Endoscopic Endonasal Repair of Cerebrospinal Fluid Leakage Caused by a Rare Traumatic Clival Fracture

Abstract

An 89-year-old male presented with cerebrospinal fluid (CSF) rhinorrhea associated with head trauma sustained as a pedestrian in a traffic accident. Computed tomography (CT) showed pneumocephalus and multiple cranial bone fractures, including the clivus. Although the CSF rhinorrhea was treated conservatively for a week, clinical symptoms did not improve and surgical repair was performed. Preoperative thin-sliced bone CT and steady-state magnetic resonance images revealed a bone defect at the middle clivus and a collection of CSF fluid from the clival fistula in the sphenoid sinus. Endoscopic endonasal reconstruction was performed, and the 3-mm diameter dural tear and bone defect at the middle clivus were well visualized. The fistula was repaired using a pedicled nasoseptal mucosal flap. The CSF rhinorrhea completely disappeared as a result of the endoscopic endonasal surgery. The present report describes a rare case of CSF rhinorrhea caused by a traumatic clival fracture and surgical management by endoscopic endonasal surgery.

Cerebrospinal Fluid Rhinorrhea and Subsequent Bacterial Meningitis due to an Atypical Clival Fracture

“…The bones are bound by spheno-occipital synchondrosis during childhood, with complete ossification in adults ( 9 ). There are two types of traumatic clival fracture: one is caused by severe head trauma resulting in brainstem injury or brain herniation, which is associated with a high mortality rate of 38.5% ( 6 , 10 ); the other is caused by mild contusion due to a constructive vulnerability between the middle and superior portions of the clivus ( 1 , 9 ). The former type is sometimes accompanied by vertebrobasilar artery occlusion adjacent to the clivus (with a longitudinal fracture) or by multiple cranial nerve palsies (with a transverse fracture) ( 6 , 10 ).…”

“…It involved an alert 89-year-old man who presented after a traffic accident, who only had CSF leakage through a clival defect ( 1 ). In our patient, a clival flap fracture was detected, extending from the middle to the superior thinner portion, which may have been fragile to external force ( 1 ). However, the patient did not develop CSF rhinorrhea until 1 month after trauma.…”

“…Cerebrospinal fluid (CSF) rhinorrhea is a symptom caused by the leakage of CSF into the nasal sinus, resulting from a defect in the skull base. It is often caused by trauma (head trauma and iatrogenic insult), followed by idiopathic, congenital, and neoplastic lesions ( 1 , 2 ). CSF rhinorrhea is usually detected by nasal endoscopy and/or endonasal examination after fluorescein lumbar puncture, the detection of beta-2 transferrin, computed tomography (CT), or magnetic resonance imaging (MRI).…”