Cerebrospinal Fluid Leak Presenting as Oculorrhea After Blunt Orbitocranial Trauma

Abstract

Cerebrospinal fluid (CSF) leak is an uncommon but well-documented occurrence after blunt head trauma, typically manifesting as otorrhea or rhinorrhea. Blunt cranio-orbital trauma also may cause CSF leak into the orbit, manifesting as orbitocele, blepharocele, chemosis, or tearing ("oculorrhea"). We report a patient who developed oculorrhea after blunt head trauma, and neuroimaging disclosed comminuted fractures of the left frontal, greater sphenoid wing, nasal, and maxillary bones. Because he also displayed chemosis and markedly reduced ocular ductions and periocular pain, carotid-cavernous fistula was suspected but appropriate vascular imaging was negative. Aspiration of subconjunctival fluid was positive for beta-2 transferrin, a specific marker for CSF. Chemosis lessened and the oculorrhea ceased spontaneously within 6 days of the trauma. This manifestation of CSF leak must not be overlooked because of the threat of meningitis.

Complications of Facial Trauma of the Fronto-orbital Region

“…Delaying operative intervention for other fractures is thought to minimize the risk of recurrent leaks and menegitis. [24][25][26]…”

Imaging of Cerebrospinal Fluid Leak

“…Improved characterization of associated meningoceles is another useful feature [1,3,13,15]. Although MRC is more sensitive for active leaks, some authors have reported successful localization of intermittent or low flow leaks [9,31].…”

“…Approximately 80% of these patients present with rhinorrhea while the remaining 20% have otorrhea [1]. Very rarely, CSFL may present with oculorrhea [9]. Most cases [70-80%] present in the first week and almost all cases manifest clinically within the first three months [5,10,11].…”

Persistent post-traumatic orbital cerebrospinal Fluid Fistula with multiple episodes of meningitis: Systematic Case Review and Case Report

“…Cerebrospinal fluid (CSF) fistulas are a well-known complication of head trauma [1]. These fistulas form communications between the subarachnoid space and an internal or external cavity.…”

“…They usually are a result of fractures and dural tearing in the skull base [2], causing CSF to leak through the nasal, middle ear or orbital cavity [18]. Nasal and middle ear fistulas are a lot more common and are justified by the physical features inherent to these cavities [1,18,7]. Orbital CSF fistulas are very rare [2,16] and manifest as orbitocele, blepharocele [7], chemosis, or excessive tearing ("oculorrhea") [13,16].…”