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

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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Sinonasal Packing is Not a Requisite for Successful Cerebrospinal Fluid Leak Repair

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0041-1740622 ◽

2021 ◽

Author(s):

Karam Asmaro ◽

Frederick Yoo ◽

Abdulkader Yassin-Kassab ◽

Michael Bazydlo ◽

Adam M. Robin ◽

...

Keyword(s):

Emergency Department ◽

Cerebrospinal Fluid ◽

Operating Room ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Secondary Outcome ◽

Defect Sites ◽

Snot 22 ◽

Csf Leaks

Abstract Background Numerous methods have been described to repair nasal cerebrospinal fluid (CSF) leaks. Most studies have focused on optimizing CSF leak repair success, leading to closure rates of 90 to 95%. Objective This study aimed to determine if excellent reconstruction rates could be achieved without using sinonasal packing. Methods A prospective case series of 73 consecutive patients with various CSF leak etiologies and skull base defects was conducted to evaluate reconstruction success without sinonasal packing. The primary outcome measure was postoperative CSF leak. Secondary outcome measures were postoperative epistaxis requiring intervention in operating room or emergency department, infectious sinusitis, and 22-item sinonasal outcome test (SNOT-22) changes. Results Mean age was 54.5 years and 64% were female. Multilayered reconstructions were performed in 55.3% of cases, with collagen or bone epidural inlay grafts, and nasal mucosal grafts or nasoseptal flaps for onlay layers. Onlay-only reconstructions with mucosal grafts or nasoseptal flaps were performed in 44.7% of cases. Tissue sealants were used in all cases, and lumbar drains were used in 40.8% of cases. There were two initial failures (97.4% initial success), but both resolved with lumbar drains alone (no revision surgeries). There were no instances of postoperative epistaxis requiring intervention in the operating room or emergency department. Infectious sinusitis occurred in 2.7% of patients in the first 3 months postoperatively. SNOT-22 did not change significantly from preoperatively to first postoperative visits, then improved over time. Conclusion Nasal CSF leaks from various etiologies and defect sites were successfully repaired without using sinonasal packing, and patients experienced minimal sinonasal morbidity.

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Endonasal Free Flap Reconstruction Combined With Draf Frontal Sinusotomy for Complex Cerebrospinal Fluid Leak: A Technical Report & Case Series

Operative Neurosurgery ◽

10.1093/ons/opab309 ◽

2021 ◽

Author(s):

Jake J Lee ◽

Elizabeth H Wick ◽

Michael R Chicoine ◽

Joshua L Dowling ◽

Eric C Leuthardt ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Free Flap ◽

Frontal Sinus ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Flap Reconstruction ◽

Free Flap Reconstruction ◽

Endoscopic Endonasal ◽

Csf Leaks

Abstract BACKGROUND Frontal sinus cranialization with closure via bifrontal pericranial flaps is the gold standard for separating the nasofrontal recess from the intracranial cavity for posterior table defects. Despite the high success rate, cerebrospinal fluid (CSF) leak may persist and is particularly challenging when vascularized reconstructive options from the bicoronal incision are exhausted. OBJECTIVE To assess a novel endonasal technique using an adipofascial radial forearm free flap delivered to the frontal recess through a Draf sinusotomy to repair complex CSF leaks from the frontal sinus. METHODS A retrospective review of 3 patients (all male; ages 42, 43, and 69 yr) with persistent CSF leak despite frontal sinus cranialization and repair with bifrontal pericranium was performed. Etiology of injury was traumatic in 2 patients and iatrogenic in 1 patient after anaplastic meningioma treatment. To create space for the flap and repair the nasofrontal ducts, endoscopic Draf III (Case 1, 3) or Draf IIb left frontal sinusotomy (Case 2) was performed. The forearm flap was harvested, passed through a Caldwell-Luc exposure, and placed within the Draf frontal sinustomy. The flap vessels were tunneled to the left neck and anastomosed to the facial vessels by the mandibular notch. RESULTS Intraoperatively, the flaps were well-seated and provided a watertight seal. Postoperative hospital courses were uncomplicated. There were no new CSF leaks or flap necrosis at 12, 14, and 16 mo. CONCLUSION Endoscopic endonasal free flap reconstruction through a Draf procedure is a novel viable option for persistent CSF leak after failed frontal sinus cranialization.

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Middle Turbinate Friendly Technique for Cribriform Cerebrospinal Fluid Leak Repair

Otolaryngology ◽

10.1177/0194599819847944 ◽

2019 ◽

Vol 161 (3) ◽

pp. 522-528 ◽

Cited By ~ 5

Author(s):

Lauren J. Luk ◽

Allison Ikeda ◽

Sarah K. Wise ◽

John M. DelGaudio

Keyword(s):

Cerebrospinal Fluid ◽

Primary Repair ◽

Tertiary Care ◽

Middle Turbinate ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Secondary Outcome ◽

Free Graft ◽

Fluid Leak ◽

Csf Leaks

ObjectiveTo compare surgical outcomes between 2 techniques for cribriform cerebrospinal fluid leak (CSF) repair with middle turbinate preservation (MTP) vs middle turbinate resection (MTR). A secondary outcome is to examine the effectiveness of collagen dura matrix (CDM) as a grafting material for repair of isolated cribriform skull base defects.Study DesignA retrospective chart review was performed of consecutive patients who underwent cribriform CSF repair at Emory University over the past 15 years.SettingTertiary care rhinology practice.SubjectsAdult patients with cribriform defects limited to the cribriform plate that did not extend lateral to the middle turbinate (MT) and were reconstructed with a free graft (mucosal or synthetic).MethodsPatients were stratified into 2 primary groups by surgical technique: MTP vs MTR. A subset of patients underwent repair with CDM alone and was analyzed separately for CSF repair failure rate.ResultsOf 68 patients identified with cribriform defects, 42 underwent repair with MTP and 26 underwent repair with MTR. Average follow-up time was 495 days. Patients with idiopathic intracranial hypertension were also equally distributed ( P = .20). Primary CSF leak repair success was 95.6%, with 100% of leaks ultimately repaired. A subset of 39 patients underwent repair with CDM alone, with a primary repair success rate of 94.9%.ConclusionsWe present an effective method for repair of cribriform CSF leaks while preserving the MT. CDM can be successfully used as a free graft alone for repair of isolated cribriform CSF leaks.

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The role of ICP monitoring in patients with persistent cerebrospinal fluid leak following spinal surgery: a case series

Acta Neurochirurgica ◽

10.1007/s00701-016-2882-5 ◽

2016 ◽

Vol 158 (9) ◽

pp. 1813-1819 ◽

Cited By ~ 5

Author(s):

Claudia Craven ◽

Ahmed K. Toma ◽

Akbar A. Khan ◽

Laurence D. Watkins

Keyword(s):

Cerebrospinal Fluid ◽

Spinal Surgery ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Icp Monitoring ◽

Fluid Leak

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Sternberg's Canal and Defect: Is the Lateral Craniopharyngeal Canal a Source of Spontaneous Cerebrospinal Fluid Leak? Anatomic and Radiological Analysis in Pediatric and Adult Populations

Operative Neurosurgery ◽

10.1093/ons/opaa446 ◽

2021 ◽

Author(s):

Adedamola Adepoju ◽

Lucas P Carlstrom ◽

Christopher S Graffeo ◽

Avital Perry ◽

Carlos Diogenes Pinheiro-Neto ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Adult Population ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Superior Orbital Fissure ◽

Old Patients ◽

Visual Illustration ◽

Craniopharyngeal Canal ◽

High Incidence ◽

Fluid Leak

Abstract BACKGROUND The lateral craniopharyngeal or Sternberg's canal (SC) originates from superior orbital fissure (SOF) and traverses the sphenoid body into the nasopharynx. A remnant of the canal, Sternberg's defect (SD), has been debated as a source of cerebrospinal fluid (CSF) leak. The canal was described in 1888, and there is limited accurate visual illustration in the literature. OBJECTIVE To provide a detailed anatomic and radiological illustration of the canal in pediatric and adult population including the mechanism undermining the incidence of the canal, and the possibility of the canal as a source of CSF leak. METHODS A total of 195 high-resolution computed tomographies (CT) of patients (50 3-yr-old, 20 5-yr-old, and 125 adults) and 43 dry adult skulls (86 sides) were analyzed for a canal matching the description of the SC. RESULTS A SC was identified in 86% of the 3-yr-old and 40% of 5-yr–old patients. The diameter and length were 2.12 mm and 12 mm, respectively. The incidence of the canal decreased with age as sinus pneumatization extended into the sphenoid sinus. Only 0.8% of the adult skull on CT had the canal. The canal was not present on the dry adult skulls examination, but SD was found in 4.65%. CONCLUSION SC exists with high incidence in the pediatric group. Sinus pneumatization obliterates the canal in the adult population, leaving a defect in 4.65% of cases, which given the location and related anatomic structures, is unlikely to be a source of CSF leak.

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Lateral sphenoid sinus recess cerebrospinal fluid leak: a case series

European Archives of Oto-Rhino-Laryngology ◽

10.1007/s00405-014-3049-8 ◽

2014 ◽

Vol 271 (9) ◽

pp. 2587-2594 ◽

Cited By ~ 11

Author(s):

Nelson Almeida d’Ávila Melo ◽

Bruno Barros Pinto Borges ◽

Pedro Augusto Magliarelli Filho ◽

Maria Dantas Costa Lima Godoy ◽

Larissa Vilela Pereira ◽

...

Keyword(s):

Cerebrospinal Fluid ◽

Sphenoid Sinus ◽

Case Series ◽

Cerebrospinal Fluid Leak ◽

Fluid Leak

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Recurrent Spontaneous Spinal Cerebrospinal Fluid Leak Associated with “Nude Nerve Root” Syndrome: Case Report

Neurosurgery ◽

10.1227/01.neu.0000089483.30857.11 ◽

2003 ◽

Vol 53 (5) ◽

pp. 1216-1219 ◽

Cited By ~ 26

Author(s):

Wouter I. Schievink ◽

Line Jacques

Keyword(s):

Cerebrospinal Fluid ◽

Nerve Root ◽

Intracranial Hypotension ◽

Cerebrospinal Fluid Leak ◽

Csf Leak ◽

Magnetic Resonance Imaging Examination ◽

Computed Tomographic ◽

Computed Tomographic Myelography ◽

Increased Risk ◽

Csf Leaks

Abstract OBJECTIVE AND IMPORTANCE Spontaneous spinal cerebrospinal fluid (CSF) leaks have been noted occasionally at multiple sites in the same patient, but recurrent spontaneous spinal CSF leaks have not been documented. We describe a patient with a recurrent CSF leak who was found at surgery to have an absence of the entire nerve root sleeve at multiple thoracic levels. CLINICAL PRESENTATION A 29-year-old woman bodybuilder noted an excruciating orthostatic headache associated with nausea. The neurological examination was unremarkable, and a magnetic resonance imaging examination showed the typical changes of intracranial hypotension. Computed tomographic myelography showed an extensive bilateral lower cervical CSF leak. INTERVENTION The patient underwent bilateral lower cervical nerve root explorations, and several small dural holes were found. The CSF leaks were repaired, but 3 months later, computed tomographic myelography showed a new CSF leak in the midthoracic area. A thoracic laminectomy was performed, and several nerve roots were found to be completely devoid of dura. After the CSF leaks were repaired, there was significant improvement in her headaches. CONCLUSION A recurrent spontaneous spinal CSF leak may occur in patients with intracranial hypotension at a site previously documented not to be associated with a CSF leak. Absent nerve root sleeves may be found in patients with spontaneous spinal CSF leaks (“nude nerve root” syndrome), and these patients may be at increased risk of developing a recurrent CSF leak.

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