Iatrogenic Cerebrospinal Fluid Leak Research Articles

Spontaneous intracranial hypotension mimicking iatrogenic spinal cerebrospinal fluid leaks.

To raise awareness that patients with persistent post-dural puncture headache should be considered for evaluation of spontaneous cerebrospinal fluid (CSF) leak. Spontaneous intracranial hypotension (SIH) due to a spinal CSF leak may occur following more-or-less trivial traumatic events. We report our experience with spontaneous spinal CSF leaks that occur following percutaneous or open spine procedures, a potential source of diagnostic confusion. In a retrospective cohort study, using a prospectively maintained database of patients with SIH, we identified all new patients evaluated between January 1, 2022, and June 30, 2023, who were referred for evaluation of an iatrogenic spinal CSF leak but were found to have a spontaneous spinal CSF leak. Nine (4%) of the 248 patients with SIH were originally referred for evaluation of an iatrogenic spinal CSF leak. The spinal procedures included epidural steroid injections, laminectomies, epidural anesthesia, and lumbar puncture. Brain magnetic resonance imaging (MRI) showed changes in intracranial hypotension in seven of the nine patients (78%). The spontaneous CSF leak was found to be at least five levels removed from the spinal procedure in all patients. A spontaneous spinal CSF leak should be suspected in patients with recalcitrant orthostatic headaches following a spinal procedure, even if symptoms of the leak occur within hours of the spinal procedure and especially if brain MRI is abnormal.

The value of beta trace protein in CSF-leakage detection confirmed by endoscopic fluorescein evaluation.

Cerebrospinal fluid (CSF) leaks originating from defects within the anterior and middle cranial fossa typically manifest as unilateral clear watery rhinorrhea. Continuous CSF leakage mandates surgical repair due to the risk of meningitis and brain abscess. It can be categorized based on its underlying etiology into traumatic, iatrogenic and non-traumatic CSF leaks.

Iatrogenic Cerebrospinal Fluid Leak in Endoscopic Sinus Surgery: Topographical Map and Influence of Skull Base Asymmetry.

Iatrogenic cerebrospinal fluid leak (iCSF-L) is a major complication of endonasal surgeries whose occurrence is always a potential adverse event due to anatomical variation/asymmetry of the skull base (SB). The aim of this manuscript is to provide a topographical map of iCSF-L and to investigate the role of SB asymmetry in iCSF-L occurrence. In this retrospective study, the location of iCSF-L dural defect was studied and compared to patients affected by spontaneous and post-traumatic CSF-L. Considering only iCSF-L, after having collected the SB asymmetry data, the Keros, Gera, distance of the anterior ethmoidal artery from the SB, frontal sinus pneumatization, and Thailand-Malaysia-Singapore score classifications were compared to a control group of patients. A total of 153 CSF-Ls (103 spontaneous, 37 iatrogenic, and 13 traumatic) were included. A significant association was noted (p < 0.001) between the nature of the CSF-L and the areas involved. Considering iCSF-Ls, only the Gera classification was significantly different (p < 0.05) and the most reliable in predicting the risk of dural transgression (AUC = 0.719). ICSF-Ls present peculiar regional SB involvement with the cribriform plate, with the ethmoidal roof being the most involved. After having assessed the asymmetry of the SB, the Gera classification was the most reliable one.

Transmastoid Approach to Repair Iatrogenic Cerebrospinal Fluid Otorhinorrhea After Cerebellopontine Angle Tumor Resection.

The precise treatment of iatrogenic cerebrospinal fluid (CSF) otorhinorrhea has been poorly studied. The purpose of the study was to investigate the clinical manifestation, surgical results, and management of CSF leak. Electronic medical record database of iatrogenic CSF leaks after erebellopontine angle(CPA) surgery from 2019 to 2022 was retrospectively analyzed. Three patients returned to the hospital with the complication of CSF leak. After failed attempts of conservative strategies or reverse surgical repair, adipose tissue was applied to the mastoid cracks repair. With the techniques described above, the CSF leaks were successfully settled. The identified patients were observed for at least 10 months. and there was no recurrence or other complications. Conservative treatment and initial surgical methods for occult postoperative CSF leaks are prone to delay effective results, particularly in patients with well-evaporated temporal bone. This complication can be minimized with transmastoid closure utilizing autologous fat.

Acute Intracranial Subdural Hematoma Masquerading as a Postpartum Headache: A Case Report.

An acute subdural hematoma is a collection of blood in the space between the dural and arachnoid membranes overlying the brain. Head trauma is the most common cause. Less frequently, low cerebrospinal fluid pressure, due to a spontaneous or iatrogenic cerebrospinal fluid leak can result in a subdural hematoma. We discuss the case of a 26-year-old woman who presented with a frontal headache following epidural anesthesia for vaginal delivery. The differential diagnosis included spinal headache, postpartum hypercoagulability, dural sinus thrombosis, and intracranial hemorrhage or mass. Her vital signs and physical examination were normal. A computed tomography of the brain revealed an acute subdural hematoma along the left frontal cerebral hemisphere, without midline shift or mass effect. A blood patch was placed with complete resolution of her symptoms. This case illustrates an unusual case of an acute subdural hematoma in the postpartum period following epidural anesthesia for labor pain management. It was thought to be caused by intracranial hypotension following epidural anesthesia and a cerebrospinal fluid leak.

Expansion of the Foramen Ovale in Patients With Cerebrospinal Fluid Leak or Encephalocele.

Spontaneous cerebrospinal fluid (CSF) leaks are associated with elevated intracranial pressure and idiopathic intracranial hypertension (IIH). Skull base erosion and widening of the foramen ovale have been reported in patients with IIH. This study sought to investigate changes in the size of the foramen ovale and foramen spinosum in patients with IIH, spontaneous CSF leak, and encephalocele. Retrospective cohort study. Tertiary care academic medical center. Adult patients treated from 2014 to 2018 with computed tomographic imaging of the head and who were diagnosed with IIH, encephalocele, or CSF leak. Two blinded observers measured the long and short axes of the foramen ovale and foramen spinosum on axial computed tomographic images. Measurements were used to calculate the approximate elliptical cross-sectional area of the foramina. Length, width, and area of the foramen ovale and foramen spinosum. A total of 264 patients were identified meeting the inclusion criteria and were placed into three groups. There were 170 patients with IIH, 48 with spontaneous CSF leak or encephalocele (CSF/E group), and 46 with traumatic or iatrogenic CSF leak (control group). Mean foramen ovale short axis (4.85 ± 1.00 mm) and cross-sectional area (30.17 ± 9.25 mm2) in the CSF/E group were significantly increased compared with measurements in patients with IIH or the control groups. Foramen ovale size was positively correlated with age in the CSF/E group. No significant difference in foramen spinosum size was found. Skull base defect resulting in spontaneous CSF leak or encephalocele is associated with enlargement of the foramen ovale on axial computed tomography.

Analysis of risk factors for delayed iatrogenic cerebrospinal fluid otorrhinorrhea

Objective:To explore the common causes of iatrogenic cerebrospinal fluid（CSF） otorrhinorrhea, and further analyze the risk factors for delayed iatrogenic CSF otorrhinorrhea. Methods:The clinical data of 35 iatrogenic CSF otorrhinorrhea patients in department of Otorhinolaryngology Head and Neck Surgery from January 2010 to January 2020 were retrospectively analyzed. Patients were divided into delayed and non-delayed iatrogenic CSF leak groups, according to the time intervals from medical intervention to CSF leak occurrence. The differences of baseline data, complications and success rate between the two groups were analyzed, and the risk factors of delayed iatrogenic cerebrospinal fluid otorrhinorrhea were further analyzed. Results:Endoscopic sinus surgery （n=11）, transsphenoidal pituitary surgery（n=8）, craniotomy（n=12）, and radiotherapy（n=4） all contribute to iatrogenic CSF otorrhinorrhea. Compared with the non-delayed group, the incidence of meningitis in the delayed group was significantly higher（20% vs 60%, P=0.041）. There were no significant differences in gender, radiation, hypertension, diabetes, and success rate between the two groups. Additionally, binary logistic regression analysis showed that sex, age, history of radiation, hypertension and diabetes, as well as causes of CSF otorrhinorrhea had no association with delayed iatrogenic CSF leakage. Conclusion:Patients with delayed iatrogenic CSF otorrhinorrhea have an increased risk of meningitis. Timely diagnose and intervention with appropriate surgical approach and reconstruction method ensures good clinical outcomes.

Intrathecal morphine injection in anterior lumbar and lateral lumbar spine surgery: technical note.

Intrathecal morphine (ITM) is routinely used in many surgical specialties as an adjunct to postoperative analgesia. Patients undergoing lumbar spinal surgery commonly experience early postoperative pain. There have been multiple reports of the benefits of ITM in lumbar spine surgery where it has been shown to significantly reduce the need for intravenous opioid analgesia, improve time to mobilization, and shorten length of hospital stay. ITM is yet to become standard of care in Lumbar Spine Surgery likely due to concerns of it causing a cerebrospinal fluid (CSF) leak. In recent times anterior lumbar spine surgery (ALSS) and lateral lumbar spine surgery (LLSS) have increased in popularity although they are still performed in fewer numbers in comparison to the posterior [posterior lumbar interbody fusion (PLIF)] or transformational [transforaminal lumbar interbody fusion (TLIF)] approaches. Although the number of ALSS and LLSS procedures are increasing, to our knowledge there have been no reports of ITM administered via either approach reported in the literature. Herein we describe an intra-operative technique for injection of morphine into the dural sac via the Anterior and Lateral approaches to the lumbar spine. We propose that this technique can be performed easily and quickly with standard surgical equipment that is commonly available. Through use of this technique, patients undergoing spine surgery may benefit from ITM with minimal risk of iatrogenic CSF leak.

Treatment and Outcomes of Iatrogenic Cerebrospinal Fluid Leak Caused by Different Surgical Procedures

Iatrogenic cerebrospinal fluid (CSF) leaks are associated with serious sequelae. We analyzed the causes, complications, treatments, and outcomes of iatrogenic CSF leaks. Furthermore, the comorbidities and outcomes between timely and delayed repairs of iatrogenic CSF leaks were also compared. Medical records of patients with iatrogenic CSF leaks from January 2010 to January 2020 were reviewed. Iatrogenic CSF leaks can be attributed to endoscopic sinus surgery (ESS), transsphenoidal pituitary surgery, open craniotomy, or postradiation necrosis. Twenty-nine patients diagnosed with iatrogenic CSF leak were recruited. The primary diagnoses included 12 (41.4%) nasal lesions, 7 (24.2%) pituitary tumors, 3 (10.3%) anterior cranial fossa lesions, 4 (13.8%) cerebellopontine angle lesions, and 3 (10.3%) clival lesions. The longest interval from symptom onset to presentation at our hospital was observed after craniotomy, followed by transsphenoidal surgery and ESS, increasing the risks of meningitis in these patients. The most common leakage sites after ESS and transsphenoidal surgery were the cribriform plate/ethmoid roof and sella turcica, respectively, whereas the defect sites related to open craniotomy varied. The grafts used for repair varied according to the defect location and prior surgical history. Additionally, patients in whom repair was delayed had a higher incidence of meningitis (P= 0.003), than those with timely repair. Delayed intervention of CSF leak after transsphenoidal surgery and craniotomy was observed, increasing the risks of meningitis. Timely intervention with grafts based on the defect sites and patient prior surgical history is crucial for avoiding life-threatening comorbidities.

Lumbar Drain for Temporary Cerebrospinal Fluid Diversion: Factors Related to the Risks of Complications at a University Hospital

Lumbar drains (LDs) are often used for temporary cerebrospinal fluid (CSF) diversion. However, limited data are available on the risk factors associated with complications. We reviewed our institutional LD data to identify the common indications and outcomes, including the risk factors associated with the occurrence of complications. We performed a retrospective review of the patient medical records. All adult patients, who had an LD placed at our hospital during a 5-year period, were included in the present study. The Fisher Exact test and Mann-Whitney U test were used to compare the categorical data and continuous data, respectively; p ≤ 0.05 was considered to indicate statistical significance. During the study period, 211 patients had an LD placed and were included in the present study, of whom 133 were men (63.0%). The most common reason for LD placement was for an iatrogenic CSF leak and pseudomeningocele in 95 patients (45.0%). The mean duration of an indwelling LD was 3.7 ± 1.9 days. Meningitis was the most common complication after LD insertion, occurring in 12 patients (5.5%), followed by low pressure headaches in 10 patients (4.8%). Escherichia coli and Pseudomonas aeruginosa were the most common organisms on culture. Manipulation of the LD to draw CSF samples for analysis was a significant risk factor for the development of meningitis (p= 0.039). The most common complications in our institution were meningitis and low pressure headaches. Minimizing LD manipulation during CSF sampling could potentially decrease the risk of meningitis. Our protocol of continuing routine prophylactic antibiotics for patients with an indwelling LD might reduce the risk of meningitis; however, the results from a prospective cohort study would provide stronger evidence.

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

"Parachute" Technique for Reconstruction of Small Skull Base Defects of the Ventral Skull Base.

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa.

To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. Retrospective case review. Academic tertiary center. Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. Transmastoid or MCF CSF leak repair. Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ± 12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging.

Subfascial drainage and clipping technique for treatment of cerebrospinal fluid leak following spinal surgery.

Objectives:To investigate the treatment of iatrogenic cerebrospinal fluid (CSF) leak that develops after degenerative lumbar spinal surgery with a subfascial drainage and clipping (SDC) technique.Methods:This study retrospectively reviewed the medical records of 46 patients who developed iatrogenic CSF leak after surgery for lumbar degenerative spine disease from 2007 to 2019. Twenty-five patients were treated with the SDC procedure (SDC group), whereas 21 were not (control group). Outcomes were compared between the two groups.Results:CSF leakage ceased within 6–9 days (average 7.4±1) after the procedure in the SDC group. In the control group, CSF leakage was controlled with conservative measures in 14 patients, and in 7 patients, lumbar external drainage was performed. Among these 7, the CSF leak was controlled by lumbar external drainage in 3, and 4 required reoperation to repair the dural defect. No infection occurred in either group. Length of hospital stay was also shorter in SDC group (8.4±1 vs 10.0±1.3 days, p < 0.001).Conclusion:The SDC technique is effective for the treatment of iatrogenic CSF leak that develops after degenerative lumbar spinal surgery.

Disorders Involving a Persistent Craniopharyngeal Canal: A Case Series.

Objectives A persistent craniopharyngeal canal (CPC) is a rare embryologic remnant that presents as a well-corticated defect of the midline sphenoid body extending from the sellar floor to the nasopharynx. Our case series aims to describe three unique presentations of this congenital anomaly and their subsequent management. Design Retrospective review. Setting Tertiary academic medical center. Participants Patients who underwent endoscopic transnasal surgical repair of a CPC lesion. Main Outcome Measures Resolution of symptoms and surgical outcomes. Results A total of three patients were identified. The clinical presentation varied, however, all cases prompted further imaging which demonstrated a persistent CPC and associated pathologic lesion. The presentation of a persistent CPC with nasal obstruction and subsequent iatrogenic cerebrospinal fluid leak as in Case 1 demonstrates the importance of imaging in this work-up. Cases 2 and 3 in the series were representative of the larger subset of patients in the literature who present with the defect incidentally but still warrant surgical management. Nonetheless, a standard approach to diagnosis with preoperative imaging and subsequent transnasal endoscopic repair of the skull base defect was undertaken. Conclusion The persistent CPC is a rare congenital anomaly associated with diverse pathology and careful review of preoperative radiology is critical to the management. When warranted, subsequent surgical repair and reconstruction is associated with excellent postoperative outcomes.

Procedural predictors of epidural blood patch efficacy in spontaneous intracranial hypotension.

Epidural blood patch (EBP) is a safe and effective treatment for spontaneous intracranial hypotension (SIH), but clinical and procedural variables that predict EBP efficacy remain nebulous. This study is an institutional review board-approved retrospective case series with dichotomized EBP efficacy defined at 3 months. The study included 202 patients receiving 604 EBPs; iatrogenic cerebrospinal fluid leaks were excluded. Of the EBPs, 473 (78%) were single-level, 349 (58%) lumbar, 75 (12%) bilevel, and 56 (9%) multilevel (≥3 levels). Higher volume (OR 1.64; p<0.0001), bilevel (3.17, 1.91-5.27; p<0.0001), and multilevel (117.3, 28.04-490.67; p<0.0001) EBP strategies predicted greater efficacy. Only volume (1.64, 1.47-1.87; p<0.0001) remained significant in multivariate analysis. Site-directed patches were more effective than non-targeted patches (8.35, 0.97-72.1; p=0.033). Lower thoracic plus lumbar was the most successful bilevel strategy, lasting for a median of 74 (3-187) days. In this large cohort of EBP in SIH, volume, number of spinal levels injected, and site-directed strategies significantly correlated with greater likelihood of first EBP efficacy. Volume and leak site coverage likely explain the increased efficacy with bilevel and multilevel patches. In patients with cryptogenic leak site, and either moderate disability, negative prognostic brain MRI findings for successful EBP, or failed previous lumbar EBP, a low thoracic plus lumbar bilevel EBP strategy is recommended. Multilevel EBP incorporating transforaminal administration and fibrin glue should be considered in patients refractory to bilevel EBP. An algorithmic approach to treating SIH is proposed.

Foramen magnum syndrome after iatrogenic cerebrospinal fluid leak during lumbar spine surgery: A series of two cases

Foramen magnum syndrome (FMS) is a rare complication from lumbar spine surgery. Cerebrospinal fluid (CSF) leaks can be difficult to treat. FMS is a dangerous complication due to excessive distal CSF drainage from a dural tear or secondary to a “controlled” lumbar drainage. We present two cases of FMS after iatrogenic CSF leaks. Both patients underwent decompressive laminectomy as a part of the index surgery. Intraoperative dural tear was not identified in either case. A postoperative computed tomography (CT) myelogram ordered in view of the positional headaches indicated a CSF leak. A lumbar drain was placed, but both the patients worsened symptomatically. CT head in Case 1 indicated tonsillar ectopia within the foramen magnum, while that in Case 2 revealed a posterior fossa hemorrhage with fullness of the foramen magnum and profound hydrocephalus. Both patients were treated surgically. Additional corrective measures were also initiated to reverse the pathology. Both patients made a good recovery with resolution of symptoms. Development of neurological changes in a patient with CSF leak may indicate an acute intracranial process. Treatment of foramen magnum syndrome requires prompt realization of the underlying pathology and measures to cease or modulate the CSF drainage. The dangers of excessive distal CSF drainage, whether it is from a dural tear or from “controlled” lumbar drainage, should be considered.

Horizontal lateral lamella as a risk factor for iatrogenic cerebrospinal fluid leak. Clinical retrospective evaluation of 24 cases.

Several authors highlighted the limitations of the Keros classification system in predicting intracranial entry risk. Recently, our group proposed a new classification system based on the angle formed between the lateral lamella of the cribriform plate (LLCP) and the continuation of an horizontal plane passing through the cribriform plate (Gera classification). The aim of this study was to analyze whether the risk of iatrogenic cerebrospinal fluid leak (CSF-L) was better predicted by Keros or Gera classification. The pre-operative CT scans of 24 patients (CSF-L group) who suffered from iatrogenic CSF-L during endoscopic sinus surgery (ESS) were compared to those obtained from a group of 100 patients who underwent uneventful ESS (control group). The skull base measurements as well as the distribution of Keros and Gera classes in the 2 groups were analyzed. No difference in the distribution of Keros classes or in the depth of the cribriform plate between CSF-L and control group were demonstrated. On the contrary, significant differences in the distribution of Gera classes and in the degree of the angle formed by the LLCP and the continuation of the horizontal plane passing through the cribriform plate were found. In particular, according to Gera classification system, 19 out of 24 patients in the CSF-L group were considered at risk for iatrogenic CSF-L. Gera classification system might be more sensitive to anatomical variations associated with CSF-L than the Keros one, further suggesting the application of the former during the preoperative CT scan evaluation.

The efficacy of fluoroscopy-guided epidural blood patch in the treatment of spontaneous and iatrogenic cerebrospinal fluid leakage.

To evaluate patient outcomes following fluoroscopy-guided epidural blood patch (FGEBP), factors affecting the outcome, and to identify the rate of fluoroscopy-guided lumbar punctures (FGLP) requiring FGEBP. All FGLPs and FGEBPs between January 2014 and May 2017 were retrospectively evaluated. Information regarding patient characteristics, details of previous dural puncture (DP), details of the FGEBP, and FGEBP outcome were recorded. The outcome was classified into three categories as "complete response", "partial response", and "no response". Patients with "complete response" were compared to the combined group of "no response" and "partial response", classified as "incomplete response". Two-sample/Fisher's exact (continued/categorical variables) tests were used (p < 0.05). Sity-seven FGEBPs were performed in 63 patients (female/male, 36/27; mean age/BMI 38/28.2). Fifty-nine were referred following DP; 31 were performed by radiologists. The rate of FGLPs requiring FGEBP was 1.78% within 3.5years. The mean DP-FGEBP interval was 4.8days. "Complete response" was achieved in 56 (84.8%), "no response" was found following 4 (6%) procedures. Average applied blood volume was 16cc (5-30cc). No difference was found between "complete response" and "incomplete response" groups regarding age, sex, BMI, DP performer, DP level, DP fluoroscopy time, DP needle caliber/type, FGEBP level, FGEBP needle caliber/type, FGEBP fluoroscopy time, FGEBP performer, and applied blood volume (p > 0.05). Despite approaching significance, no statistically significant difference was found regarding the presence of previous DP (p = 0.06). The efficacy of FGEBP is high in a group of patients referred to radiology for treatment of CSF leakage with complete response in 84.8% of patients. • Fluoroscopy-guided epidural blood patch completely resolved symptoms in 85% of post-dural puncture headaches. • The success approaches 95% when including the patients with partial resolution of symptoms. • Epidural blood patch rate is found 1.8% following 1703 fluoroscopy-guided lumbar punctures.

Success Rate and Complications of Cerebrospinal Fluid Rhinorrhea Treated With a Transcranial Approach.

The aim of this study was to evaluate the clinical outcomes of cerebrospinal fluid (CSF) rhinorrhea in patients treated with transcranial surgery. Here, we retrospectively reviewed 23 patients with CSF rhinorrhea between 2008 and 2015 at our university hospital. Nine (39.1%) patients were treated conservatively, whereas 12 (52.2%) patients were treated with a transcranial approach. Our results showed that 7 (30.4%), 11 (47.8%), and 5 (21.7%) patients had spontaneous, traumatic, and iatrogenic CSF leakage, respectively. In our study, the cribriform plate was the most common site of leakage, and it was found to be involved in 5 (21.7%) patients. The mean diameter defect of the fistula was 130.40 ± 190.47 mm and there was no significant difference between this defect and the different etiology types. In our study, meningitis, third nerve palsy, and vasospasm were the main complications that arose during the treatment of CSF rhinorrhea. Moreover, 6 (26.1%) of 7 (30.4%) patients had spontaneous CSF leaks that were treated with surgery. Notably, spontaneous CSF leaks did not stop when treated with conservative measures. In addition, there were no significant differences between etiology types and CSF leaks. The primary surgical repair rate was 78.3% and the secondary surgery repair rate was 91.6%. Importantly, as we preferred using this type of transcranial surgery in our clinic, there has been a higher success rate with endoscopic treatments and fewer major complications from CSF rhinorrhea in the literature.

Cerebrospinal fluid leakage after posterior fossa surgery may impair brain metabolite clearance

The discovery of the important role of cerebrospinal fluid (CSF) drainage of cerebral metabolite waste, known as the glymphatic system, has changed our view of brain waste clearance. We recently performed experiments to evaluate the glymphatic system in non-human primates (NHP). Here, we report the case of an NHP with iatrogenic CSF leakage. In this animal, solute transport through the brain, assessed by gadolinium injection in the CSF, was severely impaired by iatrogenic pseudomeningocele. This observation raises an important question: does brain surgery, and particularly posterior fossa surgery, lead to chronic impairment of parenchymal CSF circulation and solute transport?