Classification of crista galli pneumatization and clinical considerations for anterior skull base surgery

Cerebrospinal fluid (CSF) leakage caused by frontal sinus exposure is a serious complication in the basal interhemispheric approach (BIHA). Crista galli pneumatization (CGP) is often observed on preoperative computed tomography (CT) scan. The aim of this study was to classify and describe variations in anatomical measurements of CGP. We examined CT images of 300 patients with brain tumors to assess the morphology and incidence of CGP. Crista galli were classified according to their location relative to the cribriform plate and the presence of pneumatization. The paranasal sinuses were investigated as the origin of CGP. We assessed 24 patients using the BIHA for skull base tumors; these patients were included as clinical cases to assess the range of skeletonization of the crista galli and determine the route of CSF leakage in the other 276 patients. CGP was found in 28/300 CT scans, including upper, middle, and lower type CGPs. The origin of CGPs was the frontal sinus or ethmoid sinus. All CGPs were localized in the anterior half of the crista galli. In the 24 consecutive clinical cases, there were 13 tuberculum sellae meningiomas, 3 craniopharyngiomas, and 8 with other pathologies. The preoperative crista galli height was 12.3 mm and the distance from the top of the skeletonization to the cribriform plate was 5.2 mm. CGP originating from the paranasal sinuses can lead to CSF leakage. In cases where CGP originates from the ethmoid sinus, care should be taken to seal the exposed crista galli intradurally.