Correlation of spontaneous and traumatic anterior skull base CSF leak flow rates with fluid pattern on early, delayed, and subtraction volumetric extended echo train T2-weighted MRI

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OBJECTIVE

CSF leakage is a potentially fatal condition that may result when a skull base dural defect permits CSF communication between the cranial vault and sinonasal cavities. Flow rate is an important property of CSF leaks that can contribute to surgical decision-making and predispose patients to complications and inferior outcomes. Noninvasive preoperative prediction of the leak rate is challenging with traditional diagnostic tools. The present study compares fluid configurations on early and late volumetric extended echo train T2-weighted MRI by using image tracings and sequence subtraction as a novel method of quantifying CSF flow rate, and it correlates radiological results with intraoperative findings and clinical outcomes.

METHODS

A total of 45 patients met inclusion criteria for this study and underwent 3-T MRI. Imaging sequences included two identical CUBE T2 (vendor trade name for volumetric extended echo train T2) acquisitions at the beginning and end of the scanning session, approximately 45 minutes apart. Twenty-five patients were confirmed to have definitive spontaneous or traumatic anterior skull base CSF leaks. Semiautomated volumetric segmentation of CSF intensity was performed on both CUBE data sets by using 3D-Slicer software, and volumes were subtracted to obtain accumulated CSF volume. These imaging-derived fluid accumulations were correlated with high- or low-flow states, as well as ultimate treatment outcomes including recurrences.

RESULTS

Of the 45 patients, 25 (55.6%) had definitive evidence of CSF leakage, and 22 (88%) of these underwent surgical repair. Patients with high-flow CSF leaks had higher early (4.058 cm3 vs 0.982 cm3, p = 0.04), late (4.58 cm3 vs 1.096 cm3, p = 0.04), and accumulated (0.53 cm3 vs 0.11 cm3, p = 0.01) fluid volume measurements than patients with low-flow leaks. The 5 (22.7%) patients who exhibited postoperative CSF leak recurrence had significantly greater early (6.30 cm3 vs 1.23 cm3, p = 0.008) and late (6.87 cm3 vs 1.45 cm3, p = 0.008) volumes. Accumulated volume was not significantly greater in patients with leak recurrence (0.58 cm3 vs 0.22 cm3, p = 0.07). Early, late, and accumulated volumes were significantly correlated with postoperative hospital stay as well as duration of postoperative lumbar drain placement (p < 0.05 for all measures).

CONCLUSIONS

High-resolution CUBE T2 MRI, coupled with precise volumetric segmentation and subtraction of sinonasal hyperintensity, not only demonstrated predictive value in differentiating low- and high-flow CSF leaks, but also correlated with postoperative complications such as leak recurrence. These findings may be useful in the clinical workup and neurosurgical management of patients with skull base CSF leaks.

ABBREVIATIONS BMI = body mass index; VP = ventriculoperitoneal.
Article Information

Contributor Notes

Correspondence John W. Rutland: Icahn School of Medicine at Mount Sinai, New York, NY. jack.rutland@icahn.mssm.edu.INCLUDE WHEN CITING Published online December 27, 2019; DOI: 10.3171/2019.10.JNS192500.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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References
  • 1

    Ahmed OHMarcus STauber JRWang BFang YLebowitz RA: Efficacy of perioperative lumbar drainage following endonasal endoscopic cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 156:52602017

    • Search Google Scholar
    • Export Citation
  • 2

    Barger JSiow MKader MPhillips KFatterpekar GKleinberg D: The posterior nasoseptal flap: a novel technique for closure after endoscopic transsphenoidal resection of pituitary adenomas. Surg Neurol Int 9:322018

    • Search Google Scholar
    • Export Citation
  • 3

    Bernal-Sprekelsen MAlobid IMullol JTrobat FTomás-Barberán M: Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis. Rhinology 43:2772812005

    • Search Google Scholar
    • Export Citation
  • 4

    Carrau RLSnyderman CHKassam AB: The management of cerebrospinal fluid leaks in patients at risk for high-pressure hydrocephalus. Laryngoscope 115:2052122005

    • Search Google Scholar
    • Export Citation
  • 5

    Casiano RRJassir D: Endoscopic cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary? Otolaryngol Head Neck Surg 121:7457501999

    • Search Google Scholar
    • Export Citation
  • 6

    Chaaban MRIlling ERiley KOWoodworth BA: Spontaneous cerebrospinal fluid leak repair: a five-year prospective evaluation. Laryngoscope 124:70752014

    • Search Google Scholar
    • Export Citation
  • 7

    Conger AZhao FWang XEisenberg AGriffiths CEsposito F: 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 130:8618752018

    • Search Google Scholar
    • Export Citation
  • 8

    Cukurova ICetinkaya EAAslan IBOzkul D: Endonasal endoscopic repair of ethmoid roof cerebrospinal fluid fistula by suturing the dura. Acta Neurochir (Wien) 150:8979002008

    • Search Google Scholar
    • Export Citation
  • 9

    D’Anza BTien DStokken JKRecinos PFWoodard TRSindwani R: Role of lumbar drains in contemporary endonasal skull base surgery: meta-analysis and systematic review. Am J Rhinol Allergy 30:4304352016

    • Search Google Scholar
    • Export Citation
  • 10

    Ecin GOner AYTokgoz NUcar MAykol STali T: T2-weighted vs. intrathecal contrast-enhanced MR cisternography in the evaluation of CSF rhinorrhea. Acta Radiol 54:6987012013

    • Search Google Scholar
    • Export Citation
  • 11

    Esposito FDusick JRFatemi NKelly DF: Graded repair of cranial base defects and cerebrospinal fluid leaks in transsphenoidal surgery. Oper Neurosurg (Hagerstown) 60 (4 Suppl 2):2953042007

    • Search Google Scholar
    • Export Citation
  • 12

    Fedorov ABeichel RKalpathy-Cramer JFinet JFillion-Robin JCPujol S: 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging 30:132313412012

    • Search Google Scholar
    • Export Citation
  • 13

    Harvey RJParmar PSacks RZanation AM: Endoscopic skull base reconstruction of large dural defects: a systematic review of published evidence. Laryngoscope 122:4524592012

    • Search Google Scholar
    • Export Citation
  • 14

    Hegazy HMCarrau RLSnyderman CHKassam AZweig J: Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Laryngoscope 110:116611722000

    • Search Google Scholar
    • Export Citation
  • 15

    Hu FGu YZhang XXie TYu YSun C: Combined use of a gasket seal closure and a vascularized pedicle nasoseptal flap multilayered reconstruction technique for high-flow cerebrospinal fluid leaks after endonasal endoscopic skull base surgery. World Neurosurg 83:1811872015

    • Search Google Scholar
    • Export Citation
  • 16

    Liu PWu SLi ZWang B: Surgical strategy for cerebrospinal fluid rhinorrhea repair. Neurosurgery 66 (6 Suppl Operative):2812862010

    • Search Google Scholar
    • Export Citation
  • 17

    Lobo BCBaumanis MMNelson RF: Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: a systematic review. Laryngoscope Investig Otolaryngol 2:2152242017

    • Search Google Scholar
    • Export Citation
  • 18

    Luetmer PHMokri B: Dynamic CT myelography: a technique for localizing high-flow spinal cerebrospinal fluid leaks. AJNR Am J Neuroradiol 24:171117142003

    • Search Google Scholar
    • Export Citation
  • 19

    Luginbuhl AJCampbell PGEvans JRosen M: Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope 120:8768802010

    • Search Google Scholar
    • Export Citation
  • 20

    Maher COMeyer FBMokri B: Surgical treatment of spontaneous spinal cerebrospinal fluid leaks. Neurosurg Focus 9(1):e72000

  • 21

    McCoul EDAnand VKSingh ANyquist GGSchaberg MRSchwartz TH: Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 81:1361432014

    • Search Google Scholar
    • Export Citation
  • 22

    Meier JCBleier BS: Novel techniques and the future of skull base reconstruction. Adv Otorhinolaryngol 74:1741832013

  • 23

    O’Connell JE: Primary spontaneous cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry 27:2412461964

  • 24

    Ommaya AK: Cerebrospinal fluid rhinorrhea. Neurology 14:1061131964

  • 25

    Patel KSKomotar RJSzentirmai OMoussazadeh NRaper DMStarke RM: Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. J Neurosurg 119:6616682013

    • Search Google Scholar
    • Export Citation
  • 26

    Purkey MTWoodworth BAHahn SPalmer JNChiu AG: Endoscopic repair of supraorbital ethmoid cerebrospinal fluid leaks. ORL J Otorhinolaryngol Relat Spec 71:93982009

    • Search Google Scholar
    • Export Citation
  • 27

    Schievink WI: Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension. JAMA 295:228622962006

  • 28

    Schlosser RJWilensky EMGrady MSBolger WE: Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol 17:1911952003

    • Search Google Scholar
    • Export Citation
  • 29

    Schlosser RJWilensky EMGrady MSPalmer JNKennedy DWBolger WE: Cerebrospinal fluid pressure monitoring after repair of cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 130:4434482004

    • Search Google Scholar
    • Export Citation
  • 30

    Senior BAJafri KBenninger M: Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society. Am J Rhinol 15:21252001

    • Search Google Scholar
    • Export Citation
  • 31

    Soudry ETurner JHNayak JVHwang PH: Endoscopic reconstruction of surgically created skull base defects: a systematic review. Otolaryngol Head Neck Surg 150:7307382014

    • Search Google Scholar
    • Export Citation
  • 32

    Spetzler RFWilson CB: Management of recurrent CSF rhinorrhea of the middle and posterior fossa. J Neurosurg 49:3933971978

  • 33

    Thorp BDSreenath SBEbert CSZanation AM: Endoscopic skull base reconstruction: a review and clinical case series of 152 vascularized flaps used for surgical skull base defects in the setting of intraoperative cerebrospinal fluid leak. Neurosurg Focus 37(4):E42014

    • Search Google Scholar
    • Export Citation
  • 34

    Yadav YRParihar VJanakiram NPande SBajaj JNamdev H: Endoscopic management of cerebrospinal fluid rhinorrhea. Asian J Neurosurg 11:1831932016

    • Search Google Scholar
    • Export Citation
  • 35

    Ziu MSavage JGJimenez DF: Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures. Neurosurg Focus 32(6):E32012

    • Search Google Scholar
    • Export Citation
  • 36

    Zwagerman NTWang EWShin SSChang YFFernandez-Miranda JCSnyderman CH: Does lumbar drainage reduce postoperative cerebrospinal fluid leak after endoscopic endonasal skull base surgery? A prospective, randomized controlled trial. J Neurosurg 131:117211782018

    • Search Google Scholar
    • Export Citation
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