The efficacy and safety of preoperative lumbar drain placement in anterior skull base surgery

Abstract

This study assesses the efficacy of preoperative lumbar drain (LD) placement prior to elective open cranial and endoscopic anterior skull base (ASB) surgery in reducing postoperative cerebrospinal fluid (CSF) leak. A retrospective review of 93 patients who underwent LD placement at our institution between 2006 and 2011 was performed. Of these patients, 43 underwent elective LD placement prior to ASB surgery; 2 patients had evidence of CSF rhinorrhea prior to surgery, and 41 had no evidence of a preoperative CSF leak. Of those 41 patients, 2 developed CSF rhinorrhea (2/41= 4.9%) as a result of surgery-all in our endoscopic patient population (N = 21; 2/21= 9.5%). No postoperative CSF leaks were noted in our open ASB surgery cohort (N = 20). Other complications were rare, but we encountered two instances of delayed malignant cerebral edema in the open ASB cohort that are discussed in detail. Overall, preoperative LD placement was found to be an effective means of preventing postoperative CSF leaks after ASB approaches, but potential and significant intracranial complications may occur in select patients that merit careful consideration prior to LD placement.

Keywords: anterior skull base; cerebrospinal fluid; craniotomy; endoscopic; lumbar drain.

Fig. 1

Preoperative T1-weighted, gadolinium-enhanced axial and sagittal images (top) demonstrating an isointense, poorly enhancing sellar mass with suprasellar extension causing mass effect on the optic chiasm (A). Postoperative noncontrast computed tomography (CT) head with minimal pneumocephalus noted in the resection cavity and adjacent to the bilateral frontal lobes. No intracranial hemorrhage or evidence of edema (B).

Fig. 2

Preoperative T2-weighted, noncontrast axial and coronal images revealing a well-circumscribed, homogenously contrast-enhancing, dural-based olfactory groove lesion measuring 3 × 4 cm with evidence of peritumoral vasogenic edema.

Fig. 3

Immediate postoperative, noncontrasted computed tomography (CT) head with scant pneumocephalus and trace extra-axial hemorrhage (A). Left greater than right frontal hypodensity, representing persistent edema, continued mass effect, and reduced subfalcine herniation. Postoperative day 1, noncontrasted CT head with persistent bifrontal edema, worsened mass effect on the left lateral ventricle (B). Postoperative, noncontrasted CT head status postbifrontal decompressive craniectomy (C). Evidence of extensive cerebral edema, effacement of the sulcal-gyral pattern with loss of gray-white differentiation. Slit-like ventricles. Crowding of the basilar cisterns. Herniation through the craniectomy site.

Fig. 4

Preoperative axial T2-weighted, noncontrasted enhanced (A) and coronal T1 gadolinium-enhanced (B) images showing a 3 × 3 cm, dural-based planum sphenoidale mass with local mass effect. Bifrontal vasogenic edema.

Fig. 5

Immediate postoperative, noncontrasted computed tomography (CT) head with bifrontal hypodensity representing persistent cerebral edema (A). Local mass effect. Bifrontal pneumocephalus and scant extra-axial hemorrhage. Postoperative day 1, noncontrasted CT head with persistent bifrontal edema with continued mass effect on the lateral ventricles (B). Improved pneumocephalus, extra-axial hemorrhage. Postoperative day 6, noncontrasted CT head with resolving bifrontal cerebral edema, decreased mass effect, and more appropriately demarcated sulcal-gyral pattern (C).