Evaluation and Management of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks

Pappas, Dennis G.; Hoffman, Ronald A.; Holliday, Roy A.; Hammerschlag, Paul E.; Swaid, Swaid N.

doi:10.1055/s-2008-1058944

Cited by 30 publications

(50 citation statements)

References 9 publications

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“…Spontaneous intracranial hypotension may also result from a CSF leak through the skull base but this is rare if the patient has no history of rhinorrhea or otorrhea. 34 If the nucleotide study does not show any leak but is suggestive of rapid uptake of tracer, this does not necessarily indicate the presence of generalized CSF hyperabsorption, 19,43 but a more likely alternative explanation is the presence of a leak below the limit of resolution of the study.…”

Section: Etiology and Radiographic Features Of Spontaneous Intracranimentioning

confidence: 94%

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Schievink¹,

Meyer²,

Atkinson³

et al. 1996

Journal of Neurosurgery

444

472

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Spinal cerebrospinal fluid (CSF) leaks are often implicated as the cause of the syndrome of spontaneous intracranial hypotension, but they have rarely been demonstrated radiographically or surgically. The authors reviewed their experience with documented cases of spinal CSF leaks of spontaneous onset in 11 patients including their surgical observations in four of the patients. The mean age of the six women and five men included in the study was 38 years (range 22-51 years). All patients presented with a postural headache; however, most had additional symptoms, including nausea, emesis, sixth cranial-nerve paresis, or local back pain at the level of the CSF leak. All patients underwent indium-111 radionucleotide cisternography or computerized tomographic (CT) myelography. The location of the spontaneous CSF leak was in the cervical spine in two patients, the cervicothoracic junction in three patients, the thoracic spine in five patients, and the lumbar spine in one patient. The false negative rate for radionucleotide cisternography was high (30%). Subdural fluid collections, meningeal enhancement, and downward displacement of the cerebellum, resembling a Chiari I malformation, were commonly found on cranial imaging studies. In most patients, the symptoms resolved in response to supportive measures or an epidural blood patch. Leaking meningeal diverticula were found to be the cause of the CSF leak in four patients who underwent surgery. In three patients these diverticula could be ligated with good result but in one patient an extensive complex of meningeal diverticula was found to be inoperable. Two patients had an unusual body habitus and joint hypermobility, and two other patients had suffered a spontaneous retinal detachment at a young age. In conclusion, spontaneous spinal CSF leaks are uncommon, but they are increasingly recognized as a cause of spontaneous intracranial hypotension. Most spinal CSF leaks are located at the cervicothoracic junction or in the thoracic spine, and they may be associated with meningeal diverticula. The radiographic study of choice is CT myelography. The disease is usually self-limiting, but in selected cases our experience with surgical ligation of leaking meningeal diverticula has been satisfactory. An underlying connective tissue disorder may be present in some patients with a spontaneous spinal CSF leak.

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Section: Etiology and Radiographic Features Of Spontaneous Intracranimentioning

confidence: 94%

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Schievink¹,

Meyer²,

Atkinson³

et al. 1996

Journal of Neurosurgery

444

472

View full text Add to dashboard Cite

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“…[1][2][3][4] This rare phenomenon is often due to a defect in the tegmen of the middle ear or mastoid, and rarely in the posterior fossa (PF) plate of the petrous bone. A disproportionate number of patients with middle fossa (MF) leaks are female, aged 40 to 60 with a body mass index (BMI) greater than 30.…”

mentioning

confidence: 99%

Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone

2011

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Spontaneous temporal bone cerebrospinal fluid (CSF) leak is defined as a communication between the subarachnoid space and the pneumatized space of the temporal bone, and is distinguishable from leaks caused by trauma, neoplasm, or infection. [1][2][3][4] This rare phenomenon is often due to a defect in the tegmen of the middle ear or mastoid, and rarely in the posterior fossa (PF) plate of the petrous bone. A disproportionate number of patients with middle fossa (MF) leaks are female, aged 40 to 60 with a body mass index (BMI) greater than 30. 3-8 Patients typically present with conductive hearing loss, aural fullness, and cerebrospinal otorrhea. 1,6,9,10 Due to the rarity of PF leaks, the demographics and clinical presentation are less well defined.The etiology of the defects in the dura and underlying temporal bone is subject to considerable debate in the literature. The arachnoid granulation (AG) theory has become widely cited as causative for both MF and PF leaks. The proponents of this theory describe aberrant AGs sitting against bone causing slow erosion over time. The MF is more prone to dehiscence and CSF leak due to a combination of a thinner bony plate and a higher proportion of AGs compared with the posterior petrous face. [11][12][13] Recently in the last 5 to 10 years, associations between temporal bone CSF leak, obesity, 6-8,14,15 and idiopathic intracranial hypertension (IIH) 3,5,6,14-16 have been noted. IIH interestingly shares the similar demographics of age 40 to 60, female gender, and BMI greater than 30. Some authors have incorporated these findings into the AG theory, designating the AG's as an arrowhead leading a process of erosion due to unexplained increased intracranial pressure. 6,10,13 Others simply identify Keywords ► cerebrospinal fluid leak ► arachnoid granulation ► petrous bone ► posterior fossa AbstractSpontaneous cerebrospinal fluid (CSF) leak through the posterior fossa (PF) aspect of the petrous bone is exceedingly rare. A case series allows analysis of etiologies and how they may differ from the more common middle fossa (MF) route of leakage. The design was a retrospective case series. The setting was a tertiary care institution. A series of three patients with PF spontaneous CSF leaks was identified. High-resolution imaging (CT and MRI) and intraoperative observations were evaluated. Both in this series and in previously reported cases, patients share the demographics typically found in the MF leak population. In our series, two patterns of PF CSF leak were identified: (1) large unilateral with cerebellar encephalocele and (2) small punctate defects just lateral to the endolymphatic sac. Two presented with simultaneous MF and PF leaks suggesting a shared etiology, at least in some cases, with a role for increased intracranial pressure. In spontaneous CSF leaks, it is important to evaluate the posterior petrous bone along with the tegmen. The concomitant appearance of MF with PF leaks points out the risk that repair via MF craniotomy could fail to identify a leakage site in th...

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“…The first is the congenital defect theory, which posits that tiny defects within the tegmen caused by aberrant embryologic development enlarge over time secondary to constant CSF pressure. This enlargement leads to eventual dural herniation and subsequent bony and dural thinning with resultant CSF otorrhea 2). The arachnoid granulation theory postulates that arachnoid granulations that do not find a venous termination during embryonic development come to lie in a blind-end against the inner bony surface of the skull 3).…”

Section: Discussionmentioning

confidence: 99%

Repair of Spontaneous Cerebrospinal Fluid Otorrhea from Defect of Middle Cranial Fossa

Boo

Goh

Han³

2013

Korean J Audiol

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Spontaneous cerebrospinal fluid (CSF) otorrhea is defined as CSF otorrhea where there are no identifiable causes including previous trauma, surgery, infection, neoplasm or congenital anomaly. The condition is rare. The origin of CSF leak is commonly a defect in the tegmen of the middle cranial fossa. The pathophysiology of spontaneous CSF otorrhea is unclear. Two theories of the etiology of bony defects of the temporal bone are the congenital bony defect theory and arachnoid granulation theory. The authors experienced a case of a 49-year-old female patient admitted with the complaint of persistent right ear fullness. Computed tomography revealed a large defect of the middle fossa and suspicious CSF otorrhea through the defect of tegmen tympani. Repair was successful with multiple bone chips using the transmastoid approach. The postoperative course was good and there has been no recurrence of the CSF leakage.

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Evaluation and Management of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks

Cited by 30 publications

References 9 publications

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Spontaneous spinal cerebrospinal fluid leaks and intracranial hypotension

Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone

Repair of Spontaneous Cerebrospinal Fluid Otorrhea from Defect of Middle Cranial Fossa

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