CSF Leak Presented by: Malak Gazzaz

CSF LeakCSF Leak

Presented by:Presented by:

Malak GazzazMalak Gazzaz

HistoryHistory 53 year old, Saudi, female 53 year old, Saudi, female Known case of HTN, and hypothyroidismKnown case of HTN, and hypothyroidism Complaining of watery, colorless, runny nose Complaining of watery, colorless, runny nose from the right nostril for the past 9 years, from the right nostril for the past 9 years, on and off, increasing on bending downwardson and off, increasing on bending downwards

Decrease sense of smellDecrease sense of smell Decrease visionDecrease vision No fever or neck rigidityNo fever or neck rigidity No hx of traumaNo hx of trauma She has previous hx of meningitis treated She has previous hx of meningitis treated with IV antibiotics ( cefipim and vanco for with IV antibiotics ( cefipim and vanco for 14 days)14 days)

HistoryHistory

She was diagnosed as a case of She was diagnosed as a case of CSF leak 4 years backCSF leak 4 years back

She was also diagnosed as a She was also diagnosed as a case of empty sellacase of empty sella

She refused the repair She refused the repair previously b/c she was only previously b/c she was only offered a transcranial incision offered a transcranial incision as an option for repair as an option for repair

P/EP/E

ObeseObese

Endoscopy:Endoscopy:

Nasal mass in right nostrilNasal mass in right nostril

InvestigationsInvestigations

CT cisternography was done by CT cisternography was done by injecting 7ml of intrathecal injecting 7ml of intrathecal contrast via LPcontrast via LP



Empty Sella SyndromeEmpty Sella Syndrome

Endoscopic transnasal Endoscopic transnasal repair of CSF leakrepair of CSF leak

Multidisciplinary approach Multidisciplinary approach (ENT/Neurosurgery)(ENT/Neurosurgery)

Repaired by 3 layers:Repaired by 3 layers:

1.1. Fascia lataFascia lata

2.2. Septal CartilageSeptal Cartilage

3.3. Nasal mucosaNasal mucosa


Frontal Sinus

Defect


Fascia lata

Methylene Blue on nasal mucosa


OR



Hospital courseHospital course

She was transferred to ICU to She was transferred to ICU to be closely monitoredbe closely monitored


1 day later, pt was transferred to 1 day later, pt was transferred to wardward

Pt was complaining of severe Pt was complaining of severe headache ?some fluid oozing, ?CSFheadache ?some fluid oozing, ?CSF

Lumbar drain was inserted and pain Lumbar drain was inserted and pain control medications were control medications were administeredadministered

Pt was also taking cefuroxime, Pt was also taking cefuroxime, nasal saline and fucidine ointmentnasal saline and fucidine ointment


Pt developed seizure POD 4, Pt developed seizure POD 4, induced by cerebral edema and induced by cerebral edema and treated with phenytointreated with phenytoin

CT post opCT post op

CT post op CT post op

CTCT

Site of repair


Upon serial clinical and Upon serial clinical and radiological evaluations , pt radiological evaluations , pt has improved with no CSF leak, has improved with no CSF leak, no seizures, and afebrileno seizures, and afebrile

Lumbar drain was removed 3 days Lumbar drain was removed 3 days laterlater

Pt started to ambulate without Pt started to ambulate without deficitdeficit


She was discharged 2 weeks post She was discharged 2 weeks post op with nasal irrigation by NS op with nasal irrigation by NS 30cc BID for 2 wks30cc BID for 2 wks

MASNOT QuestionnaireMASNOT Questionnaire

0 = absent0 = absent 1 = very mild1 = very mild 2 = mild2 = mild 3 = moderate3 = moderate 4 = severe4 = severe 5= very severe5= very severe

Pre opPre op 2 wks post 2 wks post opop

5 wks post 5 wks post opop

Need to Need to evacuate evacuate nostril nostril from nasal from nasal secretionssecretions

33 22 33

sneezingsneezing 33 11 22

Runny noseRunny nose 55 00 00

Nasal Nasal congestion congestion or or abstructoiabstructoinn

22 11 11

Loss of Loss of taste or taste or smellsmell

55 11 55




coughcough 33 22 11itchinessitchiness 33 33 33Post nasal Post nasal dripdrip

33 11 33

Ear Ear obstructioobstructionn

33 00 11

Pain/ Pain/ facial facial headacheheadache

44 44 33

Inability Inability to sleep to sleep deeplydeeply

11 00 00




Fatigue Fatigue upon upon waking up waking up in the in the morningmorning

44 33 44

GeneralizeGeneralized fatigued fatigue

44 44 44

Double Double visionvision

22 11 22

Decrease Decrease visual visual acutyacuty

33 33 55

Eye Eye protrusionprotrusion

00 00 00


5 wks post op5 wks post op

Transnasal Endoscopic Transnasal Endoscopic Repair of Cerebrospinal Repair of Cerebrospinal Fluid Rhinorrhea: A Meta-Fluid Rhinorrhea: A Meta-

AnalysisAnalysis Hassan M. Hegazy MD Hassan M. Hegazy MD Ricardo L. Carrau MDRicardo L. Carrau MD Carl H. Snyderman MD Carl H. Snyderman MD Amin Kassam MDAmin Kassam MD Julie Zweig MDJulie Zweig MD

AbstractAbstract

Objectives/HypothesisObjectives/Hypothesis

Trauma and surgery are the most Trauma and surgery are the most common causes of (CSF) rhinorrhea. common causes of (CSF) rhinorrhea.

Surgical repair is recommended for Surgical repair is recommended for patients with:patients with:

1.1.CSF leaks that do not respond to CSF leaks that do not respond to conservative measuresconservative measures

2.2.traumatic CSF leaks that require traumatic CSF leaks that require transcranial surgery for associated transcranial surgery for associated brain injuriesbrain injuries

3.3.iatrogenic defects that are iatrogenic defects that are discovered intraoperativelydiscovered intraoperatively

The purpose of the The purpose of the studystudy

To ascertain the outcome after To ascertain the outcome after transnasal endoscopic repair of transnasal endoscopic repair of CSF leaks and to identify CSF leaks and to identify factors regarding the patient, factors regarding the patient, CSF fistula, and treatment that CSF fistula, and treatment that may influence the results of may influence the results of the repair.the repair.

MethodsMethods

Meta-analysis of all studies Meta-analysis of all studies published between 1990 and 1999 that published between 1990 and 1999 that reported a minimum of five patients reported a minimum of five patients with CSF fistulae that were repaired with CSF fistulae that were repaired using an endoscopic approach. using an endoscopic approach.

Data analysis included type of graft Data analysis included type of graft and technique used during the and technique used during the repair, surgical complications, the repair, surgical complications, the use of packing, and the use of use of packing, and the use of lumbar drains and antibiotics. lumbar drains and antibiotics.

ResultsResults Endoscopic repair of CSF leaks was Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases successful in 90% (259/289) of the cases after a first attempt. after a first attempt.

Seventeen of 30 persistent leaks (52%) were Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. repaired using an endoscopic approach.

The success rate of repairs using any of the The success rate of repairs using any of the reported techniques and materials was high reported techniques and materials was high and not statistically different. and not statistically different.

The incidence of major complications such a The incidence of major complications such a meningitis, subdural hematoma, and meningitis, subdural hematoma, and intracranial abscess was less than 1% for intracranial abscess was less than 1% for each complication.each complication.

Surgical Repair of Surgical Repair of Cerebrospinal Fluid LeaksCerebrospinal Fluid Leaks

The review and meta-analysis suggest The review and meta-analysis suggest that the choice of the surgical that the choice of the surgical approach and the grafting materials approach and the grafting materials used during the endoscopic or used during the endoscopic or endonasal closure of CSF fistulae endonasal closure of CSF fistulae depends on the availability of the depends on the availability of the material and on the experience and material and on the experience and familiarity of the surgeon with familiarity of the surgeon with various techniques, and that their various techniques, and that their use use does notdoes not seem to alter the seem to alter the outcome. outcome.

Adjunctive techniquesAdjunctive techniques

Nasal packingNasal packing Gel foam or Gel filmGel foam or Gel film Fibrin glueFibrin glue Perioperative antibiotic Perioperative antibiotic prophylaxisprophylaxis

Lumbar spinal drainLumbar spinal drain

RecommendationRecommendation

The use of lumbar spinal drain The use of lumbar spinal drain for pts presenting with for pts presenting with idiopathic and post traumatic idiopathic and post traumatic fistulae that are highly fistulae that are highly associated with hydrochephalus associated with hydrochephalus for recurrent or persistent for recurrent or persistent leaks and for those associated leaks and for those associated with meningoceles or large skull with meningoceles or large skull base defects is recommendedbase defects is recommended

Complications of repairComplications of repair

MeningitisMeningitis Chronic headacheChronic headache PneumocephalusPneumocephalus Intracranial hematomaIntracranial hematoma Frontal lobe abscessFrontal lobe abscess AnosmiaAnosmia66

ConclusionConclusion

The endoscopic approach is The endoscopic approach is highly effectivehighly effective and is and is associated with associated with low morbidity. low morbidity.

The literature supports the The literature supports the endoscopic approach using a endoscopic approach using a variety of techniques and variety of techniques and materials for the repair of CSF materials for the repair of CSF leaks.leaks.

Spontaneous cerebrospinal Spontaneous cerebrospinal fluid leaksfluid leaks

WoodworthWoodworth Bradford Aa Bradford Aa PalmerPalmer James NbJames Nb

AbstractAbstract

Purpose of reviewPurpose of review CSF leaks that occur spontaneously are CSF leaks that occur spontaneously are challenging to manage clinically owing to challenging to manage clinically owing to frequent recurrences following attempted frequent recurrences following attempted surgical closure. surgical closure.

Understanding the underlying Understanding the underlying pathophysiology allowed the recognition pathophysiology allowed the recognition that the vast majority of these patients that the vast majority of these patients demonstrate clinical symptoms and demonstrate clinical symptoms and radiographic signs of elevated ICP.radiographic signs of elevated ICP.

Individuals with this disorder also arise Individuals with this disorder also arise from a distinct demographic group. from a distinct demographic group. Increased knowledge of the characteristics Increased knowledge of the characteristics of this patient population will provide of this patient population will provide increased success rates in the management increased success rates in the management of this clinical entity.of this clinical entity.

Recent findingsRecent findings

Current literature indicates that control Current literature indicates that control of intracranial hypertension, of intracranial hypertension, coupled coupled withwith endoscopic repair, will improve endoscopic repair, will improve success rates comparable with other success rates comparable with other etiologies. etiologies.

Improvement in preoperative Improvement in preoperative identification of radiographic signs of identification of radiographic signs of intracranial hypertension (i.e. empty intracranial hypertension (i.e. empty sella), operative technique, and sella), operative technique, and postoperative management of elevated postoperative management of elevated intracranial pressure are also reviewed. intracranial pressure are also reviewed.

Benign Intracranial Benign Intracranial HypertensionHypertension

Elevated ICP frequently manifests itself in Elevated ICP frequently manifests itself in the syndrome of benign intracranial the syndrome of benign intracranial hypertension (BIH), aka pseudotumor cerebri. hypertension (BIH), aka pseudotumor cerebri.

Symptoms include:Symptoms include: 1.1. pulsatile tinnituspulsatile tinnitus2.2. balance problemsbalance problems3.3. HeadacheHeadache4.4. visual disturbances. visual disturbances. Because this has recently been identified as Because this has recently been identified as the underlying cause in the majority of the underlying cause in the majority of individuals in this category, the term individuals in this category, the term spontaneous, rather than idiopathic, should spontaneous, rather than idiopathic, should be used in the presence of intracranial be used in the presence of intracranial hypertension hypertension


Many of these patients have total or Many of these patients have total or partial empty sella syndrome (ESS) partial empty sella syndrome (ESS)

Other radiological findings Other radiological findings associated with elevated ICP associated with elevated ICP include: include:

1.1. abnormalities of the optic nerve abnormalities of the optic nerve sheath complex, sheath complex,

2.2. encephaloceles, encephaloceles, 3.3. arachnoid pitsarachnoid pits4.4. dural ectasia dural ectasia 7,8,9,10,117,8,9,10,11


Pts with BIH have elevated readings Pts with BIH have elevated readings (typically over 25 cmH2O) on lumbar (typically over 25 cmH2O) on lumbar tap opening pressurestap opening pressures

In terms of demographics, the In terms of demographics, the majority of patients who develop majority of patients who develop the diagnosis of BIH are the diagnosis of BIH are young to young to middle-aged obese womenmiddle-aged obese women1212. The . The association of obesity with BIH has association of obesity with BIH has been reported in many studiesbeen reported in many studies1100,1,133,14.,14.

Preoperative EvaluationPreoperative Evaluation

Consists of:Consists of:

1.1. HistoryHistory

2.2. physical examinationphysical examination

3.3. nasal endoscopic examinationnasal endoscopic examination

4.4. radiographic imagingradiographic imaging


Computer-aided or image-guided Computer-aided or image-guided surgical navigation CT scans surgical navigation CT scans and MRI studies are and MRI studies are recommended. recommended.

MRI can enhance the diagnosis MRI can enhance the diagnosis of elevated ICP, as it shows of elevated ICP, as it shows evidence of totally or evidence of totally or partially empty sella up to 85% partially empty sella up to 85% of the timeof the time1515. .

Management of elevated Management of elevated ICPICP

AcetazolamideAcetazolamide Ventriculoperitoneal shuntingVentriculoperitoneal shunting


Because the underlying cause of Because the underlying cause of elevated CSF pressure (either elevated CSF pressure (either obesity or decreased arachnoid obesity or decreased arachnoid granulations) is likely to granulations) is likely to remain unchanged over time, we remain unchanged over time, we generally recommend generally recommend lifelong lifelong use of the diureticuse of the diuretic. .

Outcomes Outcomes

Treatment of the underlying Treatment of the underlying intracranial hypertension, intracranial hypertension, whether through medical or whether through medical or surgical means, was critical surgical means, was critical for success in the repair of for success in the repair of these defects these defects

Significant weight loss appears Significant weight loss appears to be required for this to to be required for this to become an effective treatmentbecome an effective treatment1616..

ConclusionConclusion

Evidence indicates that Evidence indicates that treatment of underlying treatment of underlying intracranial hypertension in intracranial hypertension in spontaneous CSF leaks coupled spontaneous CSF leaks coupled with endoscopic repair can with endoscopic repair can provide success rates (95%) provide success rates (95%) approaching those of other approaching those of other etiologiesetiologies

Thank you!Thank you!

ReferencesReferences

1 Stankiewicz JA. Cerebrospinal fluid 1 Stankiewicz JA. Cerebrospinal fluid fistula and endoscopic sinus surgery. fistula and endoscopic sinus surgery. Laryngoscope 1991; 101:250–256. Laryngoscope 1991; 101:250–256.

2 Zweig JL, Carrau RL, Celin SE, et al. 2 Zweig JL, Carrau RL, Celin SE, et al. Endoscopic repair of CSF leaks to the Endoscopic repair of CSF leaks to the sinonasal tract: predictors of success. sinonasal tract: predictors of success. Otolaryngol Head Neck Surg 2000 (in Otolaryngol Head Neck Surg 2000 (in press).press).

3 Casiano RR, Jassir D. Endoscopic 3 Casiano RR, Jassir D. Endoscopic cerebrospinal fluid rhinorrhea repair: is cerebrospinal fluid rhinorrhea repair: is a lumbar drain necessary?. Otolaryngol a lumbar drain necessary?. Otolaryngol Head Neck Surg 1999; 121:745–750.Head Neck Surg 1999; 121:745–750.


4 Lanza DC, O'Brien DA, Kennedy 4 Lanza DC, O'Brien DA, Kennedy DW. Endoscopic repair of DW. Endoscopic repair of cerebrospinal fluid fistulae and cerebrospinal fluid fistulae and encephaloceles. Laryngoscope encephaloceles. Laryngoscope 1996; 106:1119–1125.1996; 106:1119–1125.

5 Marks SC. Middle turbinate 5 Marks SC. Middle turbinate graft for repair of cerebral graft for repair of cerebral spinal fluid leaks. Am J Rhinol spinal fluid leaks. Am J Rhinol 1998; 12:417–419.1998; 12:417–419.


6 Burns JA, Dodson EE, Gross 6 Burns JA, Dodson EE, Gross CW. Transnasal endoscopic CW. Transnasal endoscopic repair of cranionasal fistulae: repair of cranionasal fistulae: a refined technique with long-a refined technique with long-term follow-up. Laryngoscope term follow-up. Laryngoscope 1996; 106:1080–1083.1996; 106:1080–1083.

ReferencesReferences 7 Mattox DE, Kennedy DW. Endoscopic 7 Mattox DE, Kennedy DW. Endoscopic management of cerebrospinal fluid leaks management of cerebrospinal fluid leaks and cephaloceles. Laryngoscope 1990; and cephaloceles. Laryngoscope 1990; 100:857–862 100:857–862

8 Hubbard JL, McDonald TJ, Pearson BW, et 8 Hubbard JL, McDonald TJ, Pearson BW, et al. Spontaneous cerebrospinal fluid al. Spontaneous cerebrospinal fluid rhinorrhea: evolving concepts in diagnosis rhinorrhea: evolving concepts in diagnosis and surgical management based on the Mayo and surgical management based on the Mayo Clinic experience from 1970 through 1981. Clinic experience from 1970 through 1981. Neurosurgery 1985; 16:314–321. Neurosurgery 1985; 16:314–321.

9 Schlosser RJ, Bolger WE. Significance of 9 Schlosser RJ, Bolger WE. Significance of empty sella in cerebrospinal fluid leaks. empty sella in cerebrospinal fluid leaks. Otolaryngol Head Neck Surg 2003; 128:32–Otolaryngol Head Neck Surg 2003; 128:32–38. 38.


10 Corbett JJ, Thompson HS. The 10 Corbett JJ, Thompson HS. The rational management of idiopathic rational management of idiopathic intracranial hypertension. Arch Neurol intracranial hypertension. Arch Neurol 1989; 46:1049–1051. 1989; 46:1049–1051.

11 Silver RI, Moonis G, Schlosser 11 Silver RI, Moonis G, Schlosser RJ, et al. Radiographic signs of RJ, et al. Radiographic signs of elevated intracranial pressure in elevated intracranial pressure in idiopathic cerebrospinal fluid leaks: a idiopathic cerebrospinal fluid leaks: a possible presentation of idiopathic possible presentation of idiopathic intracranial hypertension. Am J Rhinol intracranial hypertension. Am J Rhinol 2007; 21:257–261 2007; 21:257–261


1212 Gass A, Barker GJ, Riordan- Gass A, Barker GJ, Riordan-Eva P, et al. MRI of the optic Eva P, et al. MRI of the optic nerve in benign intracranial nerve in benign intracranial hypertension. Neuroradiology hypertension. Neuroradiology 1996; 38:769–773. 1996; 38:769–773.

1133 Radhakrishnan K, Ahlskog JE, Radhakrishnan K, Ahlskog JE, Garrity JA, et al. Idiopathic Garrity JA, et al. Idiopathic intracranial hypertension. Mayo intracranial hypertension. Mayo Clin Proc 1994; 69:169–180 Clin Proc 1994; 69:169–180


1144 Wilson DH, Gardner WJ. Benign Wilson DH, Gardner WJ. Benign intracranial hypertension with intracranial hypertension with particular reference to its particular reference to its occurrence in fat young women. Can occurrence in fat young women. Can Med Assoc J 1966; 95:102–105. Med Assoc J 1966; 95:102–105.

1155 Woodworth BA, Prince A, Chiu Woodworth BA, Prince A, Chiu AG, et al. Spontaneous CSF leaks: a AG, et al. Spontaneous CSF leaks: a paradigm for definitive repair and paradigm for definitive repair and management of intracranial management of intracranial hypertension. Otolaryngol Head Neck hypertension. Otolaryngol Head Neck Surg 2008; 138:715–720 Surg 2008; 138:715–720


1166 Radhakrishnan K, Thacker AK, Radhakrishnan K, Thacker AK, Bohlaga NH, et al. Epidemiology Bohlaga NH, et al. Epidemiology of idiopathic intracranial of idiopathic intracranial hypertension: a prospective and hypertension: a prospective and case–control study. J Neurol case–control study. J Neurol Sci 1993; 116:18–28 Sci 1993; 116:18–28

CSF Leak Presented by: Malak Gazzaz

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