The Management of Cerebrospinal Fluid Leaks in Patients at Risk for High-Pressure Hydrocephalus

Abstract

The transnasal endoscopic approach has become the preferred technique for the surgical management of patients with cerebrospinal fluid (CSF) leaks of the anterior, sellar, and parasellar skull base. The literature has reported an 85% to 100% success rate for the endoscopic repair of CSF leaks, which compares favorably with that reported after transcranial repair. Despite an adequate repair, a subpopulation of patients remain at high risk for recurrence of the CSF leak attributable to undiagnosed high-pressure hydrocephalus. Patients at high risk for high-pressure hydrocephalus include those who have had a subarachnoid hemorrhage as a result of trauma (accidental or surgical) or stroke and those with spontaneous CSF leaks. With the goal of reducing the risk of recurrence, the authors developed a protocol for the identification and management of patients with CSF leaks who are at risk for high-pressure hydrocephalus. The protocol includes endoscopic repair, temporary CSF diversion, measurement of CSF pressure after the repair, and immediate ventriculoperitoneal shunting if necessary. During the period of September 1999 to April 2002, the authors repaired 25 CSF leaks through an endonasal endoscopic approach. Nineteen patients were considered at high risk for high-pressure hydrocephalus. Using the protocol described, the authors identified six patients (31%) with CSF leaks that could be associated with undiagnosed high-pressure hydrocephalus. All CSF leaks were successfully repaired using a transnasal endoscopic repair. Six patients with high-pressure hydrocephalus underwent ventriculoperitoneal shunting after repair of the CSF Leak. No recurrence has been observed at a follow-up ranging from 24 to 84 months (median period, 30 mo). Patients with high-pressure hydrocephalus may be identified in a prospective fashion to prevent recurrence or persistence of the CSF leaks. The presence or absence of high-pressure CSF may be established by means of direct CSF pressure measurement through lumbar puncture postoperatively. This allows early intervention and prevention of recurrence.