Cerebrospinal fluid leakage after cranial surgery in the pediatric population-a systematic review and meta-analysis

Emma M H Slot, Kirsten M van Baarsen, Eelco W Hoving, Nicolaas P A Zuithoff, Tristan P C van Doormaal, Emma M H Slot, Kirsten M van Baarsen, Eelco W Hoving, Nicolaas P A Zuithoff, Tristan P C van Doormaal

Abstract

Background: Cerebrospinal fluid (CSF) leakage is a common complication after neurosurgical intervention. It is associated with substantial morbidity and increased healthcare costs. The current systematic review and meta-analysis aim to quantify the incidence of cerebrospinal fluid leakage in the pediatric population and identify its risk factors.

Methods: The authors followed the PRISMA guidelines. The Embase, PubMed, and Cochrane database were searched for studies reporting CSF leakage after intradural cranial surgery in patients up to 18 years old. Meta-analysis of incidences was performed using a generalized linear mixed model.

Results: Twenty-six articles were included in this systematic review. Data were retrieved of 2929 patients who underwent a total of 3034 intradural cranial surgeries. Surprisingly, only four of the included articles reported their definition of CSF leakage. The overall CSF leakage rate was 4.4% (95% CI 2.6 to 7.3%). The odds of CSF leakage were significantly greater for craniectomy as opposed to craniotomy (OR 4.7, 95% CI 1.7 to 13.4) and infratentorial as opposed to supratentorial surgery (OR 5.9, 95% CI 1.7 to 20.6). The odds of CSF leakage were significantly lower for duraplasty use versus no duraplasty (OR 0.41 95% CI 0.2 to 0.9).

Conclusion: The overall CSF leakage rate after intradural cranial surgery in the pediatric population is 4.4%. Risk factors are craniectomy and infratentorial surgery. Duraplasty use is negatively associated with CSF leak. We suggest defining a CSF leak as "leakage of CSF through the skin," as an unambiguous definition is fundamental for future research.

Keywords: Cerebrospinal fluid leakage; Craniectomy; Craniotomy; Pediatrics; Posterior fossa surgery.

Conflict of interest statement

TPC van Doormaal is a consultant for Polyganics B.V.

Polyganics B.V. was not involved in the content of this manuscript.

Figures

Fig. 1
Fig. 1
Flowchart of study selection
Fig. 2
Fig. 2
Forest plot incidence of CSF leakage

References

    1. Behling F, Kaltenstadler M, Noell S, et al. The prognostic impact of ventricular opening in glioblastoma surgery: a retrospective single center analysis. World Neurosurg. 2017;106:615–624. doi: 10.1016/j.wneu.2017.07.034.
    1. Bognár L, Borgulya G, Benke P, Madarassy G. Analysis of CSF shunting procedure requirement in children with posterior fossa tumors. Child’s Nerv Syst. 2003;19(5-6):332–336. doi: 10.1007/s00381-003-0745-x.
    1. Cardoso ER, Rowan JO, Galbraith S. Analysis of the cerebrospinal fluid pulse wave in intracranial pressure. J Neurosurg. 1983;59:817–821. doi: 10.3171/jns.1983.59.5.0817.
    1. Cochrane DD, Gustavsson B, Poskitt KP, et al. The surgical and natural morbidity of aggressive resection for posterior fossa tumors in childhood. Pediatr Neurosurg. 1994;20(1):19–29. doi: 10.1159/000120761.
    1. Culley DJ, Berger MS, Shaw D, et al. An analysis of factors determining the need for ventriculoperitoneal shunts after posterior fossa tumor surgery in children. Neurosurg. 1994;34(3):402–408. doi: 10.1227/00006123-199403000-00003.
    1. Dlouhy BJ, Chae MP, Teo C. The supraorbital eyebrow approach in children: clinical outcomes, cosmetic results, and complications. J Neurosurg Pediatr. 2015;15(1):12–19. doi: 10.3171/2014.10.PEDS1430.
    1. Gananalignham KK, Lafuente J, Thompson D, et al. Surgical procedures for posterior fossa tumors in children: does craniotomy lead to fewer complications than craniectomy? J Neurosurg. 2002;97(4):821–826. doi: 10.3171/jns.2002.97.4.0821.
    1. Gananalignham KK, Lafuente J, Thompson D, et al. MRI study of the natural history and risk factors for pseudomeningocoele formation following postfossa surgery in children. Br J Neurosurg. 2003;17(6):530–536. doi: 10.1080/02688690310001627777.
    1. Gopalakrishnan CV, Dhakoji A, Menon G, et al. Factors predicting the need for cerebrospinal fluid diversion following posterior fossa tumor surgery in children. Pediatr Neurosurg. 2012;48(2):93–101. doi: 10.1159/000343009.
    1. Grotenhuis JA. Costs of postoperative cerebrospinal fluid leakage: 1-Year, retrospective analysis of 412 consecutive nontrauma cases. Surg Neurol. 2005;64(6):490–493. doi: 10.1016/j.surneu.2005.03.041.
    1. Hale AT, Gannon SR, Zhao S, et al. Graft dural closure is associated with a reduction in CSF leak and hydrocephalus in pediatric patients undergoing posterior fossa brain tumor resection. J Neurosurg Pediatr. 2020;25(3):228–234. doi: 10.3171/2019.9.PEDS1939.
    1. Hidalgo ET, Dastagirzada Y, Orillac C, et al. Time to resolution of symptoms after suboccipital decompression with duraplasty in children with chiari malformation type I. World Neurosurg. 2018;117:e544–e551. doi: 10.1016/j.wneu.2018.06.073.
    1. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539–1558. doi: 10.1002/sim.1186.
    1. Hosainey SAM, Lassen B, Helseth E, Meling TR. Cerebrospinal fluid disturbances after 381 consecutive craniotomies for intracranial tumors in pediatric patients. J Neurosurg Pediatr. 2014;14(6):604–614. doi: 10.3171/2014.8.PEDS13585.
    1. Houdemont SP, De Carli E, Delion M, et al. Short-term neurological outcome of children after surgery for brain tumors: incidence and characteristics in a pediatric intensive care unit. Child’s Nerv Syst. 2011;27(6):933–941. doi: 10.1007/s00381-010-1373-x.
    1. Hutter G, Von Felten S, Sailer MH, Schulz M, Mariani L. Risk factors for postoperative CSF leakage after elective craniotomy and the efficacy of fleece-bound tissue sealing against dural suturing alone: a randomized controlled trial - clinical article. J Neurosurg. 2014;121(3):735–744. doi: 10.3171/2014.6.JNS131917.
    1. Jiang E, Sha S, Yuan X, et al. Comparison of clinical and radiographic outcomes for posterior fossa decompression with and without duraplasty for treatment of pediatric chiari I malformation: a prospective study. World Neurosurg. 2018;110:e465–e472. doi: 10.1016/j.wneu.2017.11.007.
    1. Kinaci A, Algra A, Heuts S, O’Donnell D, van der Zwan A, van Doormaal T. Effectiveness of dural sealants in prevention of cerebrospinal fluid leakage after craniotomy: a systematic review. World Neurosurg. 2018;118:368–376.e1. doi: 10.1016/j.wneu.2018.06.196.
    1. Krieger MD, McComb JG, Levy ML. Toward a simpler surgical management of Chiari I malformation in a pediatric population. Pediatr Neurosurg. 1999;30(3):113–121. doi: 10.1159/000028777.
    1. Kushel Y, Danilov G, Tekoev A, et al. A single-center retrospective descriptive cohort study of 211 pediatric patients: cerebrospinal fluid leakage after fourth ventricle tumor resection. World Neurosurg. 2019;129:e171–e176. doi: 10.1016/j.wneu.2019.05.091.
    1. Lassen B, Helseth E, Egge A, et al. Surgical mortality and selected complications in 273 consecutive craniotomies for intracranial tumors in pediatric patients. Neurosurgery. 2012;70(4):936–943. doi: 10.1227/NEU.0b013e31823bcc61.
    1. Leclercq E, Leeflang MMG, van Dalen EC, et al. Validation of search filters for identifying pediatric studies in PubMed. J Pediatr. 2013;162(3):629–634.e2. doi: 10.1016/j.jpeds.2012.09.012.
    1. Levy M, Wang M, Aryan HE, et al. Microsurgical keyhole approach for Mmiddle fossa arachnoid cyst fenestration. Neurosurgery. 2003;53(5):1138–1145. doi: 10.1227/01.NEU.0000089060.65702.03.
    1. Mehendale NH, Samy RN, Roland PS. Management of pseudomeningocele following neurotologic procedures. Otolaryngol Head Neck Surg. 2004;131:253–262. doi: 10.1016/j.otohns.2004.01.018.
    1. Moher D, Liberati A, Tetzlaff J, et al. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: the PRISMA Statement. PLOS Med. 2009;6(7):e1000097. doi: 10.1371/journal.pmed.1000097.
    1. Muszynski CA, Laurent JP, Cheek WR. Effects of ventricular drainage and dural closure on cerebrospinal fluid leaks after posterior fossa tumor surgery. Pediatr Neurosurg. 1994;21(4):227–231. doi: 10.1159/000120840.
    1. National Institutes of Health. Study quality assessment tools | National Heart, Lung, and Blood Institute (NHLBI). Natl Institutes Heal. 2014. . Accessed January 14, 2020.
    1. Panigrahi M, Krishnan SS, Varma DR. Crescent posterior fossa durotomy for occipito-marginal venous sinus preservation: a pilot study. Acta Neurochir (Wien). 2012;154(11):2115–2121. doi: 10.1007/s00701-012-1457-3.
    1. Parizek J, Mericka P, Nemecek S, et al. Posterior cranial fossa surgery in 454 children: comparison of results obtained in pre-CT and CT era and after various types of management of dura mater. Child’s Nerv Syst. 1998;14(9):426–438. doi: 10.1007/s003810050255.
    1. Parker SR, Harris P, Cummings TJ, et al. Complications following decompression of Chiari malformation type I in children: dural graft or sealant? Clinical article. J Neurosurg Pediatr. 2011;8(2):177–183. doi: 10.3171/2011.5.PEDS10362.
    1. Rickert CH, Paulus W. Epidemiology of central nervous system tumors in childhood and adolescence based on the new WHO classification. Child’s Nerv Syst. 2001;17(9):503–511. doi: 10.1007/s003810100496.
    1. Roth J, Benvenisti H, Constantini S. Watertight dural closure in pediatric craniotomies—is it really necessary? World Neurosurg. 2018;114:e743–e746. doi: 10.1016/j.wneu.2018.03.070.
    1. Soleman J, Ber R, Constantini S, Roth J. The interhemispheric approach in children: our experience and review of the literature. Childs Nerv Syst. 2019;35(3):445–452. doi: 10.1007/s00381-018-04039-2.
    1. Srinivasan J, Dailey AT, Berger MS. The bifrontal olfactory nerve-sparing approach to lesions of the suprasellar region in children. Pediatr Neurosurg. 1999;30(5):245–252. doi: 10.1159/000028805.
    1. Steinbok P, Singhal A, Mills J, et al. Cerebrospinal fluid (CSF) leak and pseudomeningocele formation after posterior fossa tumor resection in children: a retrospective analysis. Child’s Nerv Syst. 2007;23(2):171–174. doi: 10.1007/s00381-006-0234-0.
    1. Tu A, Tamburrini G, Steinbok P. Management of postoperative pseudomeningoceles: an international survey study. Childs Nerv Syst. 2014;30:1791–1801. doi: 10.1007/s00381-014-2501-9.
    1. Vedantam A, Pan IW, Staggers KA, Lam SK. Thirty-day outcomes in pediatric epilepsy surgery. Child’s Nerv Syst. 2018;34(3):487–494. doi: 10.1007/s00381-017-3639-z.
    1. Zhou X, Goodwin CR, Recinos PF, et al. Evaluation of complication rates of pediatric cranial procedures in which a polyethylene glycol sealant was used. J Neurosurg Pediatr. 2014;14(5):514–517. doi: 10.3171/2014.7.PEDS1437.

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