Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture (n = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

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Magnetic Resonance Cisternography and Thin Coronal Computerized Tomography in the Evaluation of Cerebrospinal Fluid Rhinorrhea

American Journal of Rhinology ◽

10.2500/105065897781286052 ◽

1997 ◽

Vol 11 (5) ◽

pp. 387-392 ◽

Cited By ~ 38

Author(s):

Michael J. Sillers ◽

C. Elliott Morgan ◽

Taher El Gammal

Keyword(s):

Cerebrospinal Fluid ◽

Magnetic Resonance ◽

Lumbar Puncture ◽

Computerized Tomography ◽

Contrast Study ◽

Precise Localization ◽

Csf Rhinorrhea ◽

Spin Echo Sequence ◽

Magnetic Resonance Cisternography ◽

Csf Leaks

In recent years cerebrospinal fluid (CSF) rhinorrhea has been managed successfully with transnasal endoscopic techniques. The most important and often most difficult step is the precise localization of the fistula. Computerized tomographic and radionuclide cisternography are two commonly used techniques for preoperative identification of the CSF fistula when it cannot be seen clearly with nasal endoscopy. Each of these requires a lumbar puncture, and the intrathecal placement of contrast material has been associated with transient neurotoxicities. Magnetic resonance cisternography (MRC) is a non-contrast study that does not require a lumbar puncture and has been used recently in the diagnosis of spontaneous and traumatic CSF leaks. Magnetic resonance cisternography utilizes a fast spin-echo sequence with fat suppression and video image reversal that highlights CSF. This allows precise localization of the fistula in both coronal and sagittal planes. Thin section coronal computed tomography (TCCT) is another noninvasive technique that can be helpful in localizing CSF leaks. The technique of MRC and TCCT and the results of 16 CSF leaks in 15 patients are reported. There was good correlation between MRC, TCCT, and intraoperative findings. Magnetic resonance cisternography and thin coronal computerized tomography appear to be accurate and complementary, noninvasive radiographic studies that should be considered in the evaluation CSF rhinorrhea.

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Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

Journal of Neurosurgery ◽

10.3171/2017.4.jns162451 ◽

2018 ◽

Vol 129 (2) ◽

pp. 425-429 ◽

Cited By ~ 13

Author(s):

Ben A. Strickland ◽

Joshua Lucas ◽

Brianna Harris ◽

Edwin Kulubya ◽

Joshua Bakhsheshian ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Pituitary Adenomas ◽

Transsphenoidal Approach ◽

Csf Leak ◽

Sellar Region ◽

Inclusion Criteria ◽

Csf Rhinorrhea ◽

Sellar Lesions ◽

Sellar Reconstruction ◽

Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

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Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/a-1722-4433 ◽

2021 ◽

Author(s):

Peter A. Benedict ◽

Joseph R. Connors ◽

Micah R. Timen ◽

Nupur Bhatt ◽

Richard Lebowitz ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Skull Base ◽

Postoperative Period ◽

Skull Base Surgery ◽

Tertiary Care ◽

Csf Leak ◽

Csf Rhinorrhea ◽

Predictive Values ◽

Ventral Skull Base ◽

Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

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Significance of Empty Sella in Cerebrospinal Fluid Leaks

Otolaryngology ◽

10.1067/mhn.2003.43 ◽

2003 ◽

Vol 128 (1) ◽

pp. 32-38 ◽

Cited By ~ 79

Author(s):

Rodney J. Schlosser ◽

William E. Bolger

Keyword(s):

Cerebrospinal Fluid ◽

Intracranial Hypertension ◽

Sella Turcica ◽

Radiographic Finding ◽

Empty Sella ◽

Senior Author ◽

Csf Leak ◽

Benign Intracranial Hypertension ◽

Cerebrospinal Fluid Leaks ◽

Csf Leaks

OBJECTIVE: The role of elevated cerebrospinal fluid (CSF) pressures in the pathophysiology of various CSF leaks is not clear. Empty sella syndrome (ESS) is a radiographic finding that can be associated with elevated CSF pressures and may represent a radiographic indicator of intracranial hypertension. We present our experience with CSF leaks of various causes, the prevalence of ESS in the spontaneous and nonspontaneous categories, and the potential pathophysiology and unique management issues of the spontaneous CSF leak group. METHODS: We conducted a retrospective review of medical records, imaging studies, and surgical treatment of CSF leaks in patients treated by the senior author. RESULTS: Sixteen patients with spontaneous CSF leaks and 12 patients with nonspontaneous CSF leaks were surgically treated from 1996 through 2002. In the spontaneous group, 15 patients had complete imaging of the sella turcica. Ten had completely empty sellae and 5 had partially empty sellae, for a total of 100% (15 of 15). In the nonspontaneous group, 9 patients had complete imaging of the sella. Only 11% (1 of 9) had a partially empty sella and that was a congenital leak. Comparison of proportions between these 2 groups was significant ( P = 0.01). The spontaneous group consisted primarily of obese, middle-aged females (13 of 16 patients). CONCLUSION: Empty sella probably represents a sign of elevated intracranial pressure that leads to idiopathic, spontaneous CSF leaks. Spontaneous CSF leaks are strongly associated with the radiographic finding of an empty sella and are more common in obese females, similar to benign intracranial hypertension. This unique population may require more aggressive surgical and medical treatment to prevent recurrent or multiple leaks.

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Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control

Arquivos de Neuro-Psiquiatria ◽

10.1590/s0004-282x2004000500016 ◽

2004 ◽

Vol 62 (3b) ◽

pp. 827-831 ◽

Cited By ~ 15

Author(s):

José Alberto Landeiro ◽

Marlo S. Flores ◽

Bruno C.R. Lázaro ◽

Maria Helena Melo

Keyword(s):

Cerebrospinal Fluid ◽

Surgical Management ◽

Inferior Turbinate ◽

Saline Injection ◽

Csf Rhinorrhea ◽

Cerebrospinal Fluid Rhinorrhea ◽

Endoscopic Control ◽

Free Grafts ◽

Cranial Approach ◽

Csf Leaks

The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.

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Evaluation of CSF Rhinorrhea by Computerized Tomography with Metrizamide

Otolaryngology ◽

10.1177/019459988910000204 ◽

1989 ◽

Vol 100 (2) ◽

pp. 99-105 ◽

Cited By ~ 43

Author(s):

James M. Chow ◽

David Goodman ◽

Mahmood F. Mafee

Keyword(s):

Cerebrospinal Fluid ◽

Success Rate ◽

Computerized Tomography ◽

The Other ◽

High Success Rate ◽

Csf Rhinorrhea ◽

Csf Leakage ◽

Csf Leaks

This study evaluates the ability of metrizamide computerized tomographic cisternography (MCTC) to delineate the site of leakage in patients with cerebrospinal fluid (CSF) rhinorrhea. From 1981 to 1986, thirteen patients were examined by MCTC to localize the site of CSF leakage. A total of 17 studies were performed. Thirteen scans (76%) identified the site of CSF leakage. Nine of these scans were confirmed surgically. The other four scans were performed on patients who refused surgery. Of the 15 scans in patients with active CSF leaks, 13 (87%) were positive. Of the two patients with inactive CSF leaks, neither was positive. One patient is presented in whom MCTC was both diagnostic and therapeutic. In conclusion, MCTC has a high success rate in localizing the site of active CSF leaks.

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Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series

Journal of Surgical Case Reports ◽

10.1093/jscr/rjaa484 ◽

2020 ◽

Vol 2020 (12) ◽

Author(s):

Clifford L Crutcher ◽

John M Wilson ◽

Kevin D Morrow ◽

Jessica A Shields ◽

Lindsay M Lasseigne ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

External Ventricular Drain ◽

Treatment Algorithm ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Gunshot Wounds ◽

External Ventricular Drainage ◽

Csf Leak ◽

Fluid Leak ◽

Csf Leaks

Abstract Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author’s knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

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Meningeal Carcinomatosis Presenting with Isolated Pseudotumor Cerebri

Journal of the Korean Neurological Association ◽

10.17340/jkna.2020.1.10 ◽

2020 ◽

Vol 38 (1) ◽

pp. 50-53

Author(s):

Bora Jin ◽

Jeong Yeon Kim ◽

Dae-Hyun Kim

Keyword(s):

Cerebrospinal Fluid ◽

Visual Field ◽

Intracranial Hypertension ◽

Lumbar Puncture ◽

Pseudotumor Cerebri ◽

Metastatic Carcinoma ◽

Meningeal Carcinomatosis ◽

Cytological Analysis

A 46-year-old man presented with a progressive headache lasting for 2 weeks. Initial lumbar puncture revealed a pressure of 31 cm H<sub>2</sub>0 and 30 white cells. His symptoms had worsened despite the treatment of intracranial hypertension. Visual field exam showed marked peripheral constriction and the fundus showed marked papilledema. Cytological analysis of cerebrospinal fluid demonstrated positive for metastatic carcinoma. We report a case of a patient with meningeal carcinomatosis who developed isolated intracranial hypertension with papilledema.

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Management of cerebrospinal fluid leaks after anterior decompression for ossification of the posterior longitudinal ligament: a review of the literature

Neurosurgical FOCUS ◽

10.3171/2010.12.focus10255 ◽

2011 ◽

Vol 30 (3) ◽

pp. E13 ◽

Cited By ~ 45

Author(s):

Marcus Mazur ◽

Gregory F. Jost ◽

Meic H. Schmidt ◽

Erica F. Bisson

Keyword(s):

Treatment Options ◽

Treatment Algorithm ◽

Posterior Longitudinal Ligament ◽

Postoperative Management ◽

Csf Leak ◽

Dural Tear ◽

Anterior Decompression ◽

Dural Repair ◽

Increased Risk ◽

Csf Leaks

Object Anterior decompression is an effective way to treat cervical myelopathy associated with ossification of the posterior longitudinal ligament (OPLL); however, this approach is associated with an increased risk of a dural tear and resultant CSF leak because fusion of the dura with the ossified PLL is common in these cases. The authors review the literature and present an algorithm for treatment of CSF leaks in these patients. Methods A MEDLINE review was performed to identify papers related to CSF leak after anterior decompression for OPLL, and data were summarized to identify treatment options for various situations. A treatment algorithm was identified based on these findings and the experience of the authors. Results Eleven studies were identified that presented data on intra- and postoperative management of a CSF leak during ventral surgery for OPLL. The incidence of cervical dural tears and CSF leaks after anterior decompression procedures for OPLL ranged from 4.3% to 32%. Techniques including preventative measures, intraoperative dural repair with various materials, and postoperative drainage or shunt placement have all been used. Conclusions Although direct dural repair is the preferred treatment for CSF leak, this technique is not always technically possible. In these cases, intraoperative adjuncts in combination with postoperative measures can be used to decrease the pressure gradient across the dural tear.

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SURGICAL MANAGEMENT OF ANTERIOR CRANIAL BASE FRACTURES WITH CEREBROSPINAL FLUID FISTULAE

Neurosurgery ◽

10.1227/01.neu.0000316014.97926.82 ◽

2008 ◽

Vol 62 (2) ◽

pp. 463-471 ◽

Cited By ~ 64

Author(s):

Martin Scholsem ◽

Felix Scholtes ◽

Frèderick Collignon ◽

Pierre Robe ◽

Annie Dubuisson ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Treatment Algorithm ◽

Cranial Base ◽

University Hospital ◽

Csf Leak ◽

Dural Tear ◽

Csf Rhinorrhea ◽

Csf Fistula ◽

Associated Lesions ◽

Anterior Cranial Base

Abstract OBJECTIVE The management of cerebrospinal fluid (CSF) fistulae after anterior cranial base fracture remains a surgical challenge. We reviewed our results in the repair of CSF fistulae complicating multiple anterior cranial base fractures via a combined intracranial extradural and intradural approach and describe a treatment algorithm derived from this experience. METHODS We retrospectively reviewed the files of 209 patients with an anterior cranial base fracture complicated by a CSF fistula who were admitted between 1980 and 2003 to Liège State University Hospital. Among those patients, 109 had a persistent CSF leak or radiological signs of an unhealed dural tear. All underwent the same surgical procedure, with combined extradural and intradural closure of the dural tear. RESULTS Of the 109 patients, 98 patients (90%) were cured after the first operation. Persistent postoperative CSF rhinorrhea occurred in 11 patients (10%), necessitating an early complementary surgery via a transsphenoidal approach (7 patients) or a second-look intracranial approach (4 patients). No postoperative neurological deterioration attributable to increasing frontocerebral edema occurred. During the mean follow-up period of 36 months, recurrence of CSF fistula was observed in five patients and required an additional surgical repair procedure. CONCLUSION The closure of CSF fistulae after an anterior cranial base fracture via a combined intracranial extradural and intradural approach, which allows the visualization and repair of the entire anterior base, is safe and effective. It is essentially indicated for patients with extensive bone defects in the cranial base, multiple fractures of the ethmoid bone and the posterior wall of the frontal sinus, cranial nerve involvement, associated lesions necessitating surgery such as intracranial hematomas, and post-traumatic intracranial infection. Rhinorrhea caused by a precisely located small tear may be treated with endoscopy.

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