Posttraumatic Cerebrospinal Fluid Fistula Research Articles

The efficacy of continuous lumbar drainage in post-traumatic cerebrospinal fluid fistulas.

This study aims to investigate the clinical outcomes of patients who underwent closed continuous lumbar drainage (CLD) for post-traumatic cerebrospinal fluid (CSF) fistula and to compare with those of non-traumatic patients. The data of patients who were treated in the department of neurosurgery between January 2018 and December 2019 and underwent CLD were analyzed. The diagnosis, demographic characteristics, CSF results and clinical outcomes of these patients were evaluated. The outcomes of the patients with dura defect and CSF fistula due to trauma were compared with patients who underwent CLD for other diagnoses. In this study, 45 patients underwent CLD for 51 times. The mean age was 38.84 years, and 27 (60%) of the patients were male. Seven (15.55%) patients underwent CLD due to post-traumatic CSF fistula and 38 patients after tumor or malformation surgery. While five patients developed CSF fistula due to dura defect after gunshot injury, two patients developed CSF fistula secondary to motor vehicle accident. Staphylococcus Epidermidis was isolated in one patient among post-traumatic CSF fistula patients while Serratia Marcescens was isolated in patients with CSF fistula secondary to posterior fossa tumor surgery. While none of the seven patients died during the follow-up period in post-traumatic group, one of the 38 patients with CLD secondary to tumor surgery was lost due to sepsis in the follow-up period. CLD in post-traumatic CSF fistulas is a safe and effective treatment method. Especially in patients with gunshot wounds, CLD should be performed before revision surgery in the treatment of CSF fistula. Studies with different parameters are needed in larger trauma populations.

Endoscopic repair technique for traumatic penetrating injuries of the clivus

Unlike basilar skull fractures, penetrating traumatic injuries to the clivus are uncommon. We present two novel and interesting cases of traumatic crossbow arrow injury and penetrating screwdriver injury to the clivus. A review of the literature describing methods to repair these injuries was performed. A careful, systematic approach is required when working up and treating these injuries, as airway preservation is critical. An adaptation to the previously described “gasket-seal” method for skull base repair was utilized to repair the traumatic cerebrospinal fluid (CSF) fistulas. This repair technique is unique in that it is tailored to a much smaller defect than typical post-surgical defects. Two patients are presented, one with a post-traumatic CSF fistula after penetrating crossbow injury to the clivus and one with a penetrating screwdriver injury to the clivus. The patients were treated successfully with transnasal endoscopic repair with fascia lata graft and a nasoseptal flap, a novel adaptation to the previously described “gasket-seal” technique of skull base repair.

MR cisternography/myelography of post-traumatic spinal CSF fistulae and meningeal lesions in small animals

The diagnosis of post-traumatic spinal cerebrospinal fluid (CSF) fistulae due to dural tears or lesions remains a challenge. Thus far, CT myelography is the standard test used to diagnose these complications. To evaluate the diagnostic ability of gadolinium-enhanced MR cisternography/myelography (intrathecal gadopentate dimeglumine or Gd-DTPA) in small animals that had experienced accidental spinal trauma. Four dogs and one cat suffered traumatic accidents resulting in neurological deficits underwent spinal MRI with intrathecal Gd-DTPA after routine plain films and MR images. T2-weighted SE images showed high water content in the epidural space or in the surroundings of the vertebrae in four animals. MR myelography revealed CSF leakage in all of them. In two animals CSF leaks were observed exuding from the spinal canal and tracking towards adjacent loose fat and interfascial planes. In two other animals Gd-DTPA extravasation was diffusely collected in paraspinal tissues around the vertebral arch. In the fifth animal a focal pseudomeningocele was observed adjacent to the traumatized region. Intrathecal administration of Gd-DTPA is an effective method to reveal and confirm post-traumatic spinal CSF fistulae or other dural lesions in animals with potential application in humans.

Extraordinarily Long-Term Posttraumatic Cerebrospinal Fluid Fistula

Most posttraumatic cerebrospinal fluid (CSF) leakage is noticed by the patients with the first symptom, rhinorrhea. A 38-year-old woman presented with frequent clear continuous rhinorrhea and otorrhea for 5 years after basilar skull fracture. After this, meningitis was developed with subsequent CSF fistula. Her clinical symptom was improved by medical treatment. The dural defect and CSF leakage were not detected by computerized tomography (CT) cisternography. We report a rare case of persistent posttraumatic CSF fistula that continued for five years.

Severe craniofacial fractures with frontobasal involvement and cerebrospinal fluid fistula: indications for surgical repair

Background The management of posttraumatic cerebrospinal fluid (CSF) fistulae is a controversial topic. Although recent literature shows that endoscopic repair of CSF fistula is efficacious and minimally invasive, in specific conditions open operative approach remains imperative. Methods A series of 36 patients underwent surgery for posttraumatic CSF fistula according to specific selection criteria. These criteria included: bone displacement more than 1 cm (5 cases), location of fracture in proximity to the midline (6 cases), involvement of cribriform plate (12 cases), presence of encephalocele (3 cases), and failure of the conservative treatment (10 cases). The dural defect was closed using vascularized pericranium and fibrin glue. Closure of the basal bone defect was necessary in very large fractures or in special localization of the fistula, such as near the optic nerve. Mean clinical follow-up was 5.7 years. Results Two patients presented meningitis without sequelae, and 12 with hyposmia. One patient died of the severity of the primary brain injury and associated extracranial lesions. None of the patients had recurrence. Conclusions Our results indicate that surgical dural repair in selected cases is related to low morbidity and mortality preserving from delayed risks such as recurrence and infections.

Evaluation of intrathecal gadolinium-enhanced MR cisternography in a rabbit model of traumatic nasoethmoidal CSF fistula.

This pilot study details the feasibility of intrathecal gadopentetate dimeglumine (Gd) administration in the detection of posttraumatic cerebrospinal fluid (CSF) fistula in an animal model. Five rabbits were used in this study. An attempt was made to create a traumatic CSF fistula surgically via a nasal approach. Seven days following the procedure, images of the cranium in sagittal and coronal planes were obtained utilizing a 1.9 T magnetic resonance (MR) imaging scanner before and after intrathecal injection of 16 pmol Gd. Following the imaging study, the animals were euthanized and grossly sectioned coronally to search for fistula formation. One animal died on the third day following the surgical procedure. The other four rabbits underwent the MR and gross pathologic study. Diagnosis of the fistula by intrathecal Gd-enhanced MR imaging was successful in two rabbits; this finding was confirmed by gross pathologic examination. No fistula was detected on either intrathecal Gd-enhanced MR imaging or on pathologic study in the remaining two rabbits. Intrathecal enhanced MR cisternography is a potentially promising technique for the evaluation of posttraumatic CSF fistulae.

Craneotomía bifrontal y colgajo pediculado de pericráneo en el tratamiento de las fístulas traumáticas de LCR

Between 5–11% of patients harboring skull base fractures may present with cerebrospinal fluid (CSF) fistula. Their risk is the development of posttraumatic meningits. Surgical repair of the dural defect, when conservative measures fail, is mandatory in order to avoid new episodes of meningitis. Several surgical procedures have been proposed with an overall failure rate around 25%. Between 1987–1998 we treated 56 patients with posttraumatic CSF fistula and/or posttraumatic meningits with a bifrontal craniotomy, intradural exploration and carpeting of the anterior fossa with a pediculated pericranial flap. All patients underwent preoperative axial and coronal CT-scan and deliberately we did not use other imaging techniques to 10calize the fistula. After a follow-up of 1–11 years (mean 5.6 y) no recurrent episodes of meningitis or rhinorrhea have been detected. There was not operative mortality and 2 patients developped anosmia after the surgical procedure. A bilateral surgical exploration and complete covering of the anterior fossa floor with a pediculated pericranial flap allows a safe sealing as well as an effective isolation between anterior fossa and paranasal cavities. Unilateral approaches as well as nonvascularized materials should be avoided in the management of these patients.

MR cisternography: a new method for the diagnosis of CSF fistulae.

The aim of this study was to compare a new MRI method for detecting the existence of cerebrospinal fluid (CSF) fistulae, i. e. MR cisternography, with CT cisternography. In a prospective study, 30 patients with post-traumatic CSF fistulae were examined. The MR examinations were performed with a 1.0-T whole-body MR system, using two T2(*)-weighted sequences, a 3D PSIF (time-inversed fast imaging with steady-state precession, FISP) and a 3D constructive interference steady-state (CISS) sequence. The results of MRI and CT cisternography were compared with the surgical findings. The sensitivity in detecting CSF fistulae with MR cisternography (PSIF: 89.9 %; CISS: 93.6 %) was higher than with CT cisternography (72.3 %). The sensitivity of CT cisternography at detecting CSF fistulae in patients with a size of dural lesion less than 2 mm or in patients with multiple dural lesions is significantly lower compared with the MR method. Although the localization of CSF fistulae always proved possible with MR cisternography, this could only be accomplished wih CT in 70 % of cases. The MR cisternography technique is a new examination method with a higher sensitivity for the detection of CSF fistulae than CT cisternography. The CISS technique is superior compared with PSIF and should be used in patients with high-flow CSF fistulas.

Acute traumatic CSF fistulae: the risk of intracranial infection

The management of acute traumatic cerebrospinal fluid (CSF) fistulae is still a matter of debate and hinges about what is perceived to be the risk of subsequent intracranial infection. We have therefore carried out a retrospective analysis of 160 cases of traumatic CSF leaks to assess the incidence, cumulative risk and prognosis of intracranial infection. The overall incidence of meningitis in this group before surgical dural repair was 30.6% (49/160), the cumulative risk exceeded 85% at 10 years follow-up and the meningitis was fatal in 4.1% (2/49). The recurrence of CSF leakage after initial spontaneous cessation was 7% and meningitis was recurrent in 30.6% (15/49). Prophylactic antibiotics had reduced the risk of meningitis from 61 to 34%. The commonest pathogen was pneumococcus and the CSF leakage had stopped within 7 days in 60% of those who developed meningitis and in 50% of those who did not develop meningitis. Meningitis is still a serious complication of post-traumatic CSF fistulae and is potentially fatal despite modern therapeutic agents.

Surgical management of midline skull-base tumors: a new approach.

Many surgical approaches to the clivus and upper cervical spine have been used in the treatment of skull-base tumors over the past 50 years. However, the outcome of surgery has been complicated by difficulties of access to the whole clivus, together with pharyngeal wound breakdown with subsequent development of cerebrospinal fluid (CSF) fistula and meningitis. A technique described recently utilized Le Fort I osteotomy to improve exposure of the clivus in the approach to vertebrobasilar aneurysms, facilitating control of the aneurysm and reducing the risk of posttraumatic CSF fistula. The same approach, via maxillotomy, has permitted partial or total tumor resection in 13 consecutive procedures carried out at Atkinson Morley's Hospital on 10 patients presenting with tumors of the skull base. Neurological status was either improved or unchanged in all patients postoperatively, and pain relief was obtained in five of eight cases in which this was a presenting symptom. No patient developed a CSF fistula following surgery. Cosmetic results were good, and no problems related to malocclusion were reported. This approach may be used to advantage in the surgical treatment of skull-base tumors, at initial presentation, and can be repeated without undue difficulty should there be tumor recurrence.