Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach / 中华创伤杂志(英文版)

OBJECTIVE@#To describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach.@*METHODS@#This was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent.@*RESULTS@#Thirty-five patients were included in this series. The patients' mean age was 33 years (range 11-71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3-65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus.@*CONCLUSION@#Traumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Study on CT appearance of ossification age of the normal anterior skull base in healthy children / 中华放射学杂志

Objective To explore the age at which the anterior skull base is fully ossified as assessed on CT examinations in healthy children and it may be helpful for clinical assessment of anterior cranial lesions. Methods This was a retrospective review of the CT examinations of 204 patients (age range: 0-16 years old, median age: 2 years and 2 months) from February 2014 to March 2016 at Tianjin Children's Hospital. The raw images were reformatted as the sagittal and coronal images at Philips ISPSERVER workstation.Measurements of the length and width of the anterior skull base and the presence and rate of the anterior unossified portion were determined by 2 radiologists.Skewed distribution data were indicated with median (interquartile range). Spearman correlation test was used to analyze the correlation between the measurements and age, respectively. If data were not normally distributed, they were first converted by log transformation.The linear graph was used to evaluate the ossified pattern of anterior skull base in healthy children.Results The average length and width of anterior skull base was(58.7±15.6)mm and (15.2±6.8) mm, respectively. The length and width of unossified portion and corresponding unossified rate were 2.2(10.8)mm,2.5(7.5)mm,0.04(0.22)and 0.17(0.60).The linear graph showed that the length and width of the anterior skull base were positively correlated with age(r=0.935,0.896,P<0.001),while the length,width and corresponding unossified rate of unossified portion were negatively correlated with age(r=-0.840,-0.729,-0.887,-0.833,P<0.001).The unossified portion ossified progressively and rapidly at the first 6 months after birth.The average unossified rate of length was 0.58 and 0.15 in the 1stand 6thmonth, respectively.All children had at least 50% and 80% ossification of anterior skull base at the age of 5 months and 16 months, respectively. The anterior skull base was fully ossified at 45 months in all of our cases. Conclusions There is a certain rule of ossification in anterior skull base for healthy children.The anterior skull base may be fully ossified by 45 months after birth on CT imaging.

Olfactory Groove Schwannoma ­ A Case Report and Literature Review

Olfactory groove schwannomas (OGSs) are rare benign tumors of the anterior skull base region. Considering the lack of Schwann cells in the optic and olfactory nerves, their origin remains enigmatic. Despite the precursor cell, total resection of the lesion is curative, as long as the histopathological features of the tumor are compatible with schwannoma. We report the case of a 32-year-old woman, addicted to crack, who was brought to the hospital presenting with cognitive dysfunction after being physically assaulted, whose neuroimaging revealed a large extra-axial mass in the subfrontal sagittal region. The presentation, immunohistochemical markers and histogenesis are discussed in the present study, along with a literature review.

One-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base / 中华实用儿科临床杂志

Objective To explore the surgical techniques and effects of one-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base.Methods The clinical data of 13 pediatric cases with one-stage reconstruction surgery for comminuted and depressed fractures of the frontal bone and anterior skull base were reviewed retrospectively,including 8 male and 5 female,aged from 4 to 14 years,with a mean age of 8 years.Admission Glasgow Coma Scale (GCS) was as follows:3 to 8 scores in 2 cases,9 to 11 scores in 4 cases,and 12 to 15 scores in 7 cases.The intraoperative one-stage osseous and vascular pedicle membranous reconstruction of frontal bone and anterior skull base had been performed in all patients.The periosteum-bone fragments-periosteum had been used in 4 cases whose bony defect diameter of anterior cranial fossa was over 1 cm,multimodality therapy were carried out postoperatively.The follow-ups were regularly executed after discharge.Results GCS at discharge was as follows:3 to 8 scores in 1 case,9 to 11 scores in 2 cases,and 12 to 15 scores in 10 cases.No significant difference was found in GCS between those on admission and at discharge(χ2=3.02,P>0.05).Eleven cases had a phenomenon of nasal hemorrhage and the duration was not exceeding 48 hours.No intracranial infection and cerebrospinal fluid leakage occurred in all patients.All patients received an acceptable appearance without obvious frontal depre-ssion or proptosis.Postoperative computed tomography image showed normal cranial volume,well reset of fracture pieces,no fracture pieces existing in intracerebral tissue,satisfactory hematoma evacuation,and orbital contents without compression.The complications like cerebrospinal fluid leakage,poor incision healing,brain abscess or mucous cyst had not been found in all patients from 3 months to 6 years follow-up period.Conclusions The one-stage reconstruction surgery for pediatric comminuted and depressed fractures of frontal bone and anterior skull base suggests a better prognosis,effectively less complications,which helps to avoid secondary surgery,but regular follow-ups are absolutely necessary.This procedure is worth applying and spreading to pediatric patients and medical institutions if necessary.

Diagnóstico diferencial en patología tumoral de la base de cráneo anterior / Differential diagnosis in tumor pathology of the anterior skull base

Objective. To describe a series of tumoral lesions of the anterior fossa that were treated at the Hospital de Clinicas during a determined lapse of time.Material and Methods. We evaluated the image archive and medical charts of all the patients operated on between January 2005 and May 2009 at the Neurosurgery Division of the Hospital de Clínicas. Results. From a total of 142 surgeries for expansive supratentorial lessions, 19 were for lessions of the anterior skull base (n=19) of which 7 were meningiomas (36%); four patients with gliomas (21%); one with GBM (5%); one with astrocitoma (5%); two with oligodendroglioma (10%); three patients presented tumors of the paranasal sinuses (15%); two had mucoceles (10%); one with squamous cell carcinoma (5%); three with orbital tumors; one with fibrous bone dysplasia (5%) and one with metastasis of a meduloblastoma of the posterior fossa (5%). Conclusion. The most frequent pathology found at this site is the meningioma, and secondly, gliomas. The third in frequency are the paranasal sinus tumors whose most malignant pathology is the squamous cell carcinoma. Our findings are statistically correspondent to other large series in literature.

Neurosurgical Approaches to and through the Frontal Sinus using Osteoplastic Frontal Sinusotomy

OBJECTIVE: The frontal sinus is frequently a troublesome anatomical obstacle to gain access to the medial anterior cranial base. Surgical approaches to and through the frontal sinus using osteoplastic frontal sinusotomy provide significant advantages to the treatment of lesions of the medial anterior cranial base in addition to the frontal sinus itself. However, appropriate management is necessary to avoid postoperative complications such as cerebrospinal fluid leakage, infection, mucocele formation, and deformity of the forehead. METHODS: The advantages and shortcomings of the approach along with the surgical technique are reported based on our clinical experience with pertinent literature review. The approach using the osteoplastic frontal sinusotomy was applied to two cases of osteoma in the frontal sinus, seven cases of craniofacial tumors, a case of chordoma in the sphenoid and clivus, and two cases of intradural lesions in the anterior cranial fossa. The frontal sinus was managed in such a way as to prevent the postoperative complications. RESULTS: All patients underwent gross total resection of the tumors. With a mean follow-up of 26 months, there were no postoperative complications related to frontal sinus violation. CONCLUSION: The neurosurgical approaches via the frontal sinus using osteoplastic frontal sinusotomy are versatile for various lesions of the anterior cranial base in patients with large frontal sinuses. In situations that the frontal sinus have to be violated to approach medial anterior cranial base, the osteoplastic frontal sinusotomy provides such advantages as optimal frontal sinus control to prevent postoperative complications; increases viewing angle with superior trajectory from nasofrontal suture; lower incidence of pnemocephalus due to minimal dural exposure; and excellent cosmesis without frontal burr holes.

Anatomical Relationship of the Anterior Ethmoid Canal to the Anterior Skull Base: A Computed Tomographic Analysis on the Types of the Fovea Ethmoidalis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: As the anterior ethmoid canal (AEC) provides a good surgical landmark and its injury may result in serious complications, the anatomical relationship of the AEC to the anterior skull base (ASB) should be evaluated preoperatively. Despite some studies on the ASB, studies analyzing this anatomical relationship and the types of the fovea ethmoidalis (FE) on computed tomography (CT) are rare. The aim of this study is to better understand this anatomical relationship by determining the frequency of each type of the FE and distances between anatomical structures on the CT scans with our new classification. MATERIALS AND METHOD: Four hundred sides of the FE were analyzed from the preoperative coronal CT scans of 200 chronic sinusitis patients (100 males and 100 females, aged 20 to 59 years). The FE was classified into 4 types (I: non-separated type, II: partially separated type, III: completely separated type, IV: unidentifiable type) and 2 subtypes (A: developed medial cranial wall, B: undeveloped medial cranial wall). Heights of the medial cranial wall (a), the AEC (b), and the ethmoid roof (c) were measured on the CT image. RESULTS: Frequencies of the types I-IV were 48.0% (IA: 25.2%, IB: 22.8%), 19.3% (IIA: 4.3%, IIB: 15.0%), 29.5% (IIIA: 29.5%, IIIB: 0%), and 3.2%, respectively. The medial cranial wall of type IIIA was significantly longer than those of the other types, and the AEC of type IIIA was in a significantly lower position than those of the other types. CONCLUSION: On the CT scans, we found the AEC in 96.8% and type IIIA in nearly 30% of all types of the FE. Sinus surgery should be performed only after preoperative evaluation of these anatomical relationship on the CT scans under close scrutiny. For the type IIIA, surgery should be performed with utmost care due to high risk of injury to the AEC and the medial cranial wall.

Craniofacial Resection for the Anterior Skull Base Tumors

Craniogacial resection(CFR) is an ideal approaches for tumors involving the anterior skull base. This technique may be used for benign and malignant tumors arising from the paranasal sinus, nasal cavity, and orbit that extend into the anterior skull base. Recently, we have experienced 12 cases of craniogacial resection for anterior skull ase tumors. Most of them were recurrent tumors, and received previous local excision, preoperative radiotherapy, or chemotherapy before craniofacial resection. Histologic types of tumors included 6 squamous cell carcinomas, one each of adenoid cystic carcinoma, rhabdomyosarcoma, osteoma, ossifying fibroma, cavernous hemangioma, and malignant schwannoma. Two patients died after surgery; one from recurrent infection and the other from rupture of the tumor invaded ICA. Four malignant tumors recurred after the CFR. Remaining 5 patients are doing well without tumor recurrence. In conclusion, CFR is a commendable procedure for anterior skull base tumors, providing cure for benign tu mors and at least a local control for malignancies.

A Reconstructive Transbasal Approach to Tumors Involving the Anterior Skull Base

An en bloc bilateral osteotomy of the orbital roofs and frontal sinus for large or deeply situated anterior skull base tumors offers less brain retraction and a wide exposure. The authors describe en bloc bilateral osteotomy of the orbital roofs and frontal sinus, with skull base reconstruction using inner table of the patient's own frontal bone flap. The approach in this report offers the advantage of wide exposure, one-site operation and short operation time.

Supraorbital Approach to Anterior Skull Base and Intraorbital Lesions

To get effective access to the floor of the frontal fossa and the superior orbit, the resection of supraorbital rim has been done. We performed the supraorbital approach as combined technique with uni- or bifrontal craniotomy in order to minimize frontal lobe retraction and achieve excellent exposure for safe manipulation in seven patients of anterior skull base and intraorbital lesions. Of seven patients, two patients of olfactory groove meningioma underwent the operation with supraorbital bifrontal craniotomy;one patient of tuberculum sellar meningioma, bifrontal supraorbital-pterional approach;four patients of intraorbital benign lesions(one patient of meningioma, one patient of neurilemmoma, two patients of benign lesions in lacrimal gland), supraorbital unifrontal craniotomy. There was little or no functional, anatomical, or cosmetic deficit associated with this approach technique. We believe the supraorbital approach to be a helpful technique as combined procedure of the uni- or bifrontal approach and the approach of choice for the intraorbital tumors except those in the inferior portion.

An Extended Frontal Approach to Midline Lesions of the Anterior Skull Base

Relatively huge lesions in the parasellar and midline anterior skull base region are difficult to approach for radical procedures. To minimize brain retraction and achieve excellent exposure for safe manipulation within these regions, the authors have performed an extended frontal approach, a fibrontal craniotomy and a bilateral orbitofrontal osteotomy in 11 patients, and an additional transfacial maxillotomy in 1 patient. An additional removal of the orbital rim offers excellent visualization and permits unhindered surgical manipulation including postoperative reconstruction at the anterior skull base. But disadvantages include prolonged operative time and frequent ilateral olfactory denervation. Six patients with benign tumors, two patients with malignant tumors, one patient with hematoma in the ehtmoid and sphenoid sinuses, and three patients with delayed traumatic CSF rhinorheas were operated on using this approaches, with good results. The operative technique and its results are detailed.