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Transorbital and transfrontal approaches to cerebrospinal fluid leak repair

Introduction Surgical repair of cerebrospinal fluid (CSF) leaks can be considered broadly in two categories: open field (e.g., frontal craniotomy or subcranial) and endoscopic (e.g., endoscopic transnasal). Open approaches provide the advantage of wide surgical exposure that allows ease of instrumentation and ample access to reconstructive options such as a pericranial flap. The disadvantage of these approaches is the collateral damage created in accessing the surgical…

Endoscopic reconstruction of posterior cranial fossa defects

Introduction The effectiveness of any endoscopic surgical procedure on the posterior skull base also relies on the ability to repair the resulting defect, which has been a major challenge over the past decade. The overall goals of reconstruction after endoscopic expanded approaches include separation of the cranial cavity from the sinonasal tract, protection of neurovascular structures, preservation or restoration of cosmesis, preservation or rehabilitation of function,…

Endoscopic reconstruction of middle cranial fossa defects

Introduction The most common locations for skull base defects of the middle cranial fossa (MCF) are the lateral sphenoid sinus or the thin tegmen of the temporal bone. Defects in the MCF skull base allow a direct communication between the intracranial compartment and sinonasal cavity or middle ear ( Fig. 34.1 ). This conduit not only allows intracranial contents, cerebrospinal fluid (CSF), or the herniation of…

Endoscopic reconstruction of anterior cranial fossa defects

Introduction The treatment of anterior skull base neoplasms has successfully evolved over the past few decades. Conventional approaches often employ open techniques involving transfacial dissection with or without frontal, bifrontal, pterional, or orbitozygomatic craniotomies. This may allow for en bloc resection of tumors at the expense of large cranial and possible dural defects necessitating reconstruction with regional tissue such as the pericranial or temporoparietal fascial (TPF)…

Reconstruction after transtuberculum and transplanum approaches to suprasellar pathology

Introduction Endoscopic reconstruction following transtuberculum and transplanum approaches to suprasellar pathology is an area of ongoing evolution. The cornerstones of endoscopic repair remain similar to open surgical approaches with the aims of reestablishing separation of the cranial vault and sinonasal cavity and preventing postoperative cerebrospinal fluid (CSF) leak. Since the inception of endoscopic endonasal approaches (EEAs) to intracranial pathology, anterior skull base reconstruction has continued to…

Sellar reconstruction after pituitary adenoma resection

Introduction Pituitary adenomas are the most common brain tumors, with a prevalence of 10% to 15% of all intracranial tumors. Pituitary adenomas can present as hormonally active tumors with autonomous hormone secretion or, more commonly, as nonfunctioning lesions with symptoms related to mass effect. The most common presenting symptoms include headaches, visual changes related to suprasellar extension toward the optic chiasm, and cranial nerve (CN) deficits…

Locoregional pedicled flap options for skull base reconstruction

Introduction Since the advent of endoscopic sinonasal surgery, we have continued to see rapid growth and expansion of endoscopic techniques used for a variety of other indications. We first began to see this demonstrated after comparing traditional transcranial approaches versus novel endoscopic approaches for repair of anterior cranial fossa cerebrospinal fluid (CSF) leaks. Certainly, when novel technology and operative techniques for addressing an underlying problem arise,…

The nasoseptal flap: The workhorse for skull base reconstruction

Introduction As endoscopic skull base surgery has evolved, the nasoseptal flap (NSF) has become the preferred vascular flap for the reconstruction of skull base defects. Similar to external approaches, the objectives of skull base reconstruction are to separate the sinonasal cavity from the sterile cranial cavity, to achieve a watertight closure of the dural defect, and to obliterate any dead space. After its seminal description by…

Decision making in endoscopic skull base reconstruction: A graduated approach

Introduction The three phases of any surgery are (1) surgical exposure (approach), (2) eradication of pathology, and (3) reconstruction. Although each phase may be performed sequentially by the same or different surgeons, they are interdependent, and the impact of each phase on the others needs to be considered as part of preoperative planning. One of the greatest challenges of endoscopic endonasal surgery (EES) of the skull…

Radiologic evaluation of skull base masses

Introduction Computed tomography (CT) and magnetic resonance imaging (MRI) play complementary roles in the pre- and postoperative evaluation of the various neoplasms that occur at the skull base. Typically, both imaging modalities are obtained in the diagnostic workup and treatment planning of skull base lesions. , Although CT provides excellent osseous detail with respect to the effect of the mass on adjacent bony structures, MRI gives…

Clinical evaluation of patients with skull base malignancies

Introduction Sinonasal malignancies are rare with annual incidence rates near 1 per 100,000 in most industrialized countries and represent fewer than 4% of neoplasms arising in the head and neck. , The most common malignant tumors of the anterior skull base derive from the paranasal sinuses or nasal cavity. Although squamous cell carcinoma (SCC) represents the most common type of malignant sinonasal tumor, there are a…

Clinical evaluation of the sellar mass patient

Introduction Sellar lesions are common and encompass a wide variety of pituitary and parasellar region pathologies. Broadly speaking, they can be categorized as neoplastic, congenital, inflammatory, infectious, and vascular causes with tumors being the most common sellar mass. In a recent US population-based report, tumors of the sellar region were the second most common central nervous system tumor with an incidence of 4.55 per 100,000 population.…

Postoperative management after cerebrospinal fluid leak repair in patients with idiopathic intracranial hypertension

Conflicts of Interest Bradford A. Woodworth is a consultant for Smith and Nephew, Medtronic, and Cook Medical. Richard J Harvey is a consultant with Medtronic, Olympus, and NeilMed Pharmaceuticals. He has received research grant funding from Meda Pharmaceuticals and Stallergenes. He has been on the speakers’ bureau for BHR, Seqiris, Astra Zeneca, and Glaxo-Smith-Kline and ArthroCare. Introduction Spontaneous cerebrospinal fluid (CSF) leak is an uncommon clinical…

Surgical management of spontaneous cerebrospinal fluid rhinorrhea arising from clival defects

Introduction Although cerebrospinal fluid (CSF) rhinorrhea has been recognized for centuries, spontaneous CSF rhinorrhea was first described by St. Clair Thomson as a distinct subgroup in 1899. Spontaneous CSF rhinorrhea is rare, representing only 3% to 4% of all cases. Head trauma accounts for 80% of cases, and the remaining 16% are iatrogenic in origin. Common sites of spontaneous CSF rhinorrhea include the cribriform plate, sella,…

Surgical management of lateral sphenoid recess meningoencephaloceles and cerebrospinal fluid leaks

Introduction Over the past 3 decades, the management of cerebrospinal fluid (CSF) leaks from the anterior and middle cranial fossa has changed dramatically. One reason is the robust expansion of endonasal endoscopic surgery for approach and management of these issues, shifting the paradigm of management from open to minimally invasive endoscopic techniques. One traditionally difficult area to address is the lateral recess of the sphenoid sinus…

Surgical management of spontaneous cerebrospinal fluid leak of the cribriform plate

Introduction The endoscopic endonasal approach for reconstruction of spontaneous anterior skull base defects provides a minimally invasive and equally effective outcome compared with open approaches. , Using endoscopic magnification, small defects or leaks can be identified and appropriately repaired while avoiding the morbidity associated with traditional skull base reconstruction using an open craniotomy approach. Additionally, intraoperative and postoperative adjunctive measures such as lumbar drainage and acetazolamide…

Evaluation and management of congenital skull base defects

Introduction Congenital skull base defects and resultant meningoencephaloceles can occur anywhere along the bony skull base. Defects of the anterior cranial fossa can result in herniation of intracranial contents, with or without a cerebrospinal leak (CSF), into the nasal cavity and paranasal sinuses. Such herniation pockets can be classified as meningoceles, including meninges only; encephaloceles, including meninges and brain tissue; or encephalocystoceles, which involve meninges and…

Radiologic findings in idiopathic intracranial hypertension

Disclosures Jessica W. Grayson has served on an advisory board for Glaxo-Smith-Kline. Bradford A. Woodworth serves as a consultant for Cook Medical, Smith and Nephew, and Medtronic Introduction Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri and benign intracranial hypertension, is characterized by elevated intracranial pressure (ICP) without a known etiology. The Modified Dandy Criteria, updated in 2002, defined IIH as (1) symptoms of generalized…

Ophthalmologic evaluation of idiopathic intracranial hypertension

Introduction The term idiopathic intracranial hypertension (IIH) was first introduced by Corbett and Thompson in the late 1980s, nearly 100 years after the disease was first identified. By definition, IIH refers to intracranial hypertension in the absence of all secondary causes, including intracranial or spinal neoplasms and non-neoplastic causes such as trauma, intracerebral thrombosis or vascular malformations, infections, or medications. Although the pathogenesis of IIH remains…

Surgical management of refractory idiopathic intracranial hypertension

Introduction Idiopathic intracranial hypertension (IIH) is a disorder characterized by symptoms secondary to increased intracranial pressure (ICP) with no clear identifiable cause. It is therefore a diagnosis of exclusion and necessitates the exclusion of differential diagnoses of increased ICP (i.e., intracranial mass, blockage of the ventricular system, blockage of cerebrospinal fluid [CSF] absorption, communicating hydrocephalus, obstruction of venous outflow, diffuse cerebral edema, and increased CSF secretion).…