ACTA NEUROCHIRURGICA 9 by Springer-Verlag1979
Acta Neurochirurgica 45, 237--246 (1979)
Department of Neurosurgery, School of Medicine, University of Kanazawa, Japan
Repair of Cerebrospinal Fluid Rhinorrhoea With Pedicled Dural Flap By
H. Ito, A. Ishikura, Sh. Marukawa, and Sh. Y a m a m o t o With 6 Figures Four cases of persistent cerebrospinal fluid rhinorrhoea through the ethmoid sinus are presented. Using the operative microscope, the margin of the dural defect was easily identified, and a pedicled dural flap supplied by branches of a meningeal artery was successfully sutured to the dural margin in a watertight fashion without increasing pre-existing neurological deficits. To prevent intracranial infection, the watertight closure with a predicled dural flap is presumably more complete and reasonable than are various grafts without vascular circulation. Introduction
The risk of meningitis has been variously estimated as being from 25 per cent by Lewin 28 to 50 per cent by Calvert s in untreated patients with cerebrospinal fluid rhinorrhoea. All patients with cerebrospinal fluid rhinorrhoea should be explored, and all fistulae repaired operatively, as soon as their conditions permit 7, ~3. About half the post-traumatic fistulae, however, close spontaneously in a few weeks following injury, and there is little evidence that a significant number have delayed complications. Intracranial infection usually begins during a few weeks following injury. It appears that nonoperative management of cerebrospinal fluid rhinorrhoea should be tried first. When it is not cured by conservative treatment within a few weeks surgical repair of the fistula should be attempted. Grote 18 gave the indications for surgery as follows; 1. all patients with controlled infection, 2. continuous leak of cerebrospinal fluid, 3. re0001-6268/79/0045/0237/$ 02.00
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current leak of cerebrospinal fluid, 3. a brief leak, but a radiologically clear bone defect, 5. no fluid leak, but a radiologically extensive defect, 6. pneumatocoele, and pneumocephalus. There is no general agreement among neurosurgeons as to how treatment is best accomplished to prevent recurrence. The purpose of this article is to advocate a useful technique for dural repair of persistent cerebrospinal fluid rhinorrhoea through the ethmoid sinuses. Method
Based upon recent cultures from the nose and throat and known bacterial sensitivities, antibiotics should be started 24 hours before operation in full therapeutic doses. After bilateral craniotomy the dura is opened at the posterior margin of the bone flap in order to make a pedicled dural flap (Figs. 4 and 6 B). The fistula is examined intradurally in the anterior cranial fossa. When the dural defect is too extensive for closure by suture a pedicled dural flap is shaped to the size of the dural defect from dura over the frontal convexity. Under the operating microscope, interrupted sutures are placed at a distance of 1-3 mm round the dural defect. Teflon-impregnated twisted polyester, Tevdek 4-0 (Deknatel, U.S.A.), are used for this. The threads are attached to a ring-like plate in order to prevent them from twisting (Fig. 6 E). A sheet of pedicled dural flap is then sutured with the threads previously inserted (Figs. 4 D and 6 F), and many reinforcing sutures are added. The surrounding area should be washed with a solution of bacitracin. The dural defect over the frontal convexity is closed with pericranium (Fig. 6 G). Case Reports Case 1. M. K.: A 37-year-old female complained of myopia and proptosis on the right side and headache in the right temporal region in Sept. 1960. She underwent removal of a retrobulbar neurofibroma on the right side, and thereafter received e~ In 1969 she suffered from high fever (39-40 ~ severe headache, nausea, vomiting, and discharge of clear fluid from the right nostril, so she was admitted to hospital for a month. After that she had an intermittent discharge of clear fluid once or twice a year. In Oct. 1973 she heard curious sounds in her head. When she entered our clinic on 30. Oct. 1973, neurological examination revealed bilateral anosmia, proptosis, blindness, panophthalmitis on her right side, and vision down to hand movements on the left side. Both eyes were fixed in the midposition. Her craniograms showed pneumocephalus (Figs. 1 and 2), bone defect in the orbital roof (Fig. 3), and destruction of the sella. A bifrontal craniotomy was performed on 31. Jan. 1974. There appeared to be no evidence of recurrence of intracranial turnout. The dura and bone over the
Repair of Cerebrospinal Fluid Rhinorrhoea With Pedicled Dural Flap
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right optic canal and medial portion of the right sphenoidal ridge had a 16 5< 19 mm defect. A probe placed into this hole passed into the right posterior ethmoid sinus. Accordingly, intradural repair with a pedicled dural flap was performed (Fig. 4). Her rhinorrhoea ceased immediately after the operation. Case 2. Y. O.: A 34-year-old man injured his nose during a struggle in 1962. He developed a discharge of clear fluid from the left nostril about a year after the injury. He showed a high fever (39-40 ~ with convulsions for 5-7 days, so
Fig. 1. Plain roentgenogram (case 1). Pneumocephalus and enlarged frontal horns of the lateral ventricles are shown he was treated for purulent meningitis. Thereafter, he was hospitalized at different times for high fever. When he visited our clinic on 18. Dec. 1974, cerebrospinal fluid rhinorrhoea was suggested because of repeated fever history, intermittent discharge of fluid from his nostril, and anosmia on his left side. Tomograms of the skull showed a 10 • 20 mm defect in the left cribriform plate. The 169Ybcisternograms showed leakage of isotope into the ethmoid sinus from the subarachnoid space (Fig. 5). The net counts of radioactivity in the fluid discharged from left nostril numbered 91,505 cpm/ml, and from the right 2,224 cpm/ml. At bifrontal craniotomy we found brain herniating through a 10 • 17 mm defect in the left cribriform plate. After coagulation of the ne& of the herniated brain, a pedicled dural flap was sutured to the dura round the defect in a watertight fashion (Fig. 6). He has had no discharge since the operation.
Fig. 2. Lateral view of plain roentgenogram of skull demonstrates pneumocepha!us and enlarged frontal horns of lateral ventricles (case 1)
Fig. 3. Tomogram illustrates absence of sphenoidal ridge and orbital roof and pneumocephalus continuing through right ethmoid sinus to nostril (case 1)
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Case 3. Y. M.: A 14-year-old boy had an operation for bilateral ethmoid sinusitis in Aug. 1973. Following the intermittent discharge of clear fluid from the left nostril since 1974, meningitis recurred three times in 1975. After his admission to our clinic on 26. Aug. 1975, his neurological examination revealed left anosmia. The craniograms showed diffuse homogeneous shadows in the ethmoid sinuses, and tomograms demonstrated a defect of the cribriform plate. The RI-cisternogram showed leak of RI into the left nostril. On 18. Sept. 1975,
Fig. 4. Procedures of surgical repair of cerebrospinal fluid rhinorrhoea. A Bifrontal craniotomy (vertically lined). B Incision of dura. C Site and contour of dura and bone defect (stippled zone). D Water-tight suture of a pedicled dural flap fed by means of branches of meningeal artery (horizontally-lined area with asterisk) bifrontal craniotomy was performed, and a pedicled dural flap was sewn to the dura round the dural defect in the left cribriform plate. His postoperative course was uneventful without recurrence of nasal fluid discharge. Case 4. H . D.: A 16-year-old student fell from an electric train and struck his head against a telegraph pole on 9. July 1976. When he was sent to us, he was stuporose, had vomited, and had convulsive attacks. A linear fracture of the left frontal base was shown by craniograms, and an avascular space was shown by carotid angiography. An epidural haematoma was removed by left frontal craniotomy, and he became conscious. However, left nasal bleeding continued for more than 10 days. He had a discharge of clear fluid from the left nostril on 19. July, and he had high fever and nuchal stiffness. A 5 • 5 mm dural defect was repaired with a pedicled dural flap on 19. Aug. He had no recurrence of cerebrospinal fluid rhinorrhoea.
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Dandy ll reported the first successful attempt to close cranionasal fistula. Thereafter, the transfrontal intradural approach 1, 2 28 and the combined extra- and intra-dural approach 24, as well as the
Fig. 5. The 169Yb-cisternograms (case 2). Leakage of RI activity into ethmoid sinus from subarachnoid space is shown, a) Preoperative cisternogram, b) disappearance of leakage after operation
intranasal approach 1~, s0 have been reported. Neurosurgical procedures are safer, simpler, and surer than rhinological procedures to close the cerebrospinal fluid fistula. The transfrontal extradural approach is preferable for cranionasal fistula through the frontal sinus. On the other hand the transfrontal intradural approach would be appropriate for repair of a posterior ethmoid sinus or sphenoid
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sinus fistula, because local anatomy of olfactory nerves, optic nerves, dural or bone defect, and cerebral prolapse can be scrutinized 7, 19, and the intradural procedures are relatively easy.
Fig. 6. Watertight suture with pedicled dural flap (case 2). A Bifrontal craniotomy is shown by vertically lined area. B Incised line of dura. C Cerebral herniation through fistula of left cribriform plate. D Dural and bony defect (stippled). E Many threads round dural defect held to a ringed board like a dial. F Watertight suture with pedicled dural flap fed by meningeal arterial branches (horizontally lined). G Dural defect covering frontal convexity is closed by pericranium (shown by two asterisks)
Although a solution of silver nitrate 15 or iodine have been applied to the fistula neighbourhood. A small dural defect is usually closed by watertight suture. When the dural defect is larger than 2 mm in diameter 25, is in relatively inaccessible areas, or is surrounded by friable dura, the defect is repaired with a pedicled dural flap 16, 18, ~7, 81, various autoplastic grafts such as pericranium ~4,
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fascia lata ~0, temporal fascia, or isoplastic graft of lyophylized dura 21. Furthermore, there are many kinds of substitutes, for examples vinylon-N 4, teflon -29, polyethylene 6 membrane, or stainless steel fine wire mesh. When a large skull bone defect as well as a dural defect is found, muscle 31, iodoform pa&s, bone wax, gelatine sponge 5, 9, or acrylic cements are satisfactory plugging materials. Grafts are usually sewn or fixed with adhesives ~, -2G,s0 However, the bonding substances have the disadvantage of not working well in a moist area and of being neurotoxic. Using conventional techniques, Ray and Bergland -27 had 27 per cent recurrent leakages following initial repair. Ommaya et aL 2~ reported five failures in 18 cases of non-traumatic rhinorrhoea. Postoperative focal infection would result in recurrence of rhinorrhoea. If heteroplastic grafts or any substitutes were used in the presence of latent infection, they would become a focus of bacterial growth. A pedicled dural flap with feeding arteries, however, is most invulneable to infection, as it provokes much granulation, and results in sure adherence to dura round the fistula. A dural flap from the crista galli or falx was utilized in order to cover the small defect in the cribriform plate ~6, 27. Grote also used double layers of pedicled dural flap and lyophylized dura or galea-periosteum on the dural defect ~7. 18, 81 However, the dura on the crista gall or falx is narrow, while the dural flap taken from the frontal convexity is wide and can be shaped to the dural defect with ease. Furthermore, the dural flap is tensile enough to withstand the pressure along the base of the brain and cribriform plate. A dural repair remains difficult despite the apparent simplicity of the problem, because of insufficient friable dura to sew, lack of a defined border, or inability to visualize a known site of cerebrospinal fluid leakage due to a small operative field. Recent development of microsurgical techniques can overcome many problems and make the direct watertight suture easy. Spreading a sheet of fascia lata on the anterior cranial fossa ~2, ~3 may involve the sacrifice of both olfactory nerves. However, watertight suture with a pedicled dural flap under the operating microscope can be done without damaging brain and nerves. For the above reasons, watertight repair with a pedicle graft has been found the most valuable and appropriate procedure. References
1. Adson, A. W., Cerebrospinal rhinorrhea: Surgical repair of cranio-sinus fistula. Ann. Surg. 114 (1941), 697--705. 2. Adson, A. W., Uihlein, A., Repair of defects in ethmoid. Arch. Surg. 58 (1949), 623--634.
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3. Albin, M. S., D'Agostino, A. N., White, R. J., Grindlay, J. H., Nonsuture sealing of a dural substitute utilizing a plastic adhesive, methyl-2-cyanoacrylate. J. Neurosurg. 19 (1962), 545--550. 4. Angstwurm, H., Jakoby, W., Weber, E., Die Methoden der Duraplastik. Acta neurochir. (Wien) 11 (1963), 34--60. 5. Becket, A., Die Anwendung yon Fiberschaum bei der Versorgung basofrontaler Dura-Hirnverletzungen. Arch. Ohrenheilk. 165 (1954), 229--235. 6. Busch, E., Bing, J., Hensen, E. H., Gelatine and polyethylene film as dura substitutes and polythene plates as bone substitute in skull defects. Acta chir. scand. 77 (1949), 410--416. 7. Cairns, H., Injuries of the frontal and ethmoidaI sinuses with special reference to cerebrospinal rhinorrhoea and aeroceles. J. Laryng. 52 (1937), 589--623. 8. Calvert, C. A., Injuries of the frontal and ethmoidal sinuses. Proc. roy. Soc. Med. 35 (1942), 805--809. 9. Cloward, R. B., Cunningham, E. B., The use of gelatin sponge in prevention and treatment of cerebrospinal rhinorrhea. J. Neurosurg. 4 (1947), 519--525. 10. Cushing, H., Experiences with orbito-ethmoidaI osteomata having intracranial complications with the report of four cases. Surg. Gynec. Obstet. 44 (1927), 721--743. 11. Dandy, W. E., Pneumocephalus (intracranial pneumatocele or aerocele). Arch. Surg. 12 (1926), 949--982. 12. Dietz, H., Die frontobasale Sch~idelhirnverletzung. Monographien aus dem Gesamtgebiete der Neurologie und Psychiatrie, Vol. 130. Berlin-HeidelbergNew York: Springer. 1970. 13. Dohlman, G., Spontaneous cerebrospinal rhinorrhoea. Acta Otolaryng. (Suppl.) 67 (1948), 20--23. 14. Eden, K., Traumatic cerebrospinal rhinorrhoea. Repair of the fistula by a transfrontal intradural operation. Brit. J. Surg. 29 (1941), 299--303. 15. Fox, N., Cure in a case of cerebrospinal rhinorrhoea. Arch. Otolaryng. 17 (1933), 85--86. 16. German, W. J., Cerebrospinal rhinorrhea--Surgical repair. J. Neurosurg. 1 (1944), 60--66. 17. Grote, W., Traumatische frontobasale Liquorfisteln. Chirurg 37 (1966), 102--105. 18. Grote, W., Traumatische Liquorfisteln im Kindes- und Jugendalter. Z. Kinderclair. 3 (1966), 11--20. 19. Grant, F. C., Intracranial aerocele following a fracture of the skull. (Report of a case with review of the literature.) Surg. Gynec. Obstet. 36 (1923), 251--255. 20. Hirsh, O., Successful closure of cerebrospinaI fluid rhinorrhoea by endonasal surgery. Arch. Otolaryng. 56 (1952), 1--12. 21. Lehman, R. A. W., Hayes, G. J., Martins, A. N., The use of adhesive and lyophilized dura in the treatment of cerebrospinal rhinorrhoea. J. Neurosurg. 26 (1967), 92--95. 22. Lewin, W., Cerebrospinal fluid rhinorrhoea in closed head injuries. Brit. J. Surg. 42 (1954), 1--8. 23. Lewin, W., Cerebrospinal fluid rhinorrhoea in non-missile head injuries. Clin. Neurosurg. /2 (1964), 237--252. 24. Miller, W. R. H., Cerebrospinal fluid rhinorrhoea and otorrhea. Clin. Neurosurg. 19 (1972), 263--270. 16
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25. Ommaya, A. K., DiChiro, G., Baldwin, M., Pennybecker, J. B., Non-traumatic cerebrospinal fluid rhinorrhoea. J. NeuroL Neurosurg. Psychiat. 31 (1968), 214--225. 26. Probst, C., Rahn, B. A., Plastic closure of frontobasal fistulae using BiobondTabostamp. Clinical and Experim. Trials 18 (1972), 203--212. 27. Ray, B. S., Bergland, R. M., Cerebrospinal fluid fistula; clinical aspects, techniques of localization and methods of closure. J. Neurosurg. 30 (1969), 399--405. 28. Teachenor, F. R., Pneumoventricle of the cerebrum following fracture of the skull. Ann. Surg. 78 (1923), 561--567. 29. Teng, P., Papatheodrou, Ch., The use of Teflon as a dural substitute and its other neurosurgical applications. J. NeuroL Neurosurg. Psychiat. 26 (1963), 244--248. 30. Van der Ark, G. D., Pitkethly, D. T., Ducker, T. B., Kempe, L. G., Repair of cerebrospinal fluid fistulas using a tissue adhesive. J. Neurosurg. 33 (1970), 151--155.
31. Wappenschmidt, J., Grote, W., Zur Klinik und Behandlung frontobasaler Liquorfisteln. Chirurg 29 (1958), 369--376. 32. Wessels, A., Report of case of spontaneous cerebrospinal rhinorrhoea with operative cure. Ann. Otol. Rhino. Laryng. 48 (1939), 528--530. Authors' address: Drs. H. Ito, A. Ishikura, S. Marukawa, S. Yamamoto, Department of Neurosurgery, Faculty of Medicine, Kanazawa University, 13-i Takaramachi, Kanazawa 920, Japan.
Acta Neurochirurgica 45, 237--246 (1979)
Department of Neurosurgery, School of Medicine, University of Kanazawa, Japan
Repair of Cerebrospinal Fluid Rhinorrhoea With Pedicled Dural Flap By
H. Ito, A. Ishikura, Sh. Marukawa, and Sh. Y a m a m o t o With 6 Figures Four cases of persistent cerebrospinal fluid rhinorrhoea through the ethmoid sinus are presented. Using the operative microscope, the margin of the dural defect was easily identified, and a pedicled dural flap supplied by branches of a meningeal artery was successfully sutured to the dural margin in a watertight fashion without increasing pre-existing neurological deficits. To prevent intracranial infection, the watertight closure with a predicled dural flap is presumably more complete and reasonable than are various grafts without vascular circulation. Introduction
The risk of meningitis has been variously estimated as being from 25 per cent by Lewin 28 to 50 per cent by Calvert s in untreated patients with cerebrospinal fluid rhinorrhoea. All patients with cerebrospinal fluid rhinorrhoea should be explored, and all fistulae repaired operatively, as soon as their conditions permit 7, ~3. About half the post-traumatic fistulae, however, close spontaneously in a few weeks following injury, and there is little evidence that a significant number have delayed complications. Intracranial infection usually begins during a few weeks following injury. It appears that nonoperative management of cerebrospinal fluid rhinorrhoea should be tried first. When it is not cured by conservative treatment within a few weeks surgical repair of the fistula should be attempted. Grote 18 gave the indications for surgery as follows; 1. all patients with controlled infection, 2. continuous leak of cerebrospinal fluid, 3. re0001-6268/79/0045/0237/$ 02.00
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current leak of cerebrospinal fluid, 3. a brief leak, but a radiologically clear bone defect, 5. no fluid leak, but a radiologically extensive defect, 6. pneumatocoele, and pneumocephalus. There is no general agreement among neurosurgeons as to how treatment is best accomplished to prevent recurrence. The purpose of this article is to advocate a useful technique for dural repair of persistent cerebrospinal fluid rhinorrhoea through the ethmoid sinuses. Method
Based upon recent cultures from the nose and throat and known bacterial sensitivities, antibiotics should be started 24 hours before operation in full therapeutic doses. After bilateral craniotomy the dura is opened at the posterior margin of the bone flap in order to make a pedicled dural flap (Figs. 4 and 6 B). The fistula is examined intradurally in the anterior cranial fossa. When the dural defect is too extensive for closure by suture a pedicled dural flap is shaped to the size of the dural defect from dura over the frontal convexity. Under the operating microscope, interrupted sutures are placed at a distance of 1-3 mm round the dural defect. Teflon-impregnated twisted polyester, Tevdek 4-0 (Deknatel, U.S.A.), are used for this. The threads are attached to a ring-like plate in order to prevent them from twisting (Fig. 6 E). A sheet of pedicled dural flap is then sutured with the threads previously inserted (Figs. 4 D and 6 F), and many reinforcing sutures are added. The surrounding area should be washed with a solution of bacitracin. The dural defect over the frontal convexity is closed with pericranium (Fig. 6 G). Case Reports Case 1. M. K.: A 37-year-old female complained of myopia and proptosis on the right side and headache in the right temporal region in Sept. 1960. She underwent removal of a retrobulbar neurofibroma on the right side, and thereafter received e~ In 1969 she suffered from high fever (39-40 ~ severe headache, nausea, vomiting, and discharge of clear fluid from the right nostril, so she was admitted to hospital for a month. After that she had an intermittent discharge of clear fluid once or twice a year. In Oct. 1973 she heard curious sounds in her head. When she entered our clinic on 30. Oct. 1973, neurological examination revealed bilateral anosmia, proptosis, blindness, panophthalmitis on her right side, and vision down to hand movements on the left side. Both eyes were fixed in the midposition. Her craniograms showed pneumocephalus (Figs. 1 and 2), bone defect in the orbital roof (Fig. 3), and destruction of the sella. A bifrontal craniotomy was performed on 31. Jan. 1974. There appeared to be no evidence of recurrence of intracranial turnout. The dura and bone over the
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right optic canal and medial portion of the right sphenoidal ridge had a 16 5< 19 mm defect. A probe placed into this hole passed into the right posterior ethmoid sinus. Accordingly, intradural repair with a pedicled dural flap was performed (Fig. 4). Her rhinorrhoea ceased immediately after the operation. Case 2. Y. O.: A 34-year-old man injured his nose during a struggle in 1962. He developed a discharge of clear fluid from the left nostril about a year after the injury. He showed a high fever (39-40 ~ with convulsions for 5-7 days, so
Fig. 1. Plain roentgenogram (case 1). Pneumocephalus and enlarged frontal horns of the lateral ventricles are shown he was treated for purulent meningitis. Thereafter, he was hospitalized at different times for high fever. When he visited our clinic on 18. Dec. 1974, cerebrospinal fluid rhinorrhoea was suggested because of repeated fever history, intermittent discharge of fluid from his nostril, and anosmia on his left side. Tomograms of the skull showed a 10 • 20 mm defect in the left cribriform plate. The 169Ybcisternograms showed leakage of isotope into the ethmoid sinus from the subarachnoid space (Fig. 5). The net counts of radioactivity in the fluid discharged from left nostril numbered 91,505 cpm/ml, and from the right 2,224 cpm/ml. At bifrontal craniotomy we found brain herniating through a 10 • 17 mm defect in the left cribriform plate. After coagulation of the ne& of the herniated brain, a pedicled dural flap was sutured to the dura round the defect in a watertight fashion (Fig. 6). He has had no discharge since the operation.
Fig. 2. Lateral view of plain roentgenogram of skull demonstrates pneumocepha!us and enlarged frontal horns of lateral ventricles (case 1)
Fig. 3. Tomogram illustrates absence of sphenoidal ridge and orbital roof and pneumocephalus continuing through right ethmoid sinus to nostril (case 1)
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Case 3. Y. M.: A 14-year-old boy had an operation for bilateral ethmoid sinusitis in Aug. 1973. Following the intermittent discharge of clear fluid from the left nostril since 1974, meningitis recurred three times in 1975. After his admission to our clinic on 26. Aug. 1975, his neurological examination revealed left anosmia. The craniograms showed diffuse homogeneous shadows in the ethmoid sinuses, and tomograms demonstrated a defect of the cribriform plate. The RI-cisternogram showed leak of RI into the left nostril. On 18. Sept. 1975,
Fig. 4. Procedures of surgical repair of cerebrospinal fluid rhinorrhoea. A Bifrontal craniotomy (vertically lined). B Incision of dura. C Site and contour of dura and bone defect (stippled zone). D Water-tight suture of a pedicled dural flap fed by means of branches of meningeal artery (horizontally-lined area with asterisk) bifrontal craniotomy was performed, and a pedicled dural flap was sewn to the dura round the dural defect in the left cribriform plate. His postoperative course was uneventful without recurrence of nasal fluid discharge. Case 4. H . D.: A 16-year-old student fell from an electric train and struck his head against a telegraph pole on 9. July 1976. When he was sent to us, he was stuporose, had vomited, and had convulsive attacks. A linear fracture of the left frontal base was shown by craniograms, and an avascular space was shown by carotid angiography. An epidural haematoma was removed by left frontal craniotomy, and he became conscious. However, left nasal bleeding continued for more than 10 days. He had a discharge of clear fluid from the left nostril on 19. July, and he had high fever and nuchal stiffness. A 5 • 5 mm dural defect was repaired with a pedicled dural flap on 19. Aug. He had no recurrence of cerebrospinal fluid rhinorrhoea.
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If. Ito et al.: Discussion
Dandy ll reported the first successful attempt to close cranionasal fistula. Thereafter, the transfrontal intradural approach 1, 2 28 and the combined extra- and intra-dural approach 24, as well as the
Fig. 5. The 169Yb-cisternograms (case 2). Leakage of RI activity into ethmoid sinus from subarachnoid space is shown, a) Preoperative cisternogram, b) disappearance of leakage after operation
intranasal approach 1~, s0 have been reported. Neurosurgical procedures are safer, simpler, and surer than rhinological procedures to close the cerebrospinal fluid fistula. The transfrontal extradural approach is preferable for cranionasal fistula through the frontal sinus. On the other hand the transfrontal intradural approach would be appropriate for repair of a posterior ethmoid sinus or sphenoid
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sinus fistula, because local anatomy of olfactory nerves, optic nerves, dural or bone defect, and cerebral prolapse can be scrutinized 7, 19, and the intradural procedures are relatively easy.
Fig. 6. Watertight suture with pedicled dural flap (case 2). A Bifrontal craniotomy is shown by vertically lined area. B Incised line of dura. C Cerebral herniation through fistula of left cribriform plate. D Dural and bony defect (stippled). E Many threads round dural defect held to a ringed board like a dial. F Watertight suture with pedicled dural flap fed by meningeal arterial branches (horizontally lined). G Dural defect covering frontal convexity is closed by pericranium (shown by two asterisks)
Although a solution of silver nitrate 15 or iodine have been applied to the fistula neighbourhood. A small dural defect is usually closed by watertight suture. When the dural defect is larger than 2 mm in diameter 25, is in relatively inaccessible areas, or is surrounded by friable dura, the defect is repaired with a pedicled dural flap 16, 18, ~7, 81, various autoplastic grafts such as pericranium ~4,
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fascia lata ~0, temporal fascia, or isoplastic graft of lyophylized dura 21. Furthermore, there are many kinds of substitutes, for examples vinylon-N 4, teflon -29, polyethylene 6 membrane, or stainless steel fine wire mesh. When a large skull bone defect as well as a dural defect is found, muscle 31, iodoform pa&s, bone wax, gelatine sponge 5, 9, or acrylic cements are satisfactory plugging materials. Grafts are usually sewn or fixed with adhesives ~, -2G,s0 However, the bonding substances have the disadvantage of not working well in a moist area and of being neurotoxic. Using conventional techniques, Ray and Bergland -27 had 27 per cent recurrent leakages following initial repair. Ommaya et aL 2~ reported five failures in 18 cases of non-traumatic rhinorrhoea. Postoperative focal infection would result in recurrence of rhinorrhoea. If heteroplastic grafts or any substitutes were used in the presence of latent infection, they would become a focus of bacterial growth. A pedicled dural flap with feeding arteries, however, is most invulneable to infection, as it provokes much granulation, and results in sure adherence to dura round the fistula. A dural flap from the crista galli or falx was utilized in order to cover the small defect in the cribriform plate ~6, 27. Grote also used double layers of pedicled dural flap and lyophylized dura or galea-periosteum on the dural defect ~7. 18, 81 However, the dura on the crista gall or falx is narrow, while the dural flap taken from the frontal convexity is wide and can be shaped to the dural defect with ease. Furthermore, the dural flap is tensile enough to withstand the pressure along the base of the brain and cribriform plate. A dural repair remains difficult despite the apparent simplicity of the problem, because of insufficient friable dura to sew, lack of a defined border, or inability to visualize a known site of cerebrospinal fluid leakage due to a small operative field. Recent development of microsurgical techniques can overcome many problems and make the direct watertight suture easy. Spreading a sheet of fascia lata on the anterior cranial fossa ~2, ~3 may involve the sacrifice of both olfactory nerves. However, watertight suture with a pedicled dural flap under the operating microscope can be done without damaging brain and nerves. For the above reasons, watertight repair with a pedicle graft has been found the most valuable and appropriate procedure. References
1. Adson, A. W., Cerebrospinal rhinorrhea: Surgical repair of cranio-sinus fistula. Ann. Surg. 114 (1941), 697--705. 2. Adson, A. W., Uihlein, A., Repair of defects in ethmoid. Arch. Surg. 58 (1949), 623--634.
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