MR imaging evolution of endoscopic cranial defect reconstructions using nasoseptal flaps and their distinction from neoplasm.
OBJECTIVE
Endoscopic endonasal approach is the procedure of choice for the resection of ventral skull base neoplasms, with defect closure requiring multilayer reconstruction. This study evaluates the temporal MR imaging evolution of nasoseptal flaps and free grafts used in endoscopic skull base reconstruction.


METHODS
Sixty-nine follow-up brain MRIs of 22 patients who had endoscopic skull base reconstruction using 26 nasoseptal flaps combined with 8 collagen-matrix dural grafts, 10 fascia lata grafts, and 10 intracranial fat grafts were retrospectively reviewed. Temporal changes in signal intensity, enhancement, thickness, and the configuration of reconstructive layers were evaluated. Tissue with signal intensity or enhancement different from that of normal evolving reconstructive layers at the surgical bed was evaluated, and its association with clinically confirmed tumor was assessed with the Fisher exact test.


RESULTS
All normal reconstructive layers were retracted to cranial defects and showed maturation of imaging features within 2-6 months. The immediate postoperative T2-isointensity to brain and enhancement of nasoseptal flaps persisted, but the flap thickness was reduced by 20%-30% (average thickness, 4.5 ± 1.3 mm); additionally, the C shape and vascular pedicle of the nasoseptal flaps became indistinct, but the flap location remained unchanged. The initial appearance of the nonenhancing fascia lata with variable T2 signal intensity became enhancing with increasing T2-hypointensity and a graft-thickness reduction of ≥50% (average thickness, 3.5 ± 1.6 mm). All fat grafts showed progressive resorption. In 6 patients, abnormal tissue represented residual or recurrent tumor (P = .0001).


CONCLUSIONS
Maturation and stability of multilayer endoscopic skull base reconstructions on MR imaging occurs within 2-6 months postoperatively. Understanding of the normal imaging evolution of endoscopic skull base reconstructions is essential to distinguish them from neoplasms.
From the Departments of Radiology (K.O.L., L.A.L.) Kim.Learned@uphs.upenn.edu.
K O
KO
Learned
Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
N D
ND
Adappa
Neurosurgery (J.Y.K.L.).
J Y K
JY
Lee
Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
J G
JG
Newman
Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
J N
JN
Palmer
From the Departments of Radiology (K.O.L., L.A.L.)Otorhinolaryngology-Head and Neck Surgery (N.D.A., J.G.N., J.N.P., L.A.L.), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania.
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LA
Loevner
D000368:Aged; D003937:Diagnosis, Differential; D004724:Endoscopy / Q000379:methods*; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods*; D008297:Male; D008875:Middle Aged; D009300:Nasal Septum / Q000637:transplantation*; D019651:Plastic Surgery Procedures / Q000295:instrumentation / Q000379:methods*; D012189:Retrospective Studies; D019292:Skull Base Neoplasms / Q000473:pathology* / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000379:methods; D013524:Surgical Flaps; D016896:Treatment Outcome