[Effect of factor XIII on intractable CSF leakage after a transpetrosal-approach operation: a case report]

The authors reported an experience showing that the XIII factor was effective for intractable cerebrospinal fluid (CSF) leakage after a transpetrosal operation to deal with cerebellopontine angle meningioma. A 63-year-old female noted a slight headache and a floating feeling. She became dependent on a stick for walking alone because of gradual gait disturbance. As the headache became more severe, she consulted the outpatient clinic of the department of neurosurgery of Kobe University Hospital. Magnetic resonance images (MRI) revealed a 4.3 x 3.0cm sized right cerebellopontine angle tumor. She was admitted for the purpose of removal of the tumor and preoperative examinations were performed. Neurological findings on admission showed only slight right cerebellar signs. The operation was performed via the transpetrosal approach and the tumor was totally removed (Simpson Grade II). It took 12 hours 40 minutes for the operation. The amount of blood loss was 1970ml and the blood transfusion volume was 1200ml. Postoperative course was uneventful and her complaints disappeared. There were no postoperative complications at all, but 2 weeks after the operation, CSF leakage under the skin flap appeared. As subcutaneous fluid collection after skull base surgery is usual, spinal drainage and compression of the skin flap was carried out but these measures were not effective. The collection of fluid did not disappear for 2 weeks. Based on our successful experience with the XIII factor therapy in intractable cerebrospinal fluid leakage from the nose after a transsphenoidal approach operation for recurrent pituitary adenoma, the blood level of the XIII factor activity was examined. As the result was far below the normal limit in this case, the XIII factor was infused at a rate of 750 units per day for 5 days. One week after the administration, the level of the XIII factor became normal. Fluid collection disappeared and the drainage tube was removed. Recently, in neurosurgery, skull base surgery has been used widely and the range of craniotomy has been extended because operations can now be performed without compression of cerebral cortexes. However, operation time has increased and the volumes of bleeding and of blood transfusion are increasing. Postoperative complications such as CSF leakage and infection have become new problems. In this case, the XIII factor was still far below the normal level 2 weeks after the operation and it could be considered to have caused delayed CSF leakage. Some papers have reported that the XIII factor was effective in treating intractable fistula after operations in other surgical areas. However, this is the first report of skull base surgery such as an operation using transpetrosal approach taking advantage of the effect of the XIII factor.