49Complications
Complications are relatively rare for any
approach, however the rate increases with tumor
size, as one would expect.
Cerebrospinal Fluid Leak
and Meningitis
Historical series report postoperative CSF leak in
2–7 % of patients who underwent middle fossa
approach for tumor resection [ 32 , 50 ]. In our
most recent series of patients who underwent
middle fossa tumor removal, none had a postop-
erative CSF leak. This is likely due to continuous
flushing while drilling and copious irrigation to
prevent bone dust from plugging arachnoid gran-
ulations, as well as meticulous dural plugging
with abdominal fat, attention to plugging any air
cells around the IAC, and cautious wound closure
techniques [ 44 ]. In a review of all of their trans-
labyrinthine approaches since 1974, the House
group found an initial rate of CSF leak of 20%
when using temporalis muscle to close the dura
[ 15 ]. This improved to 7% with the use of abdom-
inal fat and to 4% once they began using titanium
mesh cranioplasty plates in 2003 [ 16 , 55 ]. In a
prospective study of 71 patients compared to his-
toric controls, we found that there was no differ-
ence in incidence of CSF leak between fat graft
and resorbable mesh cranioplasty (13.4% vs
12.7%, P = 0.88) [ 56 ]. A large systematic review
published in 2012 found a rate of CSF leaks of
5.3% for the middle fossa approach and 7.1% for
the translabyrinthine approach, consistent with
previously published incidences [ 19 ].
Meningitis is becoming increasingly rare,
due to the consistent use of perioperative antibi-
otics and reduced operative times. Smaller
series published in the 1990s found rates of
2–5% in patients who underwent the middle
fossa approach, however not all of those cases
were culture proven [ 32 , 50 ]. A review of 512
patients who underwent translabyrinthine
approach from 2000 to 2004 found a rate of
postoperative meningitis of only 0.6% [ 16 ]. It is
important to note that patients can experience
meningismus secondary to chemical meningitis
in the postoperative setting. It is crucial to obtain
a lumbar puncture in this setting to rule out a
bacterial etiology.HemorrhageA rare, but serious and potentially fatal complica-
tion is a hematoma in the CPA. This presents in
the early postoperative period with signs of
increased intracranial pressure. Such a scenario is
managed by immediate exploration with removal
of the fat packing, evacuation of the hematoma,
and control of the source. This can be accommo-
dated rapidly if the patient underwent the trans-
labyrinthine approach. Incidences are isolated to
individual case reports with the middle fossa
approach, often in the forms of epidural or sub-
dural hematomas [ 3 , 45 ]. In their series of 512
patients, the House group found incidences of
0.8% and 0.6% for subdural and CPA hemato-
mas, respectively, with the translabyrinthine
approach [ 16 ].Sigmoid Sinus ThrombosisSigmoid sinus thrombosis is an uncommon but
well-recognized and potentially devastating com-
plication of surgical approaches to the CPA. Risk
factors for developing dural sinus thrombosis in
the postoperative setting include mechanical
injury during surgery, excessive manipulation
and prolonged retraction of the sinus, dehydration,
pregnancy, oral contraceptive use, infection, and
hematologic disease [ 57 , 58 ]. Though not always
symptomatic, manifestations in those who
develop this complication include headaches,
altered mental status, seizures, focal neurologic
deficits, papilledema, intracranial hemorrhage
(ICH), and infarction [ 39 , 57 , 60 ]. While there is
an abundance of literature discussing the treat-
ment options and outcomes of sigmoid sinus
thrombosis that is spontaneous or secondary to
infection or trauma, there are only small, isolated
case series discussing it in the postoperative
period. In one of the largest series of 107 patients3 Middle Fossa and Translabyrinthine Approaches