PMC4756248_01
Preoperative neuroradiological images. A: Axial thin-sliced computed tomography (CT) showing the clival defect and bone fragment (white arrow) at the middle clivus and fluid collection in the sphenoid sinus. B: Sagittal steady-state magnetic resonance image revealing the continuity of cerebrospinal fluid between the sphenoid sinus and prepontine cistern (black arrow).
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F1
Preoperatively, thin-sliced bone CT (Fig. 1A) and steady-state magnetic resonance imaging (MRI; Fig. 1B) were performed, which identified the fistula causing the CSF leakage. The axial CT bone image showed a bone defect at the middle clivus, and a free bone fragment in the sphenoid sinus (Fig. 1A). MR image (Fig. 1B). MR angiography did not show any vascular damage to the carotid, basilar, or vertebral arteries.
A: Intraoperative endoscopic images demonstrating the clival defect, small bone fragment with hematoma, and submucosal hemorrhage in the sphenoid sinus. B: Enlarged view after removal of the bone fragment and sphenoidal mucosa visualizing the basilar artery (asterisk) through the fistula. C: Pedicled nasoseptal mucosal flap being used for reconstruction. C: clivus, CP: carotid prominence, S: sellar floor, SS: sphenoid sinus.
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F2
During the operation, fluid collection was observed in the sphenoid sinus after anterior sphenoidotomy, and a fistula and small bone fragment were confirmed around the center of the clivus (Fig. 2A). The dural tear and bone defect were clearly visualized under endoscopic view after removal of the small bone fragment and the mucosa on the posterior sphenoid wall (Fig. 2B). The basilar artery came into view through the dural defect behind the clivus (Fig. 2B). The dural and bone defects at the clivus were repaired using a pedicled nasoseptal mucosal flap, and then abdominal fat and fibrin glue were applied (Fig. 2C).
Postoperative axial (A) and sagittal (B) steady-state MR images showing successful reconstruction of the clivus (black arrows).
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F3
After the endoscopic procedure, CSF rhinorrhea completely disappeared, and the clival defect and fluid collection in the sphenoid sinus had improved on MR imaging (Fig. 3A, B).