Salvage Endoscopic Endonasal Approach for CSF Leak Repair after Craniotomy

Background: Cerebrospinal fluid (CSF) rhinorrhea is a known complication of transcranial skull base procedures and revision craniotomies for CSF leak repair can carry significant risks. Endoscopic repair of spontaneous or traumatic CSF leak repair is common practice with a success rate of 90% after the first repair. However, there is a dearth of literature regarding endoscopic repair of CSF leaks after open transcranial procedures with only a few studies describing approaches and success rates. We describe salvage endoscopic CSF leak repair after skull base approaches for meningioma resection.

Methods: Charts were reviewed to identify patients who underwent endoscopic CSF leak repair after open craniotomy for meningioma resection at our institution between 2014 and 2018. We report techniques, comorbidities, and outcomes associated with salvage endoscopic CSF leak repair.

Results: Five patients met inclusion criteria. CSF leak was discovered between 1 and 9 days postoperatively after the initial craniotomy in four out of the five cases. In one case, repair was done on the same day as the index procedure because there was insufficient vascularized tissue to repair the defect transcranially. Leak locations included posterior ethmoid roof (2), cribriform plate (1), and tuberculum sella (2). In all cases, the surgeon had a high index of suspicion for the location of the leak based on the original surgery or imaging. The index procedures included transbasal approach (4) and right pterional craniotomy (1). The mean age was 54.8 years and mean BMI was 30.62 kg/m². One patient had prior history of radiation. In two cases, lumbar drains were placed after the initial surgery in an attempt to treat conservatively before endonasal repair was performed. The repair was generally performed using fascia lata or dural substitute followed by nasoseptal flap. All patients had complete resolution of CSF leak upon follow-up exam. One patient had meningitis that was detected pre-endonasal repair. No patients developed meningitis postoperatively.

Conclusion: Salvage endoscopic endonasal CSF leak repair is a less invasive approach that is an excellent alternative to revision craniotomy. In our series, the success rate of endoscopic repair was 100%, with no patients requiring a second operation for leak repair. A high index of suspicion for location of leak is helpful to guide successful repair.