Document Detail

Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery.
MedLine Citation:
PMID:  17415166     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: A graded approach to cerebrospinal fluid (CSF) leak repair after transsphenoidal surgery is presented. METHODS: Patients undergoing endonasal tumor removal during an 8-year period were reviewed. Intraoperative CSF leaks were classified as Grade 0, no leak observed; Grade 1, small leak without obvious diaphragmatic defect; Grade 2, moderate leak; or Grade 3, large diaphragmatic/dural defect. Cranial base repair was tailored to the leak grade as Grade 0, collagen sponge; Grade 1, two-layered collagen sponge repair with intrasellar titanium mesh buttress; Grade 2, intrasellar and sphenoid sinus fat grafts with collagen sponge overlay and titanium buttress; and Grade 3, same as Grade 2 with CSF diversion in most cases. A provocative tilt test was performed before patient discharge to assess the integrity of the CSF leak repair. Protocol modifications adopted in 2003 included an intrasellar fat graft in Grade 1 leaks with a large intrasellar dead space, frequent use of BioGlue (CryoLife, Inc., Atlanta, GA) in Grade 1, 2, and 3 leaks, and CSF diversion for all Grade 3 leaks. RESULTS: Among 668 cases in 620 patients (475 pituitary adenomas and 145 other lesions), an intraoperative CSF leak was observed in 57% of the cases: 32.5% Grade 1, 15% Grade 2, and 8.7% Grade 3. Postoperative repair failures occurred in 17 cases (2.5%), including 0.7, 3, 1, and 12% of Grade 0, 1, 2, and 3 CSF leaks, respectively. Bacterial meningitis occurred in three patients (0.45%). After protocol modifications in 2003, repair failures decreased from 4 to 1.2% (P = 0.02). CONCLUSION: A graded repair approach to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion in more than 60% of patients. Protocol modifications adopted in the last 340 cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks. Provocative tilt testing before patient discharge is helpful in the timely diagnosis of postoperative CSF leaks.
Felice Esposito; Joshua R Dusick; Nasrin Fatemi; Daniel F Kelly
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Neurosurgery     Volume:  60     ISSN:  1524-4040     ISO Abbreviation:  Neurosurgery     Publication Date:  2007 Apr 
Date Detail:
Created Date:  2007-04-06     Completed Date:  2007-04-23     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  7802914     Medline TA:  Neurosurgery     Country:  United States    
Other Details:
Languages:  eng     Pagination:  295-303; discussion 303-4     Citation Subset:  IM    
Division of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA.
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MeSH Terms
Aged, 80 and over
Anti-Bacterial Agents / therapeutic use
Brain Neoplasms / surgery*
Cerebrospinal Fluid Rhinorrhea / diagnosis,  surgery*
Child, Preschool
Intraoperative Complications / etiology,  surgery*
Medical Illustration
Meningitis / diagnosis,  drug therapy,  etiology
Middle Aged
Neurosurgical Procedures* / adverse effects
Postoperative Complications / etiology,  surgery*
Prostheses and Implants / adverse effects
Retrospective Studies
Skull Base / surgery*
Tilt-Table Test
Titanium / adverse effects
Treatment Outcome
Reg. No./Substance:
0/Anti-Bacterial Agents; 7440-32-6/Titanium

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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