Lucke-Wold Brandon, Mendez Gustavo, Cua David, Akins Paul, Gillham Haley, Ciporen Jeremy
Department of Neurosurgery, West Virginia University School of Medicine, USA.
Department of Radiology, Oregon Health and Science University, USA.
J Neuroinflamm Neurodegener Dis. 2018;2(1). Epub 2018 Mar 30.
High flow orbital apex or middle fossa cerebrospinal fluid (CSF) leaks can be life threatening and complex to repair. These leaks associated with large dural defects are most commonly repaired with an open temporalis muscle patch or free flaps, but these flaps do not always stop the leak.
A 65-year-old patient presented two years after orbital exenteration and radiation for squamous cell carcinoma. He developed multi-organism meningitis and pneumocephalus secondary to a large high-flow orbital apex/middle fossa CSF leak. To repair the leak, a combined endoscopic transorbital/endonasal approach with pedicled nasospetal flap and dermis fat graft was used. We describe the unique endoscopic technique that was used to treat the life threatening high flow orbital apex/middle fossa CSF leak. The technique allowed the use of the transposed pedicled flap, which is an alternative to the free flap in controlling CSF leak. Cisternogram post-operatively and clinical exam confirmed resolution of CSF leak. Although a critically ill patient at admission with a modified Rankin scale (MRS) of 5, he was discharged home on continued IV antibiotic therapy with a MRS of 3. Endoscopic evaluation at three months after treatment showed the effectiveness of the flap and he continued to improve clinically.
This is the first case to describe a combined endoscopic transorbital and endonasal repair of high flow orbital apex/middle fossa CSF leak with a pedicled nasoseptal flap. These techniques can be utilized during initial reconstruction after orbital exenteration or as a salvage flap.
高流量的眶尖或中颅窝脑脊液（CSF）漏可能危及生命且修复复杂。这些与大型硬脑膜缺损相关的漏口最常采用开放颞肌瓣修补或游离皮瓣修复，但这些皮瓣并不总能止住漏液。
一名65岁患者在因鳞状细胞癌行眶内容摘除术及放疗两年后出现症状。他继发于大型高流量眶尖/中颅窝脑脊液漏，发生了多种微生物感染性脑膜炎和气颅。为修复漏口，采用了联合内镜经眶/鼻内入路，带蒂鼻中隔瓣和真皮脂肪移植。我们描述了用于治疗危及生命的高流量眶尖/中颅窝脑脊液漏的独特内镜技术。该技术允许使用转位带蒂皮瓣，这是控制脑脊液漏时游离皮瓣的一种替代方法。术后脑池造影和临床检查证实脑脊液漏已治愈。尽管患者入院时病情危重，改良Rankin量表（MRS）评分为5分，但出院时继续接受静脉抗生素治疗，MRS评分为3分。治疗后三个月的内镜评估显示皮瓣有效，且患者临床症状持续改善。
这是首例描述采用带蒂鼻中隔瓣联合内镜经眶和鼻内修复高流量眶尖/中颅窝脑脊液漏的病例。这些技术可在眶内容摘除术后的初始重建中使用，或作为挽救性皮瓣。
