Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review

Abstract

ObjectivesTo review the safety and efficacy of surgical management for spontaneous cerebrospinal fluid (CSF) leaks of the anterior and lateral skull base.Data SourcesA systematic review of English articles using MEDLINE.Review MethodsSearch terms included spontaneous, CSF, cerebrospinal fluid, endoscopic, middle fossa, transmastoid, leak, rhinorrhea. Independent extraction of articles by 3 authors.ResultsPatients with spontaneous CSF leaks are often obese (average BMI of 38 kg/m2) and female (72%). Many patients also have obstructive sleep apnea (∼45%) and many have elevated intracranial pressure when measured by lumbar puncture. In addition to thinning of the skull base, radiographic studies also demonstrate cortical bone thinning. Endoscopic surgical repair of anterior skull base leaks and middle cranial fossa (MCF) approach for repair of lateral skull base leaks are safe and effective with an average short‐term failure rate of 9% and 6.5%, respectively. Long‐term failure rates are low. One randomized trial failed to show improved success of anterior leak repairs with the use of a lumbar drain (LD) (95% with vs. 92% without; P = 0.2). In a large retrospective cohort of MCF lateral skull base repairs, perioperative LD use was not necessary in >94% of patients.ConclusionsSpontaneous CSF leaks are associated with female gender, obesity, increased intracranial hypertension, and obstructive sleep apnea. Endoscopic repair of anterior skull base leaks and MCF or transmastoid approaches for lateral skull base leaks have a high success rate of repair. In most cases, intraoperative placement of lumbar drain did not appear to result in improved success rates for either anterior or lateral skull base leaks.Level of Evidence2a, Systematic Review.

Management and Outcomes of Spontaneous Cerebrospinal Fluid Otorrhoea

“…Spontaneous CSF otorrhoea occurs in absence of all etiologies described above (8). Over the last decade the incidence of spontaneous CSF otorrhoea has nearly doubled, parallel with an increase of patients with obesity.…”

“…CSF leakage might amongst others occur when a subsite of middle cranial fossa bony plate is defect (tegmen tympani, tegmen mastoideum), overlying dura becomes fragile and breaks. This defect might lead to life threatening events (such as meningitis, intracranial abscess, cerebritis), since it allows microbes to communicate with the subarachnoid space (4,8). The risk of developing meningitis varies by etiology of CSF leakage (12).…”

“…The risk of developing meningitis varies by etiology of CSF leakage (12). For spontaneous CSF leakage the reported rate of meningitis is around 20% (range 6-58%) (8,13,14), therefore its timely diagnosis is of great importance. The elapsing time before development of intracranial complications (i.e., meningitis) is still unknown.…”

The surgical treatment of cerebrospinal fistula: Qualitative and quantitative analysis of indications and results

“…In fact, high ICP is associated with 63%‐88% of sCSF leaks; in addition, they are associated with a 50%‐100% incidence of encephalocele and a 25%‐87% incidence of recurrence . Their etiology is not completely understood, but there is a clear association of sCSF leaks' onset with obesity (80% of patients), elevated ICP (40% of patients), and obstructive sleep apnea (OSA) (43% of patients) . This association is important because it is known that ICP spike during apneic events that suggest episodic rises in ICP may also contribute to skull base erosion over time .…”

Unilateral rhinorrhoea associated with cerebrospinal fluid leak

“…It occurs in the absence of trauma or surgery and is usually secondary to IIH 2. Elevated ICP is believed to cause gradual skull base thinning 3. This procedure results in the formation of a defect over a pneumatised space, anteriorly over nasal cavities or paranasal sinuses and laterally in the area of the temporal bone.…”