Pneumocephalus and delayed hydrocephalus following endoscopic endonasal biopsy of skull base lesion: diagnostic pitfalls and the role of immunohistochemistry
https://orcid.org/0000-0002-5623-3116
Mehmet Aktoklu
https://orcid.org/0000-0002-8721-5113
Eda Altunbag Yavuz
https://orcid.org/0000-0003-1294-5565
Ugur Yazar
https://orcid.org/0000-0003-4749-133X
Abstract
The endoscopic endonasal approach (EEA) has been increasingly utilized for interventions involving the middle cranial base because of its close anatomical relationship with the nasal cavity and nasopharynx. This technique is widely applied in neurosurgical and otorhinolaryngological practice for the management of pituitary lesions, sellar and parasellar pathologies, sphenoid sinus tumors, cavernous sinus lesions, and tumors of the nasal cavity and nasopharynx, offering improved surgical access and patient comfort. Endoscopic procedures may be associated with serious complications, including intracranial hemorrhage, pneumocephalus, cerebrospinal fluid (CSF) leakage, infection, and cranial nerve injury, which can occur in both early and late postoperative periods. We report a patient who developed early postoperative pneumocephalus, intracerebral hemorrhage, and CSF leakage following endoscopic endonasal biopsy of a lesion adjacent to the mid-cranial base. Based on clinical and radiological findings, the lesion was initially suspected to represent nasopharyngeal carcinoma. Therefore, the patient underwent an endoscopic endonasal biopsy rather than gross total resection. Histopathological and immunohistochemical analyses subsequently established the diagnosis of meningioma. Two weeks postoperatively, the patient developed CSF leakage, pneumocephalus, and intracerebral hemorrhage, and the skull base defect was repaired via an EEA. Subsequently, the patient developed hydrocephalus in the mid-to-late postoperative period, which was successfully treated with ventriculoperitoneal shunt placement, resulting in complete clinical recovery. This case highlights the need for close clinical and radiological follow-up not only in the early period but also in the mid-to-late postoperative periods. Furthermore, radiological findings suggestive of malignancy may be inconsistent with immunohistochemical results; this underscores the critical role of immunohistochemical examination in determining definitive diagnosis and prognosis.
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Skull base tumor, Endoscopic skull base surgery complications, CSF leak, Pneumochephalus, Hydrocephalus, Immunohistochemical diagnosis
2. Tayebi Meybodi A, Mignucci-Jiménez G, Lawton MT, et al. Comprehensive microsurgical anatomy of the middle cranial fossa: Part II-neurovascular anatomy. Front Surg. 2023 Mar 24;10:1132784. doi: 10.3389/fsurg.2023.1132784. PMID: 37035563; PMCID: PMC10080008.
3. Battal B, Zamora C. Imaging of Skull Base Tumors. Tomography. 2023 Jun 21;9(4):1196-1235. doi: 10.3390/tomography9040097. PMID: 37489465; PMCID: PMC10366931.
4. Chong VF, Ong CK. Nasopharyngeal carcinoma. Eur J Radiol. 2008 Jun;66(3):437-47. doi: 10.1016/j.ejrad.2008.03.029. PMID: 18485650.
5. Wang W, Shokri T, Manolidis S, Ducic Y. Complications in Skull Base Surgery and Subsequent Repair. Semin Plast Surg. 2020 Nov;34(4):286-292. doi: 10.1055/s-0040-1721765. PMID: 33380915; PMCID: PMC7759428.
6. Snyderman C, Carrau R, Kassam A. Who is the skull base surgeon of the future? Skull Base. 2007 Nov;17(6):353-5. doi: 10.1055/s-2007-986427. PMID: 18449329; PMCID: PMC2111133.
7. Porras JL, Rowan NR, Mukherjee D. Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Brain Sci. 2022 Dec 8;12(12):1685. doi: 10.3390/brainsci12121685. PMID: 36552145; PMCID: PMC9776068.
8. Laws ER, Kanter AS, Jane JA Jr, Dumont AS. Extended transsphenoidal approach. J Neurosurg. 2005 May;102(5):825-7; discussion 827-8. doi: 10.3171/jns.2005.102.5.0825. PMID: 15926704.
9. Hadad G, Bassagasteguy L, Carrau RL, et al. A novel reconstructive technique after endoscopic expanded endonasal approaches: vascular pedicle nasoseptal flap. Laryngoscope. 2006 Oct;116(10):1882-6. doi: 10.1097/01.mlg.0000234933.37779.e4. PMID: 17003708.
10. Luginbuhl AJ, Campbell PG, Evans J, Rosen M. Endoscopic repair of high-flow cranial base defects using a bilayer button. Laryngoscope. 2010 May;120(5):876-80. doi: 10.1002/lary.20861. PMID: 20422679.
11. Paluzzi A, Fernandez-Miranda JC, Tonya Stefko S, et al. Endoscopic endonasal approach for pituitary adenomas: a series of 555 patients. Pituitary. 2014 Aug;17(4):307-19. doi: 10.1007/s11102-013-0502-4. PMID: 23907570.
12. Ivan ME, Iorgulescu JB, El-Sayed I, et al. Risk factors for postoperative cerebrospinal fluid leak and meningitis after expanded endoscopic endonasal surgery. J Clin Neurosci. 2015 Jan;22(1):48-54. doi: 10.1016/j.jocn.2014.08.009. Epub 2014 Nov 22. PMID: 25439754.
13] Lai LT, Trooboff S, Morgan MK, Harvey RJ. The risk of meningitis following expanded endoscopic endonasal skull base surgery: a systematic review. J Neurol Surg B Skull Base. 2014 Feb;75(1):18-26. doi: 10.1055/s-0033-1353365. PMID: 24498585; PMCID: PMC3912147.
14. Kerr EE, Prevedello DM, Jamshidi A, et al. Immediate complications associated with high-flow cerebrospinal fluid egress during endoscopic endonasal skull base surgery. Neurosurg Focus. 2014;37(4):E3. doi: 10.3171/2014.7.FOCUS14294. PMID: 25270143.
15. Gardner PA, Tormenti MJ, Pant H, et al. Carotid artery injury during endoscopic endonasal skull base surgery: incidence and outcomes. Neurosurgery. 2013 Dec;73(2 Suppl Operative):ons261-9; discussion ons269-70. doi: 10.1227/01.neu.0000430821.71267.f2. PMID: 23695646.
16. Cavallo LM, Briganti F, Cappabianca P, et al. Hemorrhagic vascular complications of endoscopic transsphenoidal surgery. Minim Invasive Neurosurg. 2004 Jun;47(3):145-50. doi: 10.1055/s-2004-818489. PMID: 15343429.
17. Gondim JA, Almeida JP, Albuquerque LA, et al. Endoscopic endonasal approach for pituitary adenoma: surgical complications in 301 patients. Pituitary. 2011 Jun;14(2):174-83. doi: 10.1007/s11102-010-0280-1. PMID: 21181278.
18. Zhang HK, Ma N, Sun XC, Wang DH. Endoscopic Repair of the Injured Internal Carotid Artery Utilizing Oxidized Regenerated Cellulose and a Free Fascia Lata Graft. J Craniofac Surg. 2016 Jun;27(4):1021-4. doi: 10.1097/SCS.0000000000002686. PMID: 27213739.
19. Chin OY, Ghosh R, Fang CH, et al. Internal carotid artery injury in endoscopic endonasal surgery: A systematic review. Laryngoscope. 2016 Mar;126(3):582-90. doi: 10.1002/lary.25748. PMID: 26525334.
20. Banu MA, Szentirmai O, Mascarenhas L, et al. Pneumocephalus patterns following endonasal endoscopic skull base surgery as predictors of postoperative CSF leaks. J Neurosurg. 2014 Oct;121(4):961-75. doi: 10.3171/2014.5.JNS132028. PMID: 24995788.
21. Upreti G, Jonathan GE, Sundaresan R, Thomas R. Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach. Indian J Otolaryngol Head Neck Surg. 2023 Sep;75(3):2523-2528. doi: 10.1007/s12070-023-03802-5. PMID: 37636702; PMCID: PMC10447856.
22. Castle-Kirszbaum M, Wang YY, King J, et al. Tension Pneumocephalus from Positive Pressure Ventilation Following Endoscopic Skull Base Surgery: Case Series and an Institutional Protocol for the Management of Postoperative Respiratory Distress. World Neurosurg. 2020 Sep;141:357-362. doi: 10.1016/j.wneu.2020.06.079. PMID: 32562901.
23. Rennert J, Doerfler A. Imaging of sellar and parasellar lesions. Clin Neurol Neurosurg. 2007 Feb;109(2):111-24. doi: 10.1016/j.clineuro.2006.11.001. PMID: 17126479.
24. Nadarajah J, Madhusudhan KS, Yadav AK, et al. MR imaging of cavernous sinus lesions: Pictorial review. J Neuroradiol. 2015 Dec;42(6):305-19. doi: 10.1016/j.neurad.2015.04.010. PMID: 26421483.
25. Mahalingam HV, Mani SE, Patel B, et al. Imaging Spectrum of Cavernous Sinus Lesions with Histopathologic Correlation. Radiographics. 2019 May-Jun;39(3):795-819. doi: 10.1148/rg.2019180122. PMID: 30978149.
26. King AD, Lam WW, Leung SF, et al. MRI of local disease in nasopharyngeal carcinoma: tumour extent vs tumour stage. Br J Radiol. 1999 Aug;72(860):734-41. doi: 10.1259/bjr.72.860.10624338. PMID: 10624338.
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