AUTHOR= CRANIAL Consortium , Khan Danyal Z , Marcus Hani J , Bandyopadhyay Soham , Schroeder Benjamin E , Patel Vikesh , O’Donnell Alice , Neurology and Neurosurgery Interest Group , British Neurosurgical Trainee Research Collaborative , Giamouriadis Anastasios , Bhatt Pragnesh , Ram Bhaskar , Varma Adithya , Weir Philip , Hanna Brendan , Hirst Theodore C , McAleavey Patrick , Paluzzi Alessandro , Tsermoulas Georgios , Ahmed Shahzada , Soon Wai Cheong , Chowdhury Yasir Arafat , Abualsaud Suhaib , Mahmood Shumail , Naik Paresh , Haiderkhan Zohra , Al-Mahfoudh Rafid , Perera Andrea , Rus Mircea , Williams Adam , Hand Charles , Abhinav Kumar , Cernei Cristina , Dilnawaz Aiman , Mannion Richard , Santarius Thomas , Tysome James , Sharma Rishi , Kolias Angelos G , Donnelly Neil , Patel Vikesh , Venkatesh Ashwin , Hayhurst Caroline , Mohamed Amr , Stew Benjamin , Merola Joseph , Ooi Setthasorn Zhi Yang , Kamel Mahmoud , Khan Mohammad Habibullah , Abrar Sahibzada , Mckeon Christopher , McSweeney Daniel , Javadpour Mohsen , Lacy Peter , Murray Daniel , Roman Elena , Hossain-Ibrahim Kismet , Ross Peter , Bennett David , McSorley Nathan , Hounat Adam , Statham Patrick , Hughes Mark , Hamdan Alhafidz , Scott Caroline , Moudgil-Joshi Jigi , Bahl Anuj , Bjornson Anna , Gatt Daniel , Phillips Nick , Kalra Neeraj , Bautista Melissa , Shirazi Seerat , Gilkes Catherine E , Millward Christopher P , Ali Ahmad MS , Paraskevopoulos Dimitris , Bal Jarnail , Matloob Samir , Lobo Rhannon , Mendoza Nigel , Nair Ramesh , Dalton Arthur , Nadig Adarsh , Hernandez Lucas , Thomas Nick , Maratos Eleni , Shapey Jonathan , Al-Barazi Sinan , Mirza Asfand Baig , Okasha Mohamed , Malhotra Prabhjot Singh , Ahmed Razna , Dorward Neil L , Grieve Joan , Sayal Parag , Choi David , Cabrilo Ivan , Horsfall Hugo Layard , Pollock Jonathan , Shoakazemi Alireza , Maccormac Oscar , Amirthalingam Guru N K , Martin Andrew , Stapleton Simon , Hogg Florence , Richardson Daniel , Gnanalingham Kanna , Pathmanaban Omar , Fountain Daniel M , Bhalla Raj , Hannan Cathal J , Chadwick Annabel , Jenkins Alistair , Nicholson Claire , Shumon Syed , Youssef Mohamed , Allison Callum , Dow Graham , Robertson Iain , Glancz Laurence Johann , Sitaraman Murugan , Kumaria Ashwin , Bagchi Ananyo , Cudlip Simon , Halliday Jane , Piper Rory J , Boukas Alexandros , Amarouche Meriem , Veljanoski Damjan , Muquit Samiul , Edlmann Ellie , Maripi Haritha , Wang Yi , Hossain Mehnaz , Alalade Andrew , Maroof Syed , Patkar Pradnya , Sinha Saurabh , Mirza Showkat , Henderson Duncan , Khan Mohammad Saud , Mathad Nijaguna , Hempenstall Jonathan , Neurosurgery Difei Wang, Department of , Marwaha Pavan , Shaw Simon , Solomou Georgios , Shrestha Alina , Fraser Andrew , Hirst Theodore , Chowdhury Yasir , Bilal Sobiya , Wildman Jack , Venkatesh Ashwin , Babu Priya , Carey Cian , Bathuni Renitha Reddi , Hossain-Ibrahim Kismet , Brennan Joseph Nathaniel , Bjornson Anna , Ktayen Howra , Trichinopoly Sandhya T , Matloob Samir , Nadig Adarsh , Okasha Mohamed , Khan Danyal , Shoakazemi Alireza , Hogg Florence , Sobawale Seun , Suliman Amir , Kumaria Ashwin , Piper Rory , Owen Will , Edlmann Ellie , Sartaj Afaq , Goacher Edward , Strachan Euan , Solomou Giorgios TITLE=CSF rhinorrhoea after endonasal intervention to the skull base (CRANIAL): A multicentre prospective observational study JOURNAL=Frontiers in Oncology VOLUME=12 YEAR=2023 URL=https://www.frontiersin.org/journals/oncology/articles/10.3389/fonc.2022.1049627 DOI=10.3389/fonc.2022.1049627 ISSN=2234-943X ABSTRACT=Objective

Despite progress in endonasal skull-base neurosurgery, cerebrospinal fluid (CSF) rhinorrhoea remains common and significant. The CRANIAL study sought to determine 1) the scope of skull-base repair methods used, and 2) corresponding rates of postoperative CSF rhinorrhoea in the endonasal transsphenoidal approach (TSA) and the expanded endonasal approach (EEA) for skull-base tumors.

Methods

A prospective observational cohort study of 30 centres performing endonasal skull-base neurosurgery in the UK and Ireland (representing 91% of adult units). Patients were identified for 6 months and followed up for 6 months. Data collection and analysis was guided by our published protocol and pilot studies. Descriptive statistics, univariate and multivariable logistic regression models were used for analysis.

Results

A total of 866 patients were included - 726 TSA (84%) and 140 EEA (16%). There was significant heterogeneity in repair protocols across centres. In TSA cases, nasal packing (519/726, 72%), tissue glues (474/726, 65%) and hemostatic agents (439/726, 61%) were the most common skull base repair techniques. Comparatively, pedicled flaps (90/140, 64%), CSF diversion (38/140, 27%), buttresses (17/140, 12%) and gasket sealing (11/140, 9%) were more commonly used in EEA cases. CSF rhinorrhoea (biochemically confirmed or requiring re-operation) occurred in 3.9% of TSA (28/726) and 7.1% of EEA (10/140) cases. A significant number of patients with CSF rhinorrhoea (15/38, 39%) occurred when no intraoperative CSF leak was reported. On multivariate analysis, there may be marginal benefits with using tissue glues in TSA (OR: 0.2, CI: 0.1-0.7, p<0.01), but no other technique reached significance. There was evidence that certain characteristics make CSF rhinorrhoea more likely – such as previous endonasal surgery and the presence of intraoperative CSF leak.

Conclusions

There is a wide range of skull base repair techniques used across centres. Overall, CSF rhinorrhoea rates across the UK and Ireland are lower than generally reported in the literature. A large proportion of postoperative leaks occurred in the context of occult intraoperative CSF leaks, and decisions for universal sellar repairs should consider the risks and cost-effectiveness of repair strategies. Future work could include longer-term, higher-volume studies, such as a registry; and high-quality interventional studies.