Cranial Cerebrospinal Fluid Leak Research Articles

Tandem cranial and spinal cerebrospinal fluid leaks presenting with otogenic tension pneumocephalus: illustrative case.

Cranial and spinal cerebrospinal fluid (CSF) leaks are associated with opposite CSF fluid dynamics. The differing pathophysiology between spontaneous cranial and spinal CSF leaks are, therefore, mutually exclusive in theory. A 66-year-old female presented with tension pneumocephalus. The patient underwent computed tomography (CT) scanning, which demonstrated left-sided tension pneumocephalus, with an expanding volume of air directly above a bony defect of the tegmen tympani and mastoideum. The patient underwent a left middle fossa craniotomy for repair of the tegmen CSF leak. In the week after discharge, she developed a recurrence of positional headaches and underwent head CT. Further magnetic resonance imaging of the brain and thoracic spine showed bilateral subdural hematomas and multiple meningeal diverticula. Cranial CSF leaks are caused by intracranial hypertension and are not associated with subdural hematomas. Clinicians should maintain a high index of suspicion for intracranial hypotension due to spinal CSF leak whenever "otogenic" pneumocephalus is found. Close postoperative follow-up and clinical monitoring for symptoms of intracranial hypotension in any patients who undergo repair of a tegmen defect for otogenic pneumocephalus is recommended.

Laboratory testing and imaging in the evaluation of cranial cerebrospinal fluid leaks and encephaloceles.

To summarize the current evidence on the diagnostic evaluation of cranial cerebrospinal fluid (CSF) leaks and encephaloceles, including laboratory testing and imaging studies. The most sensitive and specific laboratory tests for CSF leak diagnosis are beta-2-transferrin and beta trace protein assays, the former more commonly used because of availability. Imaging studies used for localization of the leak site include high resolution computed tomography (HRCT) and magnetic resonance cisternography (MRC), often used in combination. Intrathecal contrast administration is reserved for complex cases with prior equivocal test results or for patients with multiple skull base defects to localize the leak site. Diagnosis of CSF leaks and encephaloceles is aimed at both confirming the leak and localizing the leak site. Future advancements in testing techniques may shorten the diagnostic process, limit the need for invasive testing, and improve the safety of such testing in indicated cases.

Cerebrospinal Fluid Leaks: A Review of Surgical Management and Repair Techniques

We present a review of cerebrospinal fluid (CSF) leak repairs carried out at our institution. A total of 12 cranial CSF leak repair procedures were carried out on nine patients in the ENT and Neurosurgical Department between 2008 and 2011. Three cases were spontaneous leaks and seven occurred after a neurosurgical procedure. The most common location of the leak was the pituitary fossa floor (n = 5). The other leaks occurred from the cribriform plate (n = 2), posterior ethmoid (n = 1), and mastoid air cells (n = 1). The spontaneous leaks occurred through the cribriform plate in a patient with congenital hydrocephalus and transsphenoidal and posterior ethmoid. A single repair procedure successfully controlled the leak in six patients. A second procedure was required in three cases. A fibrin sealant was used in all cases, and a fat graft was used in all but one case. The use of fluorescein dye to identify CSF leaks is a relatively new technique. This was used in one case to identify the CSF leak intraoperatively. Endoscopic repair was the technique of choice in all procedures except for two cases, and those two underwent open repair. Endoscopic sinus surgery is becoming common practice; as a result, the incidence of iatrogenic CSF leaks has increased. The comparatively low morbidity and high success rate of endoscopic repair has made it the treatment of choice for CSF leak repair. It is important that endoscopic sinus surgeons be aware of the various techniques available in identifying and closing such leaks.

Lack of causal association between spontaneous intracranial hypotension and cranial cerebrospinal fluid leaks

Spontaneous intracranial hypotension is an important cause of headaches and an underlying spinal CSF leak can be demonstrated in most patients. Whether CSF leaks at the level of the skull base can cause spontaneous intracranial hypotension remains a matter of controversy. The authors' aim was to examine the frequency of skull base CSF leaks as the cause of spontaneous intracranial hypotension. Demographic, clinical, and radiological data were collected from a consecutive group of patients evaluated for spontaneous intracranial hypotension during a 9-year period. Among 273 patients who met the diagnostic criteria for spontaneous intracranial hypotension and 42 who did not, not a single instance of CSF leak at the skull base was encountered. Clear nasal drainage was reported by 41 patients, but a diagnosis of CSF rhinorrhea could not be established. Four patients underwent exploratory surgery for presumed CSF rhinorrhea. In addition, the authors treated 3 patients who had a postoperative CSF leak at the skull base following the resection of a cerebellopontine angle tumor and developed orthostatic headaches; spinal imaging, however, demonstrated the presence of a spinal source of CSF leakage in all 3 patients. There is no evidence for an association between spontaneous intracranial hypotension and CSF leaks at the level of the skull base. Moreover, the authors' study suggests that a spinal source for CSF leakage should even be suspected in patients with orthostatic headaches who have a documented skull base CSF leak.

Lumbar peritoneal shunt

A lumbar peritoneal (LP) shunt is a technique of cerebrospinal fluid (CSF) diversion from the lumbar thecal sac to the peritoneal cavity. It is indicated under a large number of conditions such as communicating hydrocephalus, idiopathic intracranial hypertension, normal pressure hydrocephalus, spinal and cranial CSF leaks, pseudomeningoceles, slit ventricle syndrome, growing skull fractures which are difficult to treat by conventional methods (when dural defect extends deep in the cranial base or across venous sinuses and in recurrent cases after conventional surgery), raised intracranial pressure following chronic meningitis, persistent bulging of craniotomy site after operations for intracranial tumors or head trauma, syringomyelia and failed endoscopic third ventriculostomy with a patent stoma. In spite of the large number of indications of this shunt and being reasonably good, safe, and effective, very few reports about the LP shunt exist in the literature. This procedure did not get its due importance due to some initial negative reports. This review article is based on search on Google and PubMed. This article is aimed to review indications, complications, results, and comparison of the LP shunt with the commonly practiced ventriculoperitoneal (VP) shunt. Shunt blocks, infections, CSF leaks, overdrainage and acquired Chiari malformation (ACM) are some of the complications of the LP shunt. Early diagnosis of overdrainage complications and ACM as well as timely appropriate treatment especially by programmable shunts could decrease morbidity. Majority of recent reports suggest that a LP shunt is a better alternative to the VP shunt in communicating hydrocephalus. It has an advantage over the VP shunt of being completely extracranial and can be used under conditions other than hydrocephalus when the ventricles are normal sized or chinked. More publications are required to establish its usefulness in the treatment of wide variety of indications.