Postoperative CNS Infections after Extended Transnasal Skull Base Surgery

Background and Objectives: Endoscopic endonasal transsphenoidal approach (EEA) is a well-established technique for sellar region pathologies. It gained popularity over the past few decades due to its better access and visualization of skull base lesions with minimal normal tissue disruption. This technique has evolved in recent years to extend beyond sellar margins, which includes prechiasmatic sulcus anteriorly, carotic sulcus laterally, and clival recess inferiorly. The literature data of postoperative central nervous system (CNS) infections in patients undergoing extended EEA, which represents a serious problem that requires immediate attention, are limited. Our aim of this study is to evaluate the rate and risk factors of CNS infections following EEEA.

Materials and Methods: A preliminary retrospective evaluation of 44 EEEA cases operated at King Saud University Medical City, Riyadh, Saudi Arabia during the period from December 2014 to March 2018 with different skull base pathologies were included. Demographics, body mass index, diabetes mellitus, preoperative lumbar/external ventricular drain insertion, the extent of resection, postoperative CSF leak and infections with a minimum follow-up period of one month were evaluated.

Results: Data were obtained from our 44 included patients. The mean age was 38.5 (range from 6 months to 70 years). Twelve males and 32 females, 9 of them were pediatric patients. Ten patients (23%) had postoperative CSF leak and seven (16%) had early postoperative CNS infections. Six out of ten cases (60%) with CSF leaks had infections, and three infection cases (42%) occurred in pediatric patients. The most common infection is bacterial meningitis (70%), 5 out of 7 cases, followed by one cerebral abscess and a case of ventriculitis associated with external ventricular drain. Streptococcus pneumoniae, Pseudomonas aeruginosa, Staphylococcus hominis, and Candida albicans all were identified in our cases. All cases were treated with antibiotics and the cerebral abscess was drained with no mortality among our patients.

Fig. 1 Preoperative (A: sagittal, B: axial) and postoperative (C: sagittal, D: axial) olfactory groove epidermoid cyst.

Fig. 2 Preoperative (A: sagittal, B: axial) and postoperative (C: sagittal, D: axial) olfactory groove meningioma.

Fig. 3 Preoperative (A) and postoperative (B) pituitary adenoma.

Conclusion: CNS infections post extended endoscopic endonasal approach still a major challenge. It seems from our data that CSF leaks and pediatric cases have a higher risk of infections which usually occur early in the postoperative period. The prevention and management of CSF leaks and early blood and CSF cultures with appropriate antibiotic treatment may, therefore, be extremely important.