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Cerebrospinal fluid leakage prevention using the anterior transpetrosal approach with versus without postoperative spinal drainage: an institutional cohort study

June 2023
Neurosurgical Review 46(1)

June 2023
46(1)

DOI:10.1007/s10143-023-02045-w

Authors:

Kazuhide Adachi

Fujita Health University

Mitsuhiro Hasegawa

Fujita Health University

Yuichi Hirose

Fujita Health University

The efficacy of spinal drain (SD) placement for cerebrospinal fluid (CSF) leakage prevention after the anterior transpetrosal approach (ATPA) remains unclear. Thus, we aimed to assess whether postoperative SD placement improved postoperative CSF leakage after a skull base reconstruction procedure using a small abdominal fat and pericranial flap and clarify whether bed rest with postoperative SD placement increased the length of hospital stay. This retrospective cohort study included 48 patients who underwent primary surgery using ATPA between August 2011 and February 2022. All cases underwent SD placement preoperatively. First, we evaluated the necessity of SD placement for CSF leakage prevention by comparing the postoperative routine continuous SD placement period to a period in which the SD was removed immediately after surgery. Second, the effects of different SD placement durations were evaluated to understand the adverse effects of SD placement requiring bed rest. No patient with or without postoperative continuous SD placement developed CSF leakage. The median postoperative time to first ambulation was 3 days shorter (P < 0.05), and the length of hospital stay was 7 days shorter (P < 0.05) for patients who underwent SD removal immediately after surgery (2 and 12 days, respectively) than for those who underwent SD removal on postoperative day 1 (5 and 19 days, respectively). This skull base reconstruction technique was effective in preventing CSF leakage in patients undergoing ATPA, and postoperative SD placement was not necessary. Removing the SD immediately after surgery can lead to earlier postoperative ambulation and shorter hospital stay by reducing medical complications and improving functional capacity.

Schematic of the dura closure method using anterior transpetrosal approach (ATPA). This schema is a coronal section of a petrous apex lesion. The green line indicates the dura. The orange line indicates the superficial temporal fascia and pericranium membrane. a The tumor is located in the petroclival region and extends to the supratentorium over the cerebrum tentorium. b The tumor was removed using the ATPA. The petrous apex bone (Kawase’s triangle) was drilled out, the middle cranial fossa dura was cut, and the posterior fossa dura and cerebrum tentorium were cut and/or removed. The air cells of the petrous apex and squamous part of the temporal bone were opened (red air cell). c The oxidized cellulose sheet for hemostasis was positioned on the defect in the posterior fossa dura to prevent migration of the abdominal fat into the posterior fossa space. Next, we plugged the small abdominal fat into the opened air cells in the petrous apex and the squamous part of the temporal bone. Furthermore, we placed the small abdominal fat graft on the opened air cells of the petrous apex and squamous part of the temporal bone. d The pericranial flap was laid on the petrous apex defect, and the middle cranial fossa dura was sutured

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Illustrative case. Left petroapex menigioma. a Preoperative MRI CISS image. b Preoperative enhanced T1-MRI. c Preoperative CT bone image. Petrous apex air cells are well developed. d Postoperative day (POD) 1 CT bone image. Pneumocephalus of the posterior fossa is present. Abdominal fat has not migrated into the posterior fossa. e POD7 CT bone image. The pneumocephalus of the posterior fossa is not present anymore. The fluid collection in the mastoid air cells did not increase compared with that observed in the POD1 CT bone image. MRI, magnetic resonance imaging; CISS, constructive interference in steady state; CT, computed tomography

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Graphs comparing the two groups. a Duration until “time to the first ambulation.” b Length of hospital stay. GIDR, group of immediate drain removal; GRD, group of routine drainage

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Graphs comparing the two groups in terms of the postoperative duration of SD placement. a Duration until “time to first ambulation” (*P < 0.05, **P < 0.01). b Length of hospital stay (*P < 0.05, **P < 0.01). POD, postoperative day

…

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Neurosurgical Review (2023) 46:137

https://doi.org/10.1007/s10143-023-02045-w

RESEARCH

Cerebrospinal ﬂuid leakage prevention using theanterior

transpetrosal approach withversuswithoutpostoperative spinal

drainage: aninstitutional cohort study

KazuhideAdachi1· MitsuhiroHasegawa1· YuichiHirose1

Received: 25 February 2023 / Revised: 6 April 2023 / Accepted: 28 May 2023 / Published online: 7 June 2023

Abstract

The eﬃcacy of spinal drain (SD) placement for cerebrospinal ﬂuid (CSF) leakage prevention after the anterior transpetrosal

approach (ATPA) remains unclear. Thus, we aimed to assess whether postoperative SD placement improved postoperative

CSF leakage after a skull base reconstruction procedure using a small abdominal fat and pericranial ﬂap and clarify whether

bed rest with postoperative SD placement increased the length of hospital stay. This retrospective cohort study included 48

patients who underwent primary surgery using ATPA between August 2011 and February 2022. All cases underwent SD

placement preoperatively. First, we evaluated the necessity of SD placement for CSF leakage prevention by comparing the

postoperative routine continuous SD placement period to a period in which the SD was removed immediately after surgery.

Second, the eﬀects of diﬀerent SD placement durations were evaluated to understand the adverse eﬀects of SD placement

requiring bed rest. No patient with or without postoperative continuous SD placement developed CSF leakage. The median

postoperative time to ﬁrst ambulation was 3days shorter (P < 0.05), and the length of hospital stay was 7days shorter

(P < 0.05) for patients who underwent SD removal immediately after surgery (2 and 12days, respectively) than for those

who underwent SD removal on postoperative day 1 (5 and 19days, respectively). This skull base reconstruction technique

was eﬀective in preventing CSF leakage in patients undergoing ATPA, and postoperative SD placement was not necessary.

Removing the SD immediately after surgery can lead to earlier postoperative ambulation and shorter hospital stay by reduc-

ing medical complications and improving functional capacity.

Keywords Anterior transpetrosal approach· Cerebrospinal ﬂuid leakage· Pericranial ﬂap· Spinal drainage

Introduction

Anterior transpetrosal approach (ATPA) is a standard sur-

gical approach for treating petroclival lesions [1–7]. How-

ever, 5.2% of patients who undergo ATPA may experience

cerebrospinal ﬂuid (CSF) leakage as a complication [11].

Risk factors for postoperative CSF leakage related to ATPA

include the presence of air cells in the petrous apex, squa-

mous part of the temporal bone and direct tracts, and dif-

ﬁculty in achieving complete dura closure [31]. There is no

existing research on CSF leakage in relation to skull base

reconstruction techniques using ATPA.

Postoperative CSF leakage can cause increased health-

care costs and extended hospital stays due to the need for

additional treatment [23, 34]. Spinal drain (SD) placement,

which requires bed rest, may prevent postoperative CSF

leakage after skull base surgery using the ATPA [9, 27, 28].

However, bed rest for ≥ 24h increases the risk of medical

complications and muscle disuse atrophy [24, 35]. Further-

more, resultant short-term muscle disuse atrophy may result

in sarcopenia.

SD placement is performed during ATPA for two pur-

poses: reduce intracranial pressure and prevent intraopera-

tive brain contusion by draining CSF and prevent postop-

erative CSF leakage [8, 9, 22, 25, 37]. SD placement is

performed preoperatively in all cases, which has proved

useful in avoiding intraoperative brain injury. However,

the eﬃcacy of postoperative continuous SD placement in

* Kazuhide Adachi

kazu.neuro@gmail.com

1 Department ofNeurosurgery, School ofMedicine, Fujita

Health University, 1-98, Kutsugake Dengakugakubo, Aichi,

ToyoakeCity470-1192, Japan

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Prevention of Cerebrospinal Fluid Leakage in the Anterior Transpetrosal Approach

Article

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Mar 2024

Background: The anterior transpetrosal approach (ATPA) is effective for reaching petroclival lesions, and it allows for complications such as impaired venous return and neuropathy to be resolved. However, there is still room for improvement regarding cerebrospinal fluid (CSF) leakage. Here, we aim to focus on describing specific preoperative, intraoperative, and postoperative countermeasures for preventing CSF leakage when using the ATPA. Methods: Eleven patients treated using the ATPA, who were treated at our hospital from June 2019 to February 2023, were included in this descriptive study. Preoperatively, we performed a 3D simulation of the opened air cells. Then, we classified patterns of dural closure into three types based on intradural manipulation and whether it involved opened air cells or not. Intraoperatively, we performed a dural closure that included the use of more-watertight sutures (DuraGen®) and an endoscope. Furthermore, temporal bone air cell volume measurements were performed to confirm the correlation between the volume and factors related to CSF leakage. Results: No postoperative CSF leakage was observed in any patient. The temporal bone air cell volumes significantly corelated with the air cells of the petrous apex, the high-risk tract in the petrous apex, and postoperative fluid collection in mastoid air cells. Conclusions: We have described countermeasures for preventing CSF leakage when using the ATPA. Preoperative simulations and the use of multiple-layered dural reconstructions with endoscopes could be considered more reliable methods for preventing CSF leakage when using the ATPA.

Early mobilization versus bed rest for incidental durotomy: an institutional cohort study

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J NEUROSURG-SPINE

Objective: The aim of this study was to assess whether flat bed rest for > 24 hours after an incidental durotomy improves patient outcome or is a risk factor for medical and wound complications and longer hospital stay. Methods: Medical records of consecutive patients undergoing thoracic and lumbar decompression procedures from 2010 to 2020 were reviewed. Operative notes and progress notes were reviewed and searched to identify patients in whom incidental durotomies occurred. The need for revision surgery related to CSF leak or wound infection was recorded. The duration of bed rest, length of hospital stay, and complications (pulmonary, gastrointestinal, urinary, and wound) were recorded. The rates of complications were compared with regard to the duration of bed rest (≤ 24 hours vs > 24 hours). Results: A total of 420 incidental durotomies were identified, indicating a rate of 6.7% in the patient population. Of the 420 patients, 361 underwent primary repair of the dura; 254 patients were prescribed bed rest ≤ 24 hours, and 107 patients were prescribed bed rest > 24 hours. There was no statistically significant difference in the need for revision surgery (7.87% vs 8.41%, p = 0.86) between the two groups, but wound complications were increased in the prolonged bed rest group (8.66% vs 15.89%, p = 0.043). The average length of stay for patients with bed rest ≤ 24 hours was 4.47 ± 3.64 days versus 7.24 ± 4.23 days for patients with bed rest > 24 hours (p < 0.0001). There was a statistically significant increase in the frequency of ileus, urinary retention, urinary tract infections, pulmonary issues, and altered mental status in the group with prolonged bed rest after an incidental durotomy. The relative risk of complications in the group with bed rest ≤ 24 hours was 50% less than the group with > 24 hours of bed rest (RR 0.5, 95% CI 0.39-0.62; p < 0.0001). Conclusions: In this retrospective study, the rate of revision surgery was not higher in patients with durotomy who underwent immediate mobilization, and medical complications were significantly decreased. Flat bed rest > 24 hours following incidental durotomy was associated with increased length of stay and increased rate of medical complications. After primary repair of an incidental durotomy, flat bed rest may not be necessary and appears to be associated with higher costs and complications.

Cerebrospinal fluid leakage costs after craniotomy and health economic assessment of incidence reduction from a hospital perspective in the Netherlands

Article

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Dec 2021

Objectives We aim to quantify the cost difference between patients with incisional cerebrospinal fluid (iCSF) leakage and those without after intradural cranial surgery. Second, the potential cost savings per patient when a decrease in iCSF leakage rate would be achieved with and without added costs for preventative measures of various price and efficacy are modelled. Design Health economic assessment from a hospital perspective based on a retrospective cohort study. Setting Dutch tertiary referral centre. Participants We included 616 consecutive patients who underwent intradural cranial surgery between 1 September 2017 and 1 September 2018. Patients undergoing burr hole surgery or transsphenoidal surgery, or who died within 1 month after surgery or were lost to follow-up were excluded. Primary and secondary outcome measures Outcomes of the cost analysis include a detailed breakdown of mean costs per patient for patients with postoperative iCSF leakage and patients without, and the mean cost difference. For the scenario analyses the outcomes are the potential cost savings per 1000 patients when a decrease in iCSF leakage would be achieved. Results Mean cost difference between patients with and without iCSF leakage was €9665 (95%CI, €5125 to €14 205). The main cost driver was hospital stay with a difference of 8.5 days. A 25% incidence reduction would result in a mean cost saving of −€94 039 (95% CI, −€218 258 to −€7077) per 1000 patients. A maximum cost reduction of −€653 025 (95% CI, −€1 204 243 to −€169 120) per 1000 patients could be achieved if iCSF leakage would be reduced with 75% in all patients, with 72 cases of iCSF leakage avoided. Conclusions Postoperative iCSF leakage after intradural cranial surgery increases healthcare costs significantly and substantially. From a health economic perspective preventative measures to avoid iCSF leakage should be pursued.

The incidence of postoperative cerebrospinal fluid leakage after elective cranial surgery: a systematic review

Article

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NEUROSURG REV

Cerebrospinal fluid (CSF) leakage is a major complication after elective neurosurgical procedures. The aim of this systematic literature review is to summarize the incidence rates of postoperative cerebrospinal fluid leakage for neurosurgical procedures, classified by surgical approach. The Pubmed, Cochrane, Embase, and Web of Science databases were searched for studies reporting the outcome of patients undergoing elective neurosurgical procedures. The number of patients, surgical approach, and indication for surgery were recorded for each study. Outcomes related to CSF leakage such as clinical manifestation and treatment were reported as well. One hundred and thirteen studies were included, reporting 94,695 cases. Overall, CSF leaks were present in 3.8% of cases. Skull base surgery had the highest rate of CSF leakage with 6.2%. CSF leakage occurred in 5.9% of anterior skull base procedures, 6.4% of middle fossa, and 5.2% of transpetrosal surgeries. 5.8% of reported infratentorial procedures were complicated by CSF leakage versus 2.9% of supratentorial surgeries. CSF leakage remains a common serious adverse event after cranial surgery. There exists a need for standardized procedures to reduce the incidence of postoperative CSF leakage, as this serious adverse event may lead to increased health care costs.

Objective and quantitative evaluation of angiographic vascularity in meningioma: parameters of dynamic susceptibility contrast-perfusion-weighted imaging as clinical indicators of preoperative embolization

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Intraoperative lumbar drainage can prevent cerebrospinal fluid leakage during transsphenoidal surgery for pituitary adenomas: A systematic review and meta-analysis

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BMC NEUROL

Background: Perioperative cerebrospinal fluid (CSF) leakage is a major complication of pituitary adenomas transsphenoidal surgery. Lumbar drainage (LD) is a common method of treating CSF leakage. But whether intraoperative LD can prevent CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery remains controversial. Clarity on the appropriate use of LD is needed. Methods: A systematic literature review was conducted in the PubMed, EMBASE, and Web of science databases. Articles were included when they compared intraoperative LD with intraoperative no-LD CSF leakage rates during pituitary adenomas transsphenoidal surgery. Results: Overall, 5 studies containing 678 cases met the inclusion criteria. When data were provided on intraoperative CSF leakage rates, the meta-analysis showed a significant difference in favor of intraoperative LD. When data were provided on postoperative CSF leakage rates, the meta-analysis also demonstrated a significant difference in favor of intraoperative LD. Conclusions: Although the results of this meta-analysis suggest intraoperative LD can reduce the risk of CSF leakage during the perioperative period of pituitary adenomas transsphenoidal surgery, the available evidence is indefinite. To some extent the results suggest intraoperative LD's potential positive role. Further studies that include well-designed prospective, randomized controlled clinical trials are necessary for further verification.

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Background and objective: Surgical approaches to the petrous apex region are extremely challenging; while subtemporal approaches and variations represent the milestone of the surgical modules to reach such deep anatomical target, in a constant effort to develop minimally invasive neurosurgical routes, the endoscopic endonasal approach (EEA) has been tested to get a viable corridor to the petroclival junction. Lately, another ventral endoscopic minimally invasive route, i.e., the superior eyelid endoscopic transorbital approach, has been proposed to access the most lateral aspect of the skull base, including the petrous apex region. Our anatomic study aims to compare and combine such two endoscopic minimally invasive pathways to get full access to the petrous apex. Three-dimensional reconstructions and quantitative and morphometric data have been provided. Material and methods: Five human cadaveric heads (10 sides) were dissected. The lab rehearsals were run as follows: (i) preliminary pre-operative CT scans of each specimen, (ii) pre-dissection planning of the petrous apex removal and its quantification, (iii) petrous apex removal via endoscopic endonasal route, (iv) post-operative CT scans, (v) petrous apex removal via endoscopic transorbital route, and (v) final post-operative CT scan with quantitative analysis. Neuronavigation was used to guide all dissections. Results: The two endoscopic minimally invasive pathways allowed a different visualization and perspective of the petrous apex, and its surrounding neurovascular structures. After both corridors were completed, a communication between the surgical pathways was highlighted, in a so-called connection area, surrounded by the following important neurovascular structures: anteriorly, the internal carotid artery and the Gasserian ganglion; laterally, the internal acoustic canal; superiorly, the abducens nerve, the trigeminal root, and the tentorium cerebelli; inferomedially, the remaining clivus and the inferior petrosal sinus; and posteriorly, the exposed area of the brainstem. Used in a combined fashion, such multiportal approach provided a total of 97% of petrous apex removal. In particular, the transorbital route achieved a mean of 48.3% removal in the most superolateral portion of the petrous apex, whereas the endonasal approach provided a mean of 48.7% bone removal in the most inferomedial part. The difference between the two approaches was found to be not statistically significant (p = 0.67). Conclusion: The multiportal combined endoscopic endonasal and transorbital approach to the petrous apex provides an overall bone removal volume of 97% off the petrous apex. In this paper, we highlighted that it was possible to uncover a common path between these two surgical pathways (endonasal and transorbital) in a so-called connection area. Potential indications of this multiportal approach may be lesions placed in or invading the petrous apex and petroclival regions that can be inadequately reached via transcranial paths or via an endonasal endoscopic route alone.

Prediction of trigeminal nerve position based on the main feeding artery in petroclival meningioma

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The trigeminal nerve is often displaced by petroclival meningioma (PCM) compression, making it difficult to locate during PCM surgery. This study investigated whether the deviated position of the trigeminal nerve could be easily predicted using the main tumor feeding artery. We retrospectively examined 32 patients who underwent surgery for primary PCM. The deviation of the trigeminal nerve was classified as either Type 1 (displacement toward the back of the cerebellar tentorium), Type 2 (toward the back of the superior petrosal sinus), Type 3 (toward the back of the petrous apex dura), Type 4 (toward the inferior aspect of the tumor), or Type 5 (toward the surface of the brain stem). The main feeding artery was determined by preoperative angiography. The trigeminal nerve was classified as Type 2 in 60% of cases where the proximal tentorial artery (TA) was the main feeding vessel. The nerve was Type 5 where the distal portion of the TA was the main feeding vessel (60% of the cases). The nerves were Type 3 and Type 4 where the proximal inferior lateral trunk (ILT) (60%) and distal ILT (75%), respectively, were the main feeding vessels. In 66.7% of the cases where the dorsal meningeal artery was the main feeding vessel, the nerve was Type 3. Type 1 classification applied in all cases where the ascending pharyngeal artery was the main feeding artery. The main feeding artery can be used to predict trigeminal nerve transposition during PCM surgery.

Hyperostosing sphenoid wing meningiomas: surgical outcomes and strategy for bone resection and multidisciplinary orbital reconstruction

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Objective: Hyperostosing sphenoid wing meningiomas cause bony hyperostosis that may extend into the orbit, resulting in proptosis, restriction of extraocular movements, and/or compressive optic neuropathy. The extent of bony removal necessary and the optimal reconstruction strategy to prevent enophthalmos is debated. Herein, the authors present their surgical outcomes and reconstruction results. Methods: This is a retrospective review of 54 consecutive patients undergoing resection of sphenoid wing meningiomas associated with bony hyperostosis. The majority of cases were operated on by the senior author. Extent of tumor resection, volumetric bone resection, radiographic exophthalmos index, complications, and recurrence were analyzed. Results: The median age of the cohort was 52.1 years, with women comprising 83% of patients. Proptosis was a presenting symptom in 74%, and 52% had decreased visual acuity. The WHO grade was I (85%) or II (15%). The median follow-up was 2.6 years. On volumetric analysis, a median 86% of hyperostotic bone was resected. Gross-total resection of the intracranial tumor was achieved in 43% and the orbital tumor in 27%, and of all intracranial and orbital components in 20%. Orbital reconstruction was performed in 96% of patients. Postoperative vision was stable or improved in 98% of patients and diplopia improved in 89%. Postoperative complications occurred in 44% of patients, and 26% of patients underwent additional surgery for complication management. The most frequent complications were medical complications and extraocular movement deficits. The median preoperative exophthalmos index was 1.26, which improved to 1.12 immediately postoperatively and to 1.09 at the 6-month follow-up (p < 0.001). Postoperatively, 18 patients (33%) underwent adjuvant radiotherapy after subtotal resection. Tumors recurred/progressed in 12 patients (22%). Conclusions: Resection of hyperostosing sphenoid wing meningiomas, particularly achieving gross-total resection of hyperostotic bone with a good aesthetic result, is challenging and associated with notable medical and ocular morbidity. Recurrence rates in this series are higher than previously reported. Nevertheless, the authors were able to attain improvement in proptosis and visual symptoms in the majority of patients by using a multidisciplinary approach.

Extended Anterior Petrosectomy Through the Transcranial Middle Fossa Approach and Extended Endoscopic Transsphenoidal-Transclival Approach: Qualitative and Quantitative Anatomic Analysis

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Mar 2020

Background Petroclival tumors and ventro-lateral lesions of the pons present unique surgical challenges. Our cadaveric study provides qualitative and quantitative anatomic comparison for an anterior petrous apicectomy through the transcranial middle fossa (TMF) and expanded endoscopic transphenoidal-transclival (EETT) approaches. Methods In 10 silicone-injected heads, the petrous apex and clivus were drilled extradurally using middle fossa and endonasal approaches. With in situ and frameless stereotactic navigation, we defined consistent points to compare working areas, bone removal volumes, approach angles, and surgical freedom. Results Mean exposed TMF area (21.03 ± 3.46 cm²) achieved a 44.71 ± 4.13° working angle to the brainstem between cranial nerves (CNs) V and VI. Kawase’s rhomboid area measured 1.76 ± 0.34 cm² and bone removal averaged 1.20 ± 0.12 cm³ at the petrous apex. Surgical freedom on the lateral brainstem was higher halfway between CNs V and VI at the center of the rhomboid compared to midline at the basilar sulcus (P < 0.01). After clivectomy and petrous apicectomy, mean exposed EETT area was 5.29 ± 0.66 cm². Approach from either nostril showed no statistically significant differences in surgical freedom at the foramen lacerum and midpoint basilar sulcus. At the petrous apex, bone volume removed and area exposed were significantly larger for TMF approach (P< 0.001). Conclusions Expanded transclival anterior petrosectomy through the TMF approach provides an adequate corridor to lesions in the upper ventro-lateral pons. The EETT approach better fits midline lesions not extending laterally beyond CN VI and C3 carotid when evaluating normal anatomical parameters.

Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea

Article

Feb 2020

Objective: Spontaneous CSF leaks are rare, their diagnosis is often delayed, and they can precipitate meningitis. Craniotomy is the historical "gold standard" repair for these leaks. An endonasal endoscopic approach (EEA) offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success. A paucity of data exists studying EEA as the primary management for spontaneous CSF leaks. Methods: The authors retrospectively reviewed patients undergoing spontaneous CSF rhinorrhea repair at their institution from July 2010 to August 2018. Standardized management includes EEA as first-line treatment, and lumbar puncture (LP) performed 24-48 hours postoperatively. If opening pressure on LP is elevated, CSF diversion or acetazolamide therapy is used as needed. Perioperative lumbar drains are not used. Results: Of 46 patients identified, the most common CSF rhinorrhea etiology was encephalocele (28/46, 60.9%), and the most common location was cribriform/ethmoid (26/46, 56.5%). Forty-three patients underwent EEA alone, and 3 underwent a simultaneous EEA/craniotomy. The most common repair strategy was nasoseptal or other pedicled flaps (18/46, 39.1%). Postoperatively, 15 patients (32.6%) received CSF diversion due to elevated ICP, with BMI > 40 kg/m2 being a significant risk factor (odds ratio 4.35, p = 0.033) for postrepair shunt placement. Twelve patients received acetazolamide therapy for treatment of mildly elevated pressures. The average opening pressure of the shunted group was 36 cm H2O and the average for the acetazolamide-only group was 26 cm H2O. Two patients underwent CSF leak repair revision, one because of progressive fungal sinusitis and the other because of recurrent CSF leak. The mean follow-up duration was 15 months. Conclusions: The paradigm of EEA repair of spontaneous CSF rhinorrhea with postoperative LP to identify undiagnosed idiopathic intracranial hypertension appears to be safe and effective. In the authors' cohort, morbid obesity was statistically associated with the need for postoperative CSF diversion. This has implications for future surgical treatment as obesity levels continue to rise worldwide.

Cerebrospinal fluid leakage prevention using the anterior transpetrosal approach with versus without postoperative spinal drainage: an institutional cohort study

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