J Korean Neurosurg Soc.  2021 Jul;64(4):619-630. 10.3340/jkns.2020.0231.

Multi-Layer Onlay Graft Using Hydroxyapatite Cement Placement without Cerebrospinal Fluid Diversion for Endoscopic Skull Base Reconstruction

• Kim YH
• Kang H
• Dho YS
• Hwang K
• Joo JD
• Kim YH

• KMID: 2517694
• DOI: http://doi.org/10.3340/jkns.2020.0231

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.

Keyword

Skull base neoplasms; Cerebrospinal fluid leak; Hydroxyapatite cement; Endoscopy

Figure

• 

  Fig. 1. Preoperative MR images (A, B, G, H, M, N, S, and T) and CT scans (C, I, O, and U). The postoperative MR images (D, E, J, K, P, Q, V, and W) showed no artifacts due to the reconstruction the immediate postoperative CT scan (F, L, R, and X). The extent of the HAC covering the skull base bone could be evaluated with the immediate postoperative CT scans (F, L, R, and X). A-F : Tuberculum sellae meningioma. G-L : Craniopharyngioma. M-R : Pituitary adenoma. S-X : Chordoma. Pre- and post-operative MR images and CT scans of representative diseases. The postoperative MR images showed the well-enhanced PNF and no artifact by the reconstruction materials. The postoperative CT scans is useful to evaluate the extent of the HAC covering the skull base bone. A-F : Preoperative MR images (A and B) and CT scan (C) of tuberculum sellae meningioma with postoperative MR images (D and E) and CT scans (F) after trans-tuberculum approach. G-L : Preoperative MR images (G and H) and CT scan (I) of craniopharyngioma. The postoperative MR images (J and K) and CT scans (L) showed the well-reconstructed skull base after trans-tuberculum and trans-clivus approach with resection of dorsum sellae. M-R : Preoperative MR images (M and N) of giant pituitary adenoma with lateral extension. The preoperative CT scan (O) showed the preserved tuberculum and sellar floor. Postoperative MR images (P and Q) and CT scan (R) showed the clear sphenoid sinus and surgical window of trans-sella approach. S-X : Preoperative MR images (S and T) and CT scans (U) showed the displaced pituitary gland upwardly and destructed clivus and dorsum sellae by the tumor. Postoperative MR images and CT scans (V-X) showed the normally located pituitary gland with the rigid support by the HAC. MR : magnetic resonance, CT : computed tomography, HAC : hydroxyapatite cement.

• 

  Fig. 2. Illustrations for steps of the multiple onlayers watertight reconstruction in trans-tuberculum approaches. A and B : Intraoperative (A) and sagittal (B) view of the skull base defect. C and D : The complete onlayer sealing of bony defect with FSPs achieved a temporary watertight barrier. E and F : The HAC were injected and layered on the FSPs and surrounding denuded skull base bone along the margin of the FSP. G and H : The consolidated HAC in the dry state was covered by the PNF, and the attachment of the PNF to the denuded bone around the HAC was confirmed. FSP : fibrin sealant patch, HAC : hydroxyapatite cement, PNF : pedicled nasoseptal flap.

Reference

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