Endoscopic management of frontal sinus CSF leaks / Manejo endoscópic de fístulas liquóricas do seio frontal

Abstract Introduction: Endoscopic management of frontal sinus cerebrospinal fluid leaks has become the gold standard of treatment, with high success rates and low morbidity. The aim of this study is to review our experience in managing this challenging condition. Objective: To review our experience in treating frontal sinus cerebrospinal fluid leaks through an endonasal endoscopic approach. Methods: A retrospective evaluation of patients undergoing endoscopic surgery for frontal sinus cerebrospinal fluid leaks was performed. Demographics, defect location and etiology, surgical and reconstructive technique, complications, and postoperative followup were examined. Results: Twenty-two patients with a mean age of 40.4 years were treated surgically by the senior author between 2015 and 2019. Cerebrospinal fluid leak was either traumatic (17) or spontaneous (5). Successful first-attempt endoscopic repair was accomplished in all cases. A combined endoscopic-trephination approach was necessary in 5 patients (22.8%). No serious complications were reported, and frontal sinus drainage pathway was patent in all our cases. Revision surgery was necessary in only 2 patients for synechia formation. The mean patient followup was 22.7 months (range: 7 - 41 months). Conclusion: Progress in the field of endoscopic surgery has shifted the paradigm, establishing endoscopic repair of frontal sinus leaks as the standard of care. A few remaining limits of this approach could be addressed by combining endoscopy with frontal trephination.

Resumo Introdução: O manejo endoscópico das fístulas liquóricas do seio frontal tornou-se o padrão-ouro, com altas taxas de sucesso e baixa morbidade. Objetivo: Revisar nossa experiência no tratamento de fístulas liquóricas do seio frontal por meio de uma abordagem endoscópica endonasal. Método: Foi feita uma avaliação retrospectiva de pacientes submetidos à cirurgia endoscópica para fístulas liquóricas do seio frontal. Dados demográficos, localização e etiologia do defeito, técnica cirúrgica e reconstrutiva, complicações e seguimento pós-operatório foram analisados. Resultados: Foram tratados cirurgicamente pelo autor principal 22 pacientes com média de 40,4 anos entre 2015 e 2019. A fístula liquórica foi traumática (17) ou espontânea (5). O reparo endoscópico foi feito com sucesso na primeira tentativa em todos os casos. Uma abordagem combinada de trefinação e endoscopia foi necessária em 5 pacientes (22,8%). Nenhuma complicação grave foi relatada e a via de drenagem do seio frontal estava patente em todos os nossos casos. A cirurgia de revisão foi necessária em apenas 2 pacientes devido à formação de sinéquia. O seguimento médio dos pacientes foi de 22,7 meses (variação: 7 a 41). Conclusão: O progresso no campo da cirurgia endoscópica mudou o paradigma, estabeleceu o reparo endoscópico de fístulas liquóricas do seio frontal como o padrão de tratamento. Alguns poucos limites remanescentes dessa abordagem podem ser resolvidos pela combinação da endoscopia com a trefinação frontal.

Delayed Operation of Acute Subdural Hematoma in Subacute Stage by Trephine Drainage using Urokinase / 대한신경손상학회지

OBJECTIVE: The principle operation of acute subdural hematoma (ASDH) is a craniotomy with hematoma removal, but a trephination with hematoma evacuation may be another method in selected cases. Trephine drainage was performed for ASDH patients in subacute stage using urokinase (UK) instillation, and its results were evaluated. METHODS: Between January 2016 and December 2018, the trephine evacuation using UK was performed in 9 patients. The interval between injury and operation was from 1 to 2 weeks. We underwent a burr hole trephination with drainage initially, and waited until the flow of liquefied hematoma stopped, then instilled UK for the purpose of clot liquefaction. RESULTS: The mean age of patients was 71.6 years (range, 38–90 years). The cause of ASDH was trauma in 8 cases, and supposed a complication of anticoagulant medication in 1 case. Four out of 8 patients took antiplatelet medications and one of them was a chronic alcoholism. The range of the Glasgow Coma Scale score before surgery was from 13 to 15. Most of patients, main symptom was headache at admission. The Glasgow Outcome Scale score was 5 in 8 cases and 3 in 1 case. CONCLUSION: It is thought to be a useful operation method in selected patients with ASDH that the subdural drainage in subacute stage with UK instillation. This method might be another useful option for the patients with good mental state regardless of age and the patients with a risk of bleeding due to antithrombotic medications.

Disappearance of Arachnoid Cyst after Burrhole Trephination: Case Series / 대한신경손상학회지

We report 3 cases of arachnoid cysts (ACs) that completely disappeared after burr hole drainage, without cyst fenestration into the subarachnoid space or cystoperitoneal shunt. The first patient was a 21-year-old female with an AC of the right cerebral convexity, found incidentally. After endoscopic AC fenestration was performed, the patient complained of persistent headache. Two-month postoperative brain imaging revealed reaccumulated AC and associated multi-stage subdural hematoma. Burr hole drainage was performed to resolve the chronic subdural hematoma (CSDH). Three months later, brain computed tomography showed that the CSDH and the AC had disappeared. The second patient was an 11-year-old male who had a history of trauma 1 month prior to presentation at the clinic. Brain magnetic resonance imaging revealed an AC in the left sylvian fissure with CSDH. We performed burr hole drainage to treat the CSDH first. Subsequently, the AC as well as the CSDH disappeared. The third case was an AC of the right parietal convexity, found incidentally. Only burr hole drainage was performed, following which, the AC disappeared. This case series shows that an AC can disappear naturally after rupture into the subdural space by trauma or the burr hole procedure.

Expanding Subdural Hematomas in the Subacute Stage and Treatment via Catheter Drainage / 대한신경손상학회지

OBJECTIVE: Rapid expansion of subacute subdural hematomas (saSDHs) is an uncommon complication in the course of acute subdural hematomas (SDHs). The current study evaluated relevant factors and treatment methods for saSDHs with neurologic deterioration and mass effect. METHODS: A saSDHs was chronologically defined as an SDH occurring 4 to 21 days after head trauma. All cases of surgically treated SDHs were retrieved from the head trauma bank at our institution. Twenty-three patients with expanding saSDHs who met the following criteria were enrolled in the study: defined age of the hematoma, clinical deterioration, and radiological expansion of the hematoma. Cases were analyzed according to demographic factors, trauma mechanism, medical co-morbidity, and surgical method. RESULTS: Expanding saSDHs occurred more often in older (≥60 years old) than in younger patients (69.6% vs. 30.4%, respectively); they also occurred more often in men than in women (64% vs. 36%, respectively). Antiplatelet or anticoagulant therapy was used in 52% of patients. The Glasgow Coma Scale score was 13 at the time of the trauma and deteriorated to 11 at the time of surgery. The mean time from the trauma to development of the expanding saSDH from an SDH was 13.3 days. Regarding surgical methods, closed-system drainage was performed in 22 patients, and only one patient underwent craniotomy with hematoma removal. All patients exhibited neurological improvements after surgery. CONCLUSION: An expanding saSDH usually occurs around 13 days after trauma in older adults. Minimal trephination with closed-system drainage can be used to manage an expanding saSDHs.

Trephination mini-craniectomy for traumatic posterior fossa epidural hematomas in selected pediatric patients / 中华创伤杂志(英文版)

<p><b>PURPOSE</b>Posterior fossa epidural hematomas (PFEDH) are uncommon in children but usually require timely surgical intervention due to the risk of life-threatening brainstem compression. We attempt to make the surgical procedure less invasive by treating selected pediatric patients with trephination mini-craniectomy.</p><p><b>METHODS</b>We retrospectively reviewed the clinical courses, radiological findings, surgical procedures, and prognoses of the pediatric patients who were treated in our departments for traumatic PFEDH from January 2010 to January 2015.</p><p><b>RESULTS</b>During this period, a total of 17 patients were surgically treated for PFEDH and 7 were managed with trephination mini-craniectomy for hematoma evacuation. The outcomes were good in all 7 patients as evaluated with Glasgow Outcome Score. There was no mortality in this series. The on average 30-month clinical follow-up showed that patients experienced satisfactory recoveries without complications.</p><p><b>CONCLUSION</b>Our results suggest that trephination mini-craniectomy is a safe surgical technique for selected PFEDH patients with moderate hematoma volume and stabilized neurological functions. However, standard craniectomy is recommend when there are rapid deteriorations in patients' neurological functions or the hematomas are large and exerted severe mass effects.</p>

Remote Hemorrhage after Burr Hole Drainage of Chronic Subdural Hematoma / 대한신경손상학회지

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.

Burr hole drainage using urokinase for treatment of subacute subdural hematoma / 영남의대학술지

BACKGROUND: Enlargement of subdural hematomas is relatively rapid in subacute stage of hematoma with clinical deterioration, which eventually necessitates surgery. The purpose of this study is to investigate the feasibility and safety of burr hole drainage using urokinase for management of patients with subacute subdural hematoma (SASDH). METHODS: Nine patients with SASDH were treated by burr hole drainage using urokinase. Under local anesthesia a catheter was inserted into the hematoma through a burr hole. Burr hole drainage was followed by hematoma thrombolysis with instillation of urokinase (10,000 units) every 12 hours. Drainage was discontinued when a significant decrease of hematoma was observed on cranial computed tomography. RESULTS: The patients' median age was 70 years (range, 62-87). The median Glasgow Coma Scale score before surgery was 15 (range, 11-15). Drainage was successfully performed in all patients. All patients had Glasgow Outcome Scale scores of 5 at discharge. There was no surgery-related morbidity or mortality. CONCLUSION: A burr hole drainage using urokinase could be a safe, feasible and effective minimally invasive method with low morbidity in treatment of selected patients with SASDHs.

History of Chronic Subdural Hematoma / 대한신경손상학회지

Trephination or trepanation is an intentional surgical procedure performed from the Stone Age. It looks like escaping a black evil from the head. This technique is still used for treatment of chronic subdural hematoma (SDH). Now, we know the origin, pathogenesis and natural history of this lesion. The author try to explore the history of trephination and modern discovery of chronic SDH. The author performed a detailed electronic search of PubMed. By the key word of chronic SDH, 2,593 articles were found without language restriction in May 2015. The author reviewed the fact and way, discovering the present knowledge on the chronic SDH. The first authentic report of chronic SDH was that of Wepfer in 1657. Chronic SDH was regarded as a stroke in 17th century. It was changed as an inflammatory disease in 19th century by Virchow, and became a traumatic lesion in 20th century. However, trauma is not necessary in many cases of chronic SDHs. The more important prerequisite is sufficient potential subdural space, degeneration of the brain. Modifying Virchow's description, chronic SDH is sometimes traumatic, but most often caused by severe degeneration of the brain. From Wepfer's first description, nearly 350 years passed to explore the origin, pathogenesis, and fate of chronic SDH. The nature of the black evil in the head of the Stone Age is uncovering by many authors riding the giant's shoulder. Chronic SDH should be categorized as a degenerative lesion instead of a traumatic lesion.

A Measurement of the Frontal Sinus Depth of Korean Adults Using The Axial Images of Computed Tomography

BACKGROUND AND OBJECTIVES: Frontal sinus trephination requires understanding of frontal sinus anatomy. This study aims to identify frontal sinus depth (FSD) and bone thickness of its anterior table (FBT) using the axial images of paranasal computed tomography (CT) scans. SUBJECTS AND METHODS: We obtained the axial images taken from 30 men and 30 women. FSD and FBT were estimated at points 5, 10, and 15 mm from the midline (the straight line passing through the crista galli) on each side using the axial CT images. RESULTS: The mean male FSDs at 5, 10, and 15 mm from midline were 11.08+/-1.92, 11.38+/-2.08, and 11.49+/-2.27 mm, respectively; mean female FSDs were 8.23+/-1.38, 8.47+/-1.65, and 8.87+/-1.76 mm, respectively. Men had significantly larger FSDs than women did at all measurement points (p 0.05). CONCLUSION: These data provide the information about the frontal sinus in Korean adults.

Trepanación corneal cónica como nuevo perfil de corte para las queratoplastias penetrante y lamelar anterior / Conic corneal trephination as a new cutting profile for penetrating and anterior lamellar keratoplasties

Objetivos: describir las características y empleo de la trepanación corneal cónica. Métodos: se realizó un estudio experimental en el Instituto Cubano de Oftalmología Ramón Pando Ferrer de enero a diciembre de 2010. Se realizó la trepanación en diez globos oculares no útiles para trasplante, con un trépano corneal de vacío que tiene como característica fundamental la creación de un corte oblicuo. Se analizaron los parámetros: longitud del corte, grosor corneal, diámetro externo del botón, diámetro interno del botón y ángulo del corte. Se utilizó la estadística descriptiva para expresar los resultados. Resultados: la longitud media del corte fue de 1 776,7 ± 273,7 mm y el grosor corneal medio a nivel del corte fue de 850,0 ± 119,2 mm, con una diferencia entre estos de 926 mm. El diámetro externo medio del botón corneal fue de 7,6 ± 0,2 mm y el interno de 8,5 ± 0,4 mm, con una diferencia de 0,9 mm. El ángulo de corte medio fue de 28,4 ± 2,1°. Se estableció una fórmula para calcular la longitud o profundidad del corte en base a la paquimetría media del círculo en el que se realizó la trepanación para un ángulo de corte determinado. Conclusiones: se obtuvo un corte regular, simétrico y de mayor longitud que el grosor corneal y con el aspecto cónico planificado. Dicho patrón de corte provee una mayor área de contacto y una tendencia autosellante

Objectives: to describe the characteristics and use of the conic corneal trephination.Methods: an experimental study was performed in Ramón Pando Ferrer Cuban Institute of Ophthalmology from January to December 2010. Ten eyeballs not useful for transplantation underwent trephination, with a corneal vacuum trephine particularly designed to create an oblique corneal cut. The cutting length, the corneal thickness, the external diameter of the disc, the internal diameter of the disc and the cutting angle were the analyzed parameters. Descriptive statistics were applied to show the results. Results: the mean cutting length was 1776.7 ± 273.7 mm and the mean corneal thickness at the cutting point was 850.0 ± 119.2 mm , being the difference between them equals to 926 mm. The mean external diameter was 7.6 ± 0.2 mm and the internal diameter was 8.5 ± 0.4 mm, with a difference of 0.9 mm. The mean cutting angle amounted to 28.4 ± 2.1°. A formula was developed to calculate the cutting length or depth based on the mean pachymetry of the circle where the trephination is performed for a determined cutting angle. Conclusions: aregular symmetric cut was obtained, longer than the corneal thickness with the planned conic profile. Such cutting pattern provides a larger contact surface and self-sealing tendency

A Comparative Analysis of Chronic Subdural Hematoma in Two Age Groups of Younger and Older than 75 Years / 대한신경손상학회지

OBJECTIVE: Chronic subdural hematoma (cSDH) is one of the most common types of intracranial hemorrhage. As the number of elderly people is increasing, the incidence of cSDH is growing. Therefore, we analyzed clinical manifestation of the cSDH. METHODS: The authors retrospectively reviewed the data of the 169 patients of cSDH who were 65 years or older and undergone burr-hole trephination and closed drainage in our hospital between January 2008 and December 2012. Patients were divided into two subgroups; group A: young than 75 years, group B: 75 years or older. We analyzed the differences of clinical aspects and surgical results in both groups. RESULTS: Proportion of male patients in group A (83.8%) was higher than in group B (58.4%) with statistical significance (p=0.003). Alteration of consciousness as an initial symptom was significantly more frequent in group A (17.5%) than in group B (4.4%)(p=0.006). Postoperatively, 164 of 169 patients (97%) were free from symptom within three days in both groups. Pneumonia followed the surgery in three patients (one in group A and two in group B). CONCLUSION: There were no difference in the rate of complications between group A and B. Therefore, burr-hole trephination and external drainage is safe and effective management in both groups.

Surgical Results of Endoscopic Dacryocystorhinostomy and Lacrimal Trephination in Distal or Common Canalicular Obstruction

OBJECTIVES: To evaluate the surgical outcomes of endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stenting in patients with distal or common canalicular obstructions. METHODS: The medical records of 29 patients (31 eyes) from January 2001 to December 2009 who underwent endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone tube insertion for the treatment of distal or common canalicular obstructions were retrospectively reviewed. The level of obstruction was confirmed by intraoperative probing. The outcome of the surgery was categorized as a complete success, partial success, or failure according to the functional and anatomic patency. RESULTS: The average age of the patients was 52 years. The duration of silicone intubation ranged from 4 to 11 months with an average of 5.7+/-1.6 months. The follow-up period after stent removal ranged from 4 to 15 months with an average of 8.2+/-3.3 months. Complete success was achieved in 25 out of 31 eyes (80.6%), partial success in 4 out of 31 eyes (12.9%), and failure in 2 out of 31 eyes (6.5%). CONCLUSION: Endoscopic dacryocystorhinostomy followed by canalicular trephination and silicone stent intubation may be safe and considered as an initial treatment of patients with distal or common canalicular obstructions.

A Case of Isolated Frontal Fungal Sinusitis: Treated by Endoscopic Sinus Surgery with Frontal Sinus Minitrephination

The incidence and prevalence of human fungal sinusitis are increasing, because of recently increased immunocompromised host and developed diagnostic tool. Aspergillosis is the most common fungal infection of the paranasal sinuses. The maxillary sinus is most commonly affected by Aspergillus, followed by the sphenoid and ethmoid sinuses. However, isolated frontal fungal sinusitis is extremely rare. Recently, we experienced that a cases of Aspergillus sinusitis of isolated frontal sinus successfully was treated by endoscopic sinus surgery combined with frontal sinus minitrephination (the above and below approach). Therefore, we report this case with a review of the literatures.

Factors Affecting the Reaccumulation of Chronic Subdural Hematoma after Burr-hole Trephination and Closed-system Drainage

OBJECTIVE: The reaccumulation of hematoma is one of the most frequent problems on the chronic subdural hematoma. The aim of this study is to determine the factors affecting the reaccumulation of hematoma and the reasonable site for the burr-hole trephination to achieve a low reaccumulation rate after burr-hole trephination and closed-system drainage METHODS: The authors studied 93 patients with chronic subdural hematoma in whom the location of burr-hole trephination was randomly placed and precisely determined on postoperative brain computerized tomographic scans or skull roentgenogram. Eighty five patients with chronic subdural hematoma were obtained with brain computerized tomographic scans the postoperative 3 day. The location of the burr-hole trephination, the location of subdural catheter tip, the maximum postoperative width of the subdural space, and the percentage of the ipsilateral subdural space occupied by air postoperatively were measured and analyzed the correlation with the postoperative reaccumulation rates. RESULTS: Patients with the parietal trephination had much more subdural air and a higher of chronic subdural hematoma reaccumulation than those with the frontal one. In addition, patients with residual subdural air on brain computerized tomographic scans obtained the postoperative 3 day also had a higher reaccumulation rate than those without subdural air collections. CONCLUSION: The incidence of postoperative subdural fluid reaccumulation can be reduced by the burr-hole trephination on the frontal convexity and by preventing subdural air accumulation during operation.

Trephination with vacuum trephine in undercorrection of myopic epikeratoplasty

For the treatment of undercorrection after myopic epikeratoplasty, early suture removal, scar revision, retrephination, replacement of lenticule and, recently, excimer laser photorefractive keratoplasty have been employed. We performed trephination with Hessburg-Barron vacuum trephine on 11 eyes of 11 patients whose post-epikeratoplasty myopic power was over -4.00 diopters for 3 consecutive months. Patients were followed up on post-trephination 1 month, 3 months and 6 months. The mean duration from epikeratoplasty to trephination was 14.27 months, the mean pre-trephination spherical equivalent was -8.50 D and the mean keratometric reading was 40.87 D. The mean reduction of spherical equivalent was -4.07, -5.99, -8.02 D at post-trephination 1, 3, 6 months, respectively. The mean keratometric reading was 37.60 diopters at 1 month and 41.53 diopters at 6 months. At 1 and 3 months, there were significant reductions of myopic power in refraction and keratometry (p 0.05). There was no change of uncorrected and best corrected visual acuity between baseline and post-trephination 6 months.

Trephination Effect After Epikeratoplasty

Trephination was performed for the purpose of correction of undercorrection after epikeratoplasty. We classified two group-Delayed regression group represented regression toward myopia more than 3D again after spherical equivalant become stable. Undercorrection group represented remained myopia after epikeratoplasty. Thirteen trephinations were performed on eleven eyes. Mean follow-up period was 22.4 weeks. In skiascopy, totally 1.15D myopia was decreased. In delayed regression group myopia was increased 0.5D, while in undercorrection group, myopia was dereased 3.5D, The results of three eyes in eleven eyse were satisfactory. Those 3 cases were from undercorrection group. The results suggest that trephination might be effective method for correction of remained myopia in undercorrection group.

Clinical Studies of the Occipital Bone Fracture

In the past the patients with fracture on the occipital bone involved the lateral sinus and/or the foramen magnum, were treated with the early exploratory burr hole trephination regardless of mental state. The 64 cases occipital bone fracture were evaluated used the computed tomography of the brain scan. The fracture lines involved both the transeverse sinus and the foramen magnum were 59.4%, only the transeverse sinus were 29.7% and only the foramen magnum were 10.9%. The findings of the computed tomography of the brain scan were normal 42 cases, brain edema 13 cases. The 5 cases had large hematoma on the computed tomography of the brain scan performed emergency operation. The other 59 cases were treated with only close observation and conservative treatment. The mortality rate was 20% in operative treatment and 8.5% in conservative treatment. So we concluded that the patients with significant fracture on the occipital bone but had no surgical indication on the computed tomography of the brain scan might be treated with close observation & conservative treatment and it would not be necessary to perform the exploratory craniotomy as was done in the past.