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Non-vascularized multilayer fascial closure technique (NMFCT) can be used instead of nasoseptal flap reconstruction for dural repair in endoscopic transnasal surgery (ETS); however, due to the lack of blood supply, its long-term durability and possible limitations need to be clarified. This was a retrospective study on patients who underwent ETS with intraoperative cerebrospinal fluid (CSF) leakage. We assessed the postoperative and delayed CSF leakage rates and the associated risk factors. Among 200 ETSs with intraoperative CSF leakage, 148 (74.0%) ETSs were performed for skull base pathologies other than pituitary neuroendocrine tumor. The mean follow-up period was 34.4 months. Esposito grade 3 leakage was confirmed in 148 (74.0%) cases. NMFCT was used either with (67 [33.5%]) or without (133 [66.5%]) lumbar drainage. There were 10 cases (5.0%) of postoperative CSF leakage that necessitated reoperation. In 4 other cases (2.0%), CSF leakage was suspected but lumbar drainage alone successfully restored the condition. Multivariate logistic regression analyses revealed that posterior skull base location (P < 0.01, odds ratio 11.5, 95% CI 1.99–2.17 × 102) and craniopharyngioma pathology (P = 0.03, odds ratio 9.4, 95% CI 1.25–1.92 × 102) were significantly associated with postoperative CSF leakage. No delayed leakage occurred during the observation period except for 2 patients who underwent multiple radiotherapies. NMFCT is a reasonable alternative with long-term durability, though vascularized flap may be a better choice for cases in which vascularity of the surrounding tissues is significantly impaired due to interventions including multiple radiotherapies. [ABSTRACT FROM AUTHOR]

We present a case of lower clival meningioma treated with the endoscopic transnasal extended transclival approach. 1,2 A 52-year-old woman with a large clival meningioma had undergone transcondylar approach 3 and posterolateral approach 4 in the previous hospital and presented with mild swallowing difficulty and hypoglossal nerve palsy in the right side. The tumor compressed the medulla oblongata, involving the lower cranial nerves bilaterally and facial nerve on the right side. The patient underwent the endoscopic transnasal extended transclival approach (Video 1). The anterior aspect and the floor of the sphenoid sinus were drilled off, and the sella, bilateral carotid prominences, and clivus were revealed. The clival bone and jugular tubercles were then removed. The dura mater on the clivus was widely exposed and coagulated to manage the arterial blood supply for the tumor. The dura was incised in a rectangular shape, and the successful mass reduction was achieved except for the tumor components strongly adherent to the lower cranial nerves on the right side. For skull base reconstruction, fascia lata was placed in and on the dural defect with multilayer fashion and the pharyngeal flap was rectified. The balloon catheter was inserted and inflated to compress the fascia and pharyngeal flap, and lumber drainage with the pressure-control valve system was performed for 72 hours. 5 After surgery, her symptoms gradually improved. The residual tumor was treated with Gamma Knife surgery. The tumor was successfully controlled for 3 years, and the patient didn't show any neurologic symptom at the last follow-up. [ABSTRACT FROM AUTHOR]