Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair.

Background: Endoscopic repair of cerebrospinal fluid (CSF) leaks is a well-established procedure. The radiological workup and use of intraoperative image guidance (IGS), lumbar drain (LD), and intrathecal fluorescein (IF) are less universally accepted. This study examines endoscopic repair of CSF leaks using preoperative high-resolution CT (HRCT) and intraoperative IGS without IF or LD.

Methods: Retrospective review was performed of a single surgeon experience between September 2002 and January 2007.

Results: Forty-two anterior skull base defects in 40 patients were repaired endoscopically. The etiology of CSF leaks was traumatic in 5, spontaneous in 12, and iatrogenic in 25 defects (15 from endoscopic sinus surgeries and 10 from neurosurgical procedures). Fifty-two percent of defects presented with a meningoencephalocele. Defect location was sphenoid sinus (17 defects), ethmoid roof (14 defects), cribriform plate (9 defects), and frontal sinus (2 defects). Defect size ranged from 1x1 mm to 2x2 cm. Follow-up ranged from 8 to 46 months. All defects were identified preoperatively on HRCT with successful intraoperative IGS localization. No patients required IF for identification of CSF leak. Overall successful repair was achieved in 40 (95%) defects after initial repair, and 100% after revision. Seven patients had LD, 6 patients were early in the series. Twenty-three patients were discharged the day after surgery and 6 patients were discharged on day 2.

Conclusion: Using preoperative HRCT for diagnosis and intraoperative IGS for localization, even small skull base defects can be definitively identified. High success rates and early discharges are achieved without additional procedures such as IF or LD. This is a less invasive and more cost-efficient method of repairing CSF leaks.