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      Fístula de líquido cefalorraquídeo recidivante postraumática asociada a meningocele esfenoidal: técnica abierta-endoscópica Translated title: Cerebrospinal fluid fistula associated with posttraumatic recurrent sphenoidal meningocele: open-endoscopic technique


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          Introducción: Las fístulas de líquido cefalorraquídeo surgen tras la ruptura de las barreras que separan la cavidad nasal y senos paranasales de los espacios subaracnoideos: base craneal, duramadre y membrana aracnoidea. Aproximadamente el 80% surgen en el contexto de traumatismos craneofaciales con fracturas de la base craneal. La elección del abordaje y técnica quirúrgica más adecuada en cada caso es esencial para la obtención de resultados quirúrgicos globales satisfactorios. El desarrollo de la cirugía endoscópica endonasal ha supuesto un arma terapéutica menos invasiva y eficaz, siendo las fístulas de líquido cefalorraquídeo una indicación bien establecida para su tratamiento definitivo. Caso clínico: Se presenta el caso de una paciente con fístula de líquido cefalorraquídeo recurrente con meningoencefalocele asociado tratada vía endoscópica. Discusión: Se discute el tratamiento conservador versus quirúrgico de las fístulas de líquido cefalorraquídeo. Ventajas y desventajas de los distintos tipos de abordajes relacionados con el manejo definitivo.

          Translated abstract

          Introduction: Cerebrospinal fluid fistulas arise after the breakdown of the barriers that separate the nasal cavity and paranasal sinuses of the subarachnoid space, skull base, dura and arachnoid membrane. Approximately 80% arise in the context of craniofacial trauma with fractures of the skull base. The choice of approach, appropriate surgical technique in each case is essential to achieve a good overall surgical outcome. Development of endoscopic endonasal surgery has become a less invasive and effective therapeutic tool, with cerebrospinal fluid fistulas being a well-established indication for definitive treatment. Case report: A case of a patient with cerebrospinal fluid fistula associated with recurrent meningoencephalocele, treated endoscopically. Discussion: We discuss the surgical versus conservative treatment of spinal fluid fistulas, and the advantages and disadvantages of different types of approaches related to definitive management.

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          Most cited references37

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          A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap.

          In patients with large dural defects of the anterior and ventral skull base after endonasal skull base surgery, there is a significant risk of a postoperative cerebrospinal fluid leak after reconstruction. Reconstruction with vascularized tissue is desirable to facilitate rapid healing, especially in irradiated patients. We developed a neurovascular pedicled flap of the nasal septum mucoperiosteum and mucoperichondrium based on the nasoseptal artery, a branch of the posterior septal artery (Hadad-Bassagasteguy flap [HBF]). A retrospective review of patients undergoing endonasal skull base surgery at the University of Rosario, Argentina, and the University of Pittsburgh Medical Center was performed to identify patients who were reconstructed with a vascularized septal mucosal flap. Forty-three patients undergoing endonasal cranial base surgery were repaired with the septal mucosal flap. Two patients with postoperative cerebrospinal fluid leaks (5%) were successfully treated with focal fat grafts. We encountered no infectious or wound complications in this series of patients. One patient experienced a posterior nose bleed from the posterior nasal artery. This was controlled with electrocautery and the flap blood supply was preserved. The HBF is a versatile and reliable reconstructive technique for defects of the anterior, middle, clival, and parasellar skull base. Its use has resulted in a sharp decrease in the incidence of postoperative cerebrospinal fluid leaks after endonasal skull base surgery and is recommended for the reconstruction of large dural defects and when postoperative radiation therapy is anticipated.
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            Expanded endonasal approach: fully endoscopic, completely transnasal approach to the middle third of the clivus, petrous bone, middle cranial fossa, and infratemporal fossa.

            The middle third of the clivus and the region around the petrous internal carotid artery (ICA) is a difficult area of the skull base in terms of access. This is a deep area rich with critical neurovascular structures, which is often host to typical skull base diseases. Expanded endoscopic endonasal approaches offer a potential option for accessing this difficult region. The objective of this paper was to establish the clinical feasibility of gaining access to the paraclival space in the region of the middle third of the clivus, to provide a practical modular and clinically applicable classification, and to describe the relevant critical surgical anatomy for each module. The anatomical organization of the region around the petrous ICA, cavernous sinus, and middle clivus is presented, with approaches divided into zones. In an accompanying paper in this issue by Cavallo, et al., the anatomy of the pterygopalatine fossa is presented; this was observed through cadaveric dissection for which an expanded endonasal approach was used. In the current paper the authors translate the aforementioned anatomical study to provide a clinically applicable categorization of the endonasal approach to the region around the petrous ICA. A series of zones inferior and superior to the petrous ICA are described, with an illustrative case presented for each region. The expanded endonasal approach is a feasible approach to the middle third of the clivus, petrous ICA, cavernous sinus, and medial infratemporal fossa in cases in which the lesion is located centrally, with neurovascular structures displaced laterally.
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              Transpterygoid transposition of a temporoparietal fascia flap: a new method for skull base reconstruction after endoscopic expanded endonasal approaches.

              Endoscopic expanded endonasal approaches (EEAs) for the resection of lesions of the anterior and ventral skull base can create large defects that present a significant risk of postoperative cerebrospinal fluid (CSF) leak. These defects, especially in patients who received preoperative radiotherapy, are best reconstructed with vascularized tissue. The Hadad-Bassagasteguy flap, a pedicled nasoseptal flap, is our preferred method for reconstruction. This option is not available, however, in patients who underwent a previous posterior septectomy or in those with tumors that invade the pterygopalatine fossa (PPF) or sphenoid sinus rostrum. In this scenario, we have used a temporoparietal fascial flap (TPFF) for the reconstruction of large surgical defects. We developed a new technique for the transposition of the TPFF into the nasal cavity to reconstruct skull base defects after EEA. The flap is harvested using a conventional hemicoronal incision but is then advanced to the defect using a temporal-infratemporal tunnel and an endonasal transpterygoid approach. The latter is created using an endoscopic endonasal approach that involves the resection of the posterior wall of the antrum, dissection of the PPF, and partial resection of the pterygoid plates. These maneuvers open a bone window to accommodate the flap. The soft tissue tunnel, extending from the temporal to the infratemporal and then to the PPF, is opened with percutaneous tracheostomy dilators. We present a detailed description of the surgical technique and a retrospective review of two cases in which we used this technique. Two patients with large CSF fistulas who had undergone preoperative radiotherapy were reconstructed transposing the TPFF through a transpterygoid tunnel. We obtained an adequate exposure for placing the flap endonasally, and the flap provided complete coverage of the skull base defect. Both CSF leaks were resolved without any additional morbidity from the flap or the access technique. The TPFF is a reliable and versatile method for the reconstruction of the anterior, middle, clival, and parasellar skull base after EEAs. Its harvesting requires an external incision; thus, it is not our preferred method of reconstruction. It is recommended for large dural defects in patients with previous posterior septectomy and previous radiation treatment.

                Author and article information

                Role: ND
                Role: ND
                Role: ND
                Role: ND
                Revista Española de Cirugía Oral y Maxilofacial
                Rev Esp Cirug Oral y Maxilofac
                Sociedad Española de Cirugía Oral y Maxilofacial (Barcelona, Barcelona, Spain )
                December 2012
                : 34
                : 4
                : 172-179
                [02] Madrid orgnameHospital Universitario 12 de Octubre orgdiv1Servicio de Neurocirugía España
                [01] Madrid orgnameHospital Universitario 12 de Octubre orgdiv1Servicio de Cirugía Oral y Maxilofacial España

                This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

                : 23 September 2011
                : 11 April 2011
                Page count
                Figures: 0, Tables: 0, Equations: 0, References: 24, Pages: 8

                SciELO Spain

                Fístula de líquido cefalorraquídeo,Meningoencefalocele,Tratamiento endoscópico,Cerebrospinal fluid fistula,Meningoencephalocele,Endoscopic treatment


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