Ascending meningitis secondary to traumatic cerebrospinal fluid leaks

Cerebrospinal fluid (CSF) leakage may cause immediate or delayed complications, such as ascending meningitis and brain abscess, potentially lethal complications that may appear years or decades after the trauma. Thus, the initial treatment of a CSF fistula may decisively influence long-term outcome. In a retrospective study including 1036 consecutive patients presenting with severe cranial trauma from May 1990 to March 1996, we identified 27 patients (2.6%) with CSF fistulas. Patients with a post-traumatic CSF leak were most commonly males between 15 and 40 years involved in a motor vehicle accident. The most common sites of injury were the frontal area and anterior skull base for those patients with rhinorrhea and the temporal bone for those patients with otorrhea. A transcranial repair was used for large cranial base defects (n = 10), while conservative treatment, comprised of bedrest, lumbar drainage, and medications, was used for smaller fistulas (n = 17). Four patients (40%) initially treated with a transcranial repair, and five patients (29%) initially treated conservatively, developed a meningitis. Therefore, neither the conservative approach nor the transcranial repair was able to prevent this considerable incidence of ascending meningitis. We believe that the high incidence of meningitis is not acceptable; thus, we are now evaluating early intervention using endoscopic techniques for the identification and/or repair of post-traumatic fistulas.     

Traumatic cerebrospinal fluid leaks

This article discusses the epidemiology, diagnosis, and management of traumatic cerebrospinal fluid (CSF) leaks. An overview of traumatic CSF leaks is presented, and both conservative and operative therapies are reviewed. Management decisions are discussed based on the current literature. Controversial clinical topics are addressed, including the use of prophylactic antibiotics and the timing of surgical repair.     

Nasal cerebrospinal fluid leaks

Otolaryngologists are increasingly being called on to assist with the evaluation and management of skull base defects that result in cerebrospinal fluid (CSF) leaks and meningoencephaloceles. A thorough understanding of the underlying pathophysiology and a critical analysis of management principles and treatment options are essential to achieve the best possible results for these patients. This review article highlights the physiology, pathophysiology, diagnosis, surgical technique, and postoperative care relevant to CSF leak and encephalocele patient care for otolaryngologists with a special emphasis on the differences between CSF leaks of varying etiologies.     

Endoscopic management of cerebrospinal fluid leaks

To examine the diagnosis and treatment of patients with cerebrospinal fluid (CSF) rhinorrhea, a cohort of 36 patients treated between 1993 and 2000 were examined to consider the role of imaging and other diagnostic tests such as the presence of beta-transferrin in nasal secretion. The etiology of the condition was considered and was found to be congenital in 7 patients and acquired in 29 patients of which in 15 patients it was traumatic, in 12 patients it occurred spontaneously, and in 2 patients it was associated with Wegener's granulomatosis. Where it was possible to obtain nasal secretion, beta-transferrin proved a highly sensitive and specific test and imaging included computed tomography (CT), CT cisternography, and magnetic resonance imaging (MRI) of which fine detail coronal CT and MRI proved the most helpful. In six patients neither imaging nor beta-transferrin could be used to confirm the diagnosis in which case intrathecal fluorescein was used. Repair was performed endoscopically in all cases with one exception where the defect was felt to be too large for this technique. Middle turbinate mucosa, cartilage, and fascia were the preferred repair materials in the anterior skull base whereas dermalfat was preferentially used in the sphenoid. The overall success rate for an endoscopic approach was 94% although in three cases a second endoscopic procedure was required to produce closure and external approaches were used in two additional patients. The use of a diagnostic algorithm is helpful in both confirming the presence of CSF rhinorrhea and the optimum approach. In the vast majority of cases an endoscopic repair will be successful and it avoids many of the complications associated with craniotomy, particularly in a young population. Therefore, it is our preferred option, although surgeons must be prepared for alternative procedures should these prove necessary.     

Transnasal endoscopic closure of cerebrospinal fluid leaks

OBJECTIVES/HYPOTHESIS: To demonstrate an effective method for transnasal endoscopic closure of anterior skull base fistulas that does not involve lumbar drains or fat packing. STUDY DESIGN: Retrospective. METHODS: We reviewed the charts of 36 patients who had 37 anterior skull base defects that were repaired endoscopically between 1993 and 2001. RESULTS: Thirty-three defects were successfully closed on the first attempt. Three were successfully closed on the second attempt. One large defect was repaired by neurosurgery after a failed endoscopic attempt. Our results are similar to those of other published series. CONCLUSION: Our method is effective and does not require adjuvant procedures or prolonged hospital stays.     

Evaluation of spontaneous nasal cerebrospinal fluid leaks

PURPOSE OF REVIEW: Spontaneous nasal cerebrospinal fluid (CSF) leaks represent a distinct clinical entity that presents important diagnostic and therapeutic challenges. Recognition of the proper demographic group and presenting symptoms, as well as the radiologic features of this disease process, are integral to making the appropriate diagnosis. In addition, this patient group requires special perioperative and intraoperative considerations for suitable management. RECENT FINDINGS: Current literature echoes previously published success rates for endoscopic repair of CSF leaks at or above 90%. Success rates for closure of spontaneous CSF leaks, however, continue to be the lowest in comparison with other CSF leak etiologies. The increased failure rate for spontaneous CSF leak repair is likely due to the increased intracranial pressure present in this patient group. Patients with spontaneous CSF leaks are increasingly being recognized as belonging to a group inclusive of patients with benign intracranial hypertension and empty sella syndrome. SUMMARY: In this review, we highlight the demographic characteristics, clinical presentation and radiologic findings that distinguish spontaneous nasal CSF leak patients from those with other CSF leak etiologies. We also discuss perioperative measures advocated for patients with spontaneous nasal CSF leaks that may aid in the success of their surgical repair.     

Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks

OBJECTIVE: To analyze possible etiological factors of spontaneous cerebrospinal fluid (CSF) rhinorrhea and to assess the outcomes of endonasal endoscopic repair. DESIGN: Retrospective study. SETTING: Academic neurosurgical hospital.Patients Twenty-one consecutive patients who presented with spontaneous CSF leak and underwent endonasal endoscopic surgery from January 1999 through December 2001. INTERVENTION: Preoperative examination included computed tomographic scans; nasal endoscopy; measurement of glucose concentration in the nasal discharge; and, in some cases, cisternographic evaluations via computed tomography and/or magnetic resonance imaging. Telescopes, conventional endoscopic sinus surgery instruments, and a microdebrider were used for all patients who underwent endonasal surgery. A combination of plastic materials, ie, abdominal fat, fascia lata, rotated middle turbinate flaps, and fibrin glue, were used for fistula repair. RESULTS: At the time of surgery, CSF fistulas were found in the cribriform plate (6 patients), in the fovea ethmoidalis (6 patients), and in the sphenoid sinus (9 patients). In 5 of the 6 patients who had an extremely pneumatized sphenoid sinus, the source of the leak was located in the lateral extension of the sinus. A meningocele protruding through the bone defect was the source of the leak in 10 patients. Postoperative follow-up lasted from 9 to 42 months, and 20 patients were considered cured. There was only 1 recurrence, in a patient whose CSF rhinorrhea originated in the deep lateral recess of an overpneumatized sphenoid sinus. Thus, the overall success rate was 95.2%. There were no postoperative complications. CONCLUSIONS: Possible etiological factors of this disease include obesity, congenital malformations of the skull base, an overpneumatized sphenoid sinus (particularly in its lateral extensions), and the empty sella syndrome. Endoscopic endonasal repair of spontaneous CSF rhinorrhea appears to be a safe and successful procedure. However, techniques for endoscopic closure of CSF fistulas in the lateral part of the sphenoid sinus need further perfecting.     

Endoscopic management of sphenoid sinus cerebrospinal fluid leaks

OBJECTIVES: Cerebrospinal fluid (CSF) leaks that originate within the sphenoid sinus pose a unique surgical challenge due to difficulties with access and visualization The objective of this report is to illustrate concepts for the successful management of sphenoid sinus CSF leaks. METHODS: Retrospective data analysis was performed on 9 patients who presented to a tertiary care medical center for endoscopic repair of a sphenoid sinus CSF leak from January 2002 to January 2006. RESULTS: The patient cohort included 7 women and 2 men with a mean age of 51.7 years. In 5 cases the CSF leak was caused by a previous neurosurgical procedure; the other 4 cases were idiopathic. An endoscopic pterygomaxillary fossa approach was required in 4 cases. A layered reconstruction of the sphenoid sinus wall with collagen allografts (cadaveric acellular dermal allograft, 8 patients; bovine collagen membrane, 1 patient) and mucosa under endoscopic visualization with intraoperative surgical navigation was performed in all cases. The reconstruction was buttressed with autologous bone in 2 cases and with cartilage in 2 cases. Fibrin sealant was used in 7 cases. Two patients developed transient diabetes insipidus after the repair. Two patients developed a recurrent CSF leak necessitating revision repair 2 and 15 months, respectively, after the initial repair procedure. The average hospital stay was 6.5 days. The mean length of follow-up was 21.1 months. CONCLUSIONS: This series demonstrates that minimally invasive endoscopic repair of sphenoid sinus CSF leaks may be accomplished with an acceptable rate of morbidity and excellent outcomes. Extended endoscopic approaches, including the pterygomaxillary fossa approach, may be useful in selected instances.     

Transcochlear repair of persistent cerebrospinal fluid leaks.

OBJECTIVE: The purpose of this study is to demonstrate the utility of a modified transcochlear obliteration of the petrous apex in repair of persistent cerebrospinal fluid (CSF) leaks. A review of temporal bone computed tomography (CT) scans and histological preparations for potential air cells leading to such leaks is also presented. STUDY DESIGN: Retrospective case review in an academic tertiary referral center. METHODS: Patients for inclusion in this study had previously undergone either a suboccipital or translabyrinthine removal of an intracranial tumor with subsequent transmastoid and middle ear obliteration of air cell tracts to stop a CSF leak. Ninety CT scans and 178 temporal bones were reviewed and assessed for peritubal and petrous apex pneumatization. RESULTS: Four patients had initial obliteration of the orifice of the eustachian tube and middle ear that failed to prevent leakage of CSF. The leak was ultimately controlled by a transcochlear petrous apicectomy. From The Ohio State University temporal bone collection, 178 specimens were available for examination. Peritubal pneumatization was found in 42% of the bones examined. The CT scans showed unilateral petrous apex pneumatization in 30% of the specimens and bilateral pneumatization in 11%. CONCLUSIONS: Continuity of air cell tracts from the petrous apex surrounding the internal auditory canal to the medial eustachian tube can provide a path for CSF rhinorrhea that is difficult to stop by conventional means. A modified transcochlear approach successfully terminated persistent leaks in four such patients.     

Fibrin sealant for treatment of cerebrospinal fluid leaks

OBJECTIVE: Persistent cerebrospinal fluid leaks in the human population are rarely found in otherwise healthy individuals, but occur in patients with comorbid illnesses. These leaks are frequently resistant to dural suturing or closure of the defect site with connective tissue, cartilage, or plastic materials. In this study, fibrin sealant (ViGuard Fibrin Sealant was used to adhere muscle grafts to surgically created dural defects to close cerebrospinal fluid leaks in chinchillas. Histologic evaluation of the defect sites were conducted to assess healing and tissue response in the test and control groups. METHOD: In 20 chinchillas, after a skin incision, a 6 mm X 6 mm window was created in the right superior bulla exposing the underlying bony tegmen. Using a microcutting burr, a 3 mm X 3 mm area of tegmen was drilled out and the exposed dura was resected to create a large cerebrospinal fluid (CSF) leak. In the control group (n = 10), a small muscle graft from the surrounding tissue was placed into the defect site. In the test group (n = 10), the muscle graft was glued into the defect with ViGuard Fibrin Sealant. Bulla and skin were then closed. All animals were killed at 3 weeks into the experiment, and tissue was harvested for histologic examination. SETTING: The Department of Otolaryngology, Head and Neck Surgery Research Laboratory. University of Illinois, Chicago. RESULTS: Three weeks after surgery in the test group the tegmen defects were found to be closed by bone or connective tissue or both. Meninges had regrown, and the underlying brain appeared histologically normal. There was no evidence of CSF leak, toxicity, infection or other deleterious tissue reactions. In the control group, again the meningeal and bony tegmen defects were seen to be closed by connective tissue or bone or both. Brain tissues appeared histologically normal. There was no evidence of CSF leak, toxicity, or other deleterious tissue reactions. One animal of the test group died of unknown causes. On autopsy, no signs of meningitis or encephalitis could be detected and the cause of death was unapparent. CONCLUSION: Fibrin Sealant, made from pooled donor blood and treated with viral elimination procedures, was found in combination with muscle grafts to securely close induced CSF leaks in the chinchilla model. Inflammation, infection, or toxic reactions were not observed. We believe that ViGuard Fibrin Sealant has stronger bonding power compared with available autologous fibrin tissue adhesives.     

Endoscopic management of cerebrospinal fluid leaks and cephaloceles

The excellent visualization and atraumatic surgical techniques of endoscopic sinus surgery have been applied to the management of five cerebrospinal fluid leaks and two nasal cephaloceles. In all cases, the exact site of the lesion was identified. Four cerebrospinal fluid leaks were grafted with a free or pedicled septal mucosal graft. The fifth cerebrospinal fluid leak came from a narrow sphenoethmoid recess and stopped after the mucosa was abraded. The two cephaloceles were reduced intranasally and covered with bone and mucosal grafts. Not all cases seen in the same time period were treated endoscopically; two additional cerebrospinal fluid leaks were treated with conventional techniques because of severe nasal inflammatory disease and intracranial complications. The technique and indications for endoscopic management of cerebrospinal fluid leaks and cephaloceles are discussed.     

Endoscopic repair of frontal sinus cerebrospinal fluid leaks

OBJECTIVE: To describe endoscopic management of frontal sinus cerebrospinal fluid (CSF) leaks. STUDY DESIGN: Retrospective. METHODS: We reviewed all frontal sinus CSF leaks treated using an endoscopic approach at our institutions from 1998 to 2003. CSF leaks originated immediately adjacent to or within the frontal recess or frontal sinus proper for inclusion in the study. Data collected included demographics, presenting signs and symptoms, site and size of skull-base defect, surgical approach, repair technique, and clinical follow up. RESULTS: Seven frontal sinus CSF leaks in six patients were repaired endoscopically. Average age of presentation was 45 years (range 25-65 years). Aetiology was idiopathic (three), congenital (one), accidental trauma (one), and surgical trauma (two). All patients presented with CSF rhinorrhea; two patients presented with meningitis. Four defects originated in the frontal recess, while two others involved the posterior table and frontal sinus outflow tract. Four patients had associated encephaloceles. We performed endoscopic repair in all six patients with one patient requiring an adjuvant osteoplastic flap without obliteration. All repairs were successful at the first attempt with a mean follow up of 13 months. All frontal sinuses remained patent on both post-operative endoscopic and radiographic exam. CONCLUSIONS: Endoscopic repair of frontal sinus CSF leaks and encephaloceles can be an effective method if meticulous attention is directed toward preservation of the frontal sinus outflow tract, thus avoiding an osteoplastic flap and obliteration. The major limiting factor for an endoscopic approach is extreme extension superiorly or laterally within the posterior table beyond the reach of current instrumentation.     

Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks

BACKGROUND: Spontaneous cerebrospinal fluid (CSF) leak is a condition that previously has been considered idiopathic and classified as having "normal" intracranial pressure (ICP). We present clinical and radiographic evidence that indicates elevated ICP in this group. In addition, we review the pathophysiology and unique management issues in caring for patients with spontaneous CSF leak. METHODS: We present a retrospective review of medical records, imaging studies, ICP measurements, and surgical treatment of patients with spontaneous CSF leaks. RESULTS: Sixteen patients with spontaneous CSF leaks were surgically treated from 1996 to 2002. Ten patients underwent postoperative lumbar puncture with CSF pressure measurement during clinically indicated computed tomography cisternograms. Intracranial pressures were elevated in all 10 patients, with a mean of 26.5 cm H2O and a range of 17.3-34 cm H2O, (normal, 0-15 cm H2O). Demographically, 13/16 patients were women, all were middle-aged with a mean age of 49.6 years, and 15/16 patients were obese with a mean body mass index of 35.9 kg/m2. Radiographically, 15 patients had imaging of the sella turcica, 10 patients had completely empty sellas, and 5 patients had partially empty sellas. Surgical repair was 100% successful in leak cessation with a mean follow-up of 14.1 months. CONCLUSION: Although the precise cause and mechanism of spontaneous CSF leaks is not fully understood, this study sheds light on important factors to consider. Patients with this condition have similar physical and radiographic findings such as middle-aged, female gender, obesity, and empty sella. Additional investigation is needed to determine the exact cause of the condition, its relationship to elevated ICPs, and if further medical or surgical treatments to correct the intracranial hypertension are warranted.     

Endoscopic repair of cerebrospinal fluid leaks after neurosurgical procedures

OBJECTIVES: Endoscopic repair of cerebrospinal fluid (CSF) leaks has proven to be effective and safe. CSF rhinorrhea is a well-known complication of neurosurgical procedures in the anterior cranial fossa. We present a series of endoscopic repairs of CSF rhinorrhea secondary to neurosurgical procedures. STUDY DESIGN: Retrospective review of 13 cases. METHODS: Thirteen patients are included in the study. Eleven had CSF leaks after hypophysectomy, one after clipping of an anterior circle of Willis aneurysm, and one after posttraumatic frontal lobe debridement. Leaks were identified intraoperatively during the neurosurgical procedure (n = 8) or with intrathecal fluorescein injection during a separate procedure (n = 5). Repair was performed by exposing the skull base defect, debriding the defect margins, and sealing the defect with a free mucosal graft or abdominal fat. RESULTS: Leaks were identified in the sphenoid (n = 12) and posterior ethmoid (n = 1) sinuses. Nine patients had lumbar drains placed. One patient had recurrence of CSF rhinorrhea 2 months after initial repair requiring a revision procedure. No other recurrences were noted. One patient developed postoperative meningitis requiring intravenous antibiotics and a prolonged hospital stay. No other postoperative complications were observed. CONCLUSIONS: Endoscopic repair is a safe and effective treatment for CSF rhinorrhea encountered as a neurosurgical complication.