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Spontaneous skull base encephaloceles and fistulas: combined endonasal and endovascular techniques
EANS Academy. de Lara D. 09/26/19; 276146; EP04100
Dr. Danielle de Lara
Dr. Danielle de Lara

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Abstract
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Background: Spontaneous skull base encephaloceles and fistulas, associated with elevated intracranial pressure, have the highest recurrence rates (25%-87%) after surgical repair. Therefore, treatment goals must be restoration of normal intracranial pressure, associated to defect correction. Recent literature has suggested that in patients with idiopathic intracranial hypertension (IIH) and documented evidence of venous sinus stenosis with a pressure gradient, venous sinus stenting should be the primary treatment of choice. We describe the technical aspects and patient selection criteria involving treatment, combining endoscopic endonasal approach (EEA) and endovascular techniques.
Methods: We report a case series of five patients presenting with spontaneous anterior skull base encephaloceles and fistulas who underwent surgical treatment in our Neurological Surgery Department, combining EEA and endovascular techniques.
Results: The most common clinical presentation was intermittent rhinorrhea. EEAs were performed to correct the skull base defects and surgeries were uneventful. Early in the post-operative period, intracranial pressure was assessed again, and all patients still presenting with elevated opening pressure on the lumbar puncture underwent venous sinus stenting to treat IIH. The mean follow-up period was of 23 months. One patient presented with a femoral hematoma just after the procedure. There were no intracranial infection or bleeding complications. There was no recurrence of the fistulas or encephaloceles.
Conclusions: Treatment of spontaneous skull base fistulas and encephaloceles may be challenging, due to their multifactorial etiology. In patients with associated IIH due to venous stenosis, EEA to correct the skull base defect, associated to early venous sinus stenting seems to be a safe option in order to treat IIH and prevent the fistula recurrence.
Background: Spontaneous skull base encephaloceles and fistulas, associated with elevated intracranial pressure, have the highest recurrence rates (25%-87%) after surgical repair. Therefore, treatment goals must be restoration of normal intracranial pressure, associated to defect correction. Recent literature has suggested that in patients with idiopathic intracranial hypertension (IIH) and documented evidence of venous sinus stenosis with a pressure gradient, venous sinus stenting should be the primary treatment of choice. We describe the technical aspects and patient selection criteria involving treatment, combining endoscopic endonasal approach (EEA) and endovascular techniques.
Methods: We report a case series of five patients presenting with spontaneous anterior skull base encephaloceles and fistulas who underwent surgical treatment in our Neurological Surgery Department, combining EEA and endovascular techniques.
Results: The most common clinical presentation was intermittent rhinorrhea. EEAs were performed to correct the skull base defects and surgeries were uneventful. Early in the post-operative period, intracranial pressure was assessed again, and all patients still presenting with elevated opening pressure on the lumbar puncture underwent venous sinus stenting to treat IIH. The mean follow-up period was of 23 months. One patient presented with a femoral hematoma just after the procedure. There were no intracranial infection or bleeding complications. There was no recurrence of the fistulas or encephaloceles.
Conclusions: Treatment of spontaneous skull base fistulas and encephaloceles may be challenging, due to their multifactorial etiology. In patients with associated IIH due to venous stenosis, EEA to correct the skull base defect, associated to early venous sinus stenting seems to be a safe option in order to treat IIH and prevent the fistula recurrence.
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