Cases reported • Cerebrospinal Fluid Rhinorrhea; Cerebrospinal Rhinorrhea

1/16. Delayed postoperative CSF rhinorrhea of intrasellar arachnoid cyst.

CSF rhinorrhea due to a transsphenoidal approach usually follows accidental or intentional arachnoid opening. We report a patient with an intrasellar arachnoid cyst, who developed delayed onset of CSF rhinorrhea. A sixty-two-year-old man presented with bitemporal type visual field defect for the last 3 years. With the diagnosis of arachnoid cyst or Rathke's cleft cyst, based on MRI findings of intra-and supra-sellar cyst with CSF intensity, he successfully underwent transsphenoidal surgery without evidence of intra-operative CSF leakage. He developed CSF rhinorrhea one week later. This needed another operation for sellar floor repair. The pathomechanism of this delayed onset is explained as follows. Incomplete or oneway communication of subarachnoid space to cyst cavity, unrecognized during surgery, might cause delayed onset of CSF rhinorrhea. By using MRI, identification of the residual gland, which was compressed posteriorly, is useful for differentiating an arachnoid cyst from other cystic lesions. In highly suspect cases, even without evidence of intra-operative CSF leakage, peri-operative measures to prevent occurrence of postoperative CSF rhinorrhea are required.

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2/16. Chronic hydrocephalus and suprasellar arachnoid cyst presenting with rhinorrhea.

Spontaneous CSF leak with rhinorrhea may be secondary to many intracranial congenital and acquired conditions. However, no cases of chronic hydrocephalus and suprasellar arachnoid cyst presenting with rhinorrhea as the unique clinical manifestation are reported in the literature. A 29-year-old-man with four-month history of episodic rhinorrhea had a large suprasellar arachnoid cyst with chronic hydrocephalus on magnetic resonance. Endoscopic ventricular fenestration of the cyst failed to obtain remission of the CSF leak, because it was not possible to fenestrate the cyst with the almost completely obliterated suprasellar cistern. Clinical remission occurred after restoration of the CSF flow from the cyst to the cisternal spaces by a direct approach. The CSF leak in this case was secondary to the chronic compression over the dural and bone structures of the sellar region by the cyst or chronic hydrocephalus.

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3/16. Successful closure of recurrent traumatic csf rhinorrhea using the free rectus abdominis muscle flap.

BACKGROUND: We present two patients in whom a free rectus abdominis muscle flap was used to close recurrent traumatic CSF rhinorrhea. CASE DESCRIPTION: CT scan of both patients showed frontal lobe atrophy and porencephaly after contusional hematoma. In the first patient, because the site of CSF leakage was not identified and the patient underwent three unsuccessful attempts to close the fistula using the fascia lata, we treated the patient by unifying all paranasal sinuses and by filling them with a free rectus abdominis muscle flap. In the second patient, CSF rhinorrhea recurred 6 years after closure of the fistula using the fascia lata. The patient underwent separation of a porencephalic cyst from the paranasal sinus and a free muscle flap was placed extradurally, because the CSF pulse pressure in the enlarged left anterior horn eroded the previously repaired fascia lata, resulting in the recurrence of CSF leakage. CONCLUSION: Although duraplasty is the primary procedure for repairing dural fistulas, the vascularized free muscle flap is an alternative method when the location of the fistula is not identified or the patient with recurrent CSF rhinorrhea has severe frontal lobe atrophy and porencephaly.

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4/16. Endonasal endoscopic treatment of parasellar arachnoid cyst: report of a case.

A 40-year-old man presented with intractable headache of 5-year duration and a 1-month history of intermittent cerebrospinal fluid (CSF) rhinorrhea. magnetic resonance imaging showed a cystic lesion with signal characteristics similar to that of CSF. The patient underwent endonasal endoscopic surgery of the sphenoid sinus and the fistula was reinforced with facia, muscle cartilage, and posterior septal flap while performing cystocisternostomy. The postoperative course was uneventfiul CSF leakage stopped, and headache improved. Postoperative imaging revealed total collapse of the cyst cavity. Based on our findings, endonasal endoscopic treatment of the sellar and parasellar arachnoid cysts, if presenting into the sphenoid sinus, could be an acceptable minimally invasive alternative to the conventional modalities.

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5/16. Arachnoid cyst of the fallopian canal: a surgical challenge.

OBJECTIVE: Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are exceedingly rare, with only 6 reports appearing in the world literature. We report a seventh case that is unique in that it involves an arachnoid cyst of the fallopian canal and an associated facial nerve palsy. STUDY DESIGN: Case report. SETTING: International tertiary care referral center. CONCLUSION: CSF otorhinorrhea associated with a facial nerve palsy may be indicative of an arachnoid cyst of the fallopian canal. These fistula are extremely rare. Surgical management involves sealing the fistula while preserving facial nerve function and is extremely challenging.

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6/16. Shunt migration into the sphenoid sinus: case report.

OBJECTIVE AND IMPORTANCE: Shunt catheter migration is a potential complication of cerebrospinal fluid shunting procedures. We report an unusual case of proximal shunt migration into the sphenoid sinus. To our knowledge, there have been no previous reports of shunt migration through the bony structures of the cranial base. CLINICAL PRESENTATION: A 41-year-old man who had had a cyst-to-peritoneum shunt placed 21 years earlier for a temporal lobe arachnoid cyst presented with cerebrospinal fluid rhinorrhea. Neuroradiological imaging revealed migration of the shunt catheter through the medial wall of the middle temporal fossa into the sphenoid sinus. INTERVENTION: The patient underwent shunt removal and repair of the dural defect. Intraoperatively, the proximal catheter tip was found in the sphenoid sinus with dural and bony erosion. The patient made an uneventful recovery. CONCLUSION: We present a unique long-term complication associated with intracranial shunt catheters. We hypothesize that excessive proximal catheter length and chronic cerebrospinal fluid pulsations contributed to migration of the catheter into the sphenoid sinus.

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7/16. Repair of intractable cerebrospinal fluid rhinorrhea with mucosal flaps and recombinant human basic fibroblast growth factor: technical case report.

OBJECTIVE AND IMPORTANCE: Repair of a cerebrospinal fluid leak is not always easy, especially when a large fistula, with concomitant infection and injured mucosa, has developed from repeated transsphenoidal operations. We repaired such a sellar floor defect with mucosal flaps via the endonasal endoscopic approach and finally obliterated the fistula by promoting granulation-like tissue formation with recombinant human basic fibroblast growth factor (bFGF). CLINICAL PRESENTATION: A 27-year-old woman with intractable cerebrospinal fluid rhinorrhea was referred to our department after repeated operations for a relapsing Rathke's cleft cyst. Endonasal endoscopic examination revealed a large bone defect on the sellar floor through which previously packed fat and fascia were exposed to the nasal cavity. INTERVENTION: Mucosal flaps were harvested endoscopically from the nasal septum and the superior and middle turbinates. These pedicled flaps were transposed to the sellar defect. The flaps survived but did not cover the whole area, resulting in gaps between the flaps through which cerebrospinal fluid still leaked. Recombinant bFGF was repeatedly applied endoscopically to the mucosal flaps. The flaps turned into granulation-like tissue, and complete mucosal covering was finally achieved. CONCLUSION: bFGF has a wide range of biological effects, including stimulation of fibroblast growth and promotion of angiogenesis. It accelerates wound healing and is used clinically to treat dermal ulcers. The method presented here to treat an intractable fistula with mucosal flap and recombinant bFGF may suggest a new clinical application of bFGF. This possibility should be examined in a large number of patients in the future.

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8/16. Cerebrospinal fluid leakage during dacryocystorhinostomy in a patient with meningoencephalocele.

PURPOSE: To report a rare case of cerebrospinal fluid leakage during dacryocystorhinostomy in a patient with mobius syndrome and meningoencephalocele and to explain our experience in the management of this complication. methods: A 9-year-old girl with a history of surgically repaired fronto-ethmoidal meningoencephalocele and bilateral canthopexy was diagnosed with mobius syndrome and underwent sequential bilateral dacryocystorhinostomy and silicone intubation because of dysgenesis of the lacrimal drainage pathway. RESULTS: Both dacryocystorhinostomies resulted in cerebrospinal fluid leakage, which spontaneously ceased with conservative management. CONCLUSIONS: dacryocystorhinostomy surgery in patients with a history of trauma or surgery or congenital defects around the base of the nose or lacrimal system may rarely result in cerebrospinal fluid leakage; thus an ophthalmologist should be familiar with its management.

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9/16. Cerebrospinal fluid rhinorrhoea associated with colloid cyst.

Three cases of non-traumatic cerebrospinal fluid (CSF) rhinorrhoea secondary to colloid cysts are presented. Non-traumatic CSF rhinorrhoea is rare and in only two previous reports has it been attributed to a colloid cyst.

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10/16. Lesions of Rathke's duct: another indication for the infratemporal fossa approach.

Rathke's duct is a midline structure, arising from the primitive stomodeum and extending upward to the hypophysis. The duct, which normally involutes in utero, may persist on occasion. This most frequently results in intracranial disease. Occasionally, disease may become manifest in the extracranial skull base. We present three such cases: cystic craniopharyngioma, Rathke's cleft cyst, and a persistent cerebrospinal fluid rhinorrhea caused by a patent craniopharyngeal canal. Each lesion involved the clivus and the parasphenoid region. Surgical management of such lesions requires not only extirpation of disease, but also the ability to recognize and preserve the many important regional structures. The procedure that best allows for the wide exposure necessary to accomplish these goals is the infratemporal fossa approach to the lateral skull base.

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