Endoscopic Endonasal Management of Petroclival Cerebrospinal Fluid Leaks: Anatomical Study and Preliminary Clinical Experience

Abstract

Background: Endonasal management of most anterior cranial fossa cerebrospinal fluid leaks is a well established procedure, and even some middle cranial fossa cerebrospinal fluid leaks can be managed safely endonasally. Endonasal endoscopic management of leakages of the posterior cranial fossa represents an unique challenge.

Objective: The aim of this study was to assess the feasibility of an endoscopic endonasal approach for treating well-selected cerebrospinal fluid leaks of the petroclival region.

Methods: Clinical charts of patients with leakages of the petroclival region treated at our institution were retrospectively reviewed. Careful dissection of the petroclival region was performed, both endonasally and externally, in three fresh injected heads.

Results: Two patients presented a leakage of the petroclival region. Both the patients presented multiple skull base defects. The two patients underwent a supratubaric trans-spheno-petroclival approach; in one of these, it was performed in combination with a middle cranial fossa approach. Multilayer reconstruction was performed in both patients. No cerebrospinal fluid leak recurrences were observed during follow-up (17 and 19 months, respectively).

Conclusions: Endonasal endoscopic management of well-selected petroclival cerebrospinal fluid leaks is feasible.

Key words

cerebrospinal fluid leak - petroclival - endoscopic - multilayer plasty

References

• 1 Lai SY, Kennedy DW, Bolger WE. Sphenoid encephaloceles: disease management and identification of lesions within the lateral recess of the sphenoid sinus.  Laryngoscope. 2002;  112 1800-1805
• 2 Castelnuovo P, Dallan I, Pistochini A. et al . Endonasal Endoscopic repair of Sternberg's canal cerebrospinal fluid leaks.  Laryngoscope. 2007;  117 345-349
• 3 Martin TJ, Loehrl TA. Endoscopic CSF leak repair.  Curr Opin Otolaryngol Head Neck Surg. 2007;  15 35-39
• 4 Schick B, Prescher A, Hofmann E. et al . Two occult skull base malformations causing recurrent meningitis in a child: a case report.  Eur Arch Otorhinolaryngol. 2003;  260 518-521
• 5 Sperber GH. Craniofacial embryology. London: Wright PSG 1989
• 6 Currarino G. Canalis basilaris medianus and related defects of the basiocciput.  AJNR Am J Neuroradiol. 1988;  9 208-211
• 7 Laine FJ, Nadel L, Braun IF. CT and MR imaging of the central skull base part 1: techniques, embryologic development, and anatomy.  Radiographics. 1990;  10 591-602
• 8 Cavallo LM, Messina A, Cappabianca P. et al . Endoscopic endonasal surgery of the midline skull base: anatomical study and clinical considerations.  Neurosurg Focus. 2005;  15 (19 (1)) E2
• 9 Kassam A, Snyderman CH, Mintz A. et al . Expanded endonasal approach: the rostrocaudal axis. Part II. Posterior clinoids to the foramen magnum.  Neurosurg Focus. 2005;  15 (19 (1)) E4
• 10 Alfieri A, Jho HD, Schettino R. et al . Endoscopic endonasal approach to the pterygopalatine fossa: anatomic study.  Neurosurgery. 2003;  52 374-380
• 11 Kassam AB, Gardner P, Snyderman C. et al . Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa.  Neurosurg Focus. 2005;  19 1-10
• 12 Vescan AD, Snyderman CH, Carrau RL. et al . Vidian canal: analysis and relationship to the internal carotid artery.  Laryngoscope. 2007;  117 1338-1342
• 13 Fortes FSG, Sennes LU, Carrau RL. et al . Endoscopic anatomy of the pterygopalatine fossa and the transpterygoid approach: Development of a surgical instruction model.  Laryngoscope. 2008;  118 44-49

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