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Analysis of Various Tracts of Mastoid Air Cells Related to CSF Leak After the Anterior Transpetrosal Approach

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Analysis of Various Tracts of Mastoid Air Cells Related to CSF Leak After the Anterior Transpetrosal Approach CLINICAL ARTICLE J Neurosurg 130:360–367, 2019 Analysis of various tracts of mastoid air cells related to CSF leak after the anterior transpetrosal approach Ryota Tamura, MD,1 Ryosuke Tomio, MD, PhD,2 Farrag Mohammad, MD,1,3 Masahiro Toda, MD, PhD,1 and Kazunari Yoshida, MD, PhD1 1Department of Neurosurgery, Keio University School of Medicine, Tokyo; 2Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan; and 3Department of Neurosurgery, Assiut University, Assiut, Egypt OBJECTIVE The anterior transpetrosal approach (ATPA) was established in 1984 and has been particularly effective for petroclival tumors. Although some complications associated with this approach, such as venous hemorrhage in the temporal lobe and nervous disturbances, have been resolved over the years, the incidence rate of CSF leaks has not greatly improved. In this study, some varieties of air cell tracts that are strongly related to CSF leaks are demonstrated. In addition, other pre- and postoperative risk factors for CSF leakage after ATPA are discussed. METHODS Preoperative and postoperative target imaging of the temporal bone was performed in a total of 117 patients who underwent ATPA, and various surgery-related parameters were analyzed. RESULTS The existence of air cells at the petrous apex, as well as fluid collection in the mastoid antrum detected by a postoperative CT scan, were possible risk factors for CSF leakage. Tracts that directly connected to the antrum from the squamous part of the temporal bone and petrous apex, rather than through numerous air cells, were significantly related to CSF leak and were defined as “direct tract.” All patients with a refractory CSF leak possessed “unusual tracts” that connected to the attic, tympanic cavity, or eustachian tube, rather than through the mastoid antrum. CONCLUSIONS Preoperative assessment of petrous pneumatization types is necessary to prevent CSF leaks. Direct and unusual tracts are particularly strong risk factors for CSF leaks. https://thejns.org/doi/abs/10.3171/2017.9.JNS171622 KEY WORDS anterior transpetrosal approach; skull base; CSF leak; petrous apex; mastoid air cell HE anterior transpetrosal approach (ATPA) is effec- Development of the surgical technique, monitoring tive and often used for petroclival meningiomas, devices, and preoperative radiographic technologies was trigeminal schwannomas, and basilar trunk artery helpful to resolve complications, such as venous hemor- aneurysms.T 10,36 The ATPA is conducted by temporal cra- rhage in the temporal lobe and nervous disturbances.26,32 niotomy with anterior petrosectomy. After temporal crani- However, the incidence rate of postoperative CSF leak- otomy, the dura mater of the middle fossa floor is elevated age at our hospital was still not low—12.9% in the first to avoid tearing the lesser and greater superficial petrosal 15 years and 13.2% in the last 15 years. In most cases, nerves until the trigeminal impression is visible. Kawase’s the ATPA cannot be performed without opening the air triangle (the area enclosed by the greater superficial petro- cells, because it requires drilling of the squamous part of sal nerve, geniculate ganglion, arcuate eminence, and pe- the temporal bone and petrous apex, as described above. trosal ridge) is resected to expose the dura of the posterior In general, the large dural defect is covered by a flap of cranial fossa. The temporal lobe dura is opened toward vascularized temporalis fascia, and the opened air cells the posterior cranial fossa dura.10 Since the establishment are replaced by autologous tissues (e.g., fat or muscle tis- of the ATPA by Kawase et al. in 1984,10 as of March 2017, sue) and fibrin glue to prevent a CSF leak.10,36 However, in 325 patients had undergone surgery by ATPA at Keio Uni- large series of patients who underwent skull base surgery, versity School of Medicine. including the ATPA, up to 15% suffered from a postoper- ABBREVIATIONS ATPA = anterior transpetrosal approach. SUBMITTED July 6, 2017. ACCEPTED September 11, 2017. INCLUDE WHEN CITING Published online March 16, 2018; DOI: 10.3171/2017.9.JNS171622. 360 J Neurosurg Volume 130 • February 2019 ©AANS 2019, except where prohibited by US copyright law Unauthenticated | Downloaded 10/04/21 02:03 AM UTC R. Tamura et al. ative CSF leak.5,14,15,19,20, 24, 30, 31, 33,35 Although other modified methods (e.g., multilayer sealing techniques using fat, fas- cia, and inlay techniques) have been developed, CSF leaks have not been completely resolved.7,11, 16,18,21,25,34 In recent years, skull base surgery via the endonasal endoscopic approach has demonstrated outstanding prog- ress.3,6,8 The risk of CSF leak after the endonasal endo- scopic approach has been decreased by using fat, fascia, or muscle to plug the surgical defects.28,29 Therefore, more efficient ways to prevent and predict CSF leaks following an ATPA should be developed. Some anatomical analyses of the temporal bone and pneumatization have been published.1,13,27 Air cells in the squamous part of the temporal bone and petrous apex typ- ically connect to the attic through the mastoid antrum.1,27 In this study, we revealed different tracts that are related to CSF leaks after an ATPA. Determination of the pre- and postoperative risk factors in this study may lead to me- ticulous packing of the opened air cells and decrease the incidence ratio of CSF leaks. Methods FIG. 1. Preoperative and postoperative radiographic characteristics of The current retrospective study, performed at the Keio CSF leaks after the ATPA. A: Preoperative axial CT scan showing the University Hospital (Tokyo, Japan), was approved by the development of air cells in the petrous apex. B: Preoperative axial CT institutional review board. For this retrospective analy- scan showing the development of air cells in the squamous part of the sis, we collected all CT images obtained in 168 patients temporal bone. C: Preoperative coronal CT scan showing an extremely who underwent surgery via the petrosal approach at our thin tegmen tympani. D: Postoperative axial CT scan showing fluid col- hospital between January 2005 and March 2017. The CT lection in the mastoid antrum that is strongly related to CSF leaks after examinations were performed on a 64–detector row CT the ATPA. Figure is available in color online only. scanner (LightSpeed VCT; GE Healthcare), a 320–detec- tor row CT scanner (Aquilion ONE; Toshiba Medical Sys- tems), or a 256–multidetector row CT scanner (Revolution the perioperative period; and 3) postoperative factors— CT; GE Healthcare). fluid collection in the mastoid air cells or antrum detected Exclusion criteria of this study were as follows: 1) pa- by CT scan 1 day postoperatively (Fig. 1D). tients who underwent a combined petrosal approach (n = The chi-square test was used to compare the incidence 31), and 2) patients for whom there were no retained rec- rates of CSF leak in the presence and absence of the pa- ords (n = 20). Thus, data in 117 patients (45 males and rameters listed above. Analyses were performed with IBM 72 females, 6–76 years of age) who underwent the ATPA SPSS Statistics (IBM Corp.). were analyzed in this study. The anatomy of the petrous bone air cells was evaluated by pre- and postoperative bone window CT using direct axial imaging with 1.0- or Results 5.0-mm collimation parallel to the orbitomeatal line or The results are summarized in Table 1. Of 117 patients, target imaging of the petrous bone. To avoid the possibil- 17 (14.5%) suffered a CSF leak. One hundred fifteen pa- ity of biasing the results, this retrospective review of CT tients had a tumor, and the remaining 2 patients had neu- scans obtained in 117 patients was performed blindly by 2 ralgia. authors (R. Tamura and R. Tomio), who studied the scans independently. Surgical data were retrieved from opera- Preoperative Factors tive reports, information on tumor histology was obtained In general, pneumatization in the temporal bone con- from pathology reports, and all other perioperative infor- nects to the antrum through numerous mastoid air cells mation was collected from hospital medical records. (Fig. 2A).1,27 In this analysis, tracts that directly connected Parameters analyzed to assess their relationship to CSF to the antrum from the squamous part of the temporal leaks were as follows: 1) preoperative factors—pneumati- bone and petrous apex, rather than through numerous air zation in the petrous apex (Fig. 1A) or squamous part of cells, were identified, thereby defining “squamous direct the temporal bone (Fig. 1B), bone erosion by tumor, the tract” and “petrous direct tract” (Fig. 2B). All of the air tegmen tympani (Fig. 1C), and the anatomical features of cells in the temporal bone (including mastoid, squamous, air cell tracts around the mastoid antrum; 2) intraoperative and petrous parts) typically connect to the attic through factors—the size of craniotomy and drilled petrous apex, the mastoid antrum.1,27 However, our analyses revealed the surgeon’s intraoperative awareness of the opened air different tracts that connected to the attic, tympanic cav- cells, replacement air cells of the petrous apex by fat or ity, or eustachian tube, rather than through the mastoid an- muscle tissue, and the insertion of a spinal drain during trum, thereby defining “unusual tracts” (Fig. 2C). J Neurosurg Volume 130 • February 2019 361 Unauthenticated | Downloaded 10/04/21 02:03 AM UTC R. Tamura et al. TABLE 1. Incidence ratio of CSF leaks in 117 patients Incidence Ratio of CSF Leaks Related to Each Parameter
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