Post‐traumatic Cerebrospinal Fluid Leakage

Abstract

Posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. While most CSF leaks will cease without treatment, patients with persistent CSF leaks may be at increased risk for meningitis, and many will require surgical intervention. We reviewed the medical records of 51 patients treated between 1984 and 1998, with CSF leaks that persisted for 24 hours or longer after head trauma. Twenty-eight patients (53%) had spontaneous resolution of the leakage at an average of 5 days. Twenty-three patients (47%) required surgery. Eight patients (16%) had occult leaks presenting with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with CSF leaks had an associated skull fracture, most commonly involving the frontal sinus, while only 18 patients (35%) had parenchymal brain injury or extra-axial hematoma. Eight patients (16%) had delayed leaks at an average of 13 days posttrauma. Among patients with clinically evident CSF leakage the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved risk of meningitis. A variety of surgical approaches was used, with minimal morbidity. Three of 23 surgically treated patients (13%) required additional surgery for continued leakage. Patients with CSF leaks that persist greater than 24 hours are at risk for meningitis, and many will require surgical intervention. Prophylactic antibiotics may be effective and should be considered in this group of patients. Patients with skull fractures involving the skull base or frontal sinus should be followed for delayed leakage. Surgical outcome is excellent.

Late Onset Cerebrospinal Fluid Leakage Associated With Past Head Injury

“…3) The frequency of different types of CSF leakage, such as rhinorrhea or otorrhea, was not defined in previous reports. A total of 27 cases of CSF leakage occurred among 1036 cases of closed head injury.…”

Surgical Management of Traumatic Cerebrospinal Fluid Fistulas with Associated Lesions

“…CSF leakage has been reported to stop 4.1 days (mean value) after trauma and 5.3 days after lumbar drainage, and ratio of spontaneous cessation has been reported to be 61%. [5,8] Surgical treatment should be considered in cases with leak that persists for more than one week. [12,13] However, there are some exceptions to this principal management strategy such as high risk elderly patients, patients with diabetes mellitus and immunosuppressed condition, associated intracranial pathologies or profuse leaks.…”

“…[8,12,14] Similarly, patients with severe head trauma or low GCS should be managed with radical surgical measures since the risk of infectious complications or neurological deterioration is quite high. [5,8] Surgical intervention should also be considered for cases with subdural or epidural hematomas, tension pneumocephalus, depression fractures including comminuted skull base fractures or patients with severe contusion and edema. These lesions require decompressive measures, all of which limit the use of lumbar drainage or temporary lumbar punctures for CSF fistulae.…”

“…[1,[3][4][5] Although CSF leaks, particularly mild ones, do resolve spontaneously, some tend to persist and necessitate other treatment modalities including daily lumbar punctures or external lumbar drainage. Despite conservative measures, a portion of CSF leaks do not cease and surgical treatment should be performed.…”

The use of Prophylactic Antibiotics in Trauma

“…28 Friedman et al conducted a review of 51 head injury patients from 1984 to 1988 and showed that only 10% of patients developed meningitis with antibiotic prophylaxis, as compared to 21% in the group without antibiotics. 29 The study was only retrospective and the level of evidence was not strong. However, with respect to the severity of the complications, antibiotics are usually given.…”