CSF Leak Presented by: Malak Gazzaz

1. CSF Leak Presented by: Malak Gazzaz

2. History 53 year old, Saudi, female Known case of HTN, and hypothyroidism Complaining of watery, colorless, runny nose from the right nostril for the past 9 years, on and off, increasing on bending downwards Decrease sense of smell Decrease vision No fever or neck rigidity No hx of trauma She has previous hx of meningitis treated with IV antibiotics ( cefipim and vanco for 14 days)

3. History She was diagnosed as a case of CSF leak 4 years back She was also diagnosed as a case of empty sella She refused the repair previously b/c she was only offered a transcranial incision as an option for repair

4. P/E Obese Endoscopy: Nasal mass in right nostril

5. Investigations CT cisternography was done by injecting 7ml of intrathecal contrast via LP

6. Investigations

7. Investigations

8. Empty Sella Syndrome

9. Endoscopic transnasal repair of CSF leak Multidisciplinary approach (ENT/Neurosurgery) Repaired by 3 layers: Fascia lata Septal Cartilage Nasal mucosa

10. Endoscopic transnasal repair of CSF leak Frontal Sinus Defect

11. Endoscopic transnasal repair of CSF leak Fascia lata

12. Endoscopic transnasal repair of CSF leak Methylene Blue on nasal mucosa

13. Endoscopic transnasal repair of CSF leak OR

14. Endoscopic transnasal repair of CSF leak

15. Hospital course She was transferred to ICU to be closely monitored

16. Hospital course 1 day later, pt was transferred to ward Pt was complaining of severe headache ?some fluid oozing, ?CSF Lumbar drain was inserted and pain control medications were administered Pt was also taking cefuroxime, nasal saline and fucidine ointment

17. Hospital course • Pt developed seizure POD 4, induced by cerebral edema and treated with phenytoin

18. CT post op

19. CT post op

20. CT Site of repair

21. Hospital course Upon serial clinical and radiological evaluations , pt has improved with no CSF leak, no seizures, and afebrile Lumbar drain was removed 3 days later Pt started to ambulate without deficit

22. Hospital course She was discharged 2 weeks post op with nasal irrigation by NS 30cc BID for 2 wks

23. MASNOT Questionnaire 0 = absent 1 = very mild 2 = mild 3 = moderate 4 = severe 5= very severe

24. MASNOT Questionnaire

25. MASNOT Questionnaire

26. MASNOT Questionnaire

27. 5 wks post op

28. Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis Hassan M. Hegazy MD Ricardo L. Carrau MD Carl H. Snyderman MD Amin Kassam MD Julie Zweig MD

29. Abstract

30. Objectives/Hypothesis Trauma and surgery are the most common causes of (CSF) rhinorrhea. Surgical repair is recommended for patients with: CSF leaks that do not respond to conservative measures traumatic CSF leaks that require transcranial surgery for associated brain injuries iatrogenic defects that are discovered intraoperatively

31. The purpose of the study • To ascertain the outcome after transnasal endoscopic repair of CSF leaks and to identify factors regarding the patient, CSF fistula, and treatment that may influence the results of the repair.

32. Methods Meta-analysis of all studies published between 1990 and 1999 that reported a minimum of five patients with CSF fistulae that were repaired using an endoscopic approach. Data analysis included type of graft and technique used during the repair, surgical complications, the use of packing, and the use of lumbar drains and antibiotics.

33. Results Endoscopic repair of CSF leaks was successful in 90% (259/289) of the cases after a first attempt. Seventeen of 30 persistent leaks (52%) were closed after a second attempt. Thus ultimately 97% (276/289) of the leaks were repaired using an endoscopic approach. The success rate of repairs using any of the reported techniques and materials was high and not statistically different. The incidence of major complications such a meningitis, subdural hematoma, and intracranial abscess was less than 1% for each complication.

34. Surgical Repair of Cerebrospinal Fluid Leaks • The review and meta-analysis suggest that the choice of the surgical approach and the grafting materials used during the endoscopic or endonasal closure of CSF fistulae depends on the availability of the material and on the experience and familiarity of the surgeon with various techniques, and that their use does not seem to alter the outcome.

35. Adjunctive techniques Nasal packing Gel foam or Gel film Fibrin glue Perioperative antibiotic prophylaxis Lumbar spinal drain

36. Recommendation • The use of lumbar spinal drain for pts presenting with idiopathic and post traumatic fistulae that are highly associated with hydrochephalus for recurrent or persistent leaks and for those associated with meningoceles or large skull base defects is recommended

37. Complications of repair Meningitis Chronic headache Pneumocephalus Intracranial hematoma Frontal lobe abscess Anosmia6

38. Conclusion The endoscopic approach is highly effective and is associated with low morbidity. The literature supports the endoscopic approach using a variety of techniques and materials for the repair of CSF leaks.

39. Spontaneous cerebrospinal fluid leaks Woodworth Bradford Aa Palmer James Nb

40. Abstract

41. Purpose of review CSF leaks that occur spontaneously are challenging to manage clinically owing to frequent recurrences following attempted surgical closure. Understanding the underlying pathophysiology allowed the recognition that the vast majority of these patients demonstrate clinical symptoms and radiographic signs of elevated ICP. Individuals with this disorder also arise from a distinct demographic group. Increased knowledge of the characteristics of this patient population will provide increased success rates in the management of this clinical entity.

42. Recent findings • Current literature indicates that control of intracranial hypertension, coupled with endoscopic repair, will improve success rates comparable with other etiologies. • Improvement in preoperative identification of radiographic signs of intracranial hypertension (i.e. empty sella), operative technique, and postoperative management of elevated intracranial pressure are also reviewed. 

43. Benign Intracranial Hypertension • Elevated ICP frequently manifests itself in the syndrome of benign intracranial hypertension (BIH), aka pseudotumor cerebri. • Symptoms include: • pulsatile tinnitus • balance problems • Headache • visual disturbances. • Because this has recently been identified as the underlying cause in the majority of individuals in this category, the term spontaneous, rather than idiopathic, should be used in the presence of intracranial hypertension

44. Benign Intracranial Hypertension • Many of these patients have total or partial empty sella syndrome (ESS) • Other radiological findings associated with elevated ICP include: • abnormalities of the optic nerve sheath complex, • encephaloceles, • arachnoid pits • dural ectasia 7,8,9,10,11

45. Benign Intracranial Hypertension • Pts with BIH have elevated readings (typically over 25 cmH2O) on lumbar tap opening pressures • In terms of demographics, the majority of patients who develop the diagnosis of BIH are young to middle-aged obese women12. The association of obesity with BIH has been reported in many studies10,13,14.

46. Preoperative Evaluation • Consists of: • History • physical examination • nasal endoscopic examination • radiographic imaging

47. Recommendation • Computer-aided or image-guided surgical navigation CT scans and MRI studies are recommended. • MRI can enhance the diagnosis of elevated ICP, as it shows evidence of totally or partially empty sella up to 85% of the time15.

48. Management of elevated ICP • Acetazolamide • Ventriculoperitoneal shunting

49. Recommendation • Because the underlying cause of elevated CSF pressure (either obesity or decreased arachnoid granulations) is likely to remain unchanged over time, we generally recommend lifelong use of the diuretic.

50. Outcomes • Treatment of the underlying intracranial hypertension, whether through medical or surgical means, was critical for success in the repair of these defects • Significant weight loss appears to be required for this to become an effective treatment16.