Factors associated with cerebrospinal fluid leak after retrosigmoid approach.

Dear Editor,

We read with great interest the article by Montano et al.[1] on the factors associated with cerebrospinal fluid (CSF) leak after a retrosigmoid approach for cerebellopontine angle surgery. The authors have rightly pointed out that performing a craniectomy and a reopening procedure as significantly associated with a higher risk of CSF leak.

However, we do believe that one of the most consistent contributors in CSF leak following retrosigmoid approach is the opening method and closure of fascia following surgery. We perform a Y-shaped opening of the fascia, with the two limbs of Y-above the transverse sinus, which is not reflected from the bone. At the time of closure, both the limbs are approximated together with the vertical limb of Y-giving it a further tight sealant effect [Figure 1]. Of course, postoperative hydrocephalus and a nonwatertight dural closure are the other reasons for CSF leak post retrosigmoid surgery.

Figure 1:

Fascia is incised in a Y-shaped fashion with its limbs overlying the sinus, and is stitched back in a water tight fashion.