Tailored Reconstruction of Low- and High-Flow Cerebrospinal Fluid Leaks: A Single-Center, 1-Year Analysis Following 656 Endoscopic Endonasal Surgeries.

BACKGROUND

The endoscopic endonasal approach (EEA) has become a key surgical method for managing midline skull base lesions, offering minimally invasive access with reduced morbidity. One of the most significant complications following EEA is cerebrospinal fluid (CSF) leakage, especially in high-flow cases. Based on over 2 decades of institutional experience with 6221 EEA procedures, this study aims to categorize and evaluate standardized reconstruction strategies based on intraoperative CSF flow rates in order to optimize outcomes and reduce postoperative complications.

METHODS

This retrospective study included 179 patients with intraoperative CSF leaks among 656 EEA surgeries performed in 2024 at a tertiary center. Intraoperative CSF leaks were classified as low- or high-flow, and patients were grouped by reconstruction strategy. Techniques included free mucosal grafts, autologous fat and fascia lata, vascularized nasoseptal flaps, and lumbar drainage (LD) where necessary. Preoperative imaging, surgical details, and postoperative complications were analyzed. Statistical comparisons were performed using appropriate parametric and nonparametric tests.

RESULTS

Intraoperative CSF leakage occurred in 27.2% of cases (n = 179), of which 60.9% were high-flow leaks. Postoperative rhinorrhea developed in 2.1% of all patients and was significantly associated with extended approaches, third ventricular exposure, and high Evans ratio. Free mucosal graft-based reconstructions were effective in low-flow leaks, while complex multilayer closure using nasoseptal flaps and LD reduced complications in high-risk cases. Meningitis occurred in 1.1% of the cohort, rising to 14.3% in patients with postoperative rhinorrhea and 13% in those with LD.

CONCLUSIONS

Tailored reconstruction based on intraoperative CSF flow rate and anatomical risk factors is critical to minimizing postoperative complications following EEA. A structured, risk-based approach can enhance the safety and efficacy of skull base surgery and may serve as a model for standardized reconstruction protocols in endoscopic neurosurgery.