Site Of Cerebrospinal Fluid Leak Research Articles

Spontaneous Clival Leaks and Their Management

Abstract Introduction Cerebrospinal fluid (CSF) leaks through the nasal cavity occurrence has a rising trend, of which primary spontaneous leak is 6 to 40% of all the CSF leaks. The most common site of CSF leak is ethmoid roof where the bone is thinner in the entire skull base. Clivus being the hard bone is a rare site for spontaneous leak. We present a case series from a single quaternary care center of this rare occurrence and study its reason and management strategy. Materials and Methods A retrospective surgical audit over a period of 10 years of all patients diagnosed with CSF rhinorrhea was done. A PubMed search was conducted with keywords of CSF leak, CSF rhinorrhea, spontaneous CSF rhinorrhea, clival leak, and clivus to identify the literature and these articles were compiled and their management reviewed. Results and Analysis A total of 100 patients underwent surgical management for spontaneous CSF leak, of which there were 5 patients who had spontaneous CSF rhinorrhea from the clivus. There were four female patients; four patients had high body mass index. The most common site of leak was mid-clivus and surgical technique employed was multilayer dural plasty with a nasoseptal flap and measures were taken to reduce the intracranial pressure intra-operatively and postoperatively. Conclusion Spontaneous clival leak is a rare entity with mid and lower clivus being the common site. A combined approach by ENT and neurosurgeons results in best outcome for the patients.

A technique to localize posteriorly located spinal dural leaks associated with spontaneous intracranial hypotension: Dorsal-decubitus dynamic CT myelography.

Precise localization and understanding of the origin of cerebrospinal fluid (CSF) leak is crucial to allow targeted treatment. We report the technical feasibility and utility of dorsal-decubitus dynamic computed tomography (DDDCT) myelography to localize posteriorly located dural defects in patients with suspicion of posterolateral dural tears. This study reports a series of four consecutive patients with posteriorly located SLEC and suspicion of posterolateral CSF leak who received DDDCT to localize the site of the leak. Patients were collected between October 2022 and October 2023. The technique of DDDCT and its efficacy to detect the site of CSF leak are reported. In all four patients (three females, one male, mean age 39 years), DDDCT myelography was technically successful and precisely demonstrated the site of the CSF leak. In one patient with both anterior and posterior SLEC, DDDCT allowed to exclude the presence of a posteriorly located leak, while a subsequent ventral decubitus dynamic CT myelography localized the leak. Leak sites were all thoracic, except for one that was cervical. Information obtained from the DDDCT myelography was considered useful to target the treatment of the leak. Based on our experience, DDDCT provided sufficient spatial and temporal resolution to pinpoint fast CSF leaks and it may be considered to localize posterolateral dural defects.

Role of Conservative Treatment and Outcome of Traumatic CSF Rhinorrhea

Background: Traumatic cerebrospinal fluid (CSF) rhinorrhea, a rare but serious consequence of head injuries, poses significant challenges in diagnosis and management. Understanding the efficacy of treatment modalities is crucial to improve patient outcomes and reduce complications. Objective: This study aims to evaluate the effectiveness of conservative versus surgical treatment in managing traumatic CSF rhinorrhea and to identify factors influencing treatment outcomes. Methods: A descriptive case series was conducted at Jinnah Postgraduate Medical Center, Karachi, from September 2022 to February 2023. Thirty patients with traumatic CSF rhinorrhea, aged 18-60 years, were included. Data on patient demographics, site of CSF leakage, management approach, and recovery were collected. Diagnostic methods involved glucose oxidase test strips and imaging techniques. Statistical analysis was performed using SPSS version 23. Results: Of the patients, 73.3% were male, and 26.7% were female. CSF leakage sites included the sphenoid sinus (36.7%), frontal sinus (33.3%), ethmoidal sinus (20.0%), and cribriform plate (10.0%). Conservative treatment controlled 80% of CSF rhinorrhea cases within 48 hours. Surgical intervention was necessary in 20% of cases, primarily for persistent leaks. The mean age of patients was 40.67±10.54 years. Conclusion: The study indicates that conservative management is effective in the majority of traumatic CSF rhinorrhea cases. However, surgical intervention remains crucial for cases unresponsive to initial treatment. These findings highlight the need for individualized treatment plans and suggest further research into optimizing management strategies for traumatic CSF rhinorrhea.

Clinical effect of cervical vs. targeted epidural blood patch in spontaneous intracranial hypotension with unclear leakage sites

Background and Aims: Epidural blood patch (EBP) is the most commonly used treatment for spontaneous intracranial hypotension (SIH). EBP is generally targeted at the cerebrospinal fluid (CSF) leakage site; in unclear leakage sites, it is performed blindly in the lumbar region. Therefore, to investigate effectiveness of cervical EBP in SIH patients having unclear CSF leakage sites, we conducted a retrospective case control study to compare the effectiveness of cervical EBP for unclear leakage site and targeted EBP at leakage sites.
 Methodology: We reviewed the records of SIH patients who had undergone EBP at a single hospital. Patients were divided into Group CE (cervical EBP for unclear leakage site) and Group TE (targeted EBP at leakage site). the demographics, clinical characteristics, leakage site, EBP injection level, injected volume, and change in pain score (numeric rating scale [NRS]) were analysed for both groups.
 Results: We analysed 54 patients, with 13 and 41 patients in the CE and TE groups, respectively. EBP regions in the TE group included the cervical, thoracic, and lumbar regions. There were no significant differences in demographic data between the groups. The baseline NRS scores for headache were 7.8 ± 0.9 and 7.7 ± 0.8 (P = 0.771); scores after EBP were 2.9 ± 1.7 and 2.2 ± 1.1 (P = 0.195) in groups CE and TE, respectively. NRS changes of 4.9 ± 2.0 and 5.6 ± 1.5 (P = 0.348) occurred in groups CE and TE, respectively. The mean blood volume in the CE group was 10.4 ml. Clinical effectiveness did not differ significantly between the groups.
 Conclusion: Cervical EBP is as effective as targeted EBP when the CSF leakage site is unclear. Therefore, cervical EBP is appropriate for SIH in patients with unclear CSF leakage.
 Abbreviations: CSF - Cerebrospinal Fluid; EPB - Epidural Blood Patch; NRS - Numeric Rating Scale; SIH - Spontaneous Intracranial Hypotension
 Key words: Epidural Blood Patch; Spontaneous Intracranial Hypotension; Headache
 Citation: Ryu H, Lee HS, Kim H. Clinical effect of cervical vs. targeted epidural blood patch in spontaneous intracranial hypotension with unclear leakage sites. Anaesth. pain intensive care 2023;27(5):521−525; DOI: 10.35975/apic.v27i5.2307
 Received: July 07, 2023; Reviewed: August 28, 2023; Accepted: September 01, 2023

PMON105 Giant Growth Hormone (GH)-Secreting Pituitary Tumor with Massive Sphenoid Sinus Invasion and Spontaneous Cerebrospinal Fluid (CSF) Leak: A Case Report

Abstract Introduction Giant pituitary tumor, defined as >4cm, comprise 6-10% of all pituitary tumors. Giant GH-secreting pituitary tumors are rare and difficult to treat. They typically invade surrounding structures ​such as the cavernous sinus, making ​complete resection challenging or impossible. This report highlights a case of giant GH-secreting pituitary tumor with an unusual clinical presentation.CLINICAL CASE: A 56 Y/O male with hypertension, cardiomyopathy, obesity, and OSA presented to the ER with stroke-like symptoms. Brain CT and MRI revealed small acute to subacute infarcts within the left occipital, left frontal, right frontal, right parietal areas, and right cerebellum. An incidental finding was a 4.3 cm T2 hyperintense enhancing mass centered within the skull base with involvement of the sella, extension into bilateral cavernous sinuses, clivus, encasement of bilateral carotid arteries, and invasion through the sphenoid sinus into the nasopharyngeal space resulting in a preoperative CSF. He was overtly acromegalic with coarse facial features, prominent frontal bossing, early prognathism, and macroglossia. Hands and feet were enlarged, but non-edematous. Visual field testing was normal. Laboratory values: IGF-1, 317 ng/mL (NL <170): GH, 4 ng/ml (NL<10); prolactin, 17.6 ng/mL (NL 2.5-17.4); total testosterone, 11 ng/dL (NL 130-810); free testosterone, 2 pg/dL (NL 36-146). ACTH stimulation produced a normal cortisol response. Test for AIP gene mutation was negative. Emergent packing of the CSF leak site was done. He underwent trans-sphenoidal (TSS) debulking of the tumor along with reconstruction of the ​skull base and repair of CSF leak. Postoperatively, IGF-1 level decreased to 216 ng/mL. Immunohistochemical stains of the tumor were strongly positive for GH and somatostatin receptor type2 (SSTR2). Three weeks postoperatively, IGF-1 increased to 482 ng/mL. IGF-1 level decreased to 326 ng/mL after 3 doses of lanreotide 90 mg/month. He will be now monitored on 120 mg/month. Currently, he requires only testosterone replacement. Conclusion This patient had the unique presentation of florid acromegaly and CSF leak mainly related to his delay in seeking medical care. Absence of visual defects has been noted in only 15% of reported patients with giant GH-secreting adenomas. Massive replacement of the sphenoid sinus by a giant pituitary tumor causing a CSF leak with invasion into the ​cavernous sinuses and clivus has been rarely reported. Trans-sphenoidal resection is the preferred first-line treatment for patients with acromegaly. The remission rate decreases and can reach almost 0% for giant GH-secreting tumors. Somatostatin receptor analogs (SRA) are the preferred first-line pharmacological treatment as an adjuvant therapy for residual tumor. Our patient likely will need continued SRA and potentially other modalities to control acromegaly due to unresectable tumor anatomy. This case also highlights the complications of delayed detection and benefits of extensive TSS surgical resection with the goal to enhance his response to SRA. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

“The Up and Down Approach” to Localize and Exclude Sites of Intraspinal CSF Leaks

Myelography is a commonly performed procedure to locate cerebrospinal fluid (CSF) leaks in patients with spontaneous intracranial hypotension. Often, the site of leak within the spinal canal cannot be located creating a diagnostic dilemma for clinicians. This technical report describes a novel method to locate and exclude intraspinal CSF leaks in patients with multiple potential sites of CSF leak using a lumbar and cervical approach to inject intrathecal contrast and subsequently performing CT myelography.

68Ga-DOTA PET for Diagnosis of Spinal Cerebrospinal Fluid Leaks.

Spontaneous intracranial hypotension due to spinal cerebrospinal fluid (CSF) leakage causes substantial disease burden. In many patients, the course is protracted and refractory to conservative treatment, requiring targeted therapy. We propose PET of the CSF space with 68Ga-DOTA as a state-of-the-art approach to radionuclide cisternography (RC) and validate its diagnostic value. Methods: This study is a retrospective analysis of patients with suspected intracranial hypotension due to spinal CSF leaks and who underwent whole-body PET/CT at 1, 3, and 5 h after intrathecal lumbar injection of 68Ga-DOTA. Two independent raters unaware of the clinical data analyzed all scans for direct and indirect RC signs of CSF leakage. Volume-of-interest analysis was performed to assess the biologic half-life of the tracer in the CSF space and the ratio of decay-corrected activity in the CSF space at 5 and 3 h (simplified marker of tracer clearance). Comprehensive stepwise neuroradiologic work-up served as a reference; additional validation was provided by surgical findings and follow-up. Results: Of 40 consecutive patients, 39 patients with a working diagnosis of intracranial hypotension due to a spinal CSF leak (spontaneous, n = 31; postintervention, n = 8) could be analyzed. A spinal CSF leak was verified by the neuroradiologic reference method in 18 of 39 patients. As the only direct and indirect diagnostic signs, extrathecal tracer accumulation at the cervicothoracic junction (67% sensitivity and 90% specificity) and lack of activity over the cerebral convexities (5 h; 94% sensitivity and 67% specificity) revealed a high diagnostic value for spinal CSF leaks. Their combination provided little improvement (71% sensitivity and 95% specificity). Additional quantitative analyses yielded no benefit (94% sensitivity and 53% specificity for biological half-life; 94% sensitivity and 58% specificity for the ratio of total radioactivity within the CSF space at 5 and 3 h). The location of direct signs (extrathecal tracer accumulation) did not correlate with verified sites of spinal CSF leakage. Conclusion: We propose CSF PET with 68Ga-DOTA as a novel, fast, and convenient approach to RC for verification but not localization of spinal CSF leaks with high sensitivity and specificity. CSF PET may fulfill an important gatekeeper function for stratifying patients toward escalation (ruling in) or deescalation (ruling out) of diagnostic and therapeutic measures. Further prospective studies are needed to validate the present results and determine the potential of the methods to reduce the burden to patients.

Original technique of sealing cerebrospinal fluid leakage from dural sac causing spontaneous cerebral hypotension

Background: Spontaneous intracranial hypotension (SIH) is a rare disease characterized by a decrease in the volume and pressure of cerebrospinal fluid (CSF) resulting from its leakage through the dura mater. SIH is curable, but it can lead to serious clinical sequelae or even death if not treated properly.Case Description: A 37-year-old female with headaches occurring in standing position and increasing especially during verticalization. Magnetic resonance imaging showed an image characteristic of SIH. Conservative treatment was applied in the form of bed rest. CT myelography scan located the site of CSF leakage. As the conservative treatment proved inefficient, it was decided to perform an epidural fistula sealing using the patient’s venous blood, administered under computed tomography guidance. The performed procedure completely resolved the patient’s complaints, allowing her to be discharged home.Conclusion: Patients with suspected SIH should remain in the supine position until a definitive diagnosis is made. Sealing the meningeal fistula with venous blood under computed tomography guidance should be considered in case of conservative treatment failure.

Modern approaches to the diagnosis and treatment of spontaneous intracranial hypotension (a literature review)

The aim of this review is to analyze and summarize the existing evidence regarding the diagnosis and treatment of spontaneous intracranial hypotension. Spontaneous intracranial hypotension occurs due to a decrease in cerebrospinal fluid (CSF) volume as a result of its spontaneous leakage and has a variety of clinical and neuroimaging features, sometimes different from CSF hypotension after a lumbar puncture. Anatomical changes in spontaneous CSF leakage are complex and are often associated with structural disorders of the connective tissue, weakness of certain areas of the dura mater and its diverticulosis. One consequence of decreased CSF volume is brain descent. This leads to traction of pain-sensitive brain structures and, therefore, to headaches that are orthostatic or with some orthostatic features. The methods of choice to identify the site of CSF leak are CT-myelography and radioisotope cisternography. Epidural blood patch is the main treatment in most cases. Conclusions. The study on the most informative and minimally invasive methods to locate the site of CSF leak, conservative and surgical methods of treatment efficacy evaluation depending on the etiological factors of spontaneous intracranial hypotension are extremely important and promising scientific fields requiring further research with the development of personalized approaches considering the individual characteristics of each patient.

Spinal Cerebrospinal Fluid Leak: Current Concepts and Management Policies

In this article we provide an update on the recent developments in understanding the diagnosis and treatment of spinal cerebrospinal fluid(CSF)leaks. Patients with spinal CSF leak show an increasingly broad spectrum of clinical presentations including intractable whiplash-associated disorder(WAD)and orthostatic dysregulation in childhood, in addition to classical spontaneous intracranial hypotension(SIH). A simple understanding of the condition defined by the presence of low CSF pressure is no longer sufficient or accurate. Fat-suppressed T2-weighted magnetic resonance images and continuous epidural fluid infusion as a diagnostic therapy ensure accurate diagnosis. Accurate localization of the leak followed by targeted epidural blood patch(EBP)significantly improves the outcome of patients with spinal CSF leak. In addition to the known sites of CSF leakage, a newly identified CSF leak site, at the craniovertebral junction dural entry point of the vertebral artery(VA), is described.

Heavily T2-Weighted Magnetic Resonance Myelography as a Safe Cerebrospinal Fluid Leakage Detection Modality for Nontraumatic Subdural Hematoma.

ObjectiveNontraumatic subdural hematoma (SDH) is a common disease, and spinal cerebrospinal fluid (CSF) leakage is a possible etiology of unknown significance, which is commonly investigated by several invasive studies. This study demonstrates that heavily T2-weighted magnetic resonance myelography (HT2W-MRM) is a safe and clinically effective imaging modality for detecting CSF leakage in patients with nontraumatic SDH. MethodsAll patients who underwent HT2W-MRM for nontraumatic SDH workup at our institution were searched and enrolled in this study. Several parameters were measured and analyzed, including patient demographic data, initial modified Rankin Scale (mRS) score upon presentation, SDH bilaterality, hematoma thickness upon presentation, CSF leakage sites, treatment modalities, followup hematoma thickness, and follow-up mRS score. ResultsForty patients were identified, of which 22 (55.0%) had CSF leakage at various spinal locations. Five patients (12.5%) showed no change in mRS score, whereas the remaining (87.5%) showed decreases in follow-up mRS scores. In terms of the overall hematoma thickness, four patients (10.0%) showed increased thickness, two (5.0%) showed no change, 32 (80.0%) showed decreased thickness, and two (5.0%) did not undergo follow-up imaging for hematoma thickness measurement. ConclusionHT2W-MRM is not only safe but also clinically effective as a primary diagnostic imaging modality to investigate CSF leakage in patients with nontraumatic SDH. Moreover, this study suggests that CSF leakage is a common etiology for nontraumatic SDH, which warrants changes in the diagnosis and treatment strategies.

Diagnostic Yield of Intrathecal Gadolinium MR Myelography for CSF Leak Localization.

Intrathecal gadolinium magnetic resonance (MR) myelography can be used to localize various types of spinal cerebrospinal fluid (CSF) leaks; however, its diagnostic yield is not well known. We sought to determine the diagnostic yield of MR myelography in patients with spontaneous intracranial hypotension. Aretrospective review was performed on all patients who had undergone intrathecal gadolinium MR myelography at our institution from 2002 to 2020 for suspected spinal CSF leak. The MR myelography images were reviewed for the presence or absence of aspinal CSF leak site. Images were also evaluated for the presence an extradural fluid collection. A total of 97patients were included in the final cohort. The average age was 52.6years; 67.0% were female, 4 patients underwent 2 examinations each, yielding atotal of 101 MR myelograms. The source of aspinal CSF leak was localized in 14patients. The diagnostic yield for CSF leak localization on intrathecal gadolinium MR myelography was 14/101 (13.9%) per GdM examination and 14/97 (14.4%) per patient. Among the subset of patients without extradural fluid collections, the yield was 15.7% per examination. All detected leaks were either CSF-venous fistulas or distal nerve root sleeve tears. Intrathecal gadolinium MR myelography is capable of localizing CSF-venous fistulas and distal nerve root sleeve tears; however, our data show that it has alimited diagnostic yield. We suggest that other modalities may be abetter first step before attempting intrathecal gadolinium MR myelography.

Endonasal Endoscopic and Hybrid Surgery Techniques for Blunt Trauma Fractures of the Skull Base With Cerebrospinal Fluid Leaks.

Cerebrospinal fluid (CSF) leakage caused by skull base fracture represents high risks of bacterial meningitis, and a rate of mortality of 8.9%. Endoscopic endonasal repair of CSF leaks is quite safe and effective procedure with high rates of success. The aim of this study is to describe our technique for management of skull base CSF leaks secondary to craniofacial trauma based on the anatomic location of the leak. This is a retrospective case series of 17 patients with diagnosis of craniofacial trauma, surgically treated with sole endonasal endoscopic and combined endonasal/transcranial approaches with diagnosis of CSF leak secondary to skull base fractures. Seventeen patients met inclusion criteria for this study. Mean age was 46 years old. Most common etiology was motor vehicle. Early surgery was performed in 8 patients, and late surgery in 9 patients. The most common site of CSF leak was at ethmoid cells or at the fronto-ethmoid junction in 9 patients. Thirteen patients (76.4%) were treated only with endonasal endoscopic technique, and 4 (23.5%) with hybrid surgery, combining endonasal endoscopic and cranial bicoronal approaches with nasal and pericranial vascularized flaps, and nasal mucosal free flaps. Mean hospital stay was 23.7 days.The mean follow-up time was 25.6 months. When surgical reconstruction is indicated for CSF leaks secondary to skull base fractures, endonasal endoscopic techniques should be part of the surgical management either as a sole procedure, or in combination with classical transcranial approaches with high rates of success and low morbidity.

Use of combined radioisotope cisternography with SPECT/CT for identifying the site of cerebrospinal fluid leakage: a report of three cases

Use of combined radioisotope cisternography with SPECT/CT for identifying the site of cerebrospinal fluid leakage: a report of three cases

Combined Transcranial-endonasal Reconstructive Surgery for Cerebrospinal Fluid Leakage Resulting from Traumatic Anterior Skull Base Fractures Involving the Parasellar Region.

Extensive traumatic anterior skull base fractures from the frontal sinus to the parasellar region are frequently accompanied by multiple dural defects that cause persistent cerebrospinal fluid (CSF) leakage. Conventional transcranial reconstruction using a frontal periosteal flap is frequently insufficient, and parasellar dural defects are often deep, complex, and difficult to identify. In this report, we describe a combined transcranial–endonasal reconstructive technique and report our experience. Simultaneous combined transcranial and endoscopic surgery was performed in three patients with CSF leakage resulting from traumatic anterior skull base fractures. Dural defects were thoroughly identified from the transcranial and endonasal surgical fields, and covered using a multilayer sealing technique. The anterior regions of the anterior skull base were reconstructed using a free fascial flap and frontal periosteal flap; posterior and parasellar regions were reconstructed using a fat graft, vascularized nasoseptal flap, and endonasal balloon. Suturing the transcranial grafts to the parasellar dura mater was performed collaboratively by the transcranial and endonasal surgeons. In our cases, complete cessation of CSF leakage was achieved without perioperative lumbar drainage in all patients. Mean time to postoperative ambulation was 7 days (range, 3–11). No surgical complications occurred. Simultaneous transcranial and endonasal procedures were helpful to detect all sites of CSF leakage and secure reconstructive grafts. The combined transcranial and endonasal reconstructive technique achieved secure skull base reconstruction without recurrence of CSF leakage, and allowed early postoperative ambulation. This technique can be a reliable surgical option to repair CSF leakage resulting from extensive anterior skull base fractures.

Frontotemporal brain sagging syndrome: Craniospinal hypovolemia secondary to a T6-T7 cerebrospinal fluid-venous fistula

Background: The frontotemporal brain sagging syndrome (FTBSS) is defined as an insidious/progressive decline in behavior and executive functions, hypersomnolence, and orthostatic headaches attributed to cerebrospinal fluid (CSF) hypovolemia. Here, a T6 CSF-venous fistula (e.g., between the subarachnoid CSF and a paraspinal vein) resulted in a CSF leak responsible for craniospinal hypovolemia.Case Description: A 56-year-old male started with orthostatic headaches and fatigue after scuba diving. His symptoms included progressive, vertigo, tinnitus, nausea, lack of judgment, inappropriate behavior, memory dysfunction, apathy, tremor, orofacial dyskinesia, dysarthria, dysphagia, and hypersomnolence. The lumbar puncture revealed an opening pressure of 0 cm H2O. Magnetic resonance imaging (MRI) findings included brain sagging, bilateral temporal lobe herniation, and pachymeningeal enhancement. The computed tomography (CT) myelogram showed a thoracic diverticulum and a CSF-venous leak at the T6-T7 level. Surgery, which comprised a T6-T7 laminotomy, allowed for dissecting, clipping, and ligating the diverticulum/fistula. The patient improved postoperatively (e.g., cognitive, behavioral, and brainstem symptoms). The follow-up MRI’s showed the reversion of the sagging index/uncal herniation.Conclusion: The FTBSS should be considered in the differential diagnosis of an early onset frontotemporal dementia. Establishing the diagnosis and localizing the site of a spinal CSF/venous leak warrant both MRI and myelogram CT studies, to pinpoint the CSF leak site for proper surgical clipping/ligation of these thoracic diverticulum/CSF-venous leaks.

The Cervical Spine as a Predominant Site of Cerebrospinal Fluid Leak: Preliminary Results Using the Overflow Leak Test

Cerebrospinal fluid (CSF) hypovolemia is usually treated via an epidural blood patch (EBP). Accurate placement of the EBP at the site of CSF leakage is required for successful treatment of CSF hypovolemia. The thoracolumbar spine is evidently a common site of leakage, but because rates of detection of the leakage site via conventional imaging have historically not been high, there may be other common leakage sites. In this study, CSF leakage sites were identified via a combination of conventional imaging, a new method called the overflow leak test, and patient interviews. CSF leakage sites were identified using computed tomography myelography, radioisotope cisternography, and the overflow leak test in 14 patients with CSF hypovolemia. The patients were also asked about their history with regard to potential trauma. EBP was performed, and the accuracy of leakage site identification was assessed. Conventional imaging identified a leakage site in 7 of 14 patients, and in most cases it was in the lumbar spine. In the remaining 7 cases, the overflow leak test and ascertaining a history of trauma facilitated identification of the cervical spine as a leakage site. The site of the EBP was the cervical spine in 10 patients and the lumbar spine in 4 patients. Complete recovery was observed in 13 of 14 patients. The cervical spine was a common leakage site in this study. Leakage in the cervical spine was undetectable via conventional imaging, suggesting that many cases of cervical spine leakage may remain undetected.

"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.

Deossification of the Otic Bone in High Pressure CSF Otorhinorrhea: A New Radiological Finding.

To highlight a new radiological feature in a patient with labyrinthine malformation presenting with bilateral spontaneous high pressure cerebrospinal fluid (CSF) otorhinorrhea. Study design-retrospective case review. Setting-academic, tertiary cochlear implant center. A cochlear implantee with Incomplete Partition Defect (Type 1) presented with meningitis and CSF otorhinorrhea for which she initially underwent medical treatment. High resolution computed tomography (HRCT) of the temporal bone with CT cisternography was performed for identifying the site of the CSF leak. HRCT and CT cisternography revealed a defect in the region of the stapes foot plate and marked thinning/deossification of the cochlear promontory. These two findings were absent in the pre-implant imaging of the patient done 3years ago. Surgery by endaural approach was undertaken to close the site of CSF leak. Intraoperatively, marked thinning of the cochlear promontory was observed, corresponding to 'blue lining' of the labyrinth in otologic surgery. This intraoperative finding indicating high intralabyrinthine CSF pressure correlated well with the imaging findings. Primary surgical repair resulted in successful CSF leak closure followed by theco-peritoneal shunting to prevent recurrence of the leak. The patient is using her cochlear implant and doing well with auditory verbal therapy. She is asymptomatic till date. Thinning and deossification of the otic capsule on HRCT is an important indicator of high CSF pressure in patients with labyrinthine malformations. Our case study highlights the need for heightened radiological and clinical vigilance in this subgroup of patients to predict complications and ensure prompt intervention.

Unilateral chronic subdural hematoma due to spontaneous intracranial hypotension: a report of four cases

Background: Chronic subdural hematoma (CSDH) is a common neurosurgical disease. A subset of patients with CSDH may exhibit underlying spontaneous intracranial hypotension (SIH). Bilateral CSDH has a causal relationship with SIH, but there is no known causal relationship between unilateral CSDH and SIH.Case description: We encountered four cases of unilateral CSDH due to SIH. The patients’ age ranged between 44 and 64 years; there were three males and one female. All patients presented with headache as their initial symptom, and then became comatose. Computed tomography demonstrated unilateral CSDH and transtentorial herniation in all patients. Treatments were emergency epidural blood patch (EBP) and evacuation of CSDH. The site of cerebrospinal fluid leak could not be identified in three patients; therefore, EBP was performed at upper and lower spine. All patients recovered from SIH; however, one patient experienced poor outcome due to Duret hemorrhage and ischemic complications of transtentorial herniation. Cranial asymmetry was present in all four patients, and unilateral CSDH was located on the side of the most curved cranial convexity.Conclusions: Unilateral CSDH, asymmetric cranial morphology, and transtentorial herniation in relatively young patients may indicate underlying SIH.