Endonasal Endoscopic Repair of Spontaneous Cerebrospinal Fluid Leaks

Abstract

Possible etiological factors of this disease include obesity, congenital malformations of the skull base, an overpneumatized sphenoid sinus (particularly in its lateral extensions), and the empty sella syndrome. Endoscopic endonasal repair of spontaneous CSF rhinorrhea appears to be a safe and successful procedure. However, techniques for endoscopic closure of CSF fistulas in the lateral part of the sphenoid sinus need further perfecting.

Nontraumatic Skull Base Defects With Spontaneous CSF Rhinorrhea and Arachnoid Herniation: Imaging Findings and Correlation With Endoscopic Sinus Surgery in 27 Patients

“…3,31,42 Fistulas localized by endoscopic surgery 14 affected the cribriform plate in 6 (28.6%) of 21 patients and were disclosed by MR cisternography at the same location in 12 (32%) patients reported by Shetty et al 31 In this series, 11 (39.3%) of 28 defects affected the cribriform plate. The lamella lateralis followed in frequency in 4 (14.3%) patients in our study, 18% in the series by Shetty, 31 and 28.6% of patients investigated by Lopatin et al 14 In this series, MR and CT cisternography disclosed arachnoid herniation in 12 of 15 patients with leaks related to the ethmoid. Endoscopic surgery proved arachnoid herniation in 13 of 15 patients; in 1 patient, noncontrast CT had been unable to differentiate the soft tissue lesion from mucosal swelling.…”

“…4,37,45 In those patients examined by MR in this study, pouches of CSF intensity with strands of soft tissue were arising from the osteodural defects; contrast enhancement was not present in ethmoid lesions. Probably indicated as "meningocele" in most instances on imaging, 14,15,21 this term is imprecise because fenestration of the dura overlying the osseous defect is a frequent finding during surgery. 25,29,46 Minutoli et al 35 reported a 63-year-old man with "small arachnoid hernia in the left nasal cavity between the nasal septum and middle turbinate."…”

“…and was considered a physiologic phenomenon until Thomson, in 1899, assembled 21 patients in a monograph reporting spontaneous CSF rhinorrhea as a pathologic clinical entity. 9,10 Spontaneous CSF rhinorrhea has been recognized as a distinct entity with respect to clinical presentation, 2,11,12 treatment, [13][14][15] and propensity for recurrence. 8,16,17 As early as 1968, Ommaya et al 9 postulated the existence of "high-pressure leaks" related to intracranial tumors and of "normal pressure leaks" occasionally associated with empty sella.…”

“…18 In addition to the presence of an empty sella as a radiologic sign, 19 a common clinical constellation in patients with spontaneous CSF rhinorrhea is female sex, middle age, and obesity. 8,14,15,[18][19][20][21][22] Spontaneous CSF leaks have been postulated to represent a manifestation of benign intracranial hypertension 22 or pseudotumor cerebri. 23 Pulsatile-increased hydrostatic pressure is capable of bone erosion during the course of many years.…”

“…A confounding nomenclature exists regarding the contents of osteodural defects such as meningocele, 10,14 meningoencephalocele, 4 encephalocele, 11,34 meningeal or arachnoid hernia, 24,35 arachnoid diverticulum, 36 or arachnoid cyst. 37 These differing designations reflect variable contents of herniation and occasional inaccuracy because of the limited ability to visualize the lesions by imaging 24,29 and during transcranial surgery.…”