Spontaneous CSF leaks: A paradigm for definitive repair and management of intracranial hypertension

Woodworth, Bradford A.; Prince, Anthony; Chiu, Alexander G.; Cohen, Noam A.; Schlosser, Rodney J.; Bolger, William E.; Kennedy, David W.; Palmer, James N.

doi:10.1016/j.otohns.2008.02.010

Cited by 239 publications

(331 citation statements)

References 21 publications

(48 reference statements)

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“…Potential causes include congenital defects, trauma, infection, and intracranial hypertension. 6,7,[10][11][12]15 As the middle fossa cranial base develops progressively enlarging defects, CSF pulsations contribute to dehiscence and can lead to meningoencephalocele development and eventual dural disruption. 4,8,12,16 This sequence of events results in effusions in the middle ear and mastoid air cells that can manifest as CSF fistulas, through a disrupted tympanic membrane or via the eustachian tube.…”

Section: Neurosurg Focus 32 (6):e6 2012mentioning

confidence: 99%

“…4,8,12,16 This sequence of events results in effusions in the middle ear and mastoid air cells that can manifest as CSF fistulas, through a disrupted tympanic membrane or via the eustachian tube. [1][2][3]5,11,12,15 Given that intracranial hypertension has been implicated as a significant factor in temporal encephalocele formation, 7,[10][11][12]15 we hoped to clarify this correlation by reviewing a series of tegmen defects repaired surgically and the associated ICP measurements in these patients. Additionally, we aimed to determine the rate of and indications for VP shunt placement.…”

Section: Neurosurg Focus 32 (6):e6 2012mentioning

confidence: 99%

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Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

Kenning¹,

Willcox²,

Artz³

et al. 2012

FOC

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Object Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors. Methods The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect. Results The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m2. Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m2). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H2O, with 10 patients (43%) demonstrating an ICP > 20 cm H2O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months). Conclusions Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H2O, BMI > 30 kg/m2, preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

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Section: Neurosurg Focus 32 (6):e6 2012mentioning

confidence: 99%

Section: Neurosurg Focus 32 (6):e6 2012mentioning

confidence: 99%

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

Kenning¹,

Willcox²,

Artz³

et al. 2012

FOC

View full text Add to dashboard Cite

show abstract

“…39,40 The revision cases share similarities, namely spontaneous leaks are more difficult to manage and have lower success rates, with these patients typically being obese, middle-aged women with defects in pneumatized sphenoid lateral recesses. 4,19,20,23 Our other three failures belonged to this group and had successful revisions, with two being sphenoid and the other a posterior ethmoid roof defect.…”

Section: Discussionmentioning

confidence: 91%

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Virk¹,

Elmiyeh²,

Saleh³

2012

J Neurol Surg B

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“…Through this defect, the dura may herniate and form meningoceles or, if the defect is big, the cerebral parenchyma can also herniate through (encephalocele) 8 . A study conducted by Lieberman et al on patients with spontaneous CSF rhinorrhea proved that they had multiple simultaneous bony defects in the skull base 4 .…”

Section: Spontaneous Csf Leaksmentioning

confidence: 99%

Current insights in CSF leaks: a literature review of mechanisms, pathophysiology and treatment options

Patrascu¹,

Manea²,

Sarafoleanu³

2017

Romanian Journal of Rhinology

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A cerebrospinal fluid (CSF) leak occurs when there appears a fistula between the dura and the skull base and it is usually characterized by discharge of cerebrospinal fluid from the nose. Cerebrospinal fluid leaks may have many etiologies, the most common being trauma. The most common site of dural lesion is the cribriform plate of the ethmoid. Diagnosis can be achieved by a multitude of techniques, high-resolution computed tomography being the modality of choice and it may be completed with magnetic resonance imaging or cisternography. Treatment may be either conservative, either surgical, related to the cause, the site and the duration of CSF leak. Conservative treatment usually includes strict bed rest, elevated bed head and no straining, nose blowing or stretching, with resolution of the majority of traumatic CSF leaks in seven days. Surgical treatment consists of a variety of approaches (intracranial/extracranial, open/endoscopic). The future trend is represented by minimally invasive endoscopic approaches, with a success rate of almost 90%; however, open transcranial or extracranial interventions still have indications in the surgical management. CSF leaks must be correctly diagnosed and treated, because the risk of intracranial complications increases 10-fold when the leakage persists.

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Spontaneous CSF leaks: A paradigm for definitive repair and management of intracranial hypertension

Abstract: Spontaneous CSF leaks have the highest recurrence rate of any etiology. With treatment of underlying intracranial hypertension coupled with endoscopic repair, the success rate (95%) approaches that of other etiologies of CSF leaks.

Cited by 239 publications

References 21 publications

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

Endoscopic Management of Cerebrospinal Fluid Rhinorrhea: The Charing Cross Experience

Current insights in CSF leaks: a literature review of mechanisms, pathophysiology and treatment options

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