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As the indications for endoscopic skull base approaches have increased, so has the need for more versatile vascularized flaps for skull base reconstruction. Here, we describe a novel lateral based nasopharyngeal flap (LNPF). Two cadaver heads were dissected to elucidate flap anatomy, dimensions, and technique. A retrospective review was performed on two cases where LNPF was used to repair CSF leaks in the nasopharyngeal area, and outcomes reported. The LNPF is an ascending pharyngeal artery myomucosal flap that includes the nasopharyngeal mucosa and the superior pharyngeal constrictor muscle. The flap was 1.2 × 2.2 cm in greatest dimensions. The LNPF was used for salvage CSF leak repair in two cases: one clival and one tubal. Both patients had resolution of leak at 7 months follow-up. The LNPF is a novel flap with reconstruction potential for the nasopharynx, including the lower clivus and the eustachian tube.

OBJECTIVE: To evaluate the efficacy of a nonabsorbable, synthetic graft for the reconstruction of spontaneous middle fossa (sMF) cerebrospinal fluid (CSF) leaks.
METHODS: Six adult patients (age ≥16 yr) who had sMF CSF leaks surgically repaired within an 18-month period at a single university hospital using synthetic, nonbiological, nonabsorbable graft (Neuro-Patch) and a retrospective control group of five patients undergoing multilayer MF repair with autologous grafts.
METHODS: MF repair through a combined transmastoid/MF approach using Neuro-Patch or multilayer autologous grafts.
METHODS: The incidence of postoperative leak within 6 months postoperatively was the main outcome measure; we also recorded the need for lumbar drain, additional hearing loss, length of inpatient stay, body mass index, previous meningitis, preoperative increased intracranial pressure, and age.
RESULTS: In the Neuro-Patch group, there was no postoperative CSF leak without the need for lumbar drain. We observed no additional hearing loss; patients were monitored for 2 days without any readmissions. Increased intracranial pressure (four of six), previous episodes of meningitis (two of six) or obesity (five of six) did not affect patient outcomes. Demographic and prognostic factors were the same for the control group. However, one patient needed lumbar drain postoperatively because of residual leak; lumbar drain was used in one more case (two of five cases), whereas three of five patients had to stay for longer than 2 days (5 d).
CONCLUSIONS: Our pilot study suggests the use of Neuro-Patch via combined transmastoid/MF approach as an effective technique with minimum, if any morbidity; it could be of particular benefit for patients with larger MF dura defects. A larger number of patients are required to strengthen the evidence.

To discern the efficacy of simultaneous versus delayed VPS surgery in managing hydrocephalus linked with MMC repair: The debate over the concurrent or deferred placement of ventriculoperitoneal shunts (VPS) during myelomeningocele (MMC) repair in hydrocephalic neonates necessitates a nuanced evaluation of associated risks and benefits. While VPS placement can mitigate cerebrospinal fluid (CSF) leaks and minimize wound dehiscence post-MMC repair, it concurrently introduces potential hazards such as infections and shunt-related malfunctions. This prospective cohort study focused on144 newborns with spinal myelomeningocele and hydrocephalus. Divided into two groups based on the timing of dysraphism repair and VPS placement, 101 children underwent concurrent procedures, while 43 received deferred VPS insertion post-MMC closure. Female patients constituted 60% of the cohort, with lumbar lesions being predominant. The median age for MMC closure was three days. Analysis revealed that the deferred insertion group exhibited higher rates of shunt malfunctions, CSF leaks, and wound dehiscence compared to the concurrent insertion group. Although indications hinted at a potential increase in shunt infections in the immediate insertion group, statistical significance was lacking. The study established a statistically significant association between the timing of shunt insertion during MMC repair and specific outcomes, such as CSF leaks and wound dehiscence. The findings suggest that concurrent shunt insertion during MMC repair may reduce the incidence of these complications compared to deferred insertion. However, no substantial differences emerged in terms of shunt infection and malfunction, emphasizing the persistent challenges associated with these major complications.

BACKGROUND: Identifying spontaneous CSF leaks can be difficult on CT myelography (CTM) in patients with suspected spontaneous intracranial hypotension (SIH). The current study compared renal collecting system (RCS) density during CTM in patients with suspected SIH relative to non-SIH controls and evaluated the overall utility as an indirect sign of spontaneous CSF leak in patients with SIH.
METHODS: All CTM performed over an 8-year period (n = 392) were retrospectively reviewed and included cases (n = 295) were divided into groups consisting of SIH patients with (n = 35) or without (n = 77) confirmed CSF leak on CTM and non-SIH controls (n = 183). Average and relative average (relative to systemic contrast density) RCS densities were compared with multivariate analysis adjusting for patient characteristics and CTM technical differences.
RESULTS: Average RCS densities were greater for confirmed versus non-confirmed SIH groups and greater for both SIH groups relative to non-SIH controls. Correlations between RCS density and time from injection to CTM were higher within SIH patient groups compared to controls. Measured RCS density had a higher negative predictive value for excluding CSF leak both within the SIH patient groups as well as the overall cohort (84% and 96%, respectively), with optimized thresholds yielding 80% sensitivity and 70% specificity for the presence of leak in the overall cohort.
CONCLUSIONS: Accounting for RCS density may provide reliable additional indirect diagnostic value about the suspicion of a CSF leak in patients undergoing CTM for evaluation of SIH symptoms.

OBJECTIVE: The choroid plexus contains specialized ependymal cells responsible for CSF production. Recent studies have demonstrated volumetric and perfusion changes in the choroid plexus with age and neurodegenerative disorders, however, volumetric changes in the choroid plexus in low pressure states is not known. The purpose of this study is to evaluate volumetric differences in choroid plexus size in patients with spontaneous intracranial hypotension (SIH) resultant from spinal CSF leaks compared with healthy controls.
METHODS: This was a retrospective, institutional review board-approved study. Patients with MRI evidence of SIH and a spinal CSF leak diagnosed on myelography and subsequently confirmed at surgery were included in this study. All patients included in this study including age-matched healthy controls had a brain MRI performed on a either a 1.5 or 3T scanner with acquisition of 3D T1 postcontrast (eg, BRAVO, MPRAGE, etc). In all patients, the trigonum ventriculi volume, in the atria of the lateral ventricles, was contoured by using Visage-7 segmentation tools on the volumetric postcontrast T1 sequence. A basic 2-tailed t test was used to compare choroid plexus volumes between the 2 groups.
RESULTS: Thirty-four patients were included with 17 patients with SIH with spinal CSF leak and 17 healthy control patients who were age- and sex-matched. The mean age of patients was 45 years, standard deviation 14 years. The mean volume of the choroid plexus for patients with SIH with spinal CSF leak was 1.2 cm3 (standard deviation = 0.26) compared with 0.63 cm3 (standard deviation = 0.31) in the control group (P < .0001).
CONCLUSIONS: Results of this study demonstrate a higher choroid plexus volume in patients with SIH with spinal CSF leak compared with age- and sex-matched healthy controls. This likely reflects compensatory mechanisms to counteract intracranial hypotension by increasing CSF production as well as increased vascularity of the choroid plexus through expansion of the intracranial blood pool.

UNASSIGNED: In-office use of the Trendelenburg position has been shown to be a beneficial clinical tool to help decipher if a CSF pressure/volume component is part of the underlying etiologic process for a patient\'s persistent headache. Utilizing the Trendelenburg position at home could potentially be an additional diagnostic tool for the treating headache physician.
UNASSIGNED: Our headache practice has been using at-home self-Trendelenburg for the past 2 years and will present the clinical scenarios in which it seems to be the most helpful utilizing a case series of patients. These include (1) in those who just had a lumbar puncture and call for worsening headaches and do not have an obvious orthostatic component; (2) in those who had a spinal epidural blood patch for a presumed CSF leak and state there was no improvement; (3) in those who are on daily preventive CSF volume-lowering medications and call in with worsening headaches; (4) in those with known CSF pressure-dependent headaches high or low but who are not on daily preventive CSF volume modulatory medications; (5) in those with a history of migraine or other primary headache disorder to see if a new type of headache is possibly from a CSF leak or an abnormal reset of CSF pressure to an elevated state; (6) in those with triggered only headaches like cough or exertional headache.
UNASSIGNED: Utilizing at-home self-Trendelenburg can provide valuable information for the treating headache physician on possible underlying headache etiology and can guide specific treatment strategies. Its simplicity and quick declaration of results are very patient pleasing.

Headache is a common chief complaint among patients. When presented with this chief complaint, clinicians often form a differential diagnosis of common etiologies, including dehydration, increased stressors, and medication side effects. However, a skillful clinician must always be vigilant of rare etiologies presenting with common chief complaints. Here, we present a rare case of a cerebrospinal fluid leak in a young female presenting with primary symptoms of headache, neck stiffness, and vision changes.

UNASSIGNED: To determine the prevalence of maxillofacial fractures associated with persistent CSF leak, and to assess its bearing on clinical outcomes of consecutive patients managed at our centre.
UNASSIGNED: This was a retrospective cross-sectional study. The medical records of patients over 11-year period were analysed for age, gender, etiology of injuries, duration between injury and presentation to the hospital, types of facial fracture and their treatments, treatment done to control CSF leak, and complication(s). Descriptive and bivariate statistics were computed.
UNASSIGNED: Overall, 1473 patients were evaluated, 66 (4.5%) presented with craniofacial injuries associated with persistent CSF leak after 5 days of non-surgical treatment. Males (92.5%, P= 0.0000) and those in the 21 to 30 years age group (59.1 %, P=0.01) were predominant. The most common (68.2%) type of fracture combination was Le Fort I, II and III, NOE, zygomatic complex and mandible. The commonest clinical presentation of CSF leak was rhinorrhea only, in 66.7% of patients (P= 0.001).
UNASSIGNED: This study shows that the prevalence of maxillofacial fractures associated with persistent CSF leak was low, which was 4.5% of patients that presented with persistent CSF leak and 84.9% of the cases resolved after treatment of the various maxillofacial fractures.

Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.