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http://dx.doi.org/10.3340/jkns.2020.0231

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)
Publication Information
Journal of Korean Neurosurgical Society / v.64, no.4, 2021 , pp. 619-630 More about this Journal
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
Skull base neoplasms; Cerebrospinal fluid leak; Hydroxyapatite cement; Endoscopy;
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