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Transnasal endoscopic free vastus lateralis flap for repair of recurrent cerebrospinal fluid leaks
Elizabeth M. Kenny BS; Francesco M. Egro MBChB, MSc, MRCS; Mario G. Solari MD
University
2019-02-15
Presenter: Elizabeth Kenny
Affidavit:
Vu T. Nguyen
Director Name: Vu T. Nguyen
Author Category: Medical Student
Presentation Category: Clinical
Abstract Category: General Reconstruction
Background: While free flaps have been used to repair recurrent CSF leaks after skull base surgery, the insetting of a free flap using a transnasal endoscopic approach has not been described. We report a case where a transnasal endoscopic approach was used to inset a vastus lateralis free flap for definitive reconstruction of an anterior skull base with recurrent CSF leakage.
Case Report: A 38-year-old man with a highly extensive craniopharyngioma underwent multiple endoscopic resections. His postoperative course was complicated by craniopharyngioma recurrence, bilateral DVTs, right MCA stroke, fungal meningitis, renal insufficiency, pneumocephalus, and CSF leak recalcitrant to multiple repairs. Given his persistent CSF leak despite repairs with local flap and graft options, a vastus lateralis free flap was chosen for definitive reconstruction. Because of the patient's recent stroke, the free flap reconstruction could not be performed via craniotomy and the decision was made to perform the inset endonasally to gain adequate access to the recipient vessels. At 2-years post-reconstruction using a 6x5 cm right-sided vastus lateralis muscle-only free flap, the patient showed 100% flap viability with no CSF leak recurrence.
Conclusion: Careful consideration of defect size and location, as well as history of radiotherapy, surgery, or trauma is key in selecting the optimal anterior skull base reconstruction to prevent or manage CSF leak. Transnasal endoscopic insetting of a free vastus lateralis flap is a viable option for CSF leak management and cranial base reconstruction in select patients.
