Traumatic CSF rhinorrhea associated with COVID-19 testing: a case series and systematic review.

BACKGROUND: This report analyzes traumatic anterior skull base CSF leaks following nasopharyngeal swab testing for detection of SARS-CoV-2 in the largest case series to date, combined with a systematic literature review. METHODS: Retrospective multi-institutional case-series of traumatic anterior skull base CSF leak with clear antecedent history of COVID-19 swab was completed. A comprehensive search of databases was performed for the systematic literature review. RESULTS: Thirty-four patients with traumatic CSF leak after COVID-19 nasopharyngeal swab testing were identified. Women were more than twice as likely to experience a CSF leak, as compared to men. The majority of patients (58.8%) had no reported predisposing factor in their clinical history. Common defect sites included the cribriform plate (52.9%), sphenoid sinus (29.4%), and ethmoid roof (17.6%). Four patients (11.8%) presented with meningitis. The median time between the traumatic COVID swab and the detection of CSF leak was 4 weeks (IQR 1-9). Patients with meningitis had a median leak duration of 12 weeks (IQR 8-18). The average leak duration was significantly longer in patients with meningitis compared to without meningitis (p = 0.029), with a moderate effect size (r = - 0.68). Most cases (92.9%) managed with endoscopic endonasal surgical repair were successful. CONCLUSIONS: This report clarifies the presentation, risk factors, and management of CSF leaks attributable to diagnostic nasopharynx swabbing procedures in the COVID-19 era. Timely surgical repair is the recommended management option for such leaks.

Controlled arachnoid opening to aid endoscopic trans-sphenoidal extrarachnoidal dissection of pituitary macroadenoma.

OBJECTIVES: The arachnoid often bulges prematurely during surgical excision of large pituitary tumors obscuring the deeper regions and crevices preventing total excision. Pushing the arachnoid may not be helpful and may tear it inadvertently and extensively leading to complications. We have described controlled arachnoid opening in large pituitary macroadenomas during the final stages of excision to gain access to the hidden portions and compared our results to the conventional technique. PATIENTS AND METHODS: Patients with pituitary macroadenoma of Hardy's III and KNOSP II in whom arachnoid had bulged prematurely were considered for study. They were grouped temporally. In first group (n = 12), the arachnoid was pushed to retrieve the tumor and in the second group (n = 10) it was punctured to aid resection. The extent of resection was assessed on postoperative scans, and complications in both groups, were noted. RESULTS: In the first group where arachnoid was pushed to retrieve tumor, Gross Total Resection (GTR) could be achieved in 5 patients. Inadvertent large arachnoid tear occurred in 3 patients of which, 2 developed CSF Rhinorrhoea. No patient had neurovascular injury.In the second group, GTR could be achieved in all without any added complications. CONCLUSION: Deliberate needle puncture and controlled drainage of CSF from arachnoid that bulges prematurely while endoscopic Transsphenoidal surgery for large pituitary tumors is a safe and effective method to gain access to the hidden portions of tumor to achieve GTR.

Prolactinoma extension as a contributing factor in dopamine agonist-induced CSF rhinorrhea: a systematic review of the literature.

BACKGROUND: Dopamine agonist-induced cerebrospinal fluid (CSF) rhinorrhea is an uncommon treatment-related complication arising in 6.1% of prolactinoma patients treated with dopamine agonists. Locally invasive prolactinomas may create CSF fistulae through formation of dural and osseous skull base defects. Tumor shrinkage secondary to dopamine agonist therapy unmasks skull base defects, thus inducing CSF rhinorrhea. In these cases, repair of the leak may be achieved through collaborative surgical intervention by rhinologists and neurosurgeons. Multiple variables have been investigated as potential contributors to the risk of CSF rhinorrhea development in medically treated prolactinoma patients, with little consensus. OBJECTIVE: The primary aim of our study was the characterization of risk factors for CSF rhinorrhea development following dopamine agonist treatment. METHODS: A systematic review of the literature was conducted to identify cases of CSF rhinorrhea following dopamine agonist treatment of prolactinoma. The clinical history, radiographic findings and treatment outcomes are discussed. RESULTS: Fifty-four patients with dopamine agonist-induced CSF rhinorrhea were identified across 23 articles published from 1979 to 2019. Description of diagnostic imaging [computed tomography (CT)/magnetic resonance imaging (MRI)] was not provided for 18/54 subjects. For the 36 cases that described prolactinoma appearance on CT or MRI, invasion of the cavernous sinuses was reported in 13 (36.1%) and invasion of the sphenoid sinus was reported in 18 (50%). CONCLUSION: Based on our systematic review, we propose that CT findings of osseous erosion of the sella or the anterior skull base may predict dopamine agonist-induced CSF rhinorrhea. We recommend obtaining a thin-slice CT of the sinuses in cases with MRI evidence of sphenoid involvement.

MR findings suggestive of idiopathic intracranial hypertension in 117 patients with spontaneous cerebrospinal fluid rhinorrhea.

PURPOSE: The purpose of this study is to document the prevalence of MR findings suggestive of idiopathic intracranial hypertension (IIH) in patients undergoing endoscopic repair of spontaneous CSF rhinorrhea (SCSFR). METHODS: In a retrospective study, MR images of 117 consecutive patients who had undergone endoscopic repair of SCSFR were evaluated for features suggestive of IIH (empty sella, widened optic nerve sheath, tortuous optic nerve, flattened posterior globe, and enlarged Meckel's cave). Pituitary height was used to diagnose partial and complete empty sella. MR images were independently evaluated by two of the authors without knowledge of the clinical findings. Consensus method was used to resolve differences between the two evaluators. RESULTS: Empty or partially empty sella was diagnosed in the MR of 105 (89.7%) patients. In 38/105 (36.2%) patients with empty/partial empty sella, no additional MR findings were present. In 43/105 (41%) patients, one or more of the MR features with high specificity for diagnosis of IIH (flattened posterior globe and enlarged Meckel's cave) were seen. In the other 24 (22.9%) additional MR findings, less specific for IIH (widened optic nerve sheath, tortuous optic nerve) were noted. Papilledema was seen in 11 of 60 (18.3%) patients who underwent funduscopic examination. All patients with papilledema had empty/partial empty sella, and 9/11 (81.8%) had an additional MR finding suggestive of IIH. CONCLUSION: The majority of patients with SCSFR have MR imaging features of IIH. These imaging features should be a major component of previously published modified diagnostic criteria for IIH in patients with SCSFR.

Management of postoperative CSF rhinorrhea after retrosigmoid craniotomy: how I do it.

BACKGROUND: Cerebrospinal fluid (CSF) rhinorrhea as a complication of retrosigmoid craniotomy does not occur often today. This complication is primarily associated with the petrous bone drilling during surgery. METHOD: The management of this complication is shown by the example of the patient with a trigeminal schwannoma located in posterior cranial fossa operated through resrisigmoid craniotomy. Three steps of management and surgical stages of petrous bone plasty are shown. CONCLUSION: CSF rhinorrhea after retrosigmoid craniotomy is a preventable complication: petrous bone pneumatization should be evaluated preoperatively. If the air cells are open, primary plasty of the defect should be performed.

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.

A modification of endoscopic endonasal approach for management of encephaloceles in sphenoid sinus lateral recess.

Spontaneous cerebrospinal fluid leak with meningoencephaloceles in sphenoid sinus lateral recess is challenging. Transnasal visualization of this area is difficult, especially when large pneumatization is present. External approaches to this region involve aggressive surgery and are often associated with significant morbidity. The aim of this study is to assess the real effectiveness of a modification of the endoscopic endonasal approach for their management. This is a prospective case series study and was conducted at Otolaryngology department, Ain Shams University Hospitals, Cairo, Egypt. Seven patients with spontaneous cerebrospinal fluid leak with meningoencephaloceles in the sphenoid sinus lateral recess were included. Diagnosis was confirmed by: analysis for beta-2 transferrin and imaging. They were managed with endoscopic endonasal retrograde trans-sphenoid approach described in this study with multilayered reconstruction of the defect. Mean age of our patients was 40.14 ± 8.35 years; mean BMI was 36.37 ± 2.59 kg/m2. Primary empty sella was present and osteodural defect was identified in superior wall of sphenoid sinus lateral recess with punched out and regular smooth edges. Mean intra-cranial pressure was (26.42 ± 3.87 mmH2O) and size of defect was less than 10 mm, mean 7.85 ± 1.34. Mean-operative time was 169.28 ± 21.87 min. The mean hospital stay was 7.42 ± 1.39 days. No cerebrospinal fluid leak recurrences were observed during follow-up period that ranged from 37 to 48 months. Endoscopic endonasal retrograde trans-sphenoid approach provides a wide, safe, and direct route to the management of sphenoid sinus lateral recess cerebrospinal fluid leak.

[Cerebrospinal fluid rhinorrhea from a transclival meningocele: A case report and literature review]. / Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura.

The most common site of CSF leakage is the floor of the anterior cranial fossa, and less commonly in the sphenoid sinus. Only 3-4% of CSF fistulas are spontaneous. The fourth case is presented of a CSF rhinorrhea due to a transclival meningocele, an extremely rare location for these lesions, and the surgical approach. The patient is a 39-year-old male with no history of trauma, and a recent history of watery rhinorrhe and meningitis. CT scan and MRI showed clival bone defect and trans-sphenoidal transclival meningocele. The defect was repaired by transclival trans-sphenoidal endoscopic endonasal approach with good results. Despite the rarity of transclival meningocele, it is recommended to consider it in the differential diagnosis of spontaneous nasal fistulas. The endoscopic endonasal approach is a direct technique that provides satisfactory results in the resolution of CSF rhinorrhea.

Multimodal diagnosis of cerebrospinal fluid rhinorrhea: State of the art review and emerging concepts.

Objective: Currently, diagnosis of cerebrospinal fluid (CSF) rhinorrhea relies on a multimodal approach, increasing costs and ultimately delaying diagnosis. In the United States and internationally, the crux of such a diagnosis relies on confirmation testing (via biomarkers) and localization (e.g., imaging). Biomarker testing may require analysis at an outside facility, resulting in delays diagnosis and treatment. In addition, specialized imaging may be nonspecific and often requires an active leak for diagnosis. There remains a clear need for innovative new technology. Methods: A comprehensive review was conducted on both foundational and innovative scholarly articles regarding current and emerging diagnosis modalities for CSF. Results: Current modalities in CSF rhinorrhea diagnosis and localization include laboratory tests (namely, B2T immunofixation), imaging (CT and/or MRI) with or without intrathecal administration, and surgical exploration. Each of these modalities carry flaws, risks, and benefits, ultimately contributing to delays in diagnosis and morbidity. Promising emerging technologies include lateral flow immunoassays (LFI) and biologically functionalized field-effect transistors (BioFET). Nevertheless, these carry some drawbacks of their own, and require further validation. Conclusion: CSF rhinorrhea remains a challenging diagnosis, requiring a multimodal approach to differentiate from nonpathologic causes of rhinorrhea. Current methods in diagnosis are imperfect, as the ideal test would be a readily accessible, inexpensive, rapid, highly accurate point-of-care test without the need for excess fluid or specialized processing. Critical work is being done to develop promising, new, improved tests, though a clear successor has not yet emerged. Level of Evidence: N/A.

Trans-Nasal Endoscopic Repair of CSF Rhinorrhea: An Institutional Experience.

Introduction: Cerebrospinal Fluid (CSF) rhinorrhea results from breakdown in the integrity of structures separating the subarachnoid space and nasal cavity, namely subarachnoid space and dura mater, the bony skull base and periostea alongside the upper aerodigestive tract mucosa. Endoscopic repair is considered the treatment of choice for CSF rhinorrhea. Our aim of study was to analyze the etiopathogenesis and outcomes of treatment. Material and Methods: A retrospective study review of patients treated with endoscopic repair of CSF rhinorrhea at tertiary care hospital in ENT Department Benazir Bhutto hospital Rawalpindi from august 2013 to September 2017 identified 25 patients. Majority of them were male. The defects were closed in three layers using fat, fascia lata and nasal mucosa along with fibrin sealant in majority of patients. Pre operatively subarachnoid drain was placed in all patients. Patients were followed up to 3 months. Results: Forty-four patients underwent endoscopic repair of CSF rhinorrhea. The age group ranged from 16 to 55 years. Of the total of 44 patients 26 (59%) were males and 18(41%) females. The mean age of the patients in our study was 32.8 ± 9.7. Post trauma CSF leak was seen up to 52.3% of the patients. The most common site of leakage was identified Cribriform plate area. Our success rate of endoscopic repair was 88.6%. The most commonly observed complication was meningitis that was observed in 2 (4.5%) of the patients that too were managed conservatively. Conclusion: Accurate localization of site of leakage appears to be essential for successful endoscopic repair of CSF rhinorrhea. In our study cribriform plate area was commonly observed area of CSF leak. In our study, the success rate was 88.6% and low complication rate 4.5%.

Diagnostic efficacy of contrast-enhanced fluid-attenuated inversion recovery (FLAIR) imaging in idiopathic cerebrospinal fluid rhinorrhea.

We report a case of a 50-year-old woman in which contrast-enhanced fluid-attenuated inversion recovery (FLAIR) was used for the diagnosis of idiopathic cerebrospinal fluid rhinorrhea. The pre- and postcontrast FLAIR subtraction images showed a contrasted protrusion of the right olfactory cleft canal, highlighting the potential practicality and effectiveness of using pre- and postcontrast FLAIR subtraction images in diagnosing idiopathic cerebrospinal fluid rhinorrhea, in conjunction with conventional high-resolution computed tomography and magnetic resonance cisternography. The successful diagnosis of cerebrospinal fluid rhinorrhea allowed for treatment through endoscopic nasal surgery to close the fistula with a positive clinical outcome.

Semi-quantitative analysis of serum and cerebrospinal fluid transferrin glycoforms by top-down liquid chromatography mass spectrometry.

Detection of ß-2 transferrin in body fluid could help identify cerebrospinal fluid (CSF) leakage. The most common method, isoelectric focusing, was qualitative and could not provide detailed N-glycan structural information. We presented an alternative method using top-down liquid chromatography-time of flight mass spectrometry (LC-TOF MS). After immunoaffinity enrichment, fluid transferrin glycoforms were analyzed by a high-resolution LC-TOF MS, and the N-glycan structure predicted by accurate mass. The performance was validated with imprecision at 15%, with a cut-off of 0.04 for ß-2 transferrin to tetrasialotransferrin ratio to confirm the presence of CSF in fluid samples.

Atypical Presentation of Idiopathic Intracranial Hypertension: A Case Series and Literature Review.

Idiopathic intracranial hypertension (IIH) is a condition in which intracranial pressure (ICP) increases without an apparent cause. Typically, patients present with headaches, dizziness, pulsatile tinnitus, visual disturbances, blurred vision, diplopia, photophobia, visual field defects, and papilledema on fundoscopy. The association between IIH, spontaneous cerebrospinal fluid (CSF) rhinorrhea, and arachnoid cysts has been discussed in the literature; however, there is no clear explanation for this association. We aimed to present a series of four patients with a confirmed diagnosis of IIH with atypical presentations, discuss the management of each case, and provide an explanation for this association to alert clinicians to the atypical presentation of IIH and facilitate early diagnosis and proper treatment of this condition by CSF diversion. This was a retrospective case series of all patients who were diagnosed with IIH and showed improvement after ventriculoperitoneal shunt insertion after failure of at least one operative intervention resulting from primary radiological and clinical findings in 2001 to 2022. Data on demographics, clinical presentation, radiological findings, surgical management, and diagnostic criteria for IIH were recorded. We identified four patients with a confirmed diagnosis of IIH who presented with atypical presentations as follows: intracranial arachnoid cyst, cervical spine arachnoid cyst, giant Virchow perivascular space, and spontaneous CSF (CSF) rhinorrhea. All patients responded to CSF diversion after failure of surgical treatment targeting the primary pathology. IIH should be suspected after the failure of primary surgical treatment in cases of spontaneous CSF rhinorrhea, spinal and cranial arachnoid cysts, and symptomatic ventriculoperitoneal shunt. Treatment in such situations should be directed toward IIH with CSF diversion.

Meningioma En Plaque associated with Cerebrospinal Fluid Rhinorrhea: A Systematic Review of Literature with Case Presentation.

BACKGROUND: Meningiomas are the most frequently diagnosed benign intracranial tumors. However, meningioma en plaque (MEP) is a rare subset accounting for 2.5% of all meningiomas and is characterized by flat, carpet-like proliferation along the dura, typically arising in the spheno-orbital region; therefore, causes proptosis, decreased visual acuity, and orbital pain. We present a unique case of MEP presenting with cerebrospinal fluid (CSF) rhinorrhea and conduct a systematic review of literature. METHODS: Following PRISMA guidelines, a systematic search was conducted in PubMed and Embase databases. Keywords and standardized index terms related to MEP were used. The search was performed without restriction on the publication date. Screening, data extraction, and quality assessment were carried out. Data on demographics, clinical presentations, management modalities, and treatment outcomes were analyzed. RESULTS: The search yielded 487 titles, with 36 studies eligible for inclusion. A total of 530 patients with MEP were reported, with a mean age of 50.1±11.62 years. Proptosis was the most common symptom (95%), followed by visual impairment (57.3%), orbital pain (38.3%), ophthalmoplegia (28.6%), and headache (23%). Our patient represented the only case with a spontaneous CSF leak. Surgical resection was performed in 85%, adjuvant radiotherapy in 15.7%, and one patient received primary radiotherapy, while 8 patients were closely followed up with no intervention. CONCLUSION: MEP associated with spontaneous CSF rhinorrhea is extremely rare and poses diagnostic and therapeutic challenges. Conservative management for select cases of MEP can be a good choice, refraining the patient from surgical complications, especially for difficult-access skull base areas.

Safety and Feasibility of Steroid-Eluting Stent as a Bolster in Endoscopic Anterior Skull Base Reconstruction.

BACKGROUND: With a rising incidence of cerebrospinal fluid (CSF) leaks, endoscopic endonasal CSF leak repair is increasingly performed. Current approaches utilize a variety of materials including free mucosal grafts and vascularized flaps, but post-op leaks continue to be reported. Steroid-eluting bioabsorbable stents (SES) are used during functional endoscopic sinus surgery for chronic rhinosinusitis to reduce inflammation and scarring while maintaining patency of sinus ostia. OBJECTIVE: The aim of this study is to assess the feasibility of SES as a graft/flap bolster for endoscopic endonasal CSF leak repair. METHODS: This is a retrospective review of patients undergoing endoscopic endonasal CSF leak repair with SES placed as part of the bolster technique at a tertiary care center between January 2019 and May 2022. Age, sex, BMI, comorbid idiopathic intracranial hypertension, pathology, location of CSF leak, intraoperative CSF leak flow, reconstruction type, and presence of post-op CSF leak were recorded. RESULTS: Twelve patients (mean age 52, median BMI 30.9, 58% female) had SES placement as part of the bolster technique. The most common pathology was meningoencephalocele (75%). Reconstruction was performed with either a free mucosal graft (6), or a flap (6). No post-op CSF leaks occurred at a reconstruction site with a stent, and no known complications were reported. All sinusotomies were patent at the last follow-up visit. CONCLUSIONS: SES placement as an adjunct to graft and/or flap bolster appears to be safe and feasible during anterior skull base reconstruction and CSF leak repair providing longer term structural support and preserving sinus drainage patency.

Delayed CSF rhinorrhea presenting as a lethal acute bacterial meningitis 5 years post trauma.

Key clinical message: Delayed presentation of cerebrospinal fluid rhinorrhea is rare following head trauma. It is frequently complicated by meningitis if not addressed in time. This report highlights the importance of its timely management, the lack of which can lead to a fatal outcome. Abstract: A 33-year-old man presented with meningitis in septic shock. He had a history of severe traumatic brain injury 5 years back following which he had a history of intermittent nasal discharge for the past 1 year. On investigation, he was found to have Streptococcus pneumoniae meningitis, and CT scan of his head showed defects in the cribriform plate which established the diagnosis of meningoencephalitis secondary to cerebrospinal fluid rhinorrhea. The patient did not survive despite appropriate antibiotics.

Chronic cerebrospinal fluid rhinorrhea as an initial presentation of chordoma: illustrative case.

BACKGROUND: Skull base chordomas are typically extradural and present with cranial nerve deficits, headache, and visual disturbances. Clival chordoma involving the dura and presenting as a spontaneous cerebrospinal fluid (CSF) leak is extremely rare and can be mistaken for other skull base lesions. Here the authors present a case of chordoma with an unusual presentation. OBSERVATIONS: A 43-year-old female who presented with clear nasal drainage was diagnosed with CSF rhinorrhea secondary to a clival defect previously thought to be ecchordosis physaliphora. The patient subsequently developed bacterial meningitis and underwent endoscopic, endonasal, transclival gross-total resection of the lesion with repair of the dural defect. Pathology revealed brachyury-positive chordoma. She received adjuvant proton beam radiotherapy and has remained stable for 2 years. LESSONS: Spontaneous CSF rhinorrhea can occur as a rare primary presentation of clival chordoma, requiring careful radiological interpretation and a high index of suspicion for diagnosis. Chordoma cannot be reliably differentiated from benign notochordal lesions based on imaging alone; thus, intraoperative exploration and immunohistochemistry play key roles. Clival lesions presenting with CSF rhinorrhea should undergo prompt resection to facilitate diagnosis and prevent complications. Future studies on connections between chordoma and benign notochordal lesions may help to establish management guidelines.

A Rare Case of Tension Pneumocephalus with Spontaneous CSF Rhinorrhea Managed by Endoscopic Trans-Sphenoidal CSF Leak Repair.

Tension Pneumocephalus and spontaneous CSF rhinorrhea are very rare associations in clinical practice. We report a case of 65 years old male with clear rhinorrhea, severe frontal headache, vomiting and lethargy for a week. MR Cisternography and CT Paranasal sinuses showed significant Tension Pneumocephalus with defect in the posterior wall of sphenoid sinus and CSF pooling in the sphenoid sinus. Endoscopic trans-sphenoidal CSF leak repair was done without any delay followed by complete resolution of Tension Pneumocephalus with in 4 post op days. Prompt precise diagnosis and early intervention of Tension Pneumocephalus is vital to avoid neurological complications.

Cerebrospinal fluid fistula as a complication of reverse transcriptase-polymerase chain reaction collection for the detection of coronavirus disease 2019: illustrative cases.

BACKGROUND: The most used method to detect coronavirus disease 2019 during the pandemic is reverse transcriptase-polymerase chain reaction with nasal swab. Despite being highly effective, the test does not leave the patient risk-free and can lead to serious complications. These can be traumatic nasal cerebrospinal fluid (CSF) fistula and its consequences, such as meningitis. OBSERVATIONS: In this article, the authors present 4 case reports and a literature review. The following MeSH terms in the research were used: "CSF leak case report and covid 19." Six results were found and after searching the references and keywords 16 articles were identified. By using them, the authors tried to clarify the etiology of the fistula, its influences, and complications. LESSONS: The authors conclude that professionals must receive training, since CSF fistula originates from technical failure and lack of anatomical knowledge. The diagnosis cannot be neglected because it can bring complications to the patient's health.