Efficacy Of Conservative Management Of Early Post Traumatic Cerebrospinal Fluid Rhinorrhoea.

Background: The incidence of Post-traumatic Cerebrospinal Fluid Rhinorrhoea (PCSFR) has been decreased due to advanced therapeutic measures. The current investigative study has been arranged to assess the efficacy of conservative management of early PCSFR. Method: This cross-sectional study was conducted at departmental of Neurosurgery, Ayub Medical Institute, Abbottabad. Patients with traumatic brain injury having Cerebrospinal fluid rhinorrhoea with either gender having age 5-50 year and presenting within seven days of traumatic brain injury were included. Moreover, those with nasal fractures, penetrating head injuries having fever and neck stiffness were also included in the study. Results: A total number of 120 patients having male dominancy, i.e., 86 (72%) were included in the study with the mean age of 27 years ± 8.741 in which 77 (92%) patients were in the age range of 2nd to 4th decades. The commonest cause was trauma due to Road Traffic Accidents (RTA) having 65 (54%) patients. Conservative treatment was effective in 62 (52%) patients predominantly in the patients of 3rd decade, i.e., 31 (50%), in which the effectiveness in male gender was revealed to be 52.32% (45) and effectiveness in RTA patients was recorded to be 54.83%. Similarly, the Chi-Square value was calculated for the PCSFR patients for four groups of patients (5-20, 21-30, 31-40, 41-50) to be 48.27 having critical value of 7.81 with the p-value of 1.87e-10, which completely rejects the Null-hypothesis for the patients of various ages. Conclusion: Based on the current investigative study, it may be concluded that PCSFR is common in middle age population with slight male dominancy. It may also be inferred that RTA is the leading cause of PCSFR in our set up and majority of the patients shows improvement after conservative management. Moreover, the effectiveness of conservative management of PCSFR could be predominantly observed in the patients of 3rd decade.

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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 case of nasal discharge resulting in recurrent bacterial meningitis].

A 47-year-old man who was previously hospitalized three times due to bacterial meningitis experienced a headache and posterior neck pain in May. He was admitted to our hospital because of a fever 3 h later. He was fully conscious and febrile, with a headache and signs of meningeal irritation. A cerebrospinal fluid examination showed an increased number of cells with polynuclear cell predominance and decreased glucose levels, leading to the diagnosis of bacterial meningitis. Steroid and antibiotic treatment was initiated, at which time, large amounts of nasal discharge were observed. Cisternal scintigraphy was performed, and cerebrospinal fluid was detected in the nasal discharge. The cause was idiopathic, and endoscopic repair was performed. The nasal fluid leakage was suggested to be the cause of the recurrent bacterial meningitis in this case.

Comparison Of Lumbar Drain Insertion And Conservative Management In The Treatment Of Traumatic CSF Rhinorrhoea.

BACKGROUND: Conservative management of traumatic CSF rhinorrhoea is associated with a greater risk of developing meningitis in the presence of active CSF leak. Lumbar drains have been reported to be better than conservative management alone in stopping CSF leaks following traumatic brain injury. METHODS: This randomized controlled trial enrolled 60 patients with CSF rhinorrhoea and divided them into two groups. One group was managed with conservative management plus a lumbar drain (group A) and the other was managed with conservative management alone (Group B). Length of CSF rhinorrhoea in days was estimated in both groups. RESULTS: There was a statistically significant difference in in mean length of CSF rhinorrhoea in both groups. In group A, mean Length of CSF rhinorrhoea was found to be 3.4 days ±1.1 SD, while in group B it was 6.75 days ±1.96 SD (p=0.001). Stratification with respect to gender, age, duration and type of trauma showed similar trend (p<0.05 in all cases). CONCLUSIONS: Patients who underwent lumbar drain insertion plus conservative management demonstrated significantly shorter length of CSF rhinorrhoea when compared to conservative management alone in the treatment of traumatic CSF rhinorrhoea.

Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach.

Cerebrospinal fluid (CSF) leaks are extracranial egress of CSF into the adjacent paranasal sinus or tympanomastoid cavity due to an osteodural defect involving skull base. It can be due to a multitude of causes including accidental or iatrogenic trauma, congenital malformations and spontaneous leaks. Accurate localization of the site of the leak, underlying causes and appropriate therapy is necessary to avoid associated complications. In this paper relevant anatomy, clinical diagnosis, imaging modalities and associated findings are discussed along with a brief mention about management.

[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.

Success Rate and Complications of Cerebrospinal Fluid Rhinorrhea Treated With a Transcranial Approach.

The aim of this study was to evaluate the clinical outcomes of cerebrospinal fluid (CSF) rhinorrhea in patients treated with transcranial surgery. Here, we retrospectively reviewed 23 patients with CSF rhinorrhea between 2008 and 2015 at our university hospital. Nine (39.1%) patients were treated conservatively, whereas 12 (52.2%) patients were treated with a transcranial approach. Our results showed that 7 (30.4%), 11 (47.8%), and 5 (21.7%) patients had spontaneous, traumatic, and iatrogenic CSF leakage, respectively. In our study, the cribriform plate was the most common site of leakage, and it was found to be involved in 5 (21.7%) patients. The mean diameter defect of the fistula was 130.40 ±â€Š190.47 mm and there was no significant difference between this defect and the different etiology types. In our study, meningitis, third nerve palsy, and vasospasm were the main complications that arose during the treatment of CSF rhinorrhea. Moreover, 6 (26.1%) of 7 (30.4%) patients had spontaneous CSF leaks that were treated with surgery. Notably, spontaneous CSF leaks did not stop when treated with conservative measures. In addition, there were no significant differences between etiology types and CSF leaks. The primary surgical repair rate was 78.3% and the secondary surgery repair rate was 91.6%. Importantly, as we preferred using this type of transcranial surgery in our clinic, there has been a higher success rate with endoscopic treatments and fewer major complications from CSF rhinorrhea in the literature.

Five cases of iatrogenic cerebrospinal fluid (CSF) rhinorrhoea: Early management is crucial.

Endoscopic sinus surgery (ESS) is a standard treatment for rhinosinusitis, which failed optimum medical therapy. Iatrogenic cerebrospinal fluid (CSF) rhinorrhoea can occur during ESS warrants early repair of the leakage. The common sites for CSF leakage are cribriform plate, fovea ethmoidalis, and anterior ethmoid sinuses. We present five cases of iatrogenic CSF rhinorrhoea due to ESS and its management.

Leukocyte- and platelet-rich fibrin: a new graft material in endoscopic repair of spontaneous CSF leaks.

BACKGROUND: Spontaneous CSF leak is a challenging condition, with frequent recurrences following attempted surgical closure. The selection of graft materials depends on the experience of the operating surgeon. Leukocyte- and platelet-rich fibrin (L-PRF) is a second-generation platelet concentrate that has currently invaded every surgical specialty. To our knowledge, no previous reports about the use of L-PRF in repair of CSF leak were published. The study was conducted to assess the potential role of L-PRF in spontaneous CSF leaks repair. METHODS: This prospective controlled study was conducted on 40 patients who were randomly divided into 2 groups: In group A, L-PRF was used in addition to another layer, while patients in group B underwent multilayer repair using traditional graft materials. RESULTS: Preoperative HRCT scan showed bony dehiscence (n = 30) and opacity in a nearby sinus (n = 9). MRI findings varied between empty sella in 28 patients, and meningocele in 19 patients. Mean preoperatively measured CSF pressure was 26.6 cm H2O. Cribriform plate was identified as the commonest site of leaks. Multiple skull defects were detected in 2 cases. Failure of repair was found in 3 patients (15%) of group B and 1 patient (5%) of group A, this difference was statistically insignificant (P value = 0.28). Significance correlation between recurrence of CSF leak and elevated intracranial pressure was observed (P value; 0.04). CONCLUSION: L-PRF was found to be a good adjunct material in endoscopic spontaneous CSF leaks repair. It helps in decreasing the number of layers needed for defect closure.

[Clinical analysis of adult spontaneous cerebrospinal fluid rhinorrhea].

OBJECTIVES: To discuss the clinical characteristics, diagnosis and treatment of adult spontaneous cerebrospinal fluid rhinorrhea (CSFR). METHODS: A retrospective study was conducted on 18 patients of CSFR. Nasal secretion was collected for biochemical analysis. Imaging examination was done for identification of the bony defect in skull base. RESULTS: In all cases, the glucose concentration of nasal secretion were more than 1.7 mmol/L, and the ß-2 transferrin detected by immunoelectrophoresis technique were positive. Twelve cases were found to have bony defect in skull base. For the rest 6 cases without bony defect, MRI findings of 6 cases showed sinusoidal effusion with similar signals to cerebrospinal fluid, thus predicting the location of the leak. Conservative treatment was successful in one case, and the other 17 patients underwent endoscopic sinus surgery with computer assisted navigation system (CANS). The results of all cases underwent surgery were successful by one time. No recurrence occured during the follow-up time (11 to 24 months). CONCLUSIONS: The incidence of adult CSFR is low, hence it is easily to be missed and misdiagnosed. The majority of CSFR patients are middle-aged and elderly obese women, often combined with hypertension, diabetes, moderate and severe osteoporosis due to no daily exercise habits. Correct medical history collection, reasonable preoperative examination and accurate preoperative localization of bony defect are essential for surgical repairment. CANS used during operation can enable surgeons to locate the site of leakage accurately and shorten the operation time.

Idiopathic Cerebrospinal Fluid Rhinorrhoea (An Uncommon Diagnosis): A case report and a Review of the Literature.

Cerebrospinal fluid (CSF) rhinorrhoea is often seen among head injured patients from road traffic crashes or physical assault, and sometimes it is a complication of nasal surgical procedures. Intracranial tumours may also result in CSF leakage. Blood stained rhinorrhoea often occur at the time of initial insult or injury, while CSF rhinorrhea may be a delayed manifestation. However, idiopathic CSF rhinorrhoea is uncommon, and it is regarded as a diagnosis of exclusion. In this communication, we report a 54-year old woman who developed CSF rhinorrhoea with no prior history of head trauma, physical assault, neurosurgical or nasal surgery. Further clinical evaluation revealed an obese woman with a body mass index (BMI) of 31mg/m2, and a blood pressure (BP) of 140/80mmHg. Clinical tests for CSF rhinorrhoea were positive, though; nasal endoscopy and cranial CT-scan were not contributory. Conservative management resulted in remarkable relief of symptoms. However further investigations for confirmation of diagnosis were not possible due to non-availability of reagents in the laboratory as well as financial challenge.

Long-term management and outcomes after repair of cerebrospinal fluid rhinorrhea related to idiopathic intracranial hypertension.

PURPOSE OF REVIEW: To identify long-term management strategies and outcomes for the treatment of spontaneous cerebrospinal fluid (CSF) rhinorrhea related to idiopathic intracranial hypertension (IIH). RECENT FINDINGS: Adjuvant treatments following surgical repair of spontaneous CSF leaks are aimed at normalizing intracranial pressure (ICP) to minimize the risk of recurrence. IIH is closely linked to obesity, and growing evidence suggests that weight loss, both through conservative and surgical approaches, is effective at addressing the root cause of this disorder. Recent data also support the use of acetazolamide and dural venous sinus stenting as adjuncts for reducing ICP. SUMMARY: Spontaneous CSF rhinorrhea associated with IIH represents a challenging clinical entity, with an increased risk of recurrence compared to CSF leaks because of other causes. Adjunct therapies intended to reduce ICP likely improve outcomes after surgical repair, but further research is necessary to better characterize the effects of these treatment modalities.

Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks.

OBJECTIVES/HYPOTHESIS: Spontaneous cerebrospinal fluid (CSF) leaks are associated with increased intracranial pressure (ICP) and considered a manifestation of idiopathic intracranial hypertension. Although postoperative acetazolamide and placement of CSF shunt systems are considered valuable interventions for elevated ICP, the impact on recurrence rate remains unclear. The objective of this study was to systematically review evidence from reported literature to evaluate whether postoperative ICP management reduces recurrence rates after primary endoscopic repair. STUDY DESIGN: Prospective case series and systematic review. METHODS: Demographics, defect location, success rates, and ICP management in spontaneous CSF leak patients were prospectively collected over 8 years. A search was also conducted in PubMed to identify studies reporting cases of spontaneous CSF rhinorrhea. RESULTS: Fifty-six articles with nonduplicated data were identified and combined with a prospective series of 108 patients for a total of 679 patients treated for spontaneous CSF rhinorrhea. Average age was 50.4 years with 77% female. Average body mass index was 35.8 kg/m2 . Defects were most commonly located in the sphenoid sinus (n = 334) followed by the ethmoid (n = 318) and the frontal sinus (n = 46). Successful primary repair was 92.82% in patient cohorts where ICP evaluation and intervention with acetazolamide or CSF shunt systems was performed, but was significantly decreased to 81.87% in series with no active management of elevated ICP (P < .001). CONCLUSIONS: Evaluation and intervention for elevated ICP in spontaneous CSF leaks is associated with significantly improved success rates following primary endoscopic repair. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:2011-2016, 2017.

Analyses and treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms.

In this study, we analyze and discuss the treatments of postoperative nasal complications after endonasal transsphenoidal resection of pituitary neoplasms (PNs). We performed 129 endonasal transsphenoidal resections of PNs and analyzed and treated cases with nasal complications. After endonasal transsphenoidal resection of PNs, there were 26 cases of postoperative nasal complications (20.1%), including nasal hemorrhage (4.8%), cerebrospinal fluid rhinorrhea (6.9%), sphenoid sinusitis (2.3%), atrophic rhinitis (1.6%), olfactory disorder (1.6%), perforation of nasal septum (0.8%), and nasal adhesion (2.3%). All patients clinically recovered after therapy, which included treatment of the cavity through nasal endoscopy, intranasal corticosteroids, and nasal irrigation. We propose that regular nasal endoscopic review, specific nasal medications, and regular nasal irrigation can effectively clear nasal mucosal hyperemia-induced edema and nasal/nasoantral secretions, as well as promote regeneration of nasal mucosa, prevent nasal adhesion, maintain the sinus cavity drainage, and accelerate the recovery of the physiological function of the paranasal sinus. Timely treatment of patients with nasal complications after endonasal transsphenoidal resections of PNs could greatly relieve the clinical symptoms. Nasal cleaning is very beneficial to patients after surgery recovery.

Delayed Cerebrospinal Fluid Rhinorrhea After Gamma Knife Radiosurgery with or without Preceding Transsphenoidal Resection for Pituitary Pathology.

BACKGROUND: Skull base cerebrospinal fluid (CSF) leak after gamma knife radiosurgery (GKRS) is a very rare complication. In patients who were treated with both GKRS and transsphenoidal resection (TSR) for pituitary lesions, early CSF leak occurs at a comparable rate with the general TSR population (4%). Delayed CSF leak occurring more than a year after TSR, GKRS, or dual therapy is exceedingly rare. METHODS: Retrospective chart review and review of the literature. RESULTS: We present 2 cases of delayed CSF leak after GKRS to treat pituitary adenoma. One patient developed CSF rhinorrhea 16 years after GKRS for growth hormone-producing pituitary adenoma. The patient had previously undergone TSR surgery 7 years prior to GKRS without complication. Additionally, a second patient developed high-flow CSF rhinorrhea 2 years after GKRS for a prolactinoma that failed dopamine agonist therapy. Both patients underwent a complicated clinical course after presentation, requiring multiple revisions for definitive CSF leak repair. CONCLUSIONS: Delayed CSF leak is a rare but serious complication after GKRS independent of TSR status; urgent repair is the treatment of choice. Based on our experience, these leaks have the potential to be refractory, and we recommend aggressive reconstruction, preferably with a vascularized flap, and potentially supplemented by placement of a lumbar drain and acetazolamide. Current evidence is scant and provides little insight regarding an underlying mechanism, which may include bony destruction by the tumor, delayed radiation necrosis, or a secondary empty sella syndrome.

Management of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.

BACKGROUND: Management strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely because of limited evidence-based guidance. METHODS: A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014 to examine 5 endoscopic repair techniques and 8 perioperative management strategies for CSF rhinorrhea. Benefit-harm assessments, value judgments, and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. RESULTS: We reviewed 67 studies examining 13 practices pertinent to the management of CSF rhinorrhea, reaching a highest aggregate grade of evidence of B. The literature does not support the routine use of prophylactic antibiotics or lumbar drainage. Various endoscopic repair materials show similar success rates; however, larger defects may benefit from vascularized grafts. There were no relevant studies to address postoperative activity restrictions. CONCLUSION: Despite relatively low levels of evidence, recommendations for the management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal clinical management approaches.

[A case-series study on clinical presentation, neuroradiological characteristics, and outcome of 56 consecutive patients suspected of having spontaneous intracranial hypotension].

The author reviewed the clinical records and neuroradiologic examinations of 86 consecutive patients with orthostatic headache who visited our clinic between April 1995 and December 2014. Fifty-six patients were suspected to have spontaneous intracranial hypotension (SIH). The baseline characteristics of these patients were essentially similar to those reported in other published case series of SIH: female preponderance, mean age of approximately 40 years, and frequent association with nausea, hearing disturbances, or vertigo. In 43 patients who underwent gadolinium-enhanced MRI, 15 had partial dural enhancement and 15 had diffuse enhancement. Of 13 patients who underwent radionuclide cisternography, a direct finding of cerebrospinal fluid (CSF) leakage was demonstrated in six patients. Ordinal scales were formulated for regression of the extent of dural enhancement on cranial MRI (none: 0, partial: 1, diffuse: 2) and severity of orthostatic headache (not so severe: 1, severe: 2). Ordinal logistic regression analysis demonstrated that the extent of dural enhancement was negatively associated with the severity of orthostatic headache. A possible explanation was that patients suspected of having SIH who showed severe orthostatic headache may lack the ability to compensate for CSF loss. Epidural blood patch (EBP) is targeted at the CSF leak site or at the lumbar level when the site of CSF leak has not been determined. The interval from EBP to disappearance of orthostatic headache did not significantly differ in six patients treated with targeted EBP and five patients with lumbar EBP. Linear regression analysis demonstrated that the duration of orthostatic headache was associated with the interval from onset of headache to initial visit to our clinic, with the slope of the regression line 1.243 and intercept 14.8 days. Thus, early diagnosis of SIH appeared to correlate with earlier disappearance of orthostatic headache. No other factors were found to predict the outcome of SIH.

Manejo conservador no tratamento de fístula liquórica nasal iatrogênica / Conservative treatment of iatrogenic nasal CSF fistula

A fístula liquórica nasal, identificada pela presença de líquido cefalorraquidiano na cavidade nasal, é uma condição de risco para o desenvolvimento de meningite. Tal entidade, quando de etiologia iatrogênica, é de incidência significativa naqueles pacientes submetidos a cirurgias endoscópicas nasais e cirurgias da base do crânio. O otorrinolaringologista tem exercido o crucial papel de realizar o diagnóstico e prover o tratamento dessa entidade, com o objetivo de evitar as complicações da infecção meníngea e suas sequelas. No presente estudo descrevemos o caso de um paciente submetido à cirurgia nasal que apresentou rinoliquorreia no período pós-operatório de cirurgia nasal não especificada. O paciente apresentou evolução favorável com manejo conservador. É de suma importância o conhecimento das particularidades diagnósticas e terapêuticas dessa condição devido à sua incidência significativa e às suas complicações potencialmente deletérias (AU)

Nasal CSF leak, identified by the presence of cerebrospinal fluid in the nasal cavity, is a risk factor for the development of meningitis. Such an entity, if iatrogenic, is significantly incident in patients undergoing nasal endoscopic surgery and skull base surgery. The otolaryngologist has played a crucial role in making a diagnosis and provide treatment for such entity, in order to avoid the complications of meningeal infection and its sequelae. In the present study we report the case of a patient undergoing nasal surgery who had CSF leak in the postoperative period of unspecified nasal surgery. The patient presented favorable evolution with conservative management of the condition, with evidence of fistula closure through control cisternotomography. Knowledge of the diagnostic and therapeutic characteristics of this condition is very important due to its significant incidence and its potentially harmful complications (AU)