Supraorbital Keyhole Approach to the Skull Base: Evaluation of Complications Related to CSF Fistulas and Opened Frontal Sinus

Abstract

Aim Cerebrospinal fluid (CSF) rhinorrhea due to a breach in the frontal sinus (FS) presents one of the main postoperative complications of the supraorbital keyhole approach. The goal of this study was to further analyze the actual surgical morbidity and potential risk for patients due to an opened FS after a surgery via a supraorbital craniotomy and compare the results with data published in the current literature.

Methods and Patients A total of 350 consecutive patients who underwent surgeries via the supraorbital keyhole approach for various lesions were included in this retrospective study. Information on clinical history, neurologic symptoms, surgical approach, and postoperative complications was obtained retrospectively by a review of the patients' charts, the radiologic reports, and a thorough review of pre- and postoperative cranial computed tomography (CCT) imaging.

Results The frequency of CSF rhinorrhea after this type of craniotomy in the literature is reported to range between 0% and 9.1%. In this study, analysis of postoperative CCT scans revealed that 88 patients (25.1%) showed a radiographic breach of the FS. Only 8 of these patients (2.3%) developed a CSF leak with rhinorrhea postoperatively. In all cases conservative treatment with lumbar drainage failed, and therefore a surgical revision for permanent closure was required. Only one patient (0.3%) with a CSF leak also developed meningitis.

Conclusion Inadvertent opening of the FS during the supraorbital craniotomy is a common surgery-related morbidity; however, the risk for the patient to develop a potentially dangerous meningitis was found to be minimal.

Keywords

supraorbital keyhole approach - cerebrospinal fluid leak - meningitis

• References

• 1 Paiva-Neto MA, Tella Jr OI. Supra-orbital keyhole removal of anterior fossa and parasellar meningiomas. Arq Neuropsiquiatr 2010; 68 (3) 418-423
• 2 Ormond DR, Hadjipanayis CG. The supraorbital keyhole craniotomy through an eyebrow incision: its origins and evolution. Minim Invasive Surg 2013; 2013: 296469
• 3 Fernandes YB, Maitrot D, Kehrli P, Tella Jr OI, Ramina R, Borges G. Supraorbital eyebrow approach to skull base lesions. Arq Neuropsiquiatr 2002; 60 (2-A): 246-250
• 4 Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision. Neurosurgery 2005; 57 (4, Suppl): 242-255 ; discussion 242–255
• 5 van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg Neurol 1998; 49 (5) 481-489 ; discussion 489–490
• 6 Perneczky A, Reisch R, Kanno T, Kindel S. Concept and Surgical Technique. Vienna, Austria: Springer; 2008. . Keyhole Approaches in Neurosurgery; vol 1
• 7 Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole craniotomy. Surg Neurol 2003; 59 (3) 223-227
• 8 Perneczky A. Keyhole Concept in Neurosurgery: With Endoscopic-Assisted Microsurgery and Case Studies. Baltimore, MD: Thieme; 1999
• 9 Kobayashi S. Neurosurgery of Complex Vascular Lesions and Tumors. New York, NY: Thieme Medical Publishers; 2005
• 10 Ivan ME, Lawton MT. Mini supraorbital approach to inferior frontal lobe cavernous malformations: case series. J Neurol Surg A Cent Eur Neurosurg 2013; 74 (3) 187-191
• 11 Fischer G, Stadie A, Reisch R , et al. The keyhole concept in aneurysm surgery: results of the past 20 years. Neurosurgery 2011; 68 (1, Suppl Operative): 45-51 ; discussion 51