International Consensus Statement: Spontaneous Cerebrospinal Fluid Rhinorrhea

Abstract

Background The association between spontaneous cerebrospinal fluid CSF leak/rhinorrhea and idiopathic intracranial hypertension IIH has been increasingly recognized over the last years However considerable variability of opinion regarding the assessment investigations and management of patients with spontaneous CSF rhinorrhea remains Methods A consensus group was formed from experts from Europe Asia Australia South and North America Following literature review and open discussions with members of the panel a set of statements was produced A modified Delphi method was used to refine expert opinion with rounds of questionnaires and a consensus group meeting in Santo-Rhino meeting in September Results Fi y statements of total on spontaneous CSF leak and IIH reached consensus In of statements the median response was strongly agree and in the remaining statements the median response was agree Eleven statements were excluded because they did not reach consensus and one new statement was added during SantoRhino meeting The final statements refer to patient history and clinical examination "History taking should include presence of headache tinnitus and visual defects" investigations role of Thin Slice Computed Tomography and CISS/FLAIR sequences in Magnetic Resonance Imaging principles of management watchful waiting or measures to reduce ICP are supplementary but cannot subsitute surgical closure surgical technique intraoperative early postoperative and long term management Conclusion We present fi y consensus statements on the diagnosis investigation and management of spontaneous CSF rhinorrhea based on the currently available evidence and expert opinion Although by no means comprehensive and final we believe they can contribute to the standardization of clinical practice Early diagnosis prompt surgical closure of the defect assesment for and treatment of potentially co-existing idiopathic intracranial hypertension in a comprehensive multidisciplinary approach are essential in order to successfully manage spontaneous CSF rhinorrhea reduce associated morbidity and prevent recurrence

Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide

“…Despite some debate on the utility of lumbar drains with respect to CSF leak repair, the use of perioperative lumbar drains in this patient population is felt to be important for several reasons. 8,12,21,23 Most notably, it is well established that there is a strong relationship between idiopathic IIH and spontaneous CSF leaks and meningoencephaloceles of the skull base. 8,9,12,21,24,25 In addition, untreated IIH is also considered an independent risk factor for failure of surgical repair and recurrent postoperative CSF leak (at the same or a different site) in these patients.…”

“…The MRI should be critically surveyed for, and will often demonstrate, findings suggestive of underlying idiopathic IIH such as an empty sella, posterior flattening of the globes, tortuosity of the optic nerves, and transverse venous sinus stenosis. 12 We routinely use both CT and MRI data sets for intraoperative surgical navigation in all complex skull base cases (Figure 1).…”

“…11,12 In the past, repairing these lateral sphenoid recess defects had been challenging given their lateral and posterior locations in the skull base, wherein the transpterygoid approach offered an ideal surgical corridor. 11,12 Based on its original description, infraorbital nerve (V2) hypoesthesia, and decreased lacrimation from vidian nerve injury in the postoperative setting were described, which can be debilitating issues for patients. 13 Additionally, based on original technique, vascular ligation through encountering the sphenopalatine artery (SPA) and internal maxillary artery was required in this description.…”

Zipline Into a Case of Spontaneous Cerebrospinal Fluid Rhinorrhea

“…Although CT cisternography is considered the gold standard for evaluation of CSF fistula [2], our hospital did not have the facility of CT cisternography, thus an MRI FIESTA sequence was done that showed asymmetric accentuated linear tract via the right cribriform plate. MRI FIESTA sequence is sensitive, does not require an injection of intrathecal contrast, and is not associated with complications compared to CT cisternography [12].…”

Simplifying Access to the Lateral Sphenoid Recess: A Modification of the Transpterygoid Approach

“…In contrast, MRI allows for detailed characterization of the meningoencephalocele as well as its relationship to key neurovascular structures and/or findings suggestive of idiopathic intracranial hypertension. 5 Lastly, pre-operative counseling on the potential risks and complications of surgery in this area is critical, particularly when discussing postoperative sequela including dry eye and V2 hypoesthesia, both of which are minimized in the MTPA.…”