Factors affecting postoperative cerebrospinal fluid leaks after retrosigmoidal craniotomy for vestibular schwannomas

Clinical article

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Object

The aim of this study was to identify patients likely to develop CSF leaks after vestibular schwannoma surgery using a retrospective analysis for the identification of risk factors.

Methods

Between January 2001 and December 2006, 420 patients underwent retrosigmoidal microsurgical tumor removal in a standardized procedure. Of these 420 patients, 363 underwent treatment for the first time, and 27 suffered from recurrent tumors. Twenty-six patients had bilateral tumors due to neurofibromatosis Type 2, and 4 patients had previously undergone radiosurgical treatment. An analysis was performed to examine the incidence of postoperative CSF fistulas in all 4 groups.

Results

The incidence of CSF leakage was higher in the tumor recurrence group (11.1%) than in patients undergoing surgery for the first time (4.4%). There were no CSF fistulas in the neurofibromatosis Type 2 group or in patients with preoperative radiosurgical treatment. Tumor size was identified as a possible risk factor in a previous study.

Conclusions

Surgery for recurrent tumors is a significant risk factor for the development of CSF leaks.

Abbreviations used in this paper:CPA = cerebellopontine angle; GKS = Gamma Knife surgery; IAC = internal auditory canal; ICP = intracranial pressure; NF2 = neurofibromatosis Type 2; VS = vestibular schwannoma.

Article Information

Address correspondence to: Lennart H. Stieglitz, M.D., International Neuroscience Institute, Rudolf Pichlmayr Strasse 4, 30625 Hannover, Germany. email:lennart@stieglitze.de.

Please include this information when citing this paper: published online March 27, 2009; DOI: 10.3171/2009.2.JNS081380.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Flowchart used for detection and management of postoperative CSF fistulas in this study. The patient was informed about the risk of postoperative CSF fistulas and about recommendations to avoid elevation of the ICP postoperatively during the informed consent process. This information was given again directly after surgery. During the surgical procedure all opened air cells in the posterior wall of the IAC and around the craniotomy were sealed with muscle or fat tissue and fibrin glue. Patients suspected of having a CSF fistula underwent a provocation test, which leads to increased ICP. Fistulas were treated with continuous lumbar CSF drainage for 7 days. Success of the conservative treatment was examined using another provocation test after closure of the drainage. In cases of continued CSF fistulas, the patients underwent surgical revision.

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    Schematic drawings representing the tumor classification system used in the study. Tumor size was measured according to intra- and extrameatal tumor extension using the methodology described by Samii and Matthies: Neurosurgery 40:11–23, 1997. A: Class T1, intrameatal tumor. B: Class T2, intra- and extrameatal tumor. C: Class T3a, filling the cerebellopontine cistern. D: Class T3b, tumor reaches the brainstem. E: Class T4a, tumor compresses the brainstem. F: Class T4b, dislocation of the brainstem and compression of the fourth ventricle, leading to occlusive hydrocephalus.

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