Ito Yuhei, Jinguji Shinya, Sato Taku, Murakami Yuta, Fujii Masazumi, Sakuma Jun, Saito Kiyoshi
Department of Neurosurgery, Fukushima Medical University.
No Shinkei Geka. 2020 Jan;48(1):55-62. doi: 10.11477/mf.1436204134.
Spontaneous cerebrospinal fluid(CSF)rhinorrhea may have multiple leakage sites, and occasionally, may become difficult to manage. A 46-year-old man was admitted to our hospital presenting with bacterial meningitis that occurred after CSF rhinorrhea. The CSF leak had stopped following conservative medical treatment;however, it recurred immediately. The leakage was assumed to be in the left lateral recess of the sphenoid sinus based on the location of fluid accumulation on the CT and MR images and the nasal endoscopic findings. First, we performed an endoscopic endonasal repair of the CSF leakage sites. There were multiple defects in the roof of the sphenoid sinus, including the left lateral sphenoid recess. These bone defects were repaired with abdominal fat;however, this did not stop the CSF leak. Therefore, he underwent a craniotomy and nasal endoscopy, which were performed simultaneously using a galeal flap. The galeal flap was inserted from the middle of the skull base to the sphenoid sinus to cover the bone defects, and the position was adjusted under the guidance of nasal endoscopy. Moreover, intraoperatively, another meningocele with CSF leak was discovered in the cribriform plate and was repaired using abdominal fat. The CSF leak stopped after the second surgery. It is important to be mindful of possible multiple leakage sites when treating cases of idiopathic CSF leakage;moreover, the determination of the leakage sites can be difficult. A repair surgery using a galeal flap is preferable in cases of multiple CSF leakage sites, such as in this case, because it allows for all defects to be covered and repaired simultaneously.
自发性脑脊液鼻漏可能有多个漏口，偶尔会变得难以处理。一名46岁男性因脑脊液鼻漏后发生细菌性脑膜炎入住我院。经保守治疗后脑脊液漏已停止；然而，它立即复发。根据CT和MR图像上积液的位置以及鼻内镜检查结果，推测漏口位于蝶窦左侧隐窝。首先，我们对脑脊液漏口进行了鼻内镜下经鼻修补术。蝶窦顶部存在多个缺损，包括左侧蝶窦隐窝。这些骨缺损用腹部脂肪进行了修复；然而，这并没有止住脑脊液漏。因此，他接受了开颅手术和鼻内镜检查，同时使用帽状腱膜瓣进行操作。帽状腱膜瓣从颅底中部插入至蝶窦以覆盖骨缺损，并在鼻内镜引导下调整位置。此外，术中在筛板发现了另一个伴有脑脊液漏的脑膜膨出，并使用腹部脂肪进行了修复。第二次手术后脑脊液漏停止。在治疗特发性脑脊液漏病例时，注意可能存在多个漏口很重要；此外，确定漏口位置可能会很困难。对于像本例这样存在多个脑脊液漏口的情况，使用帽状腱膜瓣进行修复手术更可取，因为它可以同时覆盖和修复所有缺损。
