Traumatic Cerebrospinal Fluid Leaks
Section snippets
Epidemiology of cerebrospinal fluid leaks
Approximately 80% of CSF leaks result from nonsurgical trauma, 16% from surgical procedures (although this number is rising), and the remaining 4% are nontraumatic. Of the traumatic leaks, more than 50% are evident within the first 2 days, 70% within the first week, and almost all present within the first 3 months.3, 4 Delayed presentation may result from wound contraction or scar formation, necrosis of bony edges or soft tissue, slow resolution of edema, devascularization of tissues,
Presentation
Presentation of traumatic CSF leaks can be subtle, and diligence is required when one is suspected. Fain and colleagues11 presented an analysis of 80 cases of trauma to the cranial base. From these cases they determined that there are 5 types of frontobasal trauma. Type I involves only the anterior wall of the frontal sinus. Type II involves the face (craniofacial disjunction of the Lefort II type or crush face), extending upward to the cranial base and to the anterior wall of the frontal
Localization
Once confirmed, localization of the dural defect is critical to management of CSF leaks, particularly if operative management is considered. Following identification of a traumatic CSF leak, nasal endoscopy should be performed. This procedure may narrow the side/site of the leak. Findings commonly are nonspecific, including glistening of nasal mucosa, but occasionally active leaks can be identified. Although direct visualization plays an important role, imaging of the skull base is critical to
Conservative management
Once a CSF leak has been confirmed and localized, the optimal management decision depends on a variety of factors. Even if the otolaryngologist is primarily managing the CSF leak, direct input should be obtained from the trauma service, neurosurgical team and, particularly if meningitis is suspected, infectious disease colleagues. Conservative treatment consists of strict bed rest and elevation of the head at least 30°. In addition, patients should be advised to refrain from coughing, sneezing,
Transcranial Approach
Although CSF rhinorrhea was initially described in the seventeenth century, it was not until 1926 that Dandy32 reported the first successful repair by using a bifrontal craniotomy for access and a fascia lata graft for repair. With this approach, access to the cribriform plate region and roof of the ethmoid is obtained via a frontal craniotomy. An extended craniotomy and skull base dissection are required to access defects in the sphenoid sinus. After craniotomy the brain is retracted and the
Do Prophylactic Antibiotics Prevent Meningitis in Posttraumatic CSF Leaks?
Bacterial meningitis is the major cause of morbidity and mortality in patients with CSF leaks, making antibiotic prophylaxis a reasonable suggestion; however, this topic has been the source of significant controversy. The primary concern is that a CSF leak presents a direct route of infection from the contaminated nasal cavity to the intracranial space; however, unwarranted antibiotic use has the potential to select for resistant organisms. The reported incidence of meningitis in patients with
Summary
Indications for surgical intervention on traumatic CSF leaks include failure of conservative measures, identification of a CSF leak during FESS or skull base surgery, large skull base defects unlikely to heal with conservative measures (particularly if associated with pneumocephalus), or indication for associated surgical procedure to address other intracranial pathology. Recognizing that a single management strategy cannot possibly direct the care of each patient, given the varied mechanism of
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The authors have no relevant disclosures.