Torres-Bayona Sergio, Velasquez Nathalia, Nakassa Ana, Eguiluz-Melendez Aldo, Hernandez Vanessa, Vega Belen, Borghei-Razavi Hamid, Miranda-Acosta Yeiris, Wang Eric W, Snyderman Carl H, Gardner Paul A
Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States.
Department of Neurosurgery, Instituto Neurológico, Hospital Internacional de Colombia, Bucaramanga, Colombia.
J Neurol Surg B Skull Base. 2021 May 17;83(Suppl 2):e318-e323. doi: 10.1055/s-0041-1729904. eCollection 2022 Jun.
High-flow skull base dural defects are associated with an increased risk of postoperative cerebrospinal fluid (CSF) leaks. This study aimed to identify the risk factors for persistent postoperative CSF leak after endoscopic endonasal surgery (EES) and determine the ideal reconstruction strategy after initial failed repair. Patients with CSF leak after intradural EES between October 2000 and February 2017 were identified. Cases with persistent CSF leak were compared with patients with similar pathologic diagnosis without a persistent leak to identify additional risk factors. Two hundred and twenty-three out of 3,232 patients developed postoperative CSF leak. Persistent leaks requiring more than one postoperative repair occurred in 7/223 patients (3.1%). All seven had undergone intradural approach to the posterior fossa for resection of recurrent/residual clival chordomas. This group was matched with 25 patients with recurrent/residual clival chordoma who underwent EES without postoperative CSF leak (control group). Age, gender, history of diabetes, smoking, or radiotherapy were not statistically different between the groups. Obesity (body mass index > 30) was significantly more common in the group with persistent leak (86%) compared with controls (36%) ( = 0.02). All patients with a persistent CSF leak developed meningitis ( = 0.001). Five patients with persistent leak required a pericranial flap to achieve definitive repair. Multiple recurrent CSF leak after EES primarily occurs following resection of recurrent/residual posterior fossa chordoma. Obesity is a major risk factor and meningitis is universal with persistent leak. Flap necrosis may play a role in the development of persistent CSF leaks, and the use of secondary vascularized flaps, specifically extracranial-pericranial flaps, should be considered as an early rescue option in obese patients.
高流量颅底硬脑膜缺损与术后脑脊液（CSF）漏的风险增加相关。本研究旨在确定鼻内镜手术（EES）后持续性术后脑脊液漏的危险因素，并确定初次修复失败后的理想重建策略。确定了2000年10月至2017年2月间硬膜内EES术后发生脑脊液漏的患者。将持续性脑脊液漏的病例与病理诊断相似但无持续性漏液的患者进行比较，以确定其他危险因素。3232例患者中有223例发生术后脑脊液漏。7/223例患者（3.1%）发生了需要术后多次修复的持续性漏液。所有7例均采用经硬膜入路至后颅窝切除复发性/残留斜坡脊索瘤。该组与25例接受EES且术后无脑脊液漏的复发性/残留斜坡脊索瘤患者（对照组）进行匹配。两组之间的年龄、性别、糖尿病史、吸烟史或放疗史无统计学差异。与对照组（36%）相比，持续性漏液组肥胖（体重指数>30）更为常见（86%）（P=0.02）。所有持续性脑脊液漏患者均发生脑膜炎（P=0.001）。5例持续性漏液患者需要采用颅骨膜瓣才能实现最终修复。EES术后多次复发性脑脊液漏主要发生在复发性/残留后颅窝脊索瘤切除术后。肥胖是主要危险因素，持续性漏液患者普遍发生脑膜炎。皮瓣坏死可能在持续性脑脊液漏的发生中起作用，对于肥胖患者，应考虑使用二次带血管皮瓣，特别是颅外-颅骨膜瓣作为早期挽救选择。
