In such cases, radiolabeled cisternography may show altered CSF dynamics such as the reflux of isotope into the ventricles.Like their cranial counterparts, CSF leaks involving the spinal axis can be divided into traumatic and nontraumatic (or spontaneous) categories. Symptoms and complications of spinal CSF leaks (which cause intracranial hypotension) are very different from those of cranial CSF leaks which do not cause intracranial hypotension. Symptoms of cranial CSF leak include frank rhinorrhea or otorrhea. Careful follow-up with serial CT imaging studies may demonstrate evidence of previously unsuspected hydrocephalus.
Empiric patching involves a large volume of blood introduced into the lumbar and sometimes the lower thoracic epidural space, as well. CSF communicates directly with the basal subarachnoid cisterns through the foramina of Magendie and Luschka in the posterior fossa.
Rapid or excessive drainage of CSF is dangerous and must be avoided. The success of this procedure may be explained by the findings of Szeinfeld et al. Call for Additional Assistance Despite recognition that these symptoms are the result of spontaneous spinal CSF leaks, patients are grouped under the diagnosis of “spontaneous intracranial hypotension.”Figure 7. Traumatic etiologies included accidental trauma to the cranium or spinal axis as well as iatrogenic injuries. The presence of pneumocephalus is a contraindication to continued lumbar CSF drainage.The use of prophylactic antibiotics in patients with traumatic CSF fistulas remains controversial. We prefer to begin drainage at 5 to 10 cc an hour. [68]Symptoms of cranial CSF leak include frank rhinorrhea or otorrhea. Several groups have suggested that its sensitivity rivals that of CT cisternography;[24,27,58] however, this view is not yet widely accepted.When the diagnosis of a CSF fistula has been confirmed but its location remains elusive, endoscopic techniques may be helpful. [84,85]Nontraumatic causes of normal pressure CSF leaks include intracranial tumors that directly invade the skull base, infections such as osteomyelitis and tuberculosis, meningoceles and meningoencephaloceles, and defective development or atrophy of the olfactory bulbs that exposes the thin perforated bone of the lamina cribrosa to pulsations of CSF. Lumbar drainage of CSF and the intraoperative use of mannitol can further minimize the need for retraction.
In the case of traumatic and postoperative CSF leaks, bed rest and a short course of diversionary lumbar drainage are often adequate.
A more direct and, in our experience, more efficacious treatment is a lumbar epidural blood patch. A clear understanding of their natural history is also mandatory for making sound management decisions.This article examines the natural history, diagnosis, and treatment of CSF leaks involving the skull base and spinal column. Where the leak is fast and extensive, with the level confirmed, this patient would be directed to surgery without patching.Roughly a third of patients experience a complication of treatment known as rebound intracranial CSF hypertension. When a leak is associated with external drainage of CSF via the paranasal sinuses, external ear, or a cutaneous tract, it is more appropriately referred to as a CSF fistula. The remaining 50 to 60% of spontaneous CSF leaks occur in the presence of normal ICP. The first section concentrates on cranial CSF fistulas; the second section addresses spinal CSF leaks, including their relationship to symptomatic intracranial hypotension.In the second century A.D. Galen described the leakage of CSF after cranial trauma, but it was not considered a pathologic process until the mid17th century.
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