(1268) Surgical Management of Lateral Sphenoid Recess Cerebrospinal Fluid Leak and Postoperative Bilateral Sigmoid Sinus Stenosis

Introduction: Idiopathic intracranial hypertension (IIH) can occur secondary to dural venous sinus stenosis (DVSS) and is classically implicated in spontaneous CSF leaks (sCSF-L) and meningoceles. Lateral sphenoid recess meningoceles can be accessed via endoscopic transpterygoid approach. Given that DVSS is often unilateral and detected at the time of IIH diagnosis, management of bilateral DVSS after sCSF-L repair is not well described.

Methods: A 56-year-old male with BMI 20.7 presented with intermittent headaches relieved by clear right-sided rhinorrhea that was Beta-2 transferrin positive. CT scan confirmed extensive pneumatization and meningocele in the right lateral sphenoid recess. Serial intracranial pressure measurement and multimodal imaging were used to define the process before and after repair.

Results: Preoperative lumbar drain was placed with opening pressure of 6cmH2O. The patient underwent endoscopic repair via unilateral, endonasal, transmaxillary, transpterygoid approach through the infratemporal fossa with an autologous abdominal fat graft. Lumbar drain transduced at 40 cmH2O on postoperative day 2 and at 27 cmH2O after initiation of 500mg acetazolamide BID. CT venography revealed bilateral transverse and sigmoid sinus stenosis, with venous manometry pressure gradients >10 mmHg. He was discharged day 4 on 750mg acetazolamide daily and dual antiplatelet therapy prior to bilateral sigmoid sinus stenting.

Conclusions: CSF leaks in the lateral sphenoid recess can be managed endoscopically in most cases. Though atypical, sCSF-Ls can occur in nonobese individuals with normal opening pressures. This case highlights postoperative management of rebound intracranial hypertension and newly identified bilateral DVSS, with CT venography and venous manometry as cornerstones for diagnosis.