Abstract：
OBJECTIVE: Spontaneous CSF leaks into the anterior skull base nasal sinuses are often associated with meningoencephaloceles and occur in patients with idiopathic intracranial hypertension (IIH). Endonasal endoscopic repair has become the primary method of choice for repair. The authors sought to evaluate the success rate of endoscopic closure and to identify predictive factors for CSF leak recurrence.
METHODS: A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele.
UNASSIGNED: From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher\'s exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred.
CONCLUSIONS: Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.
METHODS: A consecutive series of endonasally repaired anterior skull base meningoencephaloceles was drawn from a prospectively acquired database. Lumbar punctures were not performed as part of a treatment algorithm. All patients had at least 5 months of follow-up. Chart review and phone calls were used to determine the timing and predictors of recurrence. Demographic information and details of operative technique were correlated with recurrence. Two independent radiologists reviewed all preoperative imaging to identify radiographic markers of IIH, as well as the location and size of the meningoencephalocele.
UNASSIGNED: From a total of 54 patients there were 5 with recurrences (9.3%), but of the 39 patients in whom a vascularized nasoseptal (n = 31) or turbinate (n = 8) flap was used there were no recurrences (p = 0.0009). The mean time to recurrence was 24.8 months (range 9-38 months). There was a trend to higher BMI in patients whose leak recurred (mean [± SD] 36.6 ± 8.6) compared with those whose leak did not recur (31.8 ± 7.4; p = 0.182). Although the lateral recess of the sphenoid sinus was the most common site of meningoencephalocele, the fovea ethmoidalis was the most common site in recurrent cases (80%; p = 0.013). However, a vascularized flap was used in significantly more patients with sphenoid (78.3%) defects than in patients with fovea ethmoidalis (28.6%) defects (Fisher\'s exact test, p = 0.005). Radiographic signs of IIH were equally present in all patients whose leak recurred (75%) compared with patients whose leak did not recur (63.3%); however, an enlarged Meckel cave was present in 100% (2/2) of patients whose leaks recurred compared with 13.3% (4/30) of patients whose leaks did not recur (p = 0.03). The average meningoencephalocele diameter tended to be larger (1.73 ± 1.3 cm) in patients with recurrence compared to those without recurrence (1.2 ± 0.66 cm; p = 0.22). A ventriculoperitoneal shunt was already in place in 3 patients, placed perioperatively in 5, and placed at recurrence in 2, none of whose leaks recurred.
CONCLUSIONS: Recurrence after endonasal repair of spontaneous CSF leaks from meningoencephaloceles can be dramatically reduced with the use of a vascularized flap. Although failures of endonasal repair tend to occur in patients who have higher BMI, larger brain herniations, and no CSF diversion, the lack of vascularized flap was the single most important risk factor predictive of failure.
摘要：
目的：自发性脑脊液泄漏到前颅底鼻窦通常与脑膜脑膨出有关，发生在特发性颅内高压（IIH）患者中。经鼻内镜修复已成为首选的修复方法。作者试图评估内镜下闭合的成功率，并确定脑脊液漏复发的预测因素。
方法：从前瞻性获得的数据库中提取一系列连续的经鼻修复的前颅底脑膜脑囊肿。腰椎穿刺不作为治疗算法的一部分。所有患者均有至少5个月的随访。图表审查和电话用于确定复发的时间和预测因素。人口统计信息和手术技术细节与复发相关。两名独立的放射科医生检查了所有术前影像学检查，以确定IIH的影像学标记，以及脑膜脑膨出的位置和大小。
结果：总共54例患者中有5例复发（9.3％），但是在使用血管化鼻中隔（n=31）或鼻甲（n=8）皮瓣的39例患者中，没有复发（p=0.0009）。平均复发时间为24.8个月（范围9-38个月）。与未发生泄漏的患者（31.8±7.4；p=0.182）相比，泄漏复发的患者的BMI有更高的趋势（平均[±SD]36.6±8.6）。尽管蝶窦的外侧隐窝是脑膜脑膨出最常见的部位，筛窝是复发病例中最常见的部位(80%;p=0.013).然而,血管化皮瓣用于蝶骨缺损患者(78.3%)明显多于筛孔缺损患者(28.6%)(Fisher精确检验,p=0.005)。与未复发的患者（63.3％）相比，所有泄漏复发的患者（75％）均具有IIH的影像学征象；但是，100％（2/2）的泄漏复发的患者存在扩大的Meckel洞穴，而13.3％（4/30）的泄漏没有复发（p=0.03）。与未复发患者相比，复发患者的平均脑膜脑膨出直径趋于更大（1.73±1.3cm）（1.2±0.66cm；p=0.22）。3例患者已经进行了脑室-腹腔分流术,围手术期5位，复发时2位，无漏复发。
结论：使用血管化皮瓣可以大大减少脑膜脑囊肿自发性脑脊液漏鼻内修复后的复发。尽管鼻内修复失败倾向于发生在BMI较高的患者中，更大的脑疝，没有脑脊液转移，血管化皮瓣的缺乏是预测失败的唯一最重要的危险因素.
方法：从前瞻性获得的数据库中提取一系列连续的经鼻修复的前颅底脑膜脑囊肿。腰椎穿刺不作为治疗算法的一部分。所有患者均有至少5个月的随访。图表审查和电话用于确定复发的时间和预测因素。人口统计信息和手术技术细节与复发相关。两名独立的放射科医生检查了所有术前影像学检查，以确定IIH的影像学标记，以及脑膜脑膨出的位置和大小。
结果：总共54例患者中有5例复发（9.3％），但是在使用血管化鼻中隔（n=31）或鼻甲（n=8）皮瓣的39例患者中，没有复发（p=0.0009）。平均复发时间为24.8个月（范围9-38个月）。与未发生泄漏的患者（31.8±7.4；p=0.182）相比，泄漏复发的患者的BMI有更高的趋势（平均[±SD]36.6±8.6）。尽管蝶窦的外侧隐窝是脑膜脑膨出最常见的部位，筛窝是复发病例中最常见的部位(80%;p=0.013).然而,血管化皮瓣用于蝶骨缺损患者(78.3%)明显多于筛孔缺损患者(28.6%)(Fisher精确检验,p=0.005)。与未复发的患者（63.3％）相比，所有泄漏复发的患者（75％）均具有IIH的影像学征象；但是，100％（2/2）的泄漏复发的患者存在扩大的Meckel洞穴，而13.3％（4/30）的泄漏没有复发（p=0.03）。与未复发患者相比，复发患者的平均脑膜脑膨出直径趋于更大（1.73±1.3cm）（1.2±0.66cm；p=0.22）。3例患者已经进行了脑室-腹腔分流术,围手术期5位，复发时2位，无漏复发。
结论：使用血管化皮瓣可以大大减少脑膜脑囊肿自发性脑脊液漏鼻内修复后的复发。尽管鼻内修复失败倾向于发生在BMI较高的患者中，更大的脑疝，没有脑脊液转移，血管化皮瓣的缺乏是预测失败的唯一最重要的危险因素.
