Cerebrospinal Fluid Leak Repair: Usefulness of Intrathecal Fluorescein for Correct Topographic Identification of the Skull Base Defects

Abstract

Background: In the management of cerebrospinal fluid (CSF) leak, the identification of the exact discharge spot is paramount. This process can represent a challenge for the radiologist and the surgeon. In the present study, we analyzed a series of patients affected by endonasal CSF leak who underwent endoscopic surgical reconstruction aided by the use of ITF. The purpose of this work is to assess the efficacy of intraoperative ITF in addition to computed tomography (CT) and magnetic resonance imaging for correct topographic localization of the CSF leak.

Methods: Eighty-three patients were enrolled in the study. The main outcome was the concordance between the supposed radiologic defect site and the actual one seen intraoperatively. Recurrence-free survival was evaluated as secondary outcome.

Results: ITF better defined the defect site, allowing a change in the treatment in 21 patients (25.3%), in whom nonconcordance was observed between the suspected radiologic site and the actual surgical site. Good agreement was found between the specific topographic localization (κ = 0.737; P < 0.0001), whereas fair agreement was observed considering the side of the defect (κ = 0.362; P = 0.0009) and correct identification of multiple sites (κ = 0.044; P = 0.666). The 10-year 96% estimate of recurrence-free survival confirmed the correct repair of the fistula site in most cases.

Conclusions: Our data show the usefulness and safety of intraoperative ITF for management of patients affected by endonasal CSF leak. ITF improved the topographic diagnosis of the leak site, ensuring the best target reconstruction and very low recurrence rate.

Keywords: Anterior skull base; CSF rhinorrhea; Computed tomography; Endoscopic skull base surgery; Endoscopy; Skull base; Skull base repair.