Headache, Cerebrospinal Fluid Leaks, and Pseudomeningoceles after Resection of Vestibular Schwannomas: Efficacy of Venous Sinus Stenting Suggests Cranial Venous Outflow Compromise as a Unifying Pathophysiological Mechanism

J. Nicholas Higgins; Robert Macfarlane; Patrick R. Axon; Richard A. Mannion; James R. Tysome; Neil Donnelly; David A. Moffat; John D. Pickard

doi:10.1055/s-0039-1677706

Journal of Neurological Surgery Part B: Skull Base, Table of Contents

J Neurol Surg B Skull Base 2019; 80(06): 640-647
DOI: 10.1055/s-0039-1677706

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Headache, Cerebrospinal Fluid Leaks, and Pseudomeningoceles after Resection of Vestibular Schwannomas: Efficacy of Venous Sinus Stenting Suggests Cranial Venous Outflow Compromise as a Unifying Pathophysiological Mechanism

J. Nicholas Higgins

¹Department of Radiology, Addenbrooke's Hospital, Cambridge, United Kingdom

,

Robert Macfarlane

²Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom

,

Patrick R. Axon

³Cambridge Skull Base Unit, Addenbrooke's Hospital, Cambridge, United Kingdom

,

Richard A. Mannion

²Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom

,

James R. Tysome

³Cambridge Skull Base Unit, Addenbrooke's Hospital, Cambridge, United Kingdom

,

Neil Donnelly

³Cambridge Skull Base Unit, Addenbrooke's Hospital, Cambridge, United Kingdom

,

David A. Moffat

³Cambridge Skull Base Unit, Addenbrooke's Hospital, Cambridge, United Kingdom

,

John D. Pickard

²Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, United Kingdom

› Author Affiliations

Abstract

Background Regardless of the operative approach, headache, cerebrospinal fluid (CSF) leaks, and pseudomeningoceles remain disproportionately common problems after surgery for vestibular schwannomas and have a significant negative impact on quality of life and potential to return to full employment. Recent work has raised the possibility that these problems may, in part, be related to acquired obstruction of cranial venous outflow. This article explores this idea further with respect to a group of patients with severe and intractable symptoms.

Objective The main objective of this article is to describe our experience diagnosing, investigating, and treating cranial venous outflow obstruction following translabyrinthine resection of vestibular schwannomas.

Methods Retrospective review of all patients (n = 9) at our institution referred for sigmoid sinus stenting following translabyrinthine surgery.

Results Headache resolved or improved after sigmoid stenting in all five patients in whom it was the primary symptom. CSF leak was the primary problem in two patients. In one, the leak was unchanged, but headache improved. In the other, the leak resolved, and headache improved. Two patients had symptomatic pseudomeningoceles and both resolved

Conclusion Assuming a meticulous approach to wound closure, a CSF leak following surgery for vestibular schwannoma can be viewed as a pathological, but essentially homeostatic, response to raised intracranial pressure caused by acquired obstruction to cranial venous outflow. Postoperative headache (from high or low intracranial pressure) and CSF leaks, therefore, may all respond to measures aimed at eliminating the obstructing lesion.

Keywords

vestibular schwannoma - sigmoid sinus stenting - headache - cerebrospinal fluid leak - pseudomeningocele - cerebral venous outflow obstruction

Full Text

References

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