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| LETTER TO EDITOR |
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| Year : 2012 | Volume
: 60
| Issue : 2 | Page : 259-260 |
Intravenous cannula: A rescue tool for cerebrospinal fluid diversion
Manjul Tripathi1, Rajesh Chhabra1, Amey R Savardekar1, Raja Tiwari2, Rakesh K Sharma2
1 Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
2 Department of Plastic Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| Date of Submission | 12-Mar-2012 |
| Date of Decision | 14-Mar-2012 |
| Date of Acceptance | 19-Mar-2012 |
| Date of Web Publication | 19-May-2012 |
Correspondence Address:
Rajesh Chhabra
Department of Neurosurgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.96436
How to cite this article:
Tripathi M, Chhabra R, Savardekar AR, Tiwari R, Sharma RK. Intravenous cannula: A rescue tool for cerebrospinal fluid diversion. Neurol India 2012;60:259-60 |
Sir,
Sincipital encephaloceles are more often reported from Southeast Asia and their occurrence is 1 in 5000 live births. [1] Cerebrospinal fluid (CSF) leak is the most frequent and dreaded complication of encephalocele surgery; [2] in spite of meticulous dural repair and use of biological glue, a few patients develop postoperative CSF leak, necessitating repeated lumbar puncture and drainage. [2]
A three-year-old female presented with 4 × 4 cm swelling in the nasofrontral region since birth [Figure 1]a. On clinical and radiological examination, it was diagnosed as nasofrontal encephalocele, without hypertelorism. A bicoronal scalp incision was fashioned and limited frontal craniotomy was done. There was a 4 × 3 cm defect in the anterior cranial fossa anterior to the crista galli, leading to encephalocele. The dural lining of the encephalocele was very thin and was torn during dissection. Pericranial dural graft was placed and reinforced with a fronto-galeal flap. The anterior cranial fossa and orbital roof were reconstructed with split calvarial bone grafts and fixed with titanium screws. Nasal tip and dorsum was defined with cantelevering of the calvarial bone graft. Wound was closed in layers with a negative suction drain, which was removed on fifth postoperative day. On local examination, there was boggy swelling underneath the flap with overlying skin necrosis, probably due to thinning of skin in the region of the fronto-galeal flap. This may have been pressure necrosis due to the adhesive dressing applied over the wound. The patch of skin necrosis was 1 × 0.5 cm on the right side and 0.5 × 0.5 cm on the left. A CSF fistula resulted from the margins of the necrosed skin. A lumbar drain was inserted for CSF diversion. The exact site of CSF leak could not be ascertained after radiological investigation. With continuous lumbar drainage, the leak stopped. The closure of skin defect was attempted using rotational advancement flap for the right side and with V-Y advancement flap for the left side, with continued lumbar drainage of CSF. Both flaps remained healthy but the patient developed CSF leak from the suture site in the midline despite lumbar drainage. After three days, the CSF leak stopped. The lumbar drain was put on controlled drainage for four days and removed. CSF leak recurred from the midline after four days. A thecoperitoneal shunt was done for CSF diversion but the CSF leak continued with subgaleal CSF collection. Dealing with this frustrating leak on an experimental basis, a simple intravenous cannula no. 16 was inserted through the forehead skin into the subgaleal collection and connected to a drain bag for gravitational drainage [Figure 1]b. The cannula was fixed to the skin with silk 3-0 suture. This converted the CSF fistula into a controlled drainage. The daily output was around 200 ml for the first three days which gradually decreased. With controlled CSF drainage, the fistula healed and wound improved. The lumbar drain was removed and CSF was allowed to be drained along the cannula for a week. After a trial of four days of non-drainage, the cannula was removed. The wound remained healthy and there was no discharge or swelling at six months' follow-up [Figure 1]c.  | Figure 1: (a) Pre-operative image. (b) Post-operative clinical image of the patient with the intravenous cannula inserted into the CSF collection adjoining the leak site, as a rescue diversion. (c) Photograph of the patient at follow-up showing good wound healing and disappearance of the encephalocele
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Iatrogenic CSF leaks can be particularly challenging to repair due to their high volume of flow, difficulty in identifying the precise location of the leak, potential for unrecognized mild increases in intracranial pressure, and congenital thinning of the skull base. [3] The management of non-traumatic spontaneous or iatrogenic CSF leaks, meningoceles and meningoencephaloceles has an extensive history characterized by a cornucopia of surgical approaches and different graft materials used to repair the skull base defect. [4],[5] Various studies confirm the ability of the endoscopic endonasal approach to reliably identify and repair intracranial defects in multiple locations along the anterior skull base, with reported closure rates as high as 93.8%. [5] The prerequisite for all these interventional procedures is precise anatomical localization of the defect. [6] If the site of leak is not visualized, a CSF shunting procedure can be considered. CSF shunting procedures in these patients create artificial "pressure sinks", which divert CSF flow away from the fistulas and thereby allow them to heal. [7] CSF leak is usually transient and subsides with conservative management and repeated CSF drainage from the lumbar theca. [2] Only those patients who have persistent CSF leak beyond 7-10 days, require a thecoperitoneal shunt. Before any direct operative repair is attempted, the patient must be evaluated for concomitantly impaired CSF absorption. If history suggests meningitis, severe head trauma, or previous subarachnoid hemorrhage; if preoperative studies reveal communicating hydrocephalus, or if significant ventricular reflux occurs on cisternography despite the presence of a patent dural fistula, we proceed with operative management of the abnormal CSF dynamics by shunting, rather than attempting direct repair of the dural fistula. A persistent CSF fistula can eliminate or reduce ventricular enlargement in a patient with impaired absorption and, consequently, normal-sized ventricles do not exclude abnormal CSF dynamics. [8] Our patient did not respond to attempts for CSF diversion leading to a recalcitrant CSF leak. We do not recommend an intravenous cannula routinely for CSF fistulas of unknown sites but this should be remembered as a rescue tool for local diversion of CSF in cases of persistent leaks with collection, when other methods fail.
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[Figure 1]
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