Journal of Korean Neurosurgical Society

The Korean Neurosurgical Society (대한신경외과학회)
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Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

  • Kim, Young-Hoon (Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine) ;
  • Kang, Ho (Department of Neurosurgery, Seoul National University Hospital) ;
  • Dho, Yun-Sik (Department of Neurosurgery, Chungbuk National University Hospital) ;
  • Hwang, Kihwan (Department of Neurosurgery, Seoul National University Bundang Hospital) ;
  • Joo, Jin-Deok (Department of Neurosurgery, Jeju National University Hospital) ;
  • Kim, Yong Hwy (Department of Neurosurgery, Seoul National University Hospital)
  • Received : 2020.08.11
  • Accepted : 2020.10.07
  • Published : 2021.07.01
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Abstract

Objective : The skull base reconstruction step, which prevents cerebrospinal fluid (CSF) leakage, is one of the most challenging steps in endoscopic skull base surgery (ESS). The purpose of this study was to assess the outcomes and complications of a reconstruction technique for immediate CSF leakage repair using multiple onlay grafts following ESS. Methods : A total of 230 consecutive patients who underwent skull base reconstruction using multiple onlay grafts with fibrin sealant patch (FSP), hydroxyapatite cement (HAC), and pedicled nasoseptal flap (PNF) for high-flow CSF leakage following ESS at three institutions were enrolled. We retrospectively reviewed the medical and radiological records to analyze the preoperative features and postoperative results. Results : The diagnoses included craniopharyngioma (46.8%), meningioma (34.0%), pituitary adenoma (5.3%), chordoma (1.6%), Rathke's cleft cyst (1.1%) and others (n=21, 11.2%). The trans-planum/tuberculum approach (94.3%) was the most commonly adapted surgical method, followed by the trans-sellar and transclival approaches. The third ventricle was opened in 78 patients (41.5%). Lumbar CSF drainage was not performed postoperatively in any of the patients. Postoperative CSF leakage occurred in four patients (1.7%) due to technical mistakes and were repaired with the same technique. However, postoperative meningitis occurred in 13.5% (n=31) of the patients, but no microorganisms were identified. The median latency to the diagnosis of meningitis was 8 days (range, 2-38). CSF leakage was the unique risk factor for postoperative meningitis (p<0.001). Conclusion : The use of multiple onlay grafts with FSP, HAC, and PNF is a reliable reconstruction technique that provides immediate and complete CSF leakage repair and mucosal grafting on the skull base without the need to harvest autologous tissue or perform postoperative CSF diversion. However, postoperative meningitis should be monitored carefully.

Keywords

Acknowledgement

This study is supported by a grant (No. 0520200030 to Kim YH) from Seoul National University Hospital. Authors would like to express our deepest appreciation to Mijin Jung for her support of medical illustrations.

References

  1. Abe T, Anan M, Kamida T, Fujiki M : Surgical technique for anterior skull base reconstruction using hydroxyapatite cement and titanium mesh. Acta Neurochir (Wien) 151 : 1337-1338, 2009 https://doi.org/10.1007/s00701-009-0392-4
  2. Acerbi F, Genden E, Bederson J : Circumferential watertight dural repair using nitinol U-clips in expanded endonasal and sublabial approaches to the cranial base. Neurosurgery 67(2 Suppl Operative) : 448-456, 2010
  3. Ahn JY, Kim SH : A new technique for dural suturing with fascia graft for cerebrospinal fluid leakage in transsphenoidal surgery. Neurosurgery 65(6 Suppl) : 65-71; discussion 71-72, 2009
  4. Alvarez Berastegui GR, Raza SM, Anand VK, Schwartz TH : Endonasal endoscopic transsphenoidal chiasmapexy using a clival cranial base cranioplasty for visual loss from massive empty sella following macroprolactinoma treatment with bromocriptine: case report. J Neurosurg 124 : 1025-1031, 2016 https://doi.org/10.3171/2015.2.JNS142015
  5. Arriaga MA, Chen DA : Hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma surgery. Otolaryngol Head Neck Surg 126 : 512-517, 2002 https://doi.org/10.1067/mhn.2002.124436
  6. Ascherman JA, Foo R, Nanda D, Parisien M : Reconstruction of cranial bone defects using a quick-setting hydroxyapatite cement and absorbable plates. J Craniofac Surg 19 : 1131-1135, 2008 https://doi.org/10.1097/SCS.0b013e31817bd83e
  7. Battaglia P, Turri-Zanoni M, Castelnuovo P, Prevedello DM, Carrau RL : Brain herniation after endoscopic transnasal resection of anterior skull base malignancies. Neurosurgery 11 Suppl 3 : 457-462; discussion 462, 2015
  8. Caggiano C, Penn DL, Laws ER Jr : The role of the lumbar drain in endoscopic endonasal skull base surgery: a retrospective analysis of 811 cases. World Neurosurg 117 : e575-e579, 2018 https://doi.org/10.1016/j.wneu.2018.06.090
  9. Cavallo LM, Messina A, Esposito F, de Divitiis O, Dal Fabbro M, de Divitiis E, et al. : Skull base reconstruction in the extended endoscopic transsphenoidal approach for suprasellar lesions. J Neurosurg 107 : 713-720, 2007 https://doi.org/10.3171/JNS-07/10/0713
  10. Chabot JD, Patel CR, Hughes MA, Wang EW, Snyderman CH, Gardner PA, et al. : Nasoseptal flap necrosis: a rare complication of endoscopic endonasal surgery. J Neurosurg 128 : 1463-1472, 2018 https://doi.org/10.3171/2017.2.JNS161582
  11. Chauvet D, Tran V, Mutlu G, George B, Allain JM : Study of dural suture watertightness: an in vitro comparison of different sealants. Acta Neurochir (Wien) 153 : 2465-2472, 2011 https://doi.org/10.1007/s00701-011-1197-9
  12. Chung SB, Nam DH, Park K, Kim JH, Kong DS : Injectable hydroxyapatite cement patch as an on-lay graft for the sellar reconstructions following endoscopic endonasal approach. Acta Neurochir (Wien) 154 : 659-664; discussion 664, 2012 https://doi.org/10.1007/s00701-012-1293-5
  13. Conger A, Zhao F, Wang X, Eisenberg A, Griffiths C, Esposito F, et al. : Evolution of the graded repair of CSF leaks and skull base defects in endonasal endoscopic tumor surgery: trends in repair failure and meningitis rates in 509 patients. J Neurosurg 130 : 861-875, 2018 https://doi.org/10.3171/2017.11.jns172141
  14. Dho YS, Kim YH, Se YB, Han DH, Kim JH, Park CK, et al. : Endoscopic endonasal approach for craniopharyngioma: the importance of the relationship between pituitary stalk and tumor. J Neurosurg 129 : 611-619, 2018 https://doi.org/10.3171/2017.4.JNS162143
  15. Druel B, Vandenesch F, Greenland T, Verneau V, Grando J, Salord F, et al. : Aseptic meningitis after neurosurgery: a demonstration of bacterial involvement. Clin Microbiol Infect 1 : 230-234, 1996 https://doi.org/10.1016/S1198-743X(15)60280-4
  16. Dusick JR, Esposito F, Kelly DF, Cohan P, DeSalles A, Becker DP, et al. : The extended direct endonasal transsphenoidal approach for nonadenomatous suprasellar tumors. J Neurosurg 102 : 832-841, 2005 https://doi.org/10.3171/jns.2005.102.5.0832
  17. Eloy JA, Shukla PA, Choudhry OJ, Singh R, Liu JK : Assessment of frontal lobe sagging after endoscopic endonasal transcribriform resection of anterior skull base tumors: is rigid structural reconstruction of the cranial base defect necessary? Laryngoscope 122 : 2652-2657, 2012 https://doi.org/10.1002/lary.23539
  18. Garcia-Navarro V, Anand VK, Schwartz TH : Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 80 : 563-568, 2013 https://doi.org/10.1016/j.wneu.2011.08.034
  19. Gardner P, Kassam A, Snyderman C, Mintz A, Carrau R, Moossy JJ : Endoscopic endonasal suturing of dural reconstruction grafts: a novel application of the U-Clip technology. Technical note. J Neurosurg 108 : 395-400, 2008 https://doi.org/10.3171/JNS/2008/108/2/0395
  20. George B, Matula C, Kihlstrom L, Ferrer E, Tetens V : Safety and efficacy of TachoSil (absorbable fibrin sealant patch) compared with current practice for the prevention of cerebrospinal fluid leaks in patients undergoing skull base surgery: a randomized controlled trial. Neurosurgery 80 : 847-853, 2017 https://doi.org/10.1093/neuros/nyx024
  21. Germani RM, Vivero R, Herzallah IR, Casiano RR : Endoscopic reconstruction of large anterior skull base defects using acellular dermal allograft. Am J Rhinol 21 : 615-618, 2007 https://doi.org/10.2500/ajr.2007.21.3080
  22. Gil Z, Abergel A, Leider-Trejo L, Khafif A, Margalit N, Amir A, et al. : A comprehensive algorithm for anterior skull base reconstruction after oncological resections. Skull Base 17 : 25-37, 2007 https://doi.org/10.1055/s-2006-959333
  23. Hanna AS, Grindle CR, Patel AA, Rosen MR, Evans JJ : Inadvertent insertion of nasogastric tube into the brain stem and spinal cord after endoscopic skull base surgery. Am J Otolaryngol 33 : 178-180, 2012 https://doi.org/10.1016/j.amjoto.2011.04.001
  24. Harvey RJ, Parmar P, Sacks R, Zanation AM : Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 122 : 452-459, 2012 https://doi.org/10.1002/lary.22475
  25. Hasegawa H, Shin M, Kondo K, Saito N : Reconstruction of dural defects in endoscopic transnasal approaches for intradural lesions using multilayered fascia with a pressure-control spinal drainage system. World Neurosurg 114 : e1316-e1324, 2018 https://doi.org/10.1016/j.wneu.2018.03.209
  26. Heymanns V, Oseni AW, Alyeldien A, Maslehaty H, Parvin R, Scholz M, et al. : Sandwich wound closure reduces the risk of cerebrospinal fluid leaks in posterior fossa surgery. Clin Pract 6 : 824, 2016 https://doi.org/10.4081/cp.2016.824
  27. Hoffmann TK, El Hindy N, Muller OM, Schuler PJ, Bergmann C, Hierner R, et al. : Vascularised local and free flaps in anterior skull base reconstruction. Eur Arch Otorhinolaryngol 270 : 899-907, 2013 https://doi.org/10.1007/s00405-012-2109-1
  28. Hong CK, Kim YB, Hong JB, Lee KS : Sealing of cerebrospinal fluid leakage during conventional transsphenoidal surgery using a fibrin-coated collagen fleece. J Clin Neurosci 22 : 696-699, 2015 https://doi.org/10.1016/j.jocn.2014.10.019
  29. Hong SD, Nam DH, Kong DS, Kim HY, Chung SK, Dhong HJ : Endoscopic modified transseptal transsphenoidal approach for maximal preservation of sinonasal quality of life and olfaction. World Neurosurg 87 : 162-169, 2016 https://doi.org/10.1016/j.wneu.2015.12.050
  30. Huang B, Ren Y, Wang C, Lan Z, Hui X, Liu W, et al. : Risk factors for postoperative meningitis after microsurgery for vestibular schwannoma. PLoS One 14 : e0217253, 2019 https://doi.org/10.1371/journal.pone.0217253
  31. Hutter G, von Felten S, Sailer MH, Schulz M, Mariani L : Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial. J Neurosurg 121 : 735-744, 2014 https://doi.org/10.3171/2014.6.JNS131917
  32. Ishikawa T, Takeuchi K, Nagata Y, Choo J, Kawabata T, Ishizaki T, et al. : Three types of dural suturing for closure of CSF leak after endoscopic transsphenoidal surgery. J Neurosurg 131 : 1625-1631, 2019 https://doi.org/10.3171/2018.4.JNS18366
  33. Jeon C, Hong SD, Seol HJ, Lee JI, Nam DH, Hwang YJ, et al. : Reconstructive outcome of intraoperative cerebrospinal fluid leak after endoscopic endonasal surgery for tumors involving skull base. J Clin Neurosci 45 : 227-231, 2017 https://doi.org/10.1016/j.jocn.2017.07.012
  34. Kaptain GJ, Vincent DA, Laws ER Jr : Cranial base reconstruction after transsphenoidal surgery with bioabsorbable implants. Neurosurgery 48 : 232-233; discussion 233-234, 2001 https://doi.org/10.1227/00006123-200101000-00048
  35. Kassam AB, Prevedello DM, Carrau RL, Snyderman CH, Thomas A, Gardner P, et al. : Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. J Neurosurg 114 : 1544-1568, 2011 https://doi.org/10.3171/2010.10.JNS09406
  36. Kim YH, Jeon C, Se YB, Hong SD, Seol HJ, Lee JI, et al. : Clinical outcomes of an endoscopic transclival and transpetrosal approach for primary skull base malignancies involving the clivus. J Neurosurg 128 : 1454-1462, 2018 https://doi.org/10.3171/2016.12.JNS161920
  37. Kitano M, Taneda M : Icing and multilayering technique of injectable hydroxyapatite cement paste for cranial base reconstruction after transsphenoidal surgery: technical note. Neurosurgery 61(3 Suppl) : E53-E54; discussion E54, 2007
  38. Kong DS, Hong CK, Hong SD, Nam DH, Lee JI, Seol HJ, et al. : Selection of endoscopic or transcranial surgery for tuberculum sellae meningiomas according to specific anatomical features: a retrospective multicenter analysis (KOSEN-002). J Neurosurg 130 : 838-847, 2018 https://doi.org/10.3171/2017.11.jns171337
  39. Koutourousiou M, Fernandez-Miranda JC, Stefko ST, Wang EW, Snyderman CH, Gardner PA : Endoscopic endonasal surgery for suprasellar meningiomas: experience with 75 patients. J Neurosurg 120 : 1326-1339, 2014 https://doi.org/10.3171/2014.2.JNS13767
  40. Kveton JF, Coelho DH : Hydroxyapatite cement in temporal bone surgery: a 10 year experience. Laryngoscope 114 : 33-37, 2004 https://doi.org/10.1097/00005537-200401000-00005
  41. Kveton JF, Goravalingappa R : Elimination of temporal bone cerebrospinal fluid otorrhea using hydroxyapatite cement. Laryngoscope 110(10 Pt 1) : 1655-1659, 2000 https://doi.org/10.1097/00005537-200010000-00016
  42. Lam K, Luong AU, Yao WC, Citardi MJ : Use of autologous fat grafts for the endoscopic reconstruction of skull base defects: indications, outcomes, and complications. Am J Rhinol Allergy 32 : 310-317, 2018 https://doi.org/10.1177/1945892418773637
  43. Lavigne P, Faden DL, Wang EW, Snyderman CH : Complications of nasoseptal flap reconstruction: a systematic review. J Neurol Surg B Skull Base 79(Suppl 4) : S291-S299, 2018 https://doi.org/10.1055/s-0038-1668158
  44. Leng LZ, Brown S, Anand VK, Schwartz TH : "Gasket-seal" watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62(5 Suppl 2) : ONSE342-ONSE343; discussion ONSE343, 2008
  45. Liu JK, Schmidt RF, Choudhry OJ, Shukla PA, Eloy JA : Surgical nuances for nasoseptal flap reconstruction of cranial base defects with high-flow cerebrospinal fluid leaks after endoscopic skull base surgery. Neurosurg Focus 32 : E7, 2012
  46. Luginbuhl AJ, Campbell PG, Evans J, Rosen M : Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 120 : 876-880, 2010 https://doi.org/10.1002/lary.20861
  47. Luryi AL, Schutt CA, Michaelides E, Kveton JF : Hydroxyapatite cement cranioplasty for translabyrinthine surgery: a single institution experience. Laryngoscope 130 : 206-211, 2020 https://doi.org/10.1002/lary.27907
  48. Matic D, Phillips JH : A contraindication for the use of hydroxyapatite cement in the pediatric population. Plast Reconstr Surg 110 : 1-5, 2002 https://doi.org/10.1097/00006534-200207000-00001
  49. Moon J, Kim N, Kim TJ, Jun JS, Lee HS, Shin HR, et al. : Rapid diagnosis of bacterial meningitis by nanopore 16S amplicon sequencing: a pilot study. Int J Med Microbiol 309 : 151338, 2019 https://doi.org/10.1016/j.ijmm.2019.151338
  50. Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V : Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg 14 : 144-153, 2003 https://doi.org/10.1097/00001665-200303000-00003
  51. Moussazadeh N, Prabhu V, Bander ED, Cusic RC, Tsiouris AJ, Anand VK, et al. : Endoscopic endonasal versus open transcranial resection of craniopharyngiomas: a case-matched single-institution analysis. Neurosurg Focus 41 : E7, 2016
  52. Oakley GM, Christensen JM, Winder M, Jonker BP, Davidson A, Steel T, et al. : Collagen matrix as an inlay in endoscopic skull base reconstruction. J Laryngol Otol 132 : 214-223, 2018 https://doi.org/10.1017/S0022215117001499
  53. Park JH, Choi JH, Kim YI, Kim SW, Hong YK : Modified graded repair of cerebrospinal fluid leaks in endoscopic endonasal transsphenoidal surgery. J Korean Neurosurg Soc 58 : 36-42, 2015 https://doi.org/10.3340/jkns.2015.58.1.36
  54. Phi JH, Kim YH, Kim JH, Kim DG : Clinical and anatomic features of supraglandular pituitary adenomas. World Neurosurg 92 : 241-248, 2016 https://doi.org/10.1016/j.wneu.2016.03.094
  55. Qiao N : Endocrine outcomes of endoscopic versus transcranial resection of craniopharyngiomas: a system review and meta-analysis. Clin Neurol Neurosurg 169 : 107-115, 2018 https://doi.org/10.1016/j.clineuro.2018.04.009
  56. Shorter CD, Connor DE Jr, Thakur JD, Gardner G, Nanda A, Guthikonda B : Repair of middle fossa cerebrospinal fluid leaks using a novel combination of materials: technical note. Neurosurg Focus 32 : E8, 2012
  57. So J, Park H, Sung KS, Lee KS, Hong CK : Sandwich technique using fibrin-coated collagen fleece for sellar reconstruction in large dural defects during transsphenoidal surgery. J Clin Neurosci 43 : 256-260, 2017 https://doi.org/10.1016/j.jocn.2017.06.026
  58. Soudry E, Turner JH, Nayak JV, Hwang PH : Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 150 : 730-738, 2014 https://doi.org/10.1177/0194599814520685
  59. Tabaee A, Anand VK, Brown SM, Lin JW, Schwartz TH : Algorithm for reconstruction after endoscopic pituitary and skull base surgery. Laryngoscope 117 : 1133-1137, 2007 https://doi.org/10.1097/MLG.0b013e31805c08c5
  60. Tews J, Jahromi BR, Ludtka C, Schwan S, Ota N, Meisel HJ, et al. : TachoSil dural reconstruction in extracranial-intracranial bypass surgeries. J Neurol Surg A Cent Eur Neurosurg 80 : 39-43, 2019 https://doi.org/10.1055/s-0038-1675565
  61. Volsky PG, Hillman TA, Stromberg KJ, Buchinsky FJ, Chen DA, Jackson NM, et al. : Hydroxyapatite cement cranioplasty following translabyrinthine approach: long-term study of 369 cases. Laryngoscope 127 : 2120-2125, 2017 https://doi.org/10.1002/lary.26403
  62. Yamada S, Fukuhara N, Yamaguchi-Okada M, Nishioka H, Takeshita A, Takeuchi Y, et al. : Therapeutic outcomes of transsphenoidal surgery in pediatric patients with craniopharyngiomas: a single-center study. J Neurosurg Pediatr 21 : 549-562, 2018 https://doi.org/10.3171/2017.10.PEDS17254
  63. Zwagerman NT, Geltzeiler MN, Wang EW, Fernandez-Miranda JC, Snyderman CH, Gardner PA : Endonasal suturing of nasoseptal flap to nasopharyngeal fascia using the V-Loc™ wound closure device: 2-dimensional operative video. Oper Neurosurg (Hagerstown) 16 : 40-41, 2019
  64. Zwagerman NT, Wang EW, Shin SS, Chang YF, Fernandez-Miranda JC, Snyderman CH, et al. : Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 131 : 1172-1178, 2019 https://doi.org/10.3171/2018.4.JNS172447