Surgery and interventions

Question 1

2 ways to operate CSF leak through cribriform plate/ethmoidal roof?

Answer 1

• Extradural (often ENT surgents choice)

obs! If a frontal craniotomy is performed, an
* Intradural approach SHOULD be used.
Problems DISSECTING DURA OFF FRONTAL FOSSA FLOOR. -tendency to tear.

Question 2

What is the risk of using flourescein dye intrathecally to identify leak when operating a CSF leak?

Answer 2

Risk of SEIZURES if not diluted by CSF.

Question 3

general technique of intradural approach to täta CSF leak

Answer 3

• close bone defect w fat muscle, cartilage or bone.
• close dural defect w fascia lata, temporalis muscle fascia or PERICRANIUM. Fibrin glue to help hold in place.

! If leak is unidentified preop and intraop, pack both cribriformplate and sphenoid sinus

Question 4

How to reach sphenoid sinus to pack in case of CSF leak?

Answer 4

• incise dura over tuberculum sella, drill through bone to reach sphenoid sinus, remove mucosa and pack inferiorly. Use fat!

Question 5

Use lumbar drain post packing of CSF leak?

Answer 5

Yes or no. some think it might take of pressure that helps the seal if intradural approch has been performed.

Question 6

How to treat known CSF leaks into sphenoid sinus?

Answer 6

1. LP 2 times a day or continous lumbar drainage.
2. if more than 3 days, repack sphenoid sinus and pterygoid recessses.
3. if more than 5 days, LP-shunt. (R/O obstructive hcph)

alt - intradural approach to medial aspect of middle cranial fossa
alt2. consider transnasal sellar injection of fibrin glue under local anesthesia.

Question 7

In what 3 principle situation might petrous bone cause otorrhea or rhinorrea?

Answer 7

via the eustachian tube.
1. following posterior fossa surgery (vestibular schwannoma)
2. mastoid bone frx.
3. dehiscence of staples footplate.

Question 8

Order of treatment for spontaneous intracranial hypotension

Answer 8

1- Epidural blood patch, 10-20cc. Trandelenburg position agfter to aid movement of blood.
2. Epidural blood patch again, more blood.
3. Directed epidural blood patch to the site of leakage
4. Percutaneous fibrin glue at the site of leakage
5. Last resource - surgical treatment.

Question 9

Successrate for pt w spontaneous intracranial hypotension?

Answer 9

70-75% w blood patch.

Question 10

recurrencerate of spontaneous intracranial hypotension

Answer 10

10%

Question 11

what is a Torkildsen shunt?

Answer 11

a ventriculocisternal shunt

Question 12

surgical options for hcph

Answer 12

• third ventriculoscopy
• shunting -VP,VA,Vpleural,LP,Torkildsen
  *elimination of obstruction (often high morbidity ex opening stenosed sylvian)
• choroid plexotomy - partial CSF prod. decrease

Question 13

ETV success score (VCS) for obstructive hcph. But has been used in some cases also for communicating.

Answer 13

Age:
under 1 mån - 0%
1-6mån - 10%
6mo- under1y - 30%
1y to under10 years - 40%
10 or more - 50%

Etiology:
post-infectious - 0%
MMC, IVH, non-tectal tumors 20%
Aqueduct stenosis, tectal tumor, other -30%

Shunt history:
previous shunt -0%
no previous shunt -10%

Question 14

What would be the 3rd ventriculostomy success score for a 50 y/o woman w a just detected aqueduct stenosis ?

Answer 14

90%

Question 15

What would be the 3rd ventriculostomy successcore for a 1 yo MMC child that had infection in his VP shunt?

Answer 15

40% + 20% + 0% = 60%

Question 16

What vasculature is the donor for a VA shunt?

Answer 16

jugular vein to superior vena cava.

Question 17

what is the risk of seizure after shuntplacement?

Answer 17

5.5% first year. 1.1% 3rd.

Question 18

How common is slit ventricles on CT after shunting?

Answer 18

3-80%