Treatment Of Cerebrospinal Fluid Leak Research Articles

Use of confirmatory imaging studies to illustrate adequate treatment of cerebrospinal fluid leak in spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a syndrome with serious neurological sequelae. As demonstrated by the following report, recurrent episodes of SIH can be difficult to diagnose when associated with other neurosurgical procedures, such as craniectomies. In this paper, the authors demonstrate SIH presenting as a subdural hematoma with recurrence of CSF leaks. Spontaneous intracranial hypotension was further complicated by paradoxical herniation following a craniectomy. Treatment of SIH necessitated multiple epidural blood patches for CSF leaks at different spinal levels and at different times. The efficacy of each epidural blood patch was confirmed with radionuclide imaging. Confirmation of effective blood patch placement may be useful for identifying patients at risk for a failed epidural blood patch or for patients whose neurological examination results have not fully improved.

Endoscopic treatment of cerebrospinal fluid leaks with the use of lower turbinate grafts: a retrospective review of 125 cases

Endoscopic transnasal approaches to the skull base have revolutionized the treatment of cerebrospinal fluid (CSF) fistulae, making repair less invasive and more effective compared with craniotomy or extracranial techniques. This study evaluated, retrospectively, the results of endoscopic repair of dural defects with the use of mucoperiostal grafts taken from the lower turbinate. Between January 1997 and January 2007, 125 cases of anterior skull base CSF fistulae were treated endoscopically at the Instituto Felippu de Otorrinolaringologia, Sao Paolo, Brazil, and at the Department of Otolaryngology of the University Hospital "Ospedali Riuniti", Foggia, Italy. Fistula closure was achieved by overlay apposition of a lower turbinate mucoperiostal graft fixated with fibrin glue and Surgicell. The etiology of the fistula was accidental trauma in 41 cases, iatrogenic trauma in 29, skull base tumour in 12, and spontaneous in 43. The site of the defect was the sphenoid sinus in 43 patients, the cribriform plate in 42, the anterior ethmoid roof in 21, the posterior ethmoid roof in 17, and the posterior wall of the frontal sinus in 2. The success rate at first attempt was 94.4%; the 7 cases of postoperative recurrent CSF leakage involved patients presenting with spontaneous fistula and elevated intracranial pressure; 5 of these had a body-mass index > 30 and 3 suffered from diabetes mellitus. In our hands, the success rate of endoscopic fistula repair was high, even in defects larger than 2 cm. Success rates may be further improved with accurate diagnosis of elevated intracranial pressure, a contributing factor to failure of spontaneous fistula repair.

Treatment of Cerebrospinal Fluid Leaks in High-Risk Patients

Although the surgical literature recommends vascularized tissue for repair of cerebrospinal fluid (CSF) leaks, closure has been successful using autogenous nonvascularized grafts at our institution. High-risk patients were defined as those with CSF leaks and at least 2 of the following: (1) failed attempt at repair, (2) previous radiation, (3) infection, and (4) osteomyelitis/osteonecrosis of bone flap. Data were collected regarding primary diagnosis, adjuvant radiotherapy, infection, previous attempts at closure, related hospitalizations, admissions before and after repair. The CSF leaks of 12 of 14 high-risk patients were successfully closed at a single operation. Patients with complex CSF leaks can be closed following these principles: (1) expose and identify the dural edges. This often requires resection of native cranial bone. (2) If osteomyelitis is suspected, the bone flap is discarded and skin closed over dura. (3) Dead space is avoided. If the previously mentioned principles are followed, free tissue transfers can often be avoided.

Diagnosis and treatment of cerebrospinal fluid leakage

Objective To investigate standard diagnosis and treatment of cerebrospinal fluid (CSF) leakage to improve the prognosis of the patients. Methods A retrospective study was done on 75 patients with CSF leakage from January 2004 to March 2007 in our hospital. There were 51 patients with rhinorrhea, nine with otorrhea and 15 with wound/incision leakage. Of all, 39 patients had traumatic leakage, 32 postoperative leakage and four spontaneous leakage. In the study, 23 patients were cured by position testing and drug therapy and 16 by cerebrospinal fluid drainage and/or wound debridement but 36 were treated with surgeries including craniotomy repair in 17, extracranial repair in 17 and CSF shunt in five (three received CSF shunt after repair). Results Of all, 64 patients were cured, 10 gained im-provement but one died. Conclusion Standard diagnosis and treatment of CSF leakage helps improve cure rate and reduce complications. Key words: Cerebrospinal fluid; Head injuries; Cerebrospinal rhinorrhea; Cerebrospinaloturrhea

Management of Cerebrospinal Fluid Leakage Following Cervical Spine Surgery

To investigate the management and outcome of cerebrospinal fluid leakage (CSFL) after cervical surgery. Medical records of 642 patients who underwent cervical surgery between December 1999 and December 2005 at our hospital were retrospectively reviewed. Five patients complicated by CSFL after surgery were enrolled, of which 4 cases were complicated after ossified posterior longitudinal ligament or posterior vertebral osteophyte resection directly injuring the dura, and 1 case after posterior cervical double-door laminoplasty without observed dural injury during surgery. Of the 5 CSFL cases, 4 cases occurred at 1-3 days after operation and 1 case at 9 days after operation. All 5 postoperative CSFL cases were treated through wound drainage removal, wound sutures, prophylactic antibiotics, and continuous subarachnoid drainage in the elevated head position. All 5 CSFL cases experienced leakage cessation within 1-3 days and wound healing within 4-8 days, and subarachnoid drainage lasted 11-16 days with an average volume of 320 mL (range, 150-410 mL). Four cases experienced headache, nausea and vomiting, 1 case suffered from somnolence and hyponatremia, and symptoms subsided after symptomatic treatment and intravenous fluid administration. All patients were followed up for an average of 32 months (range, 22-50 months). No occurrence of cerebrospinal fluid cyst or wound infection was observed. CSFL produced no significant negative effects upon neuromuscular function recovery. Continuous subarachnoid cavity drainage in combination with elevated head position is a simple and safe non-surgical method in treatment of CSFL following cervical surgery.

INFECTIOUS COMPLICATIONS OF TEMPORARY SPINAL CATHETER INSERTION FOR DIAGNOSIS OF ADULT HYDROCEPHALUS AND IDIOPATHIC INTRACRANIAL HYPERTENSION

Spinal catheters are often inserted for treatment of cerebrospinal fluid leaks; however, they have recently been recommended for elective cerebrospinal fluid drainage to identify patients with possible normal pressure hydrocephalus who are most likely to respond to shunt surgery. The rate of spinal catheter-associated meningitis with elective spinal catheter insertion is unknown. The objective was to determine the rate of infection and risk factors associated with elective spinal catheter insertion for evaluation of hydrocephalus and idiopathic intracranial hypertension (IIH). We retrospectively analyzed clinical and microbiological data and cerebrospinal fluid results of patients admitted during 60 consecutive months who had elective spinal catheter insertion for evaluation of normal pressure hydrocephalus or IIH. A total of 461 spinal catheters were inserted in 454 patients, including 419 (90.9%) for treatment of hydrocephalus and 42 (9.1%) for IIH. The infection rate was 3.3% (15 out of 461 patients) for the entire cohort, 3.6% (15 out of 419 patients) for the hydrocephalus cohort, and 0% for the IIH cohort. There was one death (0.2%) in the hydrocephalus cohort. The infection rate was reduced and sustained at 1.8% for 225 catheters after the topical antiseptic was changed to chlorhexidine (two-sided Fisher's exact test; P = 0.114). Although infection is the most serious complication of spinal catheter insertion for evaluation of hydrocephalus or IIH, the infection rate can be maintained below 2% with use of chlorhexidine topical antiseptic application, single-dose preprocedural antibiotic administration, and clinical surveillance of the patient. The benefit of cerebrospinal fluid drainage via spinal catheter for normal pressure hydrocephalus outweighs the risks associated with the procedure.

Difficulties in treatment of CSF leakage associated with a temporal meningocele

Temporal meningocele is a rarely encountered pathology. It is caused by communication between the subarachnoid space of the middle fossa and lateral extension of the sphenoid sinus. Cerebrospinal fluid (CSF) pressures and the hydrostatic pulsatile forces may lead to the development of pitholes on the middle fossa at the sites of arachnoid villi with herniation of dura/arachnoid or brain tissue into the sinus. We describe an adult patient who presented with spontaneous CSF rhinorrhea due to a temporal meningocele. She was first operated on transsphenoidally, but the CSF rhinorrea did not cessate, therefore she was operated transcranially five days after the first operation. There has been no CSF rhinorrhea for three and a half years. Transcranial temporal encephalocele repairment is more effective than transsphenoidal surgery. Recurrent CSF leaks can occur due to both the increased CSF pressure and the insufficient operation technique.

Prevention and Treatment of Cerebrospinal Fluid Leak After Translabyrinthine Acoustic Tumor Removal

To determine the incidence rate of cerebrospinal fluid (CSF) leak after translabyrinthine acoustic tumor removal using titanium mesh cranioplasty and to compare with previous series and historical controls. Database analysis with historical controls. Tertiary referral neurotologic private practice. The series of 389 patients who underwent titanium mesh cranioplasty after translabyrinthine tumor removal between March 2003 and July 2005. The results were compared with those in a group of 1,195 translabyrinthine tumor removal patients from our previously published series and with those in a group of 324 patients from the immediately preceding two-year period. Cranioplasty using titanium mesh after acoustic tumor removal. Rates of CSF leak for this method and previous methods of closure. Thirteen patients (3.3%) had CSF leaks when using the new method of titanium mesh closure. This compares with rates of 10.9% and 8.7% in series in which other methods of closure were used (p < 0.001 and 0.003). The rates of CSF leak requiring reoperation were 0.5%, 2.5%, and 1.9% for the new and the two older series, respectively. In our hands, titanium mesh cranioplasty seems to reduce the rate of CSF leaks after the translabyrinthine removal of acoustic tumors.

Prevention and Treatment of Cerebrospinal Fluid Leak After Translabyrinthine Acoustic Tumor Removal

Prevention and Treatment of Cerebrospinal Fluid Leak After Translabyrinthine Acoustic Tumor Removal

The Concept of Transtympanic Injection of Fibrin Caulk

Cerebrospinal fluid otorhinorrhea after basilar skull trauma poses a difficult management problem. When conservative techniques fail, more aggressive neurosurgical and otologic procedures are required to control cerebrospinal fluid leakage. We assessed a less invasive method for the repair of traumatic cerebrospinal fluid fistulas. Thirty-one adult Sprague-Dawley rats were used to develop an animal model for the treatment of cerebrospinal fluid leakage. A fistula was created by removing a thin plate of bone from the superior aspect of the rat bulla. The bulla was then plugged with a transtympanic injection of fibrin caulk. Otoscopic and histologic data were collected at selected intervals. Transtympanic injection of fibrin caulk failed to alter significantly the rate of healing of cerebrospinal fluid fistulas. Coagulum retraction, rapid fibrinolysis, and other reasons for failure are explored.

Treatment of cerebrospinal fluid leaks and gram-negative bacillary meningitis with large doses of intrathecal amikacin and systemic antibiotics

Treatment of cerebrospinal fluid leaks and gram-negative bacillary meningitis with large doses of intrathecal amikacin and systemic antibiotics

Use of tissue adhesive in the surgical treatment of cerebrospinal fluid leaks. Experience with isobutyl 2-cyanoacrylate in 12 cases.

✓ This report describes 12 cases of cerebrospinal fluid leak repaired with isobutyl 2-cyanoacrylate. We have found this tissue adhesive to be a valuable technical adjunct in the management of this problem and have not seen any general or local toxicity to the material.