Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks

Clinical article

Matei A. Banu M.D. 1 , Oszkar Szentirmai M.D. 1 , Lino Mascarenhas M.D. 1 , Al Amin Salek M.B.B.S., M.C.P.S., F.C.P.S., M.R.C.S. 1 , Vijay K. Anand M.D. 2 and Theodore H. Schwartz M.D. 1 , 2 , 3
View More View Less
  • 1 Departments of Neurological Surgery, Brain and Spine Center,
  • 2 Otolaryngology—Head and Neck Surgery, and
  • 3 Neurology and Neuroscience, Brain and Mind Institute, Weill Cornell Medical College, NewYork Presbyterian Hospital, New York, New York
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

Postoperative pneumocephalus is a common occurrence after endoscopic endonasal skull base surgery (ESBS). The risk of cerebrospinal fluid (CSF) leaks can be high and the presence of postoperative pneumocephalus associated with serosanguineous nasal drainage may raise suspicion for a CSF leak. The authors hypothesized that specific patterns of pneumocephalus on postoperative imaging could be predictive of CSF leaks. Identification of these patterns could guide the postoperative management of patients undergoing ESBS.

Methods

The authors queried a prospectively acquired database of 526 consecutive ESBS cases at a single center between December 1, 2003, and May 31, 2012, and identified 258 patients with an intraoperative CSF leak documented using intrathecal fluorescein. Postoperative CT and MRI scans obtained within 1–10 days were examined and pneumocephalus was graded based on location and amount. A discrete 0–4 scale was used to classify pneumocephalus patterns based on size and morphology. Pneumocephalus was correlated with the surgical approach, histopathological diagnosis, and presence of a postoperative CSF leak.

Results

The mean follow-up duration was 56.7 months. Of the 258 patients, 102 (39.5%) demonstrated pneumocephalus on postoperative imaging. The most frequent location of pneumocephalus was frontal (73 [71.5%] of 102), intraventricular (34 [33.3%]), and convexity (22 [21.6%]). Patients with craniopharyngioma (27 [87%] of 31) and meningioma (23 [68%] of 34) had the highest incidence of postoperative pneumocephalus compared with patients with pituitary adenomas (29 [20.6%] of 141) (p < 0.0001). The incidence of pneumocephalus was higher with transcribriform and transethmoidal approaches (8 of [73%] 11) than with a transsellar approach (9 of [7%] 131). There were 15 (5.8%) of 258 cases of postoperative CSF leak, of which 10 (66.7%) had pneumocephalus, compared with 92 (38%) of 243 patients without a postoperative CSF leak (OR 3.3, p = 0.027). Pneumocephalus located in the convexity, interhemispheric fissure, sellar region, parasellar region, and perimesencephalic region was significantly correlated with a postoperative CSF leak (OR 4.9, p = 0.006) and was therefore termed “suspicious” pneumocephalus. In contrast, frontal or intraventricular pneumocephalus was not correlated with postoperative CSF leak (not significant) and was defined as “benign” pneumocephalus. The amount of convexity pneumocephalus (p = 0.002), interhemispheric pneumocephalus (p = 0.005), and parasellar pneumocephalus (p = 0.007) (determined using a scale score of 0–4) was also significantly related to postoperative CSF leaks. Using a series of permutation-based multivariate analyses, the authors established that a model containing the learning curve, the transclival/transcavernous approach, and the presence of “suspicious” pneumocephalus provides the best overall prediction for postoperative CSF leaks.

Conclusions

Postoperative pneumocephalus is much more common following extended approaches than following transsellar surgery. Merely the presence of pneumocephalus, particularly in the frontal or intraventricular locations, is not necessarily associated with a postoperative CSF leak. A “suspicious” pattern of air, namely pneumocephalus in the convexity, interhemispheric fissure, sella, parasellar, or perimesencephalic locations, is significantly associated with a postoperative CSF leak. The presence and the score of “suspicious” pneumocephalus on postoperative imaging, in conjunction with the learning curve and the type of endoscopic approach, provide the best predictive model for postoperative CSF leaks.

Abbreviations used in this paper:BMI = body mass index; ESBS = endonasal skull base surgery; NTR = near-total resection; STR = subtotal resection.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Theodore H. Schwartz, M.D., Weill Cornell Medical College, 525 E. 68th St., Box 99, New York, NY 10065. email: schwarh@med.cornell.edu.

Please include this information when citing this paper: published online July 4, 2014; DOI: 10.3171/2014.5.JNS132028.

  • 1

    Banu MA, , Kim JH, , Shin BJ, , Woodworth GF, , Anand VK, & Schwartz TH: Low-dose intrathecal fluorescein and etiologybased graft choice in endoscopic endonasal closure of CSF leaks. Clin Neurol Neurosurg 116:2834, 2014

    • Search Google Scholar
    • Export Citation
  • 2

    Clark DW, , Citardi MJ, & Fakhri S: Endoscopic management of skull base defects associated with persistent pneumocephalus following previous open repair: a preliminary report. Otolaryngol Head Neck Surg 142:820826, 2010

    • Search Google Scholar
    • Export Citation
  • 3

    Clevens RA, , Marentette LJ, , Esclamado RM, , Wolf GT, & Ross DA: Incidence and management of tension pneumocephalus after anterior craniofacial resection: case reports and review of the literature. Otolaryngol Head Neck Surg 120:579583, 1999

    • Search Google Scholar
    • Export Citation
  • 4

    Dlouhy BJ, , Madhavan K, , Clinger JD, , Reddy A, , Dawson JD, & O'Brien EK, : Elevated body mass index and risk of postoperative CSF leak following transsphenoidal surgery. Clinical article. J Neurosurg 116:13111317, 2012

    • Search Google Scholar
    • Export Citation
  • 5

    Fatemi N, , Dusick JR, , de Paiva Neto MA, & Kelly DF: The endonasal microscopic approach for pituitary adenomas and other parasellar tumors: a 10-year experience. Neurosurgery 63:4 Suppl 2 244256, 2008

    • Search Google Scholar
    • Export Citation
  • 6

    Feiz-Erfan I, , Han PP, , Spetzler RF, , Horn EM, , Klopfenstein JD, & Porter RW, : The radical transbasal approach for resection of anterior and midline skull base lesions. J Neurosurg 103:485490, 2005

    • Search Google Scholar
    • Export Citation
  • 7

    Fraser JF, , Nyquist GG, , Moore N, , Anand VK, & Schwartz TH: Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Neurosurgery 67:3 Suppl Operative ons150ons158, 2010

    • Search Google Scholar
    • Export Citation
  • 8

    Garcia-Navarro V, , Anand VK, & Schwartz TH: Gasket seal closure for extended endonasal endoscopic skull base surgery: efficacy in a large case series. World Neurosurg 80:563568, 2013

    • Search Google Scholar
    • Export Citation
  • 9

    Greenfield JP, , Anand VK, , Kacker A, , Seibert MJ, , Singh A, & Brown SM, : Endoscopic endonasal transethmoidal transcribriform transfovea ethmoidalis approach to the anterior cranial fossa and skull base. Neurosurgery 66:883892, 2010

    • Search Google Scholar
    • Export Citation
  • 10

    Harvey RJ, , Smith JE, , Wise SK, , Patel SJ, , Frankel BM, & Schlosser RJ: Intracranial complications before and after endoscopic skull base reconstruction. Am J Rhinol 22:516521, 2008

    • Search Google Scholar
    • Export Citation
  • 11

    Hofstetter CP, , Shin BJ, , Mubita L, , Huang C, , Anand VK, & Boockvar JA, : Endoscopic endonasal transsphenoidal surgery for functional pituitary adenomas. Neurosurg Focus 30:4 E10, 2011

    • Search Google Scholar
    • Export Citation
  • 12

    Hofstetter CP, , Singh A, , Anand VK, , Kacker A, & Schwartz TH: The endoscopic, endonasal, transmaxillary transpterygoid approach to the pterygopalatine fossa, infratemporal fossa, petrous apex, and the Meckel cave. Clinical article. J Neurosurg 113:967974, 2010

    • Search Google Scholar
    • Export Citation
  • 13

    Horridge M, , Jesurasa A, , Olubajo F, , Mirza S, & Sinha S: The use of the nasoseptal flap to reduce the rate of post-operative cerebrospinal fluid leaks following endoscopic trans-sphenoidal surgery for pituitary disease. Br J Neurosurg 27:739741, 2013

    • Search Google Scholar
    • Export Citation
  • 14

    Jakimovski D, , Bonci G, , Attia M, , Shao H, , Hofstetter C, & Tsiouris AJ, : Incidence and significance of intraoperative cerebrospinal fluid leak in endoscopic pituitary surgery using intrathecal fluorescein. World Neurosurg [epub ahead of print] 2013

    • Search Google Scholar
    • Export Citation
  • 15

    Javan R, , Duszak R Jr, , Eisenberg AD, & Eggers FM: Spontaneous pneumocephalus after commercial air travel complicated by meningitis. Aviat Space Environ Med 82:11531156, 2011

    • Search Google Scholar
    • Export Citation
  • 16

    Jelsma F, & Moore DF: Cranial aerocele. Am J Surg 87:437451, 1954

  • 17

    Jensen MB, & Adams HP: Pneumocephalus after air travel. Neurology 63:400401, 2004

  • 18

    Kapoor T, & Shetty P: Pneumocephalus. J Emerg Med 35:453454, 2008

  • 19

    Kassam AB, , Prevedello DM, , Carrau RL, , Snyderman CH, , Thomas A, & Gardner P, : Endoscopic endonasal skull base surgery: analysis of complications in the authors' initial 800 patients. A review. J Neurosurg 114:15441568, 2011

    • Search Google Scholar
    • Export Citation
  • 20

    Kassam AB, , Thomas A, , Carrau RL, , Snyderman CH, , Vescan A, & Prevedello D, : Endoscopic reconstruction of the cranial base using a pedicled nasoseptal flap. Neurosurgery 63:1 Suppl 1 ONS44ONS53, 2008

    • Search Google Scholar
    • Export Citation
  • 21

    Keskil S, , Baykaner K, , Ceviker N, , Işik S, , Cengel M, & Orbay T: Clinical significance of acute traumatic intracranial pneumocephalus. Neurosurg Rev 21:1013, 1998

    • Search Google Scholar
    • Export Citation
  • 22

    Komotar RJ, , Starke RM, , Raper DM, , Anand VK, & Schwartz TH: Endoscopic endonasal versus open repair of anterior skull base CSF leak, meningocele, and encephalocele: a systematic review of outcomes. J Neurol Surg A Cent Eur Neurosurg 74:239250, 2013

    • Search Google Scholar
    • Export Citation
  • 23

    Komotar RJ, , Starke RM, , Raper DM, , Anand VK, & Schwartz TH: Endoscopic skull base surgery: a comprehensive comparison with open transcranial approaches. Br J Neurosurg 26:637648, 2012

    • Search Google Scholar
    • Export Citation
  • 24

    Kraus DH, , Shah JP, , Arbit E, , Galicich JH, & Strong EW: Complications of craniofacial resection for tumors involving the anterior skull base. Head Neck 16:307312, 1994

    • Search Google Scholar
    • Export Citation
  • 25

    Leng LZ, , Brown S, , Anand VK, & Schwartz TH: “Gasket-seal” watertight closure in minimal-access endoscopic cranial base surgery. Neurosurgery 62:5 Suppl 2 ONSE342ONSE343, 2008

    • Search Google Scholar
    • Export Citation
  • 26

    Leng LZ, , Greenfield JP, , Souweidane MM, , Anand VK, & Schwartz TH: Endoscopic, endonasal resection of craniopharyngiomas: analysis of outcome including extent of resection, cerebrospinal fluid leak, return to preoperative productivity, and body mass index. Neurosurgery 70:110124, 2012

    • Search Google Scholar
    • Export Citation
  • 27

    Levine PA, , Scher RL, , Jane JA, , Persing JA, , Newman SA, & Miller J, : The craniofacial resection—eleven-year experience at the University of Virginia: problems and solutions. Otolaryngol Head Neck Surg 101:665669, 1989

    • Search Google Scholar
    • Export Citation
  • 28

    Mammis A, , Agarwal N, , Eloy JA, & Liu JK: Intraventricular tension pneumocephalus after endoscopic skull base surgery. J Neurol Surg A Cent Eur Neurosurg 74:Suppl 1 e96e99, 2013

    • Search Google Scholar
    • Export Citation
  • 29

    Markham JW: The clinical features of pneumocephalus based upon a survey of 284 cases with report of 11 additional cases. Acta Neurochir (Wien) 16:178, 1967

    • Search Google Scholar
    • Export Citation
  • 30

    Mascarenhas L, , Moshel YA, , Bayad F, , Szentirmai O, , Salek AA, & Leng LZ, : The transplanum transtuberculum approaches for suprasellar and sellar-suprasellar lesions: avoidance of cerebrospinal fluid leak and lessons learned. World Neurosurg [epub ahead of print] 2013

    • Search Google Scholar
    • Export Citation
  • 31

    McCoul ED, , Anand VK, , Singh A, , Nyquist GG, , Schaberg MR, & Schwartz TH: Long-term effectiveness of a reconstructive protocol using the nasoseptal flap after endoscopic skull base surgery. World Neurosurg 81:136143, 2014

    • Search Google Scholar
    • Export Citation
  • 32

    Mohammed R, & Profant M: Spontaneous otogenic pneumocephalus. Acta Otolaryngol 131:670674, 2011

  • 33

    Muscatello L, , Dallan I, , Seccia V, , Marchetti M, , Sellari-Franceschini S, & Lenzi R: Endoscopic endonasal craniotomy in the management of selected ethmoidal malignancies: the University of Pisa experience. J Craniomaxillofac Surg 39:619623, 2011

    • Search Google Scholar
    • Export Citation
  • 34

    Newbold RG, , Wiener MD, , Vogler JB III, & Martinez S: Traumatic pneumorrhachis. AJR Am J Roentgenol 148:615616, 1987

  • 35

    Nyquist GG, , Anand VK, , Mehra S, , Kacker A, & Schwartz TH: Endoscopic endonasal repair of anterior skull base non-traumatic cerebrospinal fluid leaks, meningoceles, and encephaloceles. Clinical article. J Neurosurg 113:961966, 2010

    • Search Google Scholar
    • Export Citation
  • 36

    Osborn AG, , Daines JH, , Wing SD, & Anderson RE: Intracranial air on computerized tomography. J Neurosurg 48:355359, 1978

  • 37

    Palma JA, , Zubieta JL, , Dominguez PD, & Garcia-Eulate R: Pneumocephalus mimicking cerebral cavernous malformations in MR susceptibility-weighted imaging. AJNR Am J Neuroradiol 30:e83e84, 2009. (Erratum in AJNR Am J Neuroradiol 30: E112, 2009)

    • Search Google Scholar
    • Export Citation
  • 38

    Patel KS, , Komotar RJ, , Szentirmai O, , Moussazadeh N, , Raper DM, & Starke RM, : Case-specific protocol to reduce cerebrospinal fluid leakage after endonasal endoscopic surgery. Clinical article. J Neurosurg 119:661668, 2013

    • Search Google Scholar
    • Export Citation
  • 39

    Placantonakis DG, , Tabaee A, , Anand VK, , Hiltzik D, & Schwartz TH: Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 61:3 Suppl 161166, 2007

    • Search Google Scholar
    • Export Citation
  • 40

    Poole MD: Complications in craniofacial surgery. Br J Plast Surg 41:608613, 1988

  • 41

    Raza SM, , Garzon-Muvdi T, , Gallia GL, & Tamargo RJ: Craniofacial resection of midline anterior skull base malignancies: a reassessment of outcomes in the modern era. World Neurosurg 78:128136, 2012

    • Search Google Scholar
    • Export Citation
  • 42

    Reasoner DK, , Todd MM, , Scamman FL, & Warner DS: The incidence of pneumocephalus after supratentorial craniotomy. Observations on the disappearance of intracranial air. Anesthesiology 80:10081012, 1994

    • Search Google Scholar
    • Export Citation
  • 43

    Senior BA, , Ebert CS, , Bednarski KK, , Bassim MK, , Younes M, & Sigounas D, : Minimally invasive pituitary surgery. Laryngoscope 118:18421855, 2008

    • Search Google Scholar
    • Export Citation
  • 44

    Seth R, , Rajasekaran K, , Benninger MS, & Batra PS: The utility of intrathecal fluorescein in cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 143:626632, 2010

    • Search Google Scholar
    • Export Citation
  • 45

    Seth R, , Rajasekaran K III, , Luong A, , Benninger MS, & Batra PS: Spontaneous CSF leaks: factors predictive of additional interventions. Laryngoscope 120:21412146, 2010

    • Search Google Scholar
    • Export Citation
  • 46

    Shaikh N, , Masood I, , Hanssens Y, , Louon A, & Hafiz A: Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: a case report. Surg Neurol Int 1:27, 2010

    • Search Google Scholar
    • Export Citation
  • 47

    Steudel WI, & Hacker H: Prognosis, incidence and management of acute traumatic intracranial pneumocephalus. A retrospective analysis of 49 cases. Acta Neurochir (Wien) 80:9399, 1986

    • Search Google Scholar
    • Export Citation
  • 48

    Sudhakar N, , Ray A, & Vafidis JA: Complications after transsphenoidal surgery: our experience and a review of the literature. Br J Neurosurg 18:507512, 2004

    • Search Google Scholar
    • Export Citation
  • 49

    Tran P, , Reed EJ, , Hahn F, , Lambrecht JE, , McClay JC, & Omojola MF: Incidence, radiographical features, and proposed mechanism for pneumocephalus from intravenous injection of air. West J Emerg Med 11:180185, 2010

    • Search Google Scholar
    • Export Citation
  • 50

    Tucker A, , Miyake H, , Tsuji M, , Ukita T, , Nishihara K, & Ito S, : Spontaneous epidural pneumocephalus. Neurol Med Chir (Tokyo) 48:474478, 2008

    • Search Google Scholar
    • Export Citation
  • 51

    Yates H, , Hamill M, , Borel CO, & Toung TJ: Incidence and perioperative management of tension pneumocephalus following craniofacial resection. J Neurosurg Anesthesiol 6:1520, 1994

    • Search Google Scholar
    • Export Citation
  • 52

    Yildiz A, , Duce MN, , Ozer C, , Apaydin FD, , Eğilmez H, & Kara E: Disseminated pneumocephalus secondary to an unusual facial trauma. Eur J Radiol 42:6568, 2002

    • Search Google Scholar
    • Export Citation

Metrics