Abstract
F. Esposito; J.R. Dusick; N. Fatemi; D.F.
Kelly
Objective
A graded approach to
cerebrospinal fluid (CSF) leak repair after transsphenoidal surgery is
presented.
Methods
Patients undergoing
endonasal tumor removal during an 8-year period were reviewed. Intraoperative
CSF leaks were classified as Grade 0, no leak observed; Grade 1, small leak
without obvious diaphragmatic defect; Grade 2, moderate leak; or Grade 3, large
diaphragmatic/dural defect. Cranial base repair was tailored to the leak grade
as Grade 0, collagen sponge; Grade 1, two-layered collagen sponge repair with
intrasellar titanium mesh buttress; Grade 2, intrasellar and sphenoid sinus fat
grafts with collagen sponge overlay and titanium buttress; and Grade 3, same as
Grade 2 with CSF diversion in most cases. A provocative tilt test was performed
before patient discharge to assess the integrity of the CSF leak repair.
Protocol modifications adopted in 2003 included an intrasellar fat graft in
Grade 1 leaks with a large intrasellar dead space, frequent use of BioGlue
(CryoLife, Inc., Atlanta, GA) in Grade 1, 2, and 3 leaks, and CSF
diversion for all Grade 3 leaks.
Results
Among 668 cases in
620 patients (475 pituitary adenomas and 145 other lesions), an intraoperative
CSF leak was observed in 57% of the cases: 32.5% Grade 1, 15% Grade 2, and 8.7%
Grade 3. Postoperative repair failures occurred in 17 cases (2.5%), including
0.7, 3, 1, and 12% of Grade 0, 1, 2, and 3 CSF leaks, respectively. Bacterial
meningitis occurred in three patients (0.45%). After protocol modifications in
2003, repair failures decreased from 4 to 1.2% (P = 0.02).
Conclusion
A graded repair approach
to CSF leaks in transsphenoidal surgery avoids tissue grafts and CSF diversion
in more than 60% of patients. Protocol modifications adopted in the last 340
cases have reduced the failure rate to 1% overall and 7% for Grade 3 leaks.
Provocative tilt testing before patient discharge is helpful in the timely
diagnosis of postoperative CSF leaks.