Non-traumatic Cerebrospinal Fluid Research Articles

Systematic Review: Success Rate of Endoscopic Endonasal versus Combined Endonasal and Transorbital Neuroendoscopic Approach for Nontraumatic Cerebrospinal Fluid Leak Repairs in the Lateral Recess of Sphenoid Sinus

Abstract Background Cerebrospinal fluid (CSF) leaks from the lateral recess of the sphenoid sinus (LRS) occur due to a skull base defect and are important to treat due to the associated morbidity, e.g., life-threatening meningitis. Nontraumatic CSF leaks have a predilection toward obesity which is a rising phenomenon. LRS is notoriously difficult to access because of its lateral location and its associated neurovascular complications. An alternative surgical corridor has been explored which is the transorbital neuroendoscopic (TONES) approach. Objective To compare the success rate of the endoscopic endonasal with the TONES approaches. Rationale This is the first systematic review on the endoscopic endonasal and combined transorbital approaches to treat CSF leaks from the LRS. Method A PRISMA-concordant systematic review. PubMed, MEDLINE, EMBASE, Web of Science, and SCOPUS were searched. The studies underwent abstract and full-text screening by two reviewers. The data collected included patient demographic, surgical approach, reconstruction method, layers and materials, follow-up period, ROBINS-I bias, complications, and success rate. Results In total, 26 of 4,385 studies were included for further synthesis. Of these studies, a total of 336 patients were identified from a cohort of 910 patients. The endoscopic endonasal approach showed a repair success rate of 95.24% and the combined TONES and endonasal approach showed a success rate of 100%. Conclusion Both the endoscopic endonasal and transorbital approach provide a good success rate. However, due to the small TONES sample, large, randomized control trials are needed.

Spontaneous delayed CSF rhinorrhea associated with encephalocele following surgical resection of a giant frontoparietal meningioma, an extremely rare entity and overlook of English literature

Introduction and importance: Spontaneous cerebrospinal fluid (CSF) rhinorrhea without a history of head trauma is rare. The authors describe a scarce case of spontaneous, nontraumatic, delayed CSF rhinorrhea due to ethmoidal encephalocele associated with frontoparietal giant meningioma. Case presentation: A 49-year-old male complained of a slowly growing skull mass lasting 10 years since a blunt head trauma and progressive hemiparesis 3 months ago and was referred to our center. There was a heterogeneous extra-axial mass (77×77×70 mm) with calcified components at his right frontal lobe, demonstrating notable adjacent parenchymal edema and a midline shift to the left. There was a sizeable extra-axial mass (113×95×80 mm) in his right front-temporoparietal lobe associated with adjacent invasion to calvarium leading to the lytic and sclerotic appearance of the calvarial bone showing intense heterogeneous contrast enhancement and an adjacent enhancing dural tail. A considerable mass effect on the adjacent frontotemporal cortex is evident, with mild parenchymal edema leading to a notable midline shift to the left, right uncal herniation, and left ventriculomegaly. On postoperation day 5, the patient developed a recurrent CSF leak exacerbated by hydrocephalus. He was rescheduled to undergo endoscopic endonasal surgery and dural repair on postoperative day 7. The postoperative course was uneventful. Clinical discussion: Frontoparietal lobe encephaloceles represent the least common cause of spontaneous CSF rhinorrhea. Early diagnosis and surgical management remain crucial to minimize the subsequent complications. Conclusion: The ventricular anatomy and CSF fluid dynamics alteration following tumor surgical resection seem to contribute to an environment by which a herniated ethmoidal encephalocele developed a delayed nontraumatic CSF leak.

Management of Traumatic and Non-Traumatic Cerebrospinal Fluid Rhinorrhea-Experience from Three Southeast Asian Countries.

Cerebrospinal fluid (CSF) rhinorrhea requires proper management to avoid disastrous consequences. The objectives of this study were to ascertain the patient characteristics, etiologies, sites of defect, skull base configurations, methods of investigation, and management outcomes of CSF rhinorrhea. A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes. A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days. Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.

075 A case of spontaneous CSF rhinorrhea in a patient with marfan syndrome

IntroductionSpontaneous cerebrospinal fluid leak is uncommon condition and frequently associated with hereditary disorders of connective tissues. Nasal CSF leakage is extremely rare.1Methods and resultsWe present the case of a 40-year-old woman presented to hospital for few days history of postural headache associated with clear intermittent discharge from right nostril without any signs of meningism. There was no history of trauma. She has a background history of Marfan syndrome with associated complications of ASD repair at age 2, mechanical Aortic and Mitral valve replacement, aortic root repair, previous ST elevation MI with LV dysfunction, automated implantable cardioverter-defibrillator in situ, atrial fibrillation, and Hashimoto’s thyroiditis. Her regular medications are warfarin, bisoprolol and thyroxine. The clear nasal discharge was positive for β-2 transferrin confirming cerebrospinal fluid. Her CT Brain did not reveal any clear site of CSF leak. She had a flexible nasendoscopy which showed normal nasal passageway, no defect in nasal mucosa and no active CSF leakage. She was managed conservatively with strict bed rest and advised to minimise strenuous activity and heavy lifting.ConclusionSpontaneous cerebrospinal fluid leak is uncommon condition and frequently associated with hereditary disorders of connective tissues. Nasal CSF leakage is extremely rare.1 Testing β-2 transferrin has high sensitivity and specificity.2Initial treatment may include bed rest, oral or intravenous hydration, oral caffeine or corticosteroids.3 4 If conservative therapy fails, surgical repair with nasal endoscopic approach is recommended.2 5ReferencesOmmaya A, Di Chiro G, Baldwin M, Pennybacker J. Non-traumatic cerebrospinal fluid rhinorrhoea. Journal of Neurology, Neurosurgery & Psychiatry 1968;31(3):214-–225.Wang E, Vandergrift W, Schlosser R. Spontaneous CSF Leaks. Otolaryngologic Clinics of North America 2011;44(4):845–856.Milledge J, Ades L, Cooper M, Jaumees A, Onikul E. Severe spontaneous intracranial hypotension and Marfan syndrome in an adolescent. Journal of Paediatrics and Child Health 2005;41(1–2):68–71.Placantonakis D, Bassani L, Graffeo C, Behrooz N, Tyagi V, Wilson T, et al. Noninvasive diagnosis and management of spontaneous intracranial hypotension in patients with marfan syndrome: Case Report and Review of the Literature. Surgical Neurology International 2014;5(1):8.Spontaneous cerebrospinal fluid rhinorrhea. Medicine 2018;97(7):e9954.

Non-Traumatic Cerebrospinal Fluid Leak from a Sphenoid Sinus Midline Roof Defect Previously Managed as Allergic Rhinitis

Objective: To present a case of a non-traumatic cerebrospinal fluid (CSF) rhinorrhea from a midline sphenoid sinus roof that presented as a persistent postnasal drip and was previously managed as allergic rhinitis for 43 years.
 
 Methods:
 Design: Case Report
 Setting: Tertiary Private University Hospital
 Participants: One
 
 Results: A 58-year-old obese and hypertensive man presented with persistent post nasal drip and intermittent clear watery rhinorrhea. He had been managed as a case of allergic rhinitis for 43 years and was maintained on nasal steroid sprays without relief. Nasal endoscopy revealed pulsating clear watery discharge from the sphenoid ostium. On trans-sphenoidal surgery, a midline sphenoid sinus roof defect was sealed using a Hadad-Bassagasteguy flap.
 
 Conclusion: CSF rhinorrhea is uncommon and may mimic more common diseases such as allergic rhinitis. Because misdiagnosis can then lead to life threatening complications, physicians should be vigilant when seeing patients with clear watery rhinorrhea to be able to arrive at a proper diagnosis and provide prompt treatment.
 
 Keywords: cerebrospinal fluid rhinorrhea; cerebrospinal fluid leak; sphenoid sinus midline roof defect

Spontaneous cerebrospinal fluid (CSF) otorrhoea in Western Australia—an emerging entity?

Background: Spontaneous cerebrospinal fluid (CSF) otorrhea appears to be an emerging clinical entity. The aetiology, characteristics and treatment outcomes of these group of patients are poorly described so we aimed to further investigate this growing cohort. Methods: A retrospective review across the three largest tertiary hospitals in Western Australia (WA) over a 5-year period was conducted. Twenty-eight patients with non-iatrogenic, and non-traumatic spontaneous CSF otorrhea were included. Baseline demographics, presenting symptoms, past medical history, clinical examination, investigation (biochemical and radiological), management and outcomes were analysed. The study was approved by the South Metropolitan Health Services Ethics Committee (approval number RG001008). Results: The majority of patients were female (61%), obese (mean BMI =29.5 kg/m 2 ) and presented with a unilateral middle ear effusion and conductive hearing loss. Beta-trace protein sampling of the fluid was positive for CSF in 26 of the 28 patients. The most frequent site of leak was at the tegmen mastoideum and middle cranial fossa repair was the most commonly performed procedure with excellent outcomes. Only one patient had confirmed benign intracranial hypertension and two patients presented emergently to hospital with meningitis thought to be due to the CSF leak. Conclusions: Spontaneous CSF otorrhea should be suspected in unilateral middle ear effusion of unknown cause, especially occurring in at-risk individuals including those whom are obese and of female gender. Clinical or radiological diagnosis alone appears inadequate in diagnosing a spontaneous CSF leak unless clinicians have a high index of suspicion. This emerging entity does not appear to be solely a consequence of raised intracranial pressure and further studies to elucidate the cause are required.

Skull base defects multilayer plasty in patients with spontaneous cerebrospinal fluid leak: our experience

Spontaneous cerebrospinal fluid (CSF) leak is one of the types of non-traumatic CSF leaks in which the etiologic factor is unknown. Skull base defects transnasal endoscopic plasty is the initial method of surgical repair of spontaneous cerebrospinal fluid leaks. METHODS: Forty-five patients with spontaneous CSF leaks were managed using multilayer transplant technique. The basic choice criteria of endoscopic transnasal surgical approach and materials to reconstruction of skull base defects were the size of defect and its localization. In all cases pediculated flaps in combination with free graft were used. RESULTS: In 43 (96%) cases CSF leaks was successfully managed in primary surgery, which indicates high efficiency of the described surgical interventions.

Anteromedial temporal encephalocele: A rare cause for spontaneous cerebrospinal fluid rhinorrhoea

Spontaneous cerebrospinal fluid (CSF) rhinorrhea in an adult without prior history of head trauma is a rare occurrence. Neuroimaging is done to ascertain the site of bony defects in the cranium and breach in the continuity of dura to localize the site of CSF leakage. Encephaloceles into the sphenoid sinus occurring through congenital bony defects in the walls of the sinus are an extremely rare cause for CSF rhinorrhea. We present a case of spontaneous, nontraumatic CSF rhinorrhea due to an anteromedial encephalocele where the temporal lobe was seen herniating into the right sphenoid sinus through a congenital bony defect in the wall of the sinus. A review of the present literature is also presented.

Neural differentiation of choroid plexus epithelial cells: role of human traumatic cerebrospinal fluid

As the key producer of cerebrospinal fluid (CSF), the choroid plexus (CP) provides a unique protective system in the central nervous system. CSF components are not invariable and they can change based on the pathological conditions of the central nervous system. The purpose of the present study was to assess the effects of non-traumatic and traumatic CSF on the differentiation of multipotent stem-like cells of CP into the neural and/or glial cells. CP epithelial cells were isolated from adult male rats and treated with human non-traumatic and traumatic CSF. Alterations in mRNA expression of Nestin and microtubule-associated protein (MAP2), as the specific markers of neurogenesis, and astrocyte marker glial fibrillary acidic protein (GFAP) in cultured CP epithelial cells were evaluated using quantitative real-time PCR. The data revealed that treatment with CSF (non-traumatic and traumatic) led to increase in mRNA expression levels of MAP2 and GFAP. Moreover, the expression of Nestin decreased in CP epithelial cells treated with non-traumatic CSF, while treatment with traumatic CSF significantly increased its mRNA level compared to the cells cultured only in DMEM/F12 as control. It seems that CP epithelial cells contain multipotent stem-like cells which are inducible under pathological conditions including exposure to traumatic CSF because of its compositions.

Spontaneous Intracranial Hypotension Associated with Kinetic Tremor and Ataxia.

BackgroundSpontaneous intracranial hypotension (SIH) is a clinically variable syndrome caused by low cerebrospinal fluid (CSF) pressure due to a non-traumatic CSF leak.Phenomenology ShownThis case describes a 68-year-old gentleman who presents with chronic and slightly progressive kinetic tremor of bilateral hands associated with gait ataxia and gait start hesitation.Educational ValueThis case underscores the importance of having a high index of suspicion for the diagnosis of SIH when encountering a patient presenting with late-onset progressive kinetic tremor and gait ataxia syndrome.

Spontaneous Intracranial Hypotension Associated with Kinetic Tremor and Ataxia

<strong>Background:</strong> Spontaneous intracranial hypotension (SIH) is a clinically variable syndrome caused by low cerebrospinal fluid (CSF) pressure due to a non-traumatic CSF leak. <strong>Phenomenology Shown:</strong> This case describes a 68-year-old gentleman who presents with chronic and slightly progressive kinetic tremor of bilateral hands associated with gait ataxia and gait start hesitation. <strong>Educational Value:</strong> This case underscores the importance of having a high index of suspicion for the diagnosis of SIH when encountering a patient presenting with late-onset progressive kinetic tremor and gait ataxia syndrome.

CT-cisternography in the diagnosis and treatment of non-traumatic cerebrospinal fluid rhinorrhoea: Clinical series and literature review

CT-cisternography in the diagnosis and treatment of non-traumatic cerebrospinal fluid rhinorrhoea: Clinical series and literature review

Management of Cerebrospinal Fluid Leaks of the Anterior and Lateral Skull Base

Objectives: Non-traumatic cerebrospinal fluid (CSF) leaks along the anterior or lateral skull base are often secondary to intracranial hypertension. Surgical repair of these bony defects along with resection of an associated encephalocele helps to prevent meningitis. While reconstruction of the skull base is necessary and may be curative in some cases, patients with intracranial hypertension are at increased risk of recurrent CSF leaks at the reconstruction site or elsewhere along the skull base. The goal of this study is to present our treatment algorithm and outcomes in patients who present with a CSF leak.

Endoscopic Endonasal Approaches for Cerebrospinal Fluid Leaks Repair

A variety of techniques have been described for the repair of cerebrospinal fluid (CSF) leaks at the anterior skull base. Conservative management includes bed rest, avoidance of straining activities, and temporary CSF diversion with serial lumbar punctures or lumbar drains. Surgical repair may be achieved transcranially through a bifrontal craniotomy, extracranially through an external ethmoidectomy or frontal sinusotomy, or transnasally with microscopic or endoscopic visualization. Between January 2006 and May 2011, 30 patients with nontraumatic and traumatic CSF rhinorrhea were treated at the Departments of Neurosurgery and Maxillofacial Surgery of the Universities of Rome 'La Sapienza'. All patients underwent surgery: 5 patients (15%) were treated by a combined intracranial and endoscopic endonasal approach and 25 patients were treated (91.1%) by the endoscopic endonasal approach alone. In our study, we used autologous material, the fascia lata, free grafts of septal or middle turbinate mucoperichondrium, and septal cartilage grafts, and in cases with a large deficit in the posterior wall of the sphenoid or clivus, a pedicle flap from sphenopalatine artery of septal mucosa is used. Only in 2 cases was there an appearance of secondary rhinoliquorrhea with a success rate of 94%, in line with what is described in international literature. Posttraumatic cerebrospinal leak in our experience can be treated through endoscopic approach, in selected cases, using autologous materials with a few relapse of the pathology. Endoscopic endonasal technique offers a high viewing of surgical field and it permits to manage even larger lesions with minimally invasivity.

A case of cerebrospinal fluid rhinorrhoea: a surgical challenge.

CEREBROSPINAL FLUID rhinorrhoea is defined as the leakage of CEREBROSPINAL FLUID through the nose due to communication between nasal cavity and Sub-arachnoid space. It occurs due to breach in 4 layers - mucosa of the nose and PNS, skull base, Duramater, Subarachnoid membrane. With the advent of nasal endoscope and advancement in technology, Endoscopic Endonasal closure of CEREBROSPINAL FLUID leak has reached tremendous heights due to exact localization and precise placement of graft. In this article, we are publishing a case report of Non-traumatic normal pressure CEREBROSPINAL FLUID leak of more than 1.5cm in size which was successfully closed Endoscopically by multilayered technique.

Critical basilar expansion of the sphenoidal sinus associated with a spontaneous cerebrospinal fluid fistula: the relevance of multidetector computed tomographic cisternography

A 46-year-old woman presented with an intermittent nontraumatic cerebrospinal fluid (CSF) left rhinorrhea. A multidetector computed tomographic (MDCT) study was performed to investigate a CSF fistula (Figure) […] Critical basilar expansion of the sphenoidal sinus associated with a spontaneous cerebrospinal fluid fistula: the relevance of multidetector computed tomographic cisternography

Non-traumatic cerebrospinal fluid rhinorrhea caused by ethmoid sinus osteoma

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of ethmoid sinus osteoma, considering its benign and indolent nature. We present a 36-year-old female patient with symptomatic CSF rhinorrhea as a primary presentation of ethmoid sinus osteoma. We have highlighted the imaging features and emphasised the importance of imaging in the diagnosis of spontaneous CSF leak.

Nontraumatic cerebrospinal fluid rhinorrhea as a result of pseudotumor cerebri

Objective The purpose of this study is to demonstrate that pseudotumor cerebri, also known as benign intracranial hypertension, can be an overlooked cause of spontaneous, nontraumatic cerebrospinal fluid (CSF) rhinorrhea. Study design and methods This study presents a literature review and 2 case reports. The medical records of 2 patients who had nontraumatic CSF rhinorrhea were reviewed. Results The patients were diagnosed as having spontaneous, nontraumatic CSF rhinorrhea, believed to have been caused by pseudotumor cerebri, and were surgically treated. The patients are obese, middle-aged women. Conclusions Cerebrospinal fluid rhinorrhea is most often the result of trauma, but it may also occur spontaneously because of nontraumatic causes in some patients. Pseudotumor cerebri can be an overlooked cause of spontaneous, nontraumatic CSF rhinorrhea. A patient with signs and symptoms of pseudotumor cerebri should be evaluated and treated, if the condition is present, to prevent complications that include irreversible visual loss and CSF rhinorrhea.

Transpterygoid Trans-sphenoid Approach to the Lateral Extension of the Sphenoid Sinus to Repair a Spontaneous CSF Leak

Cerebrospinal fluid (CSF) fistula from the middle cranial fossa into the sphenoid sinus is a rare condition. In the past, the treatment of choice has been closure via a craniotomy. Only few geriatric cases are known, which were successfully operated by endoscopic surgery. We present a further case of nontraumatic CSF fistula originating from the middle cranial fossa. A new endoscopic technique was applied. We discuss treatment options for this rare defect. A 76-year-old patient presented with a 2-year history of rhinorrhea. High levels of beta-trace protein pointed to a diagnosis of CSF fistula. The defect was located at the anterior and inferior aspect of the pterygoid recess of the left sphenoid sinus. The patient was operated using an endoscopic trans-sphenoidal approach. After endoscopic opening of the maxillary and sphenoid sinus, a complete posterior ethmoidectomy was performed. The medial part of the pterygoid process was removed, allowing endoscopic exposure and closure of the defect. At 1-year follow-up, the CSF fistula had not recurred and the patient had no sequel from the surgical procedure. In selected cases, this new endoscopic partial transpterygoid approach to the middle cranial fossa is recommended for surgical repair of CSF fistula involving the lateral extension of the sphenoid sinus. To our knowledge, ours is the oldest patient with this condition successfully operated by endoscopic means at the world's most northern university hospital.

Chronic subdural haematoma associated with nontraumatic CSF rhinorrhea: A management challenge

We report an unusual case of chronic subdural haematoma (CSH) associated with cerebrospinal fluid (CSF) rhinorrhoea emphasizing the importance of managing both conditions simultaneously. A 59- year-old man presented with watery discharge from the right nostril, of 2 months duration. MRI of the brain showed a CSH in the left fronto-parietal region with significant mass effect. There was an arachnoidocoele with a defect in the planum sphenoidale. He first underwent a burr hole evacuation of the CSH following which the CSF rhinorrhea did not subside, even with bed rest. Transnasal endoscopic closure of the CSF dural fistula was done. On the first post-operative day, he was disoriented and a CT scan showed a recollection of the subdural haematoma that required repeat evacuation. The patient was asymptomatic at discharge. To our knowledge this is the first reported case of CSF rhinorrhoea associated with CSH. Simultaneous closure of the CSF dural fistula at the time of evacuation of a coexisting CSH would be the optimal management.