11/21. The "yo-yo" technique to prevent cerebrospinal fluid rhinorrhea after anterior clinoidectomy for proximal internal carotid artery aneurysms.OBJECTIVE: Resection of the anterior clinoid process is important for the exposure of aneurysms on clinoidal and supraclinoidal segments of the internal carotid artery. Cerebrospinal fluid (CSF) rhinorrhea can complicate anterior clinoidectomy when the optic strut is pneumatized and its removal communicates the subarachnoid space with the sphenoid sinus. We present a technique for repairing this defect and preventing CSF rhinorrhea. methods: A suture is secured around a strip of temporalis muscle, which is then pushed through the opening in the optic strut completely into the sphenoid sinus. The ends of suture that trail the muscle are used to retract the muscle from the sphenoid sinus back into the optic strut. The suture is trimmed and the repair is covered with sealant or fibrin glue. RESULTS: During an 8-year period in which 127 patients with proximal internal carotid artery aneurysms that required anterior clinoidectomy were treated, pneumatized optic struts were encountered in 14 patients (11%). Four patients were treated with the "yo-yo" technique, none of whom experienced CSF rhinorrhea. Before using this technique, 10 patients were managed with standard packing techniques (wax, muscle, and gel foam) and four of these patients subsequently experienced CSF rhinorrhea (40%). In these four patients, all required reoperation with either craniotomy and packing with pericranium (one patient), Couldwell-Luc procedure (one patient), or endoscopic transnasal obliteration of the sphenoid sinus with fat (two patients). CONCLUSION: The "yo-yo" technique of tightly wedging a muscle plug into the optic strut proved to be simple, fast, and effective, preventing CSF rhinorrhea in all patients in whom it was applied. Although experience with this technique is limited, reversing the direction of packing and pulling muscle from the sphenoid sinus into the optic strut eliminated a complication that occurred in 40% of patients with standard packing techniques.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
12/21. Spontaneous cerebrospinal fluid rhinorrhea in untreated macroprolactinoma--an indication for primary surgical therapy.BACKGROUND: Medical therapy is usually indicated as first-line treatment for prolactinomas. Surgery is generally reserved as second-line therapy if prolactinomas are non-responsive to dopamine agonists (DA) or DA therapy is not tolerated. Herein, we draw attention to the rare occurrence of spontaneous CSF rhinorrhea in prolactinomas requiring primary surgical therapy. Only 8 cases of confirmed prolactinomas with spontaneous rhinorrhea have been reported in the literature so far. case reports: Two out of 267 surgical cases with pituitary adenomas presented with spontaneous rhinorrhea. Both patients harbored invasive prolactinomas. In both cases, the defect was exposed using a transsphenoidal procedure and was sealed with fascia lata. RESULTS: Urgent surgical repair of the leak prevented meningitis. In one case, a second operation was required due to recurrent rhinorrhea under postoperative dopamine-agonist therapy of the residual tumor. The clinical course was otherwise uncomplicated. CONCLUSION: Certain clinical settings still require primary surgical therapy of prolactinomas. Spontaneous rhinorrhea caused by invasive macroprolactinomas represents a mandatory indication for initial surgery. Early detection and surgical repair of a CSF leak is crucial for a favorable clinical outcome.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
13/21. The use of fibrin sealant in cerebrospinal fluid leakage.Cerebrospinal fluid leakage is one of the central problems facing neurosurgeons, both due to its occasional difficulty in management and to the catastrophical significance of ensuing infection. An important tool emerging in the surgical management of CSF leakage is fibrin sealant, the natural coagulation product. Thirteen cases of CSF leakage, due to meningomyelocele, posttraumatic, and secondary to tumor, that were managed surgically with fibrin sealant are presented. Several of the cases were successfully operated upon following failure of conventional surgical techniques. Additional uses of fibrin sealant in neurosurgery are discussed.- - - - - - - - - - ranking = 7keywords = seal (Clic here for more details about this article) |
14/21. Management of cerebrospinal fluid otorhinorrhea complicating the retrosigmoid approach to the cerebellopontine angle.The retrosigmoid approach is currently used in the resection of small acoustic schwannomas or the vestibular nerve in selected patients with recurrent vertigo. Cerebrospinal fluid otorhinorrhea associated with the approach is often due to a failure to completely obliterate exposed air cells of the posteromedial and posterosuperior tracts of the temporal bone. A therapeutic protocol for managing a postoperative spinal fluid leak is outlined on the basis of these anatomic features and the status of the patient's hearing. If serviceable hearing has been preserved, the operative site is explored and incompletely obliterated or exposed cells are sealed with bone wax. If a leak persists, or if hearing is lost with the initial procedure, the mastoid cavity and middle ear cleft are obliterated with abdominal fat and the eustachian tube orifice occluded with proplast through a facial recess approach.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
15/21. Transantral repair of cerebrospinal fluid fistulas using bone chips, Tisseel, fascia and plaster of paris.Cerebrospinal rhinorrhea is a potentially serious symptom due to the risk of an ascending infection, which may produce a fulminant meningitis. Plaster of paris has been used to obliterate the sphenoidal sinus and posterior ethmoids in five patients with cerebrospinal rhinorrhea. The fistulas were identified by computed cisternography and repaired by a transantral approach using a microsurgical technique, and bone chips, Tisseel and fascia to seal the fistulas. There have been no postoperative problems or leakage in the three patients with fistulas to the sphenoidal sinus. The cerebrospinal rhinorrhea recurred four and six months after operation in the two patients with fistulas to the posterior ethmoids probably due to surgical, technical problems in one patient and to less support by the plaster of paris, when the fistulas end in this region. However, the described surgical technique seems to be a good alternative for fistulas to the sphenoidal sinus and should be included in our surgical armamentarium.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
16/21. A simple procedure for management of spontaneous cerebrospinal fluid rhinorrhea by injection of fibrin sealant. Technical note.A simple and safe procedure is proposed to manage cases of "empty sella" complicated by rhinorrhea. It is performed under fluoroscopic control only by introducing a needle in the sphenoid sinus via a transnasal route and by injecting fibrin glue into the sinusal cavity. This procedure requires a short hospitalization and it allows to avoid the compliances of other techniques.- - - - - - - - - - ranking = 4keywords = seal (Clic here for more details about this article) |
17/21. Intramastoid packing for CSF rhinorrhea following acoustic neurinoma removal.A case is presented of cerebrospinal fluid rhinorrhea following operation on an acoustic neurinoma by suboccipital transmeatal approach. The rhinorrhea was cured by sealing the mastoid air cells with muscle pieces. Possible route of CSF rhinorrhea and significance of its treatment are discussed.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
18/21. Cyanoacrylate adhesive used to stop CSF leaks during orbital surgery.Butyl-2-cyanoacrylate (Histoacryl Blue) tissue adhesive successfully sealed three cases of CSF leaks encountered during orbital surgery. The application of tissue adhesive was followed by prompt cessation of leak. We have found this tissue adhesive to be a valuable technical adjunct in the intraoperative management of this difficult problem and have not seen any general or local toxic reaction to the material.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
19/21. Severe cochlear dysplasia causing recurrent meningitis: a surgical lesson.meningitis may be the sole presenting sign of a cerebrospinal fluid (CSF) fistula of the temporal bone. An eight-year-old boy suffering from recurrent meningitis was found to have bilateral severe cochlear dysplasia. Bilateral tympanotomies were performed, planning to obliterate each vestibule. In the right ear a stapedectomy was performed, resulting in a torrential 'CSF gusher' and difficulty in packing the vestibule. CSF rhinorrhoea requiring revision surgery and two episodes of gram-negative bacterial meningitis complicated the post-operative management, resulting in a prolonged hospital stay. Subsequently, the left ear was managed in a different fashion, leaving the stapes in situ, with grafts placed to seal the oval window niche. We would recommend this alternative procedure in cases of severe cochlear dysplasia, where abnormalities of the vestibule and basal turn of the cochlea mean that performing a stapedectomy to pack the vestibule may result in a severe 'CSF gusher', by opening directly into the subarachnoid space.- - - - - - - - - - ranking = 1keywords = seal (Clic here for more details about this article) |
20/21. meningitis after cochlear implantation in Mondini malformation.Although the potential for CSF leakage and subsequent meningitis after cochlear implantation in the malformed cochlea has been recognized, this complication has not been previously reported. We report a case of CSF otorhinorrhea and meningitis after minor head trauma developing 2 years after cochlear implantation in a child with Mondini malformation. Leakage of CSF was identified from the cochleostomy around the electrode of the implant, and this leak was sealed with a temporalis fascia and muscle plug. Although this complication appears to be rare, care must be taken to seal the cochleostomy in children with inner ear malformations at the initial surgery, and any episode of meningitis after surgery must be thoroughly investigated to rule out CSF leakage from the labyrinth.- - - - - - - - - - ranking = 2keywords = seal (Clic here for more details about this article) |
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