The patient is a 57-year-old female who presented with 5 months of progressively worsening visual acuity and diabetes insipidus. Magnetic resonance imaging (MRI) showed a heterogeneous rim-enhancing 17 x 13 x 25 mm suprasellar lesion. The patient has no significant medical comorbidities. An endoscopic endonasal resection of the lesion was performed. DURAFOAM dural graft implant was used to close the dura and a nasoseptal flap was placed over the defect. The lesion was confirmed on pathology to be an adamantinomatous craniopharyngioma. Day 1 postoperative computed tomography of the brain (CTB) showed a small bifrontal pneumocephalus [Figure 1a]. Two days postoperatively, the patient developed rhinorrhoea and lower limb diplegia. CTB demonstrated an expanding pneumocephalus with mass effect [Figure 1b]. This was decompressed via bilateral frontal burr holes and CTB showed a slight reduction in the volume of the pneumocephalus [Figure 1c]. Four days after the operation, her Glasgow Coma Scale (GCS) again deteriorated to 10 (M6V1E3) with lower limb diplegia. Percutaneous aspiration of the pneumocephalus via bilateral frontal burr holes was performed. The aspiration continued until the patient started to verbalize and move her lower limbs.
A transnasal transphenoidal repair of the dural defect was performed. Dural substitute was removed and a fascia lata graft inlay was used to repair the defect. However, the negative intracranial pressure drew the fascia lata graft intradurally. A fascia lata onlay graft with autologous blood patch was then used and the nasoseptal flap was replaced and secured with a TISSEEL fibrin sealant. Ten hours after the operation, the patient's GCS dropped to 11 (M6V1E4) and CTB again showed re-accumulation of the pneumocephalus. Percutaneous aspiration was performed and the patient returned to her neurological baseline.
Three days after the last percutaneous aspiration, rhinorrhoea was again observed. This was followed 2 days later by another episode of GCS reduction to 13 (M6V3E4) with diplegia. CTB showed an expanding anterior pneumocephalus with mass effect. Percutaneous aspiration was performed with GCS recovery. The following day, GCS dropped to 9 (M6V2E1), and percutaneous aspiration was again performed for improvement in GCS. An endoscopic repair of the CSF leak was performed. During the operation, a leak was found between the leaflets of the previous fascia lata repair. A fat bath plug was placed over the defect with a large single piece of fascia overlaid. The repair was then tested with Valsalva three times. The nasoseptal flap was overlaid and augmented with a left inferior turbinate free mucosal graft. Postoperative CTB showed a significant reduction in the size of the pneumocephalus [Figure 1d]. The patient made an uneventful recovery and discharged GCS 15 with no neurological deficit.