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P262: PERSISTENT CEREBROSPINAL FLUID LEAK FOLLOWING ENDOSCOPIC ENDONASAL SKULL BASE SURGERY: CASE-BASED INSIGHTS FROM A MEDICAL CENTER IN TAIWAN
Yun-Kai Chan, MD¹; Kai-Chun Lin, MD¹; Po-Kai Huang, MD²; Chia-Hsing Lin, MD²; Ying-Piao Wang, MD, PhD²; ¹Department of Neurosurgery, MacKay Memorial Hospital, Taipei, Taiwan; ²Department of Otolaryngology-Head and Neck Surgery, MacKay Memorial Hospital, Taipei, Taiwan

Introduction: Cerebrospinal fluid (CSF) leak is a significant postoperative complication in endoscopic endonasal skull base surgery, potentially leading to meningitis, prolonged hospitalization, and need for reoperation. To reduce this risk, we established a structured reconstruction algorithm at the Skull Base Center of MacKay Memorial Hospital, a medical center in Taiwan, beginning in 2021. This study presents a five-year institutional experience focusing on persistent CSF leaks and the clinical lessons derived.

Materials and Methods: Between January 2021 and September 2025, 166 patients underwent endoscopic endonasal skull base surgery with individualized, flow-directed reconstruction. Our algorithm stratified reconstruction techniques by defect location and CSF leak grading. All patients received an inlay dura substitute. High-flow leaks were reinforced using pedicled flaps, primarily nasoseptal flaps (NSF), occasionally supplemented with fascia lata, fat graft, or lumbar drainage depending on defect complexity. Patient outcomes and complications were retrospectively reviewed.

Results: Persistent postoperative CSF leak occurred in 4 patients (2.4%), all requiring revision reconstruction:

1. A pituitary adenoma patient with a mucosal graft (middle turbinate) developed a CSF leak due to inadequate postoperative compliance and nasal trauma caused by improper use of cotton-tipped applicators.
2. A patient with a giant pituitary adenoma developed a CSF leak secondary to a postoperative hematoma, which displaced the reconstruction flap after subtotal tumor resection via the endoscopic endonasal approach.
3. A patient with a metastatic sellar tumor developed a CSF leak, likely related to impaired wound healing in the context of poor general condition and compromised nutritional status.
4. A suprasellar case with large dural defect had incomplete NSF coverage, leading to leak despite primary flap reconstruction.

All cases were successfully managed with secondary reconstruction by using NSF. No re-leak or intracranial infection occurred during follow-up.

Discussion and Conclusions: Our five-year experience demonstrates that a structured reconstruction algorithm—based on anatomical location and intraoperative CSF leak grading—can achieve a low rate of persistent CSF leak (2.4%) following endoscopic endonasal skull base surgery. Nevertheless, patient-specific factors—including postoperative behavior, tumor burden, nutritional status, and flap design—remain critical determinants of reconstruction failure. Early recognition, timely revision, and individualized surgical strategies are essential for durable repair. These findings underscore the importance of protocol adherence and patient education in optimizing outcomes in skull base reconstruction.

Figure 1. Structured skull base reconstruction algorithm at the Skull Base Center of MacKay Memorial Hospital, stratified by anatomical defect location and intraoperative cerebrospinal fluid (CSF) leak grading.

Figure 2.

1. Patient 1. The white asterisk indicates a self-induced tract at the left nasal cavity, caused by the patient’s improper use of cotton-tipped applicators, leading to disruption of the reconstruction site.
2. Patient 2. The white triangle indicates the nasoseptal flap (NSF); the white square denotes a hematoma between the NSF and tumor cavity, displacing the flap.
3. Patient 3. The white arrow marks the site of persistent CSF leak due to impaired healing between the NSF and the exposed sphenoid sinus bone.
4. Patient 4. The white circle highlights an area of incomplete NSF coverage, with exposed artificial dura underneath.

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