Traumatic Cerebrospinal Fluid Rhinorrhea Research Articles

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.

A CASE SERIES ON MANAGEMENT OF SPONTANEOUS CEREBROSPINAL FLUID RHINORRHEA

Introduction: Cerebrospinal fluid (CSF) rhinorrhea is defined as leakage of cerebrospinal fluid that occurs from a direct communication between the CSF-containing subarachnoid space and the paranasal sinuses. Non traumatic or spontaneous CSF rhinorrhea is very rare and reported to have occurred in only 4% of the CSF leak cases. Materials and Methods: A retrospective hospital-based study was conducted in a tertiary care centre on seven cases of spontaneous CSF Rhinorrhea. Observation and Results: Among seven cases, five patients were of age less than 45 years and two patients were more than 45 years old. All subjects were females and were diagnosed with spontaneous CSF rhinorrhea. CT paranasal sinuses and CT Cisternogram were the most common imaging modalities used for diagnosis in all patients. All patients underwent Transnasal endoscopic repair of CSF rhinorrhea. Conclusion: Transnasal endoscopic repair of the defect gives a successful outcome following failure of the conservative management in spontaneous CSF rhinorrhea.

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.

The Frequency of Early Post Traumatic Cerebrospinal Fluid Rhinorrhea in Patients with Head Trauma

Objective: To determine the frequency of early post-traumatic CSF (cerebrospinal fluid) rhinorrhea in patients with head trauma. Materials and Methods: A prospective study was conducted in the Department of Neurosurgery, Jinnah Postgraduate Medical Centre, Karachi from 13th December 2019 to 12th December 2020. This study comprised 155 patients who had suffered head trauma. All patients were followed for one week. If patients developed clear, watery discharge from the nose, this was documented as being CSF rhinorrhea. The frequency was then further divided into immediate and early. Results: The ages of the patients were 34.28 ± 14.20 years on average. The prevalence of CSF rhinorrhea was observed in 3.2% (5/155) patients. In all the patients, the CSF leak presented within the first 48 hours i.e. it was immediate. Conclusion: Although rare, this post-traumatic complication continues to be a challenge in terms of morbidity and subsequent mortality. Key Words: Cerebrospinal fluid, Rhinorrhea, Head Trauma.

A Comparative Analysis of Transcranial and Endoscopic Repair for Traumatic CSF Rhinorrhea.

Surgical treatment of anterior cranial base traumatic cerebrospinal fluid (CSF) rhinorrhea is challenging and is fraught with complications. Whether a person should be offered open craniotomy or endoscopic endonasal repair is a dilemma faced by most surgeons. This study is one of the few to directly compare the two forms of management. Data were collected from two groups of 15 patients each who underwent transcranial CSF leak repair and endoscopic endonasal CSF leak repair in a tertiary care hospital over a 3-year period. Information including demographics, recurrence rates, complications, and hospital and intensive care unit (ICU) stay was recorded and analyzed. Outcome was assessed up to 6 months. Recurrence was seen in 9/30 patients, 6 in the transcranial group and 3 in the endoscopic group. Hospital stay was longer than 1 week in all the transcranially operated patients and only in 73% of the endoscopically operated patients (p = 0.439) although ICU stay was reduced in the endoscopic group (p = 0.066). Complications were more common with transcranial repair (seven of eight patients who underwent transcranial repair, p = 0.035) with anosmia being the most common (33.3%, p = 0.042). The transcranial open repair is a reasonable choice especially for leaks that occur through the frontal sinus and extend backward into the frontoethmoidal region. However, this approach has the drawbacks of greater number of complications, higher recurrence rate, and longer ICU and overall hospital stay. The endoscopic endonasal repair enjoys a lower morbidity profile although it may not be an adequate treatment for leaks that are placed far laterally in the frontal sinus.

Long-Term Follow-up of Patients Managed Conservatively for Acute Traumatic CSF Rhinorrhea

Conservative management of acute traumatic cerebrospinal fluid rhinorrhea (TCR) results in cessation of the leak in most patients. The objective of this study was to estimate the incidence of recurrent cerebrospinal fluid (CSF) rhinorrhea and meningitis in these patients on long-term follow-up and to determine the risk factors associated with them. Data on 50 patients with acute TCR who were successfully treated with conservative management between 2013 and 2015 and had long-term follow-up was retrieved from our head injury database. Patient variables were analyzed to determine the risk factors associated with recurrence of CSF rhinorrhea and meningitis. All patients in our series developed CSF rhinorrhea within 48 hours of trauma. The mean duration of follow-up was 6.3 ± 1.3 years. CSF rhinorrhea recurred in 16 (32%) patients, 15 (93.8%) of whom developed it within 3 years of trauma. Meningitis occurred in 5 (10%) patients and 1 died. Sphenoid sinus fractures and features of raised intracranial pressure on computerized tomography of the brain at admission were significantly associated with the development of meningitis. There were no risk factors identified for the recurrence of CSF rhinorrhea. Patients with acute TCR in whom rhinorrhea subsides with conservative therapy have the highest risk for recurrence of leak or meningitis within 3 years of the trauma. Therefore, we recommend that these patients be counselled about the need for periodic follow-up for several years.

A retrospective study to analyze treatment of post traumatic cerebro spinal fluid rhinorrhea and role of trans cranial pedicled pericranial repair in present day context

: Skull base fractures are a major cause of morbidity and mortality in head injury. Anterior cranial Fossa (ACF) skull base fracture, leading to Cerebro Spinal Fluid (CSF) Rhinorrhea is one of the most commonly encountered presentation in ACF base fractures. The key to successful management of such cases lies in early diagnosis and surgical management before it leads to meningitis and avoidable mortality.To evaluate the cases of post traumatic CSF rhinorrhea and analyze the parameters utilized to guide the management strategies. An attempt was made to come up with guidelines for its management in a tertiary care hospital.This was a retrospective study in which all cases of traumatic CSF Rhinorrhea admitted to Tertiary care hospital were included. Patients were divided into three groups. First group was conservatively managed in which the rhinorrhea and serial imaging findings showed favourable response.In thesecond group patients were subjected to endoscopic repair by the ENT surgeon based on anatomical considerations. The third group included patients who were had failed the trial of conservative management and the site of leak did not favor endoscopic repair.The outcomes in all these groups were analyzed and conclusions drawn.A total of 54 patients were included in the study which was conducted between Jan 2014 to 2020. 24 were successfully managed conservatively,10 were managed with endoscopic repair and 20 were managed by bifrontal craniotomy and pedicled pericranial ACF Base repair. There was one case from the first group who developed CSF leak after one month necessitating ACF base repair. There was no recurrence reportedin the cases managed endoscopically, whereas one case subjected to craniotomy had recurrence requiring lumbar drain placement. With each transcranial surgery there was a refinement in the technique further minimizing complications. We have elaborated on the surgical nuances to ensurebetter outcomes. : Pedicledpericranial flap ACF base repair is an elegant approach which requires an understanding of the mechanism of CSF leak from skull base fractures. This procedure can easily be mastered and when performed correctly provides best results for cases where there are multiple ACF defects, those not accessible by endoscope and also in those cases where imaging is not able to localize the exact site of defect leading to CSF rhinorrhea. Anosmia is an in evitable complication of this procedure. However, the trade off between mortality resulting from meningitis versus anosmia makes it a viable and attractive treatment option.

Efficacy of absorbable dural substitute for pediatric traumatic cerebrospinal fluid rhinorrhea

Efficacy of absorbable dural substitute for pediatric traumatic cerebrospinal fluid rhinorrhea

Post-traumatic cerebrospinal fluid rhinorrhea and Transcranial approach surgical outcomes.

Objective: To assess the outcomes of the transcranial approach in traumatic cerebrospinal fluid rhinorrhea. Study Design: Descriptive study. Setting: J.P.M.C, Karachi. Period: 15-1-2017 to 17-7- 2019. Material & Method: Total of 57 patient were included. Including criteria were patient with a history of trauma, fall, assault, and delayed onset, however, patients presenting with spontaneous cerebrospinal fluid (CSF) rhinorrhea, brain abscess, brain space-occupying lesion, skull base surgery operated elsewhere were excluded. fasia lata, Pericranial flaps were used for the surgical repair. Data were analyzed on SPSS version 22.0. Result: Patients gone through the surgical approach having intradural repair in all patients, 25 (43.85%) patients with fasia lata graft while pericranium in 32 (56.1%) and the defect was filled with small bone pieces. In 38(66.6%) unilateral sub frontal approach was done while in 19 patients (33.3 %%) bicoronal craniotomy was carried out. All patient had dura defected, 37 patients (64.9%) had a fractured cribriform plate, 9 (15%) patient had fovea ethmoidal fracture. 30(52.63%) had right side leak, 20 had left side leak (35%), 7(12.28%) had bilateral from both nasals leakage. No reoperation was done. 93% procedure showed successfully. Conclusions: This method is effective with the low rate of morbidity in patients, it can be preferred for traumatic cerebrospinal fluid (CSF) leaks with the injuries associated with the brain, recurrent leak cases with a success rate of > 93%

Treatment of traumatic cerebrospinal fluid rhinorrhea via extended extradural anterior skull base approach

ObjectiveTo describe and assess the repair technique and perioperative management for cerebrospinal fluid (CSF) leak resulting from extensive anterior skull base fracture via extradural anterior skull base approach. MethodsThis was a retrospective review conducted at the Department of Neurosurgery of the Shanghai Tenth People's Hospital from January 2015 to April 2020. Patients with traumatic CSF rhinorrhea resulting from extensive anterior skull base fracture treated surgically via extended extradural anterior skull base approach were included in this study. The data of medical and radiological records, surgical approaches, repair techniques, peritoperative management, surgical outcome and postoperative follow-up were analyzed. Surgical repair techniques were tailored to the condition of associated injuries of the scalp, bony and dura injuries and associated intracranial lesions. Patients were followed up for the outcome of CSF leak and surgical complications. Data were presented as frequency and percent. ResultsThirty-five patients were included in this series. The patients’ mean age was 33 years (range 11–71 years). Eight patients were treated surgically within 2 weeks; while the other 27 patients, with prolonged or recurrent CSF rhinorrhea, received the repair surgery at 17 days to 10 years after the initial trauma. The mean overall length of follow-up was 23 months (range 3–65 months). All the patients suffered from frontobasal multiple fractures. The basic repair tenet was to achieve watertight seal of the dura. The frontal pericranial flap alone was used in 20 patients, combined with temporalis muscle and/or its facia in 10 patients. Free fascia lata graft was used instead in the rest 5 patients. No CSF leak was found in all the patients at discharge. There was no surgical mortality in this series. Bilateral anosmia was the most common complication. At follow-up, no recurrent CSF leak or meningitis occurred. No patients developed mucoceles, epidural abscess or osteomyelitis. One patient ultimately required ventriculoperitoneal shunt because of progressive hydrocephalus. ConclusionTraumatic CSF rhinorrhea associated with extensive anterior skull base fractures often requires aggressive treatment via extended intracranial extradural approach. Vascularized tissue flaps are ideal grafts for cranial base reconstruction, either alone or in combination with temporalis muscle and its fascia---fascia lata sometimes can be opted as free autologous graft. The approach is usually reserved for patients with traumatic CSF rhinorrhea in complex frontobasal injuries.

Parainfectious vasculitis due to Pneumococcal meningitis following traumatic CSF rhinorrhoea resulting in cerebellar infarction

Parainfectious vasculitis is a rare life threatening complication of Streptococcus pneumoniae (S.pneumoniae) meningitis. There is a 19% risk of developing meningitis in the patients with cerebrospinal fluid (CSF) rhinorrhoea. The patient being reported developed CSF rhinorrhoea due to traumatic fracture of cribriform plate, followed by pneumococcal meningitis and parainfectious vasculitis resulting in cerebellar infarction.

Clinical analysis of transnasal endoscopic repair of cerebrospinal fluid rhinorrhea

Objective:To summarize the common clinical types of cerebrospinal fluid（CSF） rhinorrhea and key points of transnasal endoscopic repair of CSF rhinorrhea. To evaluate clinical effects. Method:In 29 patients with cerebrospinal fluid rhinorrhea, 9 patients with traumatic CSF rhinorrhea, 10 patients with spontaneous CSF rhinorrhea, 7 patients with CSF rhinorrhea after tumour excision, and 3 patients with iatrogenic CSF rhinorrhea. All the 29 patients were treated with transnasal endoscopic repair of CSF rhinorrhea. Result:There were 25 patients were successfully repaired at one time. Three patients developed intracranial infection and 2 patient developed pneumocephalus after surgery, all of them were cured with conservative treatment. All the patients who were followed-up for more than half a year had no recurrence. Conclusion:Transnasal endoscopic repair of CSF rhinorrhea is safe and effective, the success rate of operation is high, it is not easy to recur, and the complications are few. It can be used as the first choice for repairing of CSF rhinorrhea and effective prevention measures. Accurate location of leak, appropriate repair, effective reconstruction of the skull base, continuous drainage of the lumbar cistern when necessary and active prevention of intracranial infection are critical to the success of operation.

Frontal sinus osteoplastic flap: is it relevant today?

In the present era where frontal sinus surgery is synonymous with functional endoscopic sinus surgery, we present a case series comprising six cases of varied frontal sinus pathology that were managed with an external approach using an osteoplastic flap technique. The study was carried out in the ENT Department of Calcutta National Medical College, a tertiary care center in Kolkata. A unilateral osteoplastic flap approach was adopted in three cases, of which two were reported as osteomas and one was that of inverted papilloma. Bicoronal osteoplastic flap was raised in another group, which included a case of communited fracture of the anterior wall of the frontal sinus with obvious cosmetic facial deformity, a case of fracture of the posterior wall of the frontal sinus with traumatic cerebrospinal fluid rhinorrhea with pneumoencephalus, and a case of plasmacytoma of the frontal sinus. The mean follow-up period ranged from 1 to 3 years. There was no recurrence of disease and no significant postoperative complications have been reported during the follow-up period so far.

Traumatic Cerebrospinal Fluid Rhinorrhea following Septorhinoplasty

Traumatic Cerebrospinal Fluid Rhinorrhea following Septorhinoplasty

A Case of Transnasal Endoscopic Repair for Traumatic Cerebrospinal Fluid Rhinorrhea after Multiple Cranial Surgeries

A Case of Transnasal Endoscopic Repair for Traumatic Cerebrospinal Fluid Rhinorrhea after Multiple Cranial Surgeries

TRANSCRANIAL DURAL REPAIR;

Objectives: To determine efficacy of transcranial dural repair in managementof early traumatic cerebrospinal fluid (CSF) rhinorrhea by measuring the rate of resolution ofrhinorrhea following repair. Material and Study Design: Descriptive study. Period: 18 monthsfrom March 2014 to September 2015. Setting: Department of Neurosurgery Naseer Teachinghospital Peshawar. Methods: 30 patients, all head injury patients with CSF rhinorrhea of eithergender and any age, reporting to Accident and emergency department were included in thestudy. MRI Brain T2 Weighted in prone position done in all cases to identify the dural rent.Transcranial intradural repair was done through subfrontal approach. Post op complicationswere documented and follow at two months. Results: In this study 30 patients with cerebrospinalfluid (CSF) leak were observed. The minimum age was 8 years and the maximum was 59 years.23 (76.6%) were male and 7 (23.3%) were female. 18 (60%) patients have CSF rhinorrhea dueto road traffic accident, 7 (23.3%) patient with history of fall, while 5 (6.6%) patient were in othercategory. MRI brain T-2 Weighted done in all patient to identify the dural defect. The surgicalapproach was intradural in all of the 30 (100%) patients having fascia lata graft in 28 (93.3%)patients and pericranium in 2 (7%) patients to cover the defect properly. Among the immediatecomplications 3 (10%) patients had recurrent CSF leak, 2(6.6%) had meningitis, 5 (16.6%)had Pneumoencephalus while 3(10%) patients had other complications like subarachnoidhemorrhage, wound infection etc. The overall success rate was 90%. Conclusion: It isconcluded that in post traumatic cerebrospinal fluid (CSF) rhinorrhea, if the defect in dura isdemonstrated it must be repaired as soon as possible in order to prevent fulminant meningitis.

Late Post-Traumatic Cerebrospinal Rhinorrhoea

Cerebrospinal fluid (CSF) rhinorrhoea results from anatomical breach between the subarachnoid space and air sinus cavities of the skull base and traumatic CSF rhinorrhoea accounts for 80% - 90% of all cases of CSF leaks. We sought to report the case of a 16-year-old patient with a history of head injury following a fall from a tree, who developed a post-traumatic CSF rhinorrhoea after an onset of meningitis. The patient sustained a fall from a 6-meter tree in 2008, and was reviewed by our neurosurgical team in February 2016 for a 1-month history of progressive headaches associated with fever, asthenia and left CSF rhinorrhoea. Clinical examination revealed frank meningism and abundant CSF leak from the left nostril. CT scanning showed fractures of the left frontal bone and sinus wall associated with a massive pneumocephalus. The patient benefited from surgical repair of the tear and post-operative lumbar punctures at day 15. The patient’s guardian was informed that non-identifiable information from the case would be submitted for publication and he provided consent.

Multilayered Closure of Cerebrospinal Fluid Rhinorrhea with Inlay Fascia Lata, Autologous Fat, and Outlay Fascia Lata: Our Experience

Background/Aims: Since the initial use in 1981 by Wigand, different endoscopic endonasal surgery techniques have been proposed to close ventral skull base defects, all of which include multilayer closure involving vascularized mucoseptal flaps, autologous grafts, and synthetic materials. These methods are used individually or in combination, as required by the operative condition. Methods: In this study we aimed to describe our endoscopic technique using inlay-outlay fascia lata and autologous fat with fibrin sealant to close spontaneous and traumatic cerebrospinal fluid (CSF) rhinorrhea. Results and Conclusion: Twenty-one CSF rhinorrhea patients were operated with this technique in our hospital. Two patients had large skull base defects and 15 patients had high-flow CSF leaks. We reached a 100% success rate in the first attempt without any long-term recurrence. Multilayered endoscopic closure with this technique offers satisfactory results with minimal morbidity even in large defects and high-flow CSF leaks.

Purely endoscopic pterional extradural approach: A novel technique for repair of cerebrospinal fluid rhinorrhea.

Study Design:Retrospective descriptive study of an innovative surgical technique.Objective:To assess the feasibility and success of repair of transfrontal sinus cerebrospinal fluid (CSF) rhinorrhea through pterional transcranial extradural approach using endoscope.Summary of Background Data:Repair of CSF rhinorrhea has seen advancement with the evolution of endoscopic transnasal techniques. However, leaks from defect in the posterior wall of frontal sinus still remain a challenge for the skull base surgeons and requires conventional craniotomy more often. We describe a novel technique to repair these leaks by purely endoscopic pterional extradural (PEPE) approach thereby avoiding complications associated with conventional craniotomy and endoscopic transnasal approaches.Materials and Methods:Thirty-five patients with traumatic CSF rhinorrhea from the posterior wall of frontal sinus underwent repair with the present technique. They were followed up for 6–18 months and were evaluated for feasibility of procedure, recurrence of leak, and occurrence of the fresh neurological deficit.Results:Thirty-five patients underwent CSF rhinorrhea repair using the above technique. The procedure was accomplished in all patients without any intraoperative complications. There was no requirement of blood transfusion in any case. All patients had a cessation of CSF leak in the postoperative period, and there was no recurrence. There was no evidence of frontal lobe retraction injury in any of these patients, and no fresh neurological deficit was observed.Conclusion:This PEPE approach to repair CSF leak through the posterior wall of the frontal sinus is a novel technique in which we can avoid disadvantages associated with both conventional craniotomy as well as transnasal endoscopic approaches.

CT-guided open craniocerebral operations for delayed traumatic cerebrospinal fluid rhinorrhea

Objective To investigate the value of CT lamellar scan on cranial base and three-dimensional reconstruction towards the diagnosis of traumatic cerebrospinal fluid rhinorrhea (TCFR) and the therapeutic effect of craniocerebral operations on delayed traumatic cerebrospinal fluid rhinorrhea. Methods TCFR in 9 male patients closed with autogroft multistrata repair after open craniotomy between May 2006 and December 2013 were analyzed. Consistency on ventage location determined by preoperative radiological examination and intraoperative probe was compared. Relapse of rhinorrhea and postoperative complications were concluded. Results Basal fracture(or defection), intracranial pneumatocele, and cerebromalacia focus noted on CT scan and three-dimensional reconstruction could accurately indicate the location of ventage. All the 9 patients got a full healing at one stage after rhinorrhea multistrata repair with free or peduncular autologous tissue transplants (e. g. temporal muscle anadesma, abdominal wall fat and temporal muscle flap). There was no relapse during the follow-up of 4-96 months. Except that one patient suffered from epilepsy postoperatively, no other complications occurred. Conclusions Preoperative CT lamellar scan on cranial base and three-dimensional reconstruction provide accurate ventage location of TCFR. Multistrata TCFR repair with autologous tissue transplants may result in a good therapeutic effect with less complications. Key words: Brain injuries; Cerebrospinal fluid rhinorrhea; Craniotomy; Tomography, X-ray computed