and duration of the leak were collected. Results: 41 patients, 35 females and 6 males, presented with spontaneous CSF rhinorrhea with a mean BMI of 38 ± 4.16 Kg/m2. The mean pre-operative ICT manometry was 17.2 ± 5.9 cmH2O (range, 10 - 26 cmH2O). 43.9% of the patients were found to have an increased ICT (≥20 cmH2O) and underwent a permanent CSF diversion at the same setting of the endoscopic repair. None of the patients had a recurrence during the follow-up period. Conclusion: The prespecified treatment algorithm with measuring the ICT at the same setting of the endoscopic repair has a better result for control of spontaneous CSF rhinorrhea. This has led to no recurrence and decreased hospital stay.展开更多
This work aimed at investigating the possibility and effectiveness of osteoinductive calcium phosphate(CaP)ceramics to close the drilled skull holes and prevent the postoperative cerebrospinal fluid(CSF)leaking in chi...This work aimed at investigating the possibility and effectiveness of osteoinductive calcium phosphate(CaP)ceramics to close the drilled skull holes and prevent the postoperative cerebrospinal fluid(CSF)leaking in children’s endoscopic neurosurgery.Five children patients(four boys and one girl,3-to 8-years old)underwent the surgery,in which the endoscopic third ventriculostomy(ETV)was operated in four cases of hydrocephalus,and biopsy and ETV were both performed in one case of pineal tumor.The drilled skull holes were filled with the commercial osteoinductive CaP ceramics.The patients were followed up by CT scan at 1,7 days,3 and 6 months postoperatively.All the five cases were successful,and the holes were closed well after filled with the ceramics.The follow-up survey showed that no CSF leaking or rejection reaction was found.The CT scan indicated that the drilled holes began healing at 7 days postoperatively,and a relatively complete healing happened at 6 months postoperatively.The excellent ability of the CaP ceramics to induce bone regeneration was also confirmed by repairing the skull defects in a monkey model.The results of μ-CT and histological analysis showed that a bony structure with irregular array occurred at the defect area,and the newly formed bone volume density reached 65.7%.In conclusion,the osteoinductive CaP ceramics could be an ideal material to treat the drilled skull holes in children’s endoscopic neurosurgery and prevent CSF leaking afterwards.However,further investigation with more cases and longer follow-up was required to evaluate the clinical effect.展开更多
文摘Background: Spontaneous CSF leak represents less frequent cause of CSF leak, but cases are more difficult to control, with the highest failure rate and recurrence despite adequate repair. The problems in these cases might be related to an underlying undiagnosed associated intracranial hyper-tension. Recognition and long-term treatment of elevated ICP is therefore critical to the successful management of these patients. Objective: To evaluate the CSF pressure in cases of spontaneous CSF rhinorrhea and to describe our same setting combined protocol to the repair of the leak, measurement and management of CSF pressure. Patients and Methods: All patients presenting to Ain Shams University Hospitals, Cairo, Egypt, with spontaneous CSF leak were included prospectively in the study. Clinical and radiologic data were collected to suspect elevated intracranial pressure. After CSF repair, CSF pressure was measured and if found to be more than 20 cmH2O, a lumboperitoneal shunt was used. Results: Twenty-seven cases, 23 women and 4 men, presented with spontaneous CSF leak. 23 patients had BMI above 30. All patients had empty sella syndrome (100%), and a meningoencephalocele was found in 13 cases (48%). CSF pressure ranged from 5 to 39 cmH2O (mean = 28.7). A pressure above 21 cmH2O was found in19 patients (70%) and subsequently had lumboperitoneal shunt in the same setting. No recurrence occurred in this subset of patients with 6 - 60 months follow-up period. Conclusion: A selective and specific same setting protocol can result in a better diagnosis and control of the accompanying elevated ICP in cases of spontaneous CSF leak. It avoids a second operative intervention, and shortens the hospital stay, with an increase in the success rate. In the same time, the smaller number of patients with normal ICP can avoid further drainage.
文摘Intracranial hypotension (ICH) is a benign syndrome which is often under-diagnosed. It is characterized by orthostatic headache which is predominantly occipital. ICH is diagnosed in the presence of a typical history and characteristic imaging findings. Further confirmation by lumbar puncture to document low CSF pressure might be necessary in some cases. Treatment is mainly conservative in the form of bed rest and intravenous saline infusion. However, surgical intervention may be required if conservative measures fail. In this report we presented a case of 42-year-old male patient who presented with symptoms of orthostatic occipital headache of three-month duration and was subsequently diagnosed with intracranial hypotension based on characteristic MRI findings of pachymeningeal enhancement on gadolinium enhanced MRI of the brain with sagging of the mid-brain.
文摘Introduction: Adequate reconstruction of the skull base is the key to avoiding cerebrospinal fluid (CSF) leak following endonasal skull base surgery. The use of an endocranial “gasket” plug has been reported for this and is used in our institution. We present a simple refinement of the “gasket” technique using commonly available materials that helps ensure proper size and positioning of the gasket by applying stress on a suture attached on the center of the gasket implant. Materials and Methods: We report a case of massive CSF leak following endonasal transsphenoidal surgery for pitui- tary macroadenoma. The skull base was reconstructed in a multi-layered fashion with fascia lata and bony buttress reinforced with a vascularized nasoseptal flap. In order to avoid implant slippage from too-small size or malpositioning, we performed a “stress test” using traction applied to a suture attached to the center of the implant (Medpor?), which allowed us to confirm intraoperatively that the buttress was positioned securely. Results: The patient did well without recurrence of CSF leak. At two-year follow-up, there has been no recurrence of CSF leak or occurrence local complica- tions. We have not verified whether bony regrowth into the implant has occurred. Conclusion: The suture-pull refinement of the gasket implant technique is a simple, inexpensive and low risk method to assure secure endocranial positioning over the skull base defect, and may prevent CSF leak resulting from too-small sizing or buttress malpositioning.
文摘Introduction: The exact pathophysiology of spontaneous CSF rhinorrhea is not always understood in some patients. Idiopathic intracranial hypertension (IIH) is now recognized as one of the causes of spontaneous CSF leak in the neurosurgical and ENT literature. Our aim was to set a management protocol for such cases according to the same setting intracranial tension (ICT). Methods: We prospectively managed patients with spontaneous CSF rhinorrhea who were admitted to our hospital between 1st of January 2014 and 31st of December 2017 with a prespecified treatment algorithm. Patients with a history of previous cranial or nasal surgery, trauma, skull base congenital malformations were excluded from the study. The patient’s demographics, clinical data, comorbidities, body mass index (BMI), first time or recurrent leakage and duration of the leak were collected. Results: 41 patients, 35 females and 6 males, presented with spontaneous CSF rhinorrhea with a mean BMI of 38 ± 4.16 Kg/m2. The mean pre-operative ICT manometry was 17.2 ± 5.9 cmH2O (range, 10 - 26 cmH2O). 43.9% of the patients were found to have an increased ICT (≥20 cmH2O) and underwent a permanent CSF diversion at the same setting of the endoscopic repair. None of the patients had a recurrence during the follow-up period. Conclusion: The prespecified treatment algorithm with measuring the ICT at the same setting of the endoscopic repair has a better result for control of spontaneous CSF rhinorrhea. This has led to no recurrence and decreased hospital stay.
基金This work was financially supported by the National Key Research and Development Program of China(2016YFC1102000,2016YFC1102003)the National Natural Science Foundation of China(81190131,31370973)+1 种基金the Provincial Key Technology Support Program of Sichuan(2015SZ0026)the‘111’Project of China(B16033).
文摘This work aimed at investigating the possibility and effectiveness of osteoinductive calcium phosphate(CaP)ceramics to close the drilled skull holes and prevent the postoperative cerebrospinal fluid(CSF)leaking in children’s endoscopic neurosurgery.Five children patients(four boys and one girl,3-to 8-years old)underwent the surgery,in which the endoscopic third ventriculostomy(ETV)was operated in four cases of hydrocephalus,and biopsy and ETV were both performed in one case of pineal tumor.The drilled skull holes were filled with the commercial osteoinductive CaP ceramics.The patients were followed up by CT scan at 1,7 days,3 and 6 months postoperatively.All the five cases were successful,and the holes were closed well after filled with the ceramics.The follow-up survey showed that no CSF leaking or rejection reaction was found.The CT scan indicated that the drilled holes began healing at 7 days postoperatively,and a relatively complete healing happened at 6 months postoperatively.The excellent ability of the CaP ceramics to induce bone regeneration was also confirmed by repairing the skull defects in a monkey model.The results of μ-CT and histological analysis showed that a bony structure with irregular array occurred at the defect area,and the newly formed bone volume density reached 65.7%.In conclusion,the osteoinductive CaP ceramics could be an ideal material to treat the drilled skull holes in children’s endoscopic neurosurgery and prevent CSF leaking afterwards.However,further investigation with more cases and longer follow-up was required to evaluate the clinical effect.
