Presence Of Cerebrospinal Fluid Leak Research Articles

Cerebrospinal fluid leak after combat penetrating gunshot wound to the head

Introduction: Cerebrospinal fluid leak is a common complication after head gunshot wounds, which commonly leads to infectious complications. This complication may prolong hospital staying and prevents soldiers from return to operation theatre as soon as possible. 
 The purpose of this article is to determine the impact of the quality of primary surgical debridement and other factors that influenced the presence of cerebrospinal fluid leak in the military stuff with gunshot wounds to the head. 
 Materials and methods: This is a retrospective study of 20 military cases with cerebrospinal fluid leak, which were admitted during the combat actions in Eastern Ukraine in the period from March 2014 to the end of December 2017. Information was collected on demographics, evacuation assistance, type of injury and infectious complications. R commander version 4.2.0 (http://www.r-project.org) was used for statistical analysis. Statistical significance was defined as p<0.05.
 Results: Cerebrospinal fluid fistulas were detected in 20 cases (25,31%). Factors affecting the rate of leaks are number of re-operations (p<0.001), multiple sites of injury (p=0.002), ventricular injury (p<0.005). CSF leakage significantly lengthens hospitalization time.
 Conclusions: CSF fistula influenced significantly rate of infection complication. Reoperation should follow initial surgery in cases of CSF leak development. To avoid development of cerebrospinal fluid fistulas, the operation should be performed by neurosurgeons in specialized department.

Management of Aesthetic and Functional Deficits in Frontal Bone Trauma.

Frontal bone trauma has an increasing incidence and prevalence due to the wide-scale use of personal mobility devices such as motorcycles, electric bicycles, and scooters. Usually, the patients are involved in high-velocity accidents and the resulting lesions could be life-threatening. Moreover, there are immediate and long-term aesthetic and functional deficits resulting from such pathology. The immediate complications range from local infections in the frontal sinus to infections propagating inside the central nervous system, or the presence of cerebrospinal fluid leaks and vision impairment. We review current trends and available guidelines regarding the management of cases with frontal bone trauma. Treatment options taken into consideration are a conservative attitude towards minor lesions or aggressive surgical management of complex fractures involving the anterior and posterior frontal sinus walls. We illustrate and propose different approaches in the management of cases with long-term complications after frontal bone trauma. The team attending to these patients should unite otorhinolaryngologists, neurosurgeons, ophthalmologists, and maxillofacial surgeons. Take-home message: Only such complex interdisciplinary teams of trained specialists can provide a higher standard of care for complex trauma cases and limit the possible exposure to further legal actions or even malpractice.

Management of Frontal Bone Fracture in a Tertiary Neurosurgical Care Center-A Retrospective Study.

Objective We present our experience in the management of frontal bone fractures using the previously described radiologic classification of frontal bone fractures. Methodology A retrospective study was conducted, which reviewed the medical records and computed tomographic (CT) scan images of patients with frontal bone fracture from January 2016 to February 2019. Patients with complete medical records and a follow-up of minimum 1 year were included in the study. Demographic details, mechanism of injury, associated intracranial injuries, maxillofacial fractures, management, and complications were analyzed. CT scan images were used to classify the frontal bone fractures using the novel classification given by Garg et al (2014). The indications for surgical treatment were inner table frontal sinus fracture with cerebrospinal fluid (CSF) leak, intracranial hematoma with significant mass effect requiring surgical evacuation, and outer table comminuted fracture that is either causing nasofrontal duct obstruction or for cosmetic purpose. Results A total of 55 patients were included in the study. Road traffic accidents as the commonest cause of frontal bone fractures. The most common fracture pattern was type 1 followed by type 5 and depth B followed by depth A. Four patients presented with CSF rhinorrhea. CSF rhinorrhea was more frequent with fracture extension to the skull base (depth B, C, D), which was statistically significant ( p < 0.001). Conclusion Frontal bone fracture management has to be tailor-made for each patient based on the extent of the fracture, presence of CSF leak, and associated intracranial and maxillofacial injuries.

Single-Center Experience With Antibiotic Prophylaxis and Infectious Complications in Civilian Cranial Gunshot Wounds

Abstract BACKGROUND Despite the widespread adoption of systemic antibiotic prophylaxis in civilian cranial gunshot wounds (cGSWs), there remains a lack of consensus on microbial coverage and duration of therapy. OBJECTIVE To analyze a 6-yr experience with prophylactic antibiotics in civilian cGSWs with a focus on infectious complications. METHODS Records were reviewed for demographic and injury characteristics that could influence the risk of intracranial infection. Patients over 16 yr of age with cGSWs who survived more than 48 h were included. Antimicrobial prophylaxis was initiated at the discretion of the treating neurosurgeon, with eligible patients divided into 3 groups: no prophylaxis, single agent, and multiagent. Univariate analysis and multivariable logistic regression were performed to determine variables contributing to the development of intracranial infection. RESULTS Of 75 eligible patients, prophylactic antibiotics were utilized in 61 (81.3%) with a 5 d median duration. Injury Severity Score (ISS) was significantly higher and Glasgow Coma Scale (GCS) was significantly lower in those who received prophylaxis. Eight intracranial infections were documented (10.7%) over a range of 1 wk to 3 yr from injury. Antibiotic prophylaxis did not contribute to infection, but the presence of cerebrospinal fluid (CSF) leak was associated with intracranial infection risk in multivariable regression (odds ratio [OR] = 11.8, P = .013). CONCLUSION In a cohort of cGSW patients, those with a more severe injury profile were more likely to receive multiagent antimicrobial prophylaxis. However, we found that multiagent antimicrobial prophylaxis did not confer an advantage, and that the presence of CSF leak may be a more important contributing variable to the development of intracranial infection.

2143. Incidence of Infection in Patients Receiving Short vs. Long Duration of Antimicrobial Prophylaxis in Neurosurgery

BackgroundSurgical site infections in neurosurgery occur in up to 10% of procedures. The American Society of Health-System Pharmacists guidelines promote antimicrobial prophylaxis (AP) for up to 24 hours from neurosurgery using cefazolin while the Neurocritical Care Society guidelines promote single pre-procedural dose of AP for extraventricular drain (EVD) monitoring. Despite these guidelines, practice variation exists with often longer antimicrobial exposure and subsequent complications.MethodsThis retrospective study included patients admitted to Baylor University Medical Center from January 1, 2014 to September 20, 2017 and underwent cranial or spinal neurosurgery requiring AP. This study excluded patients with basilar skull fracture, presence of cerebrospinal fluid leak, penetrating trauma, meningitis, and patients receiving antibiotics for documented or suspected infection unrelated to neurosurgery. Patients who received AP for up to 24H (short course) were compared with patients who received AP for greater than 24H (long course) at 90 days. Data were analyzed using the Fisher exact test, Student’s t-test and Wilcoxon rank-sum tests as applicable.ResultsA total of 183 patients were included with 90 and 93 patients receiving short or long courses of AP, respectively. Baseline characteristics were similar for the groups. Patients in the short course AP group received a mean antibiotic duration of 16.9 ± 4.3H while those in the long course AP group received 72.2 ± 50.9H (P < 0.001). The mean number of antimicrobials prescribed was 1.1 vs. 1.8 (P < 0.001) in the short vs. long groups, respectively. At 90 days, there were no significant differences in the rate of surgical site infections (1.1% vs. 2.1%, P = 0.99), development of multi-drug-resistant infections (2.2% vs. 2.2%, P = 0.99), and Clostridium difficile infection (0% vs. 1.1%, P = 0.99) in the short vs. long groups, respectively.ConclusionThe rate of surgical site infections was not significantly different in patients that received short vs. long durations of antimicrobial prophylaxis. These results highlight an opportunity to improve antibiotic use and promote principles of antimicrobial stewardship in neurosurgery.Disclosures All authors: No reported disclosures.

Recurrent sampling and ventriculostomy-associated infections: a case-control study.

External ventricular drain (EVD) insertion is a common neurosurgical procedure with a significant risk of ventriculostomy-associated infections (VAIs), other morbidities and mortality. Several risk factors have been identified but their effect is unclear. Our primary objective was to assess whether recurrent EVD sampling increased the risk of VAIs. The secondary objective was to explore the effect of sampling frequency, duration of EVD stay, presence of cerebrospinal fluid leak and concurrent infections. Ours was a retrospective, single-centre, age-matched, case control study of 83 patients and 249 controls who underwent EVD insertion between 1 January 2010- 31 December 2016. Patients with primary CNS infections, age under 1year and death within 5days of EVD insertion were excluded. Blinded abstractors collected all patient data through the electronic patient record system and regression analysis was used to compare the two groups. Sampling the EVD more than once did not increase the risk of infection (OR 0.47, 95% CI 0.27-0.83, p = 0.01). Risk factors significantly associated with VAI included CSF leak (OR 2.06, 95% CI 1.16-3.67, p = 0.01), concurrent infection (OR 1.85, 95% CI 1.09-3.16, p = 0.02), and an EVD duration of >10days (OR 2.28, 95% CI 1.24-4.18, p = 0.01). Our findings do not support the notion that increased sampling of EVDs is associated with a higher risk of VAI. CSF leaks, concurrent infection and long-term EVDs are also statistically significant risk factors for infection.

A Comparative Evaluation of Risk Factors and Various Antibiotic Regimens in Postoperative Neurosurgical Infections: A Prospective Randomized Controlled Study

Introduction Postoperative neurosurgical infections are a major problem, and the importance of keeping them to an absolute minimum cannot but be overemphasized. In this prospective study, we plan to evaluate the efficacy of three antibiotic regimens designed keeping the availability, affordability, and efficacy upon the common bacterial flora isolated at our center. We will also analyze the incidence and evaluate the risk factors of surgical site infections following clean, nonimplant, fresh, elective craniotomies. Material and Methods This prospective randomized control study was conducted at our institute, a tertiary referral center, for a period of 2 years. The study cohort included all patients undergoing clean, nonimplant, fresh, elective craniotomies at our institute. The antibiotic protocol was chosen according to the current bacterio-epidemiological data based on the prevalence of infectious agent. One of the three drug regimens was chosen. Results The results of univariate analysis revealed that there are multiple factors that are significantly associated with postoperative surgical site infection. In the multivariate analysis, only the presence of cerebrospinal fluid leak was the most significant factor associated with postoperative infections. Among the three different antibiotic regimens, cefazolin and amoxicillin–clavulanic acid were much better prophylactic agents for preventing surgical site infections when compared with cefotaxime. Conclusion The present study has provided an insight into the incidence and risk factors contributing to surgical site infections as well as the efficacious antibiotic regimen protocols. The present study is one of the few studies to compare the efficacy of different antibiotic regimen protocols and also prospectively analyze the factors contributing to postoperative infections. This study will help us in optimizing the prophylaxis protocols and prevent emergence of multidrug-resistant strains, especially in a country like India.

Surgical management of traumatic frontal sinus fractures: Case series from a single institution and literature review.

Background:Neurosurgeons are frequently involved in the management of patients with traumatic frontal sinus injury; however, management options and operative techniques can vary significantly. In this study, the authors review the current literature and retrospectively review the clinical series at a single tertiary referral center.Methods:After Institutional Review Board approval, the medical records and computed tomographic (CT) imaging of patients whose traumatic frontal sinus fractures were treated surgically at the University of Utah were retrospectively reviewed. Demographic information, mechanism of injury, associated injuries, operative technique, and pattern of injury on CT were analyzed.Results:Between 2000 and 2012, 33 patients underwent successful cranialization of the frontal sinus following traumatic injury. The material used to obliterate the sinus varied. No patients required immediate or delayed reoperation. Nasofrontal outflow tract obstruction, the importance of which has been emphasized in the plastic surgery literature, was apparent on either initial or retrospective review of the available CT imaging in 96%.Conclusions:In this series, we successfully surgically treated 33 patients with frontal sinus fractures. The presence of cerebrospinal fluid leak, nasofrontal outflow tract injury, associated depressed skull fractures, and subsequent formation of communicating pathways and infection must be considered when constructing a treatment plan. The goals of treatment should be: (i) surgical repair of the defect and elimination of the conduit from the intracranial space to the outside and (ii) elimination of any cerebrospinal fluid pressure gradient that may develop across the surgical repair. We present a treatment algorithm focusing on the presence of nasofrontal outflow tract injury/obstruction, cosmetic deformity, and cerebrospinal fluid leak.

Management of Cerebrospinal Fluid Leaks After Vestibular Schwannoma Surgery

To evaluate the incidence and treatment of cerebrospinal fluid (CSF) leaks after resection of vestibular schwannomas and to propose a treatment algorithm for their management. Retrospective chart review. Tertiary referral center. Review of 1,922 subjects who underwent resection of vestibular schwannomas from 1970 to 2010. Surgical resection of vestibular schwannoma. Patient demographics, surgical approach used, CSF leak incidence, meningitis, treatment, and success in the management of CSF leaks. Postoperative CSF leaks were observed in 12.9% of our patients. There was no significant difference between the type of approach and the presence of CSF leak with translabyrinthine, suboccipital and middle fossa CSF leak rates of 12%, 12%, and 13%, respectively (p = 0.07). Patients presented with a wound leak or rhinorrhea almost equally. Ultimately, 92% of patients with rhinorrhea underwent surgical intervention. The probability of a patient with rhinorrhea requiring a second intervention was higher when the initial intervention was conservative rather than surgical. However, the probability of a patient with a wound leak requiring a second intervention was essentially the same when initially treated conservatively or surgically. Our data suggests that there is no difference in CSF leak rates between the different surgical approaches. The appropriate treatment strategy is dependent on the presentation of the CSF. Although conservative treatment is effective for managing wound leaks, it is less effective in managing patients with rhinorrhea. Therefore, surgical treatments should play an early role in the treatment algorithm of patients with CSF rhinorrhea.

The utility of intrathecal fluorescein in cerebrospinal fluid leak repair

ObjectiveTo evaluate the utility of intrathecal fluorescein (IF) for intraoperative localization and successful repair of cerebrospinal fluid (CSF) leaks. Study DesignCase series with chart review. SettingTertiary-care medical center. Subjects and MethodsSubjects included those undergoing endoscopic CSF leak repair with or without the use of IF. Informed consent was obtained from all patients undergoing the administration of IF (total dose 10 mg). ResultsA total of 103 patients underwent CSF leak repair, and in 47 cases (45.6%), IF was used. Patients who were administered IF were more likely to have spontaneous CSF leak etiology (61.7% vs 16.1%; P < 0.001). Of the 47 cases with IF use, fluorescein was visualized at the skull base in 31 cases (66.0%), 11 (23.4%) had visible CSF leak without fluorescein coloration, and five (10.6%) had neither clear nor fluorescein-colored CSF visualized. Sensitivity and specificity for fluorescein detection was 73.8 percent (95% confidence interval [CI] 57.7%-85.6%) and 100 percent (95% CI 46.3%-100%), respectively. The false-negative rate was 26.2 percent (95% CI 15.8%-43.5%). Localization of the leak site was greater when fluorescein-colored CSF was visualized (100% vs 81.3%; P = 0.035). When fluorescein-colored CSF was not visualized intraoperatively, recurrence rates were 31.3 percent versus 9.7 percent when fluorescein coloration was seen, although this finding was not statistically significant (P = 0.10). ConclusionThe use of IF facilitates the accurate localization of CSF leaks and may assist the surgeon in confirming a watertight closure. The lack of intraoperative fluorescein visualization should not rule out the presence of CSF leak, as evidenced by a false-negative rate of 26.2 percent.

A study of temporal bone fractures

Many young adults are now killed and injured in accidents than from another causes. More than 75% of these injuries are to the head, and the ear being the most frequently injured sensory organ of the body. Temporal bone or basilar skull fractures are extremely common in any head injury. Injuries to the temporal bone may be considered in three groups: Those affecting the external auditory meatus (extralabyranthine fractures), those largely affecting middle ear cleft (tympanolabyranthine) and those affecting the internal ear (labyrinthine fractures). Many injuries, however, involve all these structures.The sudden onset of facial paralysis, vertigo and hearing impairment after a head injury is a matter of great concern for the patients and clinicians. Presence of cerebrospinal fluid leak (CSF Otorrhoea) can be a challenge for both the neurosurgeons and otologists. We hereby present 86 patients of temporal bone fractures who presented in the departments of emergency, Neurosurgery or ENT of Himalayan Institute of Medical Sciences, Dehradun during last 10 years (1996-2006).

Ventriculostomy-associated infections: Incidence and risk factors

The objective of this study was to assess the incidence of ventriculostomy-associated infections (VAI) and to examine the related risk factors. Data on all consecutive patients with ventriculostomy catheters admitted to the intensive care unit (ICU) in a tertiary care center over a 3-year period were identified from the ICU database and from medical records. VAI was documented using a preset definition. The following patient data were documented: demographics, severity of illness measures, indication for the catheter, presence of cerebrospinal fluid (CSF) leak, and length of stay and mortality. The following catheter data were collected: venue of catheter placement (operating room or nonoperating room areas), use of antibiotic irrigation and prophylactic systemic antibiotics, and number of catheter days. The frequency of CSF sampling was documented. In 84 patients, 99 catheters were placed, of which 19% developed VAI. There was a total of 586 catheter days (infection rate, 32 per 1000 catheter days). The risk of VAI increased steadily until catheter day 7 then reached a plateau. Among patients' factors, repeat catheter insertion was associated with a significant increase in VAI. There were no significant associations with age, severity of illness, indication for the catheter, craniatomy, or presence of CSF leak. Among catheter factors, the number of catheter days and repeat catheter insertion emerged as significant independent predictors on multivariate analysis. Placement outside the operating room was associated with a trend toward higher VAI. The use of prophylactic antibiotic or antibiotic irrigation did not significantly alter VAI rates. Routine surveillance cultures of CSF were no more likely to detect infection than cultures obtained when clinically indicated. Gram-negative bacilli were responsible for 50% of the infections, followed by gram-positive cocci (29%) and others (21%). The risk of VAI increases with increasing duration of catheterization and with repeated insertions. The use of local antibiotic irrigation or systemic antibiotics does not appear to reduce the risk of VAI. Routine surveillance cultures of CSF were no more likely to detect infection than cultures obtained when clinically indicated. These findings need to be considered in infection control policies addressing this important issue.

Fractures of the middle third of the face and cerebrospinal fluid rhinorrhoea.

The incidence of cerebrospinal fluid (CSF) rhinorrhoea in patients with facial fractures is about 25%. Although the management of facial fractures is well documented, its timing and role in the presence of CSF leak is still open to debate. This study evaluates facial manipulation in 89 facial fractures associated with CSF rhinorrhoea, with a mean follow-up of 4 years. The facial fractures were reduced in 26 patients (29%) and the CSF fistula was repaired in 75 (84%). Twenty-three (25.8%) had both facial manipulation and dural repair with no deaths, post operative infection, failure or recurrence of CSF leak. On the other hand, when facial manipulation or dural repair was performed alone, the CSF rhinorrhoea either persisted or recurred in a significant number of patients requiring further intervention. Although this is a retrospective analysis of patients treated over several years and, there has been a change in the methods of investigation and treatment of these patients, one can conclude that manipulation of facial fractures and surgical dural repair can be carried out at the same sitting without increasing the surgical morbidity and mortality.

Factors affecting the development of cerebrospinal fluid leak and meningitis after translabyrinthine acoustic tumor surgery

Meningitis and cerebrospinal fluid (CSF) leak are serious complications of acoustic tumor surgery. Previous reports have varied in the incidence of and the predisposing factors to these complications. This study reviews a series of 723 acoustic tumors removed via the translabyrinthine approach at the House Ear Clinic in Los Angeles. The incidences of CSF leak and meningitis were 6.8% and 2.9%, respectively. The patients who developed these problems were compared to the remainder of the study population for differences in age at surgery, tumor size, operative time, and length of hospital stay. Meningitis occurred more frequently in larger tumors, and patients with either complication had a longer hospital stay. The presence of CSF leak did not predispose to meningitis. It is concluded that technical factors account for postoperative CSF leak and meningitis after translabyrinthine acoustic tumor removal.