Risk Factors and Predictors of Intraoperative Cerebrospinal Fluid Leak after Endoscopic Transnasal Transsphenoidal Surgery for Tumor Resection: A 1,088 Patients’ Prospectively Collected Series

Introduction: Cerebrospinal fluid (CSF) leak, both during or after surgery, is a risk for all patients undergoing endoscopic transnasal transsphenoidal (eTNTS) tumor resection. The following risk factors have been identified in the literature for intraoperative CSF leaks: smoking, increased BMI, older age, prior TNTS, suprasellar extension, tumor size, irregularity, or consistency, nonfunctional tumors, gonadotrophic-positive staining and preoperative gonadotrophic hormone abnormalities, concurrent hydrocephalus, craniopharyngioma, and ACTH adenomas. We performed a retrospective analysis of our large institutional series to identify clinical, radiographic, and histopathologic predictive factors of intraoperative CSF leaks during a TNTS surgery for tumor resection.

Methods: We reviewed a large academic center's prospectively maintained database of all consecutive patients who underwent eTNTS between December 2007 and July 2020. We excluded patients treated for spontaneous CSF leak repair and those who underwent combined craniotomy and TNTS surgical approaches. Various patient- and tumor-related variables were analyzed. Univariate analysis was performed using Wald and Pearson χ2 tests for continuous and binary variables, and one-way ANOVA testing for categorical (>2) variables. Multivariate logistic regression determined the variables independently associated with intraoperative CSF leaks.

Results: A total of 1,088 patients were included in the study. [Tables 1] and [2] summarize the cohort's patient and tumor characteristics, respectively. There were 406 (37%) intraoperative (16%, grade 1; 18%, grade 2; and 3.9%, grade 3) and 82 (7.5%) postoperative CSF leaks of which 62 (76%) also had an intraoperative leak. Univariate analysis of preoperative risk factors for intraoperative leaks showed that age >60 years, presence of diabetes, hypertension, smoking history, history of pituitary radiation, prior TNTS, tumor size >1 cm, and adherent or firm tumor consistency significantly increased the risk of intraoperative CSF leak, as well as a pathology of meningioma, craniopharyngioma or esthesioneuroblastoma, suprasellar or severe extension, and transcribriform or transtuberculum approach (p < 0.05; [Table 3]). Presence of pituitary adenoma pathology (especially functional adenomas) or soft consistency of the tumor significantly decreases the risk of intraoperative CSF leak ([Table 3]). On multivariate analysis, smoking history, prior TNTS, meningioma pathology, and severe extension were shown to be independently associated with intraoperative leaks when adjusted for patient and operative factors ([Table 4]). Notably, prior TNTS was associated with a two-fold increase in risk (OR = 2.04, p = 0.005), and meningioma pathology was associated with greater than a five-fold increased risk of intraoperative CSF leak (OR = 5.73, p = 0.021).

Conclusion: This is the second largest series in the literature aiming to isolate patient and tumor related risk factors of intraoperative CSF leaks in TNTS surgery patients. However, this series included all tumor pathologies and investigated the largest published number of potential CSF leak risk factors in these patients. We found that the most significant predictors after multivariate analysis were prior TNTS, severe extension of the tumor, and meningioma pathology. Our findings help improve preoperative risk stratification and surgical decision-making to better mitigate the risks of CSF leak on an individual patient basis with certain of these risk factors being modifiable.

Table 1 Patient demographics and comorbidities

Table 2 Tumor characteristics

Table 3 Univariate analysis of intraoperative CSF leak predictive factors

Table 4 Multivariate analysis of intraoperative CSF leak predictive factors

 

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Die Autoren geben an, dass kein Interessenkonflikt besteht.

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Artikel online veröffentlicht:
15. Februar 2022