4. Transclival

– This approach may lead to communication between the nose and the prepontine cistern, resulting in high-flow CSF rhinorrhea.

– Similar to the transtuberculum approach, postoperative CSF rhinorrhea is minimized by multilayered reconstruction and possible addition of a lumbar drain.

– Postoperative CSF rhinorrhea rates as high as 25% to 33% are reported following resection of clival malignancies.

• Prevention and management of CSF leaks

1. Grafts

– Useful for small, low-flow defects

– Graft options include bone, cartilage, mucosa, fat, fascia, or acellular tissue matrix.

– The grafts can be used as a simple onlay or as a combined inlay/onlay.

– The gasket seal is a particularly effective combination graft that includes a rigid inlayed buttress with a soft-tissue scaffold. which is itself both an inlay and onlay graft.

2. Vascularized flaps

– Options include the nasoseptal flap, inferior turbinate flap, and the pericranial flap.

– For large or high-flow defects, vascularized flaps decrease postoperative CSF rhinorrhea rate by approximately 50%.

– The nasoseptal flap is the most frequently used vascularized flap, and is based on the septal branch of the sphenopalatine artery.

3. Lumbar drains

– Benefits of lumbar drainage include diversion of CSF away from the repair site, ability to instill fluorescein to look for leak, and access for postoperative intracranial pressure monitoring.

– Risks of lumbar drain include headache, infections (cellulitis, meningitis, ventriculitis), tension pneumocephalus, subdural hemorrhage, and brain herniation.

– Given the risks of lumbar drainage and proven efficacy of current endoscopic skull base repairs such as the nasoseptal flap, routine lumbar drainage following repair of intra-operative CSF leak is not recommended.

– Lumbar drains may be useful as a supplement to multilayered reconstruction in the following circumstances:

a. Early postoperative CSF leak

b. High-flow leak areas such as the clivus

c. Revision surgery with prior leak

Vascular Injury

Posterior Septal Artery

• Contributes to the majority of post-operative arterial bleeds

• This branch of the sphenopalatine artery is located inferior to the sphenoid os and splits into an inferior and superior branch prior to entering the septum.

• Prevention of vessel injury:

1. Careful inferior mobilization of this mucosa (rostrum and posterior septum) during sphenoidotomy

2. Prophylactic partial nasoseptal flap elevation (“rescue flap” to prevent injury to the artery during procedure

• Prophylactic cautery of the vessel is not recommended since it is critical for reconstruction of skull base defects.

Anterior and Posterior Ethmoidal Arteries

• Injury to these arteries is most often seen in the transcribriform approach.

• Arterial injury may be followed by retraction into the orbit with resultant rapid development of orbital hematoma, rise in intra-orbital pressure, optic nerve ischemia, and subsequent blindness.

• A slower developing orbital hematoma may also develop from venous bleeding from orbital fat or extra-ocular muscle injury.

• Prevention is accomplished by identification and cautery of arteries during the approach, and extreme care when removing the lamina papyracea or periorbita.

• Early signs of orbital hematoma include preseptal edema, ecchymosis, and proptosis.

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