Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

Spontaneous CSF fistula as a manifestation of idiopathic intracranial hypertension

INTRODUCTION

Spontaneous cerebrospinal fluid (CSF) fistula, of unknown origin, is a rare condition whose aetiology is increasingly related to idiopathic intracranial hypertension (IIH). This study tries to raise awareness that they should not be considered as two different processes, but that fistulas can be a form of debut, requiring a study and subsequent treatment. Repair techniques are described, as well as the study of HII.

RESULTS

We treated 8 patients, 5 women and three men, aged between 46 and 72 years, with a diagnosis of spontaneous CSF fistula, four nasal and four otics who underwent surgical treatment. After repair, a diagnostic study was performed for IIH by MRI and Angio-MRI, presenting in all cases a transverse venous sinus stenosis. The intracranial pressure values obtained by lumbar puncture showed values of 20mm Hg or higher. All patients were diagnosed with HII. The one-year follow-up did not reveal any recurrence of the fistulas, maintaining a control of the HII.

CONCLUSION

Despite their low frequency of both cranial CSF fistula and IIH, an association of both conditions should be considered by continuing the study and surveillance of these patients after fistula closure.

Risk factors of cerebrospinal fluid leakage after neuroendoscopic transsphenoidal pituitary adenoma resection: a systematic review and meta-analysis

Introduction

Cerebro spinal fluid (CSF) leakage is common and might lead to severe postoperative complications after endoscopic transsphenoidal pituitary adenoma resection. However, the risk factors of postoperative CSF leakage are still controversial. This article presents a systematic review to explore the explicit risk factors of CSF leakage after endoscopic transsphenoidal pituitary adenomere section.

Methods

PRISMA and AMSTAR guidelines were followed to assess the methodological quality of the systematic review. PubMed, Medline, Embase, Web of Science, Cochrane, Clinical Trails, CNKI, CBM, Wan Fang, and VIP databases were searched for all studies on postoperative CSF leak risk factors. The quality of the included studies was assessed by the Newcastle-Ottawa scale. Review Manager 5.4 software was used to calculate the pooled effect size of potential factors with statistical significance.

Results

A total of 6775 patients with pituitary adenoma across 18 articles were included, containing 482 cases of postoperative CSF leakage (accounting for 7.11%). All of the articles had a quality score > 5, indicating good quality. Meta-analysis showed that an increased risk of CSF leak was found for higher levels of BMI (MD=1.91, 95% CI (0.86,2.96), bigger tumor size [OR=4.93, 95% CI (1.41,17.26)], greater tumor invasion (OR=3.01, 95% CI (1.71, 5.31), the harder texture of tumor [OR=2.65, 95% CI (1.95,3.62)], intraoperative cerebrospinal fluid leakage [OR=5.61, 95% CI (3.53,8.90)], multiple operations [OR=2.27, 95% CI (1.60,3.23)].

Conclusion

BMI, multiple operations, tumor size, tumor invasion, hard texture, and intraoperative cerebrospinal fluid leakage are the risk factors of postoperative CSF leakage. Clinical doctors should pay attention to these risk factors, and conduct strict skull base reconstruction and careful postoperative management.

The Examination of Prognostic Factors and Treatment Strategies for Traumatic Cerebrospinal Fluid Leakage

Introduction This study aimed to determine the optimal timing for surgical intervention and the prognostic factors of cerebrospinal fluid (CSF) leakage. Methods We identified 25 patients with probable CSF leaks from 472 consecutive patients with head trauma. In addition to baseline characteristics and findings on admission, injury severity score (ISS), abbreviated injury score (AIS), and other factors related to CSF leakage were considered. We analyzed the prognostic factors after setting the primary endpoint as the modified Rankin Scale (mRS) at the time of discharge to determine the appropriate timing for surgical intervention. Results Univariate analysis revealed significantly poorer prognoses for elderly patients (p<0.001) and cases with low Glasgow Coma Scale (GCS) levels (p=0.039) and high D-dimer levels (p=0.028), which was consistent with findings from the analyses of all patients with head trauma. We found that multiple traumas (AIS≥3 at two or more sites, p=0.047) and high lactate levels (p=0.043) were poor prognostic factors specific to CSF leakage cases, while a longer time to CSF leakage cessation was also associated with a poorer prognosis (median, six days versus 13 days, p=0.014). An evaluation of the time to closure found that spontaneous cessation occurred within 14 days in most cases. Conclusions Conservative medical treatment is the first choice for most cases of traumatic CSF leakage. Surgical intervention should be considered if leakage does not cease after 14 days post injury. Furthermore, severe multiple injuries and high lactate levels were poor prognostic factors specific to patients with CSF leakage.

[Diagnosis and Treatment in frontobasal fractures]

Traumatic brain injury can result in frontobasal fractures (FBF). The goals of treatment for FBF are to eliminate primary morbidity and/or prevent secondary morbidity. Of particular importance in this regard is the proximity of important sensory organs for hearing, vision, smell, and taste, as well as their supplying nervous structures. Medical history, clinical findings, or CT scan are necessary and should lead to an individual evaluation. Depending on the severity of the fractures, the following disciplines may be involved in the treatment of FBF: neurosurgery, plastic surgery, oral and maxillofacial surgery, and/or otorhinolaryngology. Particularly less invasive endoscopic endonasal therapy is a specialty of otorhinolaryngologic surgeons and has not been widely established in other disciplines. The present work provides an overview of the current state of the art in terms of the following aspects, taking into account the current literature: anatomic principles, classification of fractures, diagnostics (in particular clinical examination, imaging, and laboratory chemistry tests), clinical symptoms, and treatment.

A rare case of posttraumatic meningitis presenting with acute hydrocephalus

Posttraumatic meningitis is a severe complication of traumatic brain injury (TBI) that dramatically increases its mortality. Skull-base fractures increase the risk of posttraumatic meningitis. Posttraumatic hydrocephalus was encountered in 0.7 %–29 % of the patients with severe head injury. Posttraumatic hydrocephalus should be differentiated from ventriculomegaly due to brain atrophy.

We present a clinical case of a 52-year-old patient after a mild TBI and a linear skull base fracture who developed acute hydrocephalus in the context of a posttraumatic meningitis within the first week after the injury. The occurrence of hydrocephalus in patients with posttraumatic meningitis is not well studied but could lead to rapid deterioration of the patient. It results from injury-induced disturbance of CSF flow either through obstruction or lack of CSF reabsorption. Factors increasing the risk of posttraumatic meningitis are - operative interventions, skull base fractures and CSF leakage. Patients with meningitis usually present with lower GCS score. The lower GCS is a harbinger of worse prognosis. Therefore, aggressive medical treatment is warranted.

With this case study we show that meningitis presenting with PTH can develop rapidly over 24 h within the first week post mild head injury with basilar skull fracture. A swift response in providing timely ventricular drainage, together with an appropriate antimicrobial coverage, can greatly reduce any lasting neurological deficits and produce a good clinical outcome.

[Traumatology of the lateral skull base]

The most common cause of lateral skull base fractures are still road traffic accidents, followed by falls. The radiologic classification into otic capsule-sparing or otic capsule-violating fractures correlates well with an increased risk of injury to the sensitive structures of the middle ear with otic capsule-violating fractures. In case of immediate onset complete facial nerve paralysis, decompression surgery is generally recommended if bony impingement can be demonstrated on high-resolution CT of the temporal bone. For many other facials nerve complications, recent publications have achieved good to excellent facial nerve recovery rates with watchful waiting under conservative treatment with prednisolone administration.

Cerebrospinal fluid external leak after penetrating trauma in a neurologic intact infant patient: a case report

Cranial cerebrospinal fluid (CSF) leak is an extremely rare complication of blunt head trauma causing skull fractures, especially fractures involving the skull base. We present the case of a 10-month-old male who received glass fragments on the midline and posterior tier of his anterior fontanelle producing a cranial cerebrospinal fluid leak without any skull fracture or symptoms. Neurologic exam was completely normal and a superficial stitch wound repair was performed. He was observed for 24 h, had no antibiotic, and left with a 1-week outpatient neurosurgical follow-up. The patient had no negative outcome. Cerebrospinal fluid leak should be included in the differential diagnosis of a head trauma in a patient with open fontanelles. No similar case was found in literature.

Pneumocephalus as result of nonsurgical peri-implantitis treatment with an air-polishing device for submucosal debridement-A case report

Background

A subcutaneous emphysema is an infrequent but potentially life‐threatening complication after dental treatment involving instruments functioning with pressurized air. Emphysemata after the use of high‐speed handpieces and air‐syringes are well documented, however, more recently several reports on emphysemata produced by air‐polishing devices during management of peri‐implant biological complications have appeared. To the best of our knowledge, direct development of pneumocephalus after a dental procedure has never been reported before. Introduction of air likely contaminated with oral bacteria to the intracranial space bares the risk of developing meningitis.

Case Presentation

This case report describes the spreading of a subcutaneous emphysema into the intracranial space (i.e., development of a pneumocephalus) after treatment of a peri‐implantitis lesion with an air‐polishing device equipped with the nozzle for submucosal debridement. A subcutaneous emphysema was noticed during the use of an air‐polishing device and the subsequent computed tomography (CT) examination revealed a quite unexpected spreading of the emphysema into the intracranial space. The patient was admitted to the hospital for close surveillance, CT follow‐up, and intravenous antibiotics to prevent the development of meningitis due to the introduction of air—likely contaminated with oral bacteria—into the intracranial space. After 3 days, the patient was discharged in good condition without any further complications.

Conclusion

In case of an extensive subcutaneous emphysema as result of a dental procedure, a more extended radiographic examination including the mediastinal and cranial space should be considered, to assess the risk for potentially life‐threatening complications.

Cerebrospinal fluid leak management in anterior basal skull fractures secondary to head trauma

OBJECTIVE

To summarize the presentation, diagnosis, and management of cerebrospinal fluid (CSF) leaks in the setting of traumatic anterior skull base fracture.

METHODS

Wide literature research has been performed as well as the authors' own clinical experience has been summarized.

RESULTS

Articles from the most recent 30 years have been reviewed and a typical case of our own has been presented. Based on the most updated evidence, a treatment algorithm for CSF leaks has been proposed.

CONCLUSION

Anterior skull base fracture accounts for about 4% of all head injuries and CSF leaks is a complication that commonly presents with clear fluid emanating from the nasal passage. A positive beta-2-transferrin study is highly specific for diagnosis, while thin-slice CT scanning and MRI cisternography are also useful tools. The majority of the CSF leaks tend to be resolved spontaneously, and conservative management is attempted first with or without the augmentation of a lumbar drain. Surgical management mainly includes open surgery and endoscopic surgery, which have their own pros and cons.

Case Report: An Intracranial Complication of COVID-19 Nasopharyngeal Swab

INTRODUCTION

Cerebrospinal fluid (CSF) leaks are often the result of trauma or recent surgical procedures; however, a subset can develop from non-traumatic etiologies. Cerebrospinal fluid leaks from congenital and spontaneous encephaloceles can be clinically occult and have devastating consequences if undetected for prolonged periods of time. This report highlights a unique case of meningitis after CSF leak caused by ruptured congenital meningocele during a routine nasopharyngeal swab.

CASE REPORT

A 54-year-old female with diagnosed CSF leak presented to the emergency department (ED) with acute onset of severe headache, and neck and back pain. Prior to this presentation, the patient had experienced two months of persistent headache and rhinorrhea since her coronavirus disease 2019 (COVID-19) nasopharyngeal swab. As part of her outpatient workup, an otolaryngology consultation with subsequent beta-2 transferrin testing and magnetic resonance imaging was performed and she was diagnosed with a CSF leak from ruptured congenital meningocele. On ED presentation, she was afebrile, but with mild tachycardia, leukocytosis, and meningismus. Lumbar puncture revealed acute streptococcal meningitis. This patient's meningitis developed due to prolonged occult CSF leak after her COVID-19 nasopharyngeal swab ruptured a pre-existing congenital meningocele.

CONCLUSION

Nasopharyngeal swabs are being performed much more frequently due to the COVID-19 pandemic. All front-line providers should be aware of the potential presence and rupture of congenital meningoceles in patients who have undergone recent nasopharyngeal swab when risk-stratifying for potential CSF leak and meningitis.

Our Experience on Temporal Bone Fractures: Retrospective Analysis of 141 Cases

Temporal bone fractures are a common lesion of the base of the skull. The diagnosis and management of temporal bone fractures require a multidisciplinary approach. Variable clinical presentations may arise from such fractures, ranging from an asymptomatic course to very serious consequences. The aim of this study was to report our experience with a series of patients with temporal bone fractures and to propose a diagnostic/therapeutic algorithm. This study enrolled 141 patients, 96 (68.1%) males and 45 (31.9%) females, ranging in age from 20 to 60 (average age: 39 ± 4.1 years), with temporal bone fractures who were referred to Cardarelli Hospital between 2006 and 2018. The present paper presents a classification of temporal bone fractures and typical clinical sequelae and provides an illustration of their prognosis and treatment.

Evidenced-Based Practice Among Trainees: A Survey on Facial Trauma Wound Management

OBJECTIVE

Assess whether facial trauma wound care and antibiotic use recommendations are guided by evidence-based practice (EBP) or practice patterns, and investigate strategies to improve EBP adoption among surgical trainees.

DESIGN

We conducted a survey of all trainees who manage facial trauma (general surgery, emergency medicine, plastic surgery, otolaryngology) to assess clinical knowledge and sources of treatment recommendations. Clinical questions were based on Oxford Center for Evidence-Based Medicine Level 1 or 2 evidence. We measured internal validity of questions using Cronbach's α. Results were weight-adjusted for nonresponse and then analyzed using Welch t test and descriptive statistics.

STUDY SETTING

Stanford Hospital and Clinics, a Level I trauma center.

RESULTS

Response rate was 50.3% overall (78/155). For recommendations on facial trauma wound and antibiotic use, nonspecialty junior residents most frequently relied on their own senior or specialty residents (79.1%); nonspecialty senior residents relied on specialty residents (67.9%). Specialty junior residents most often relied on their own senior residents (51.0%), the majority of whom made recommendations based on their own knowledge (73.2%). Questions assessing EBP knowledge had Cronbach's α of 0.98; response accuracy was similar between specialty and nonspecialty residents (54.6% vs 55.5%, p = 0.96). When provided recommendations that conflict with EBP, both nonspecialty and specialty residents more frequently followed recommendations rather than EBP; junior residents reported doing so to avoid conflict with superiors. Total 92.6% of surveyed residents felt cross-departmental EBP guidelines would improve patient care.

CONCLUSIONS

Facial trauma wound care and antibiotic recommendations disseminate down seniority and from craniofacial specialty to nonspecialty residents, yet knowledge of EBP among senior specialty and nonspecialty residents was weak. EBP may be difficult to adopt in the absence of consensus society guidelines. To address this gap, we published a review of EBP for facial trauma and plan to update our trauma manual with cross-departmental guidelines to facilitate EBP adoption among trainees.

Spontaneous Cerebrospinal Fluid Rhinorrhea: A Case Report

Cerebrospinal fluid (CSF) rhinorrhea refers to the loss of CSF through the nasal cavity. Its causes can be classified as either spontaneous or non-spontaneous. Spontaneous causes of CSF rhinorrhea include congenital anatomical defects and are extremely rare, accounting for less than 4% of reported cases. Following failure of conservative management, definitive treatment most commonly involves an endoscopic transsphenoidal repair of the defect. We present a case of spontaneous CSF rhinorrhea in a previously well 52-year-old female, which required surgical intervention due to failure of conservative management.

Post-Traumatic Meningitis Is a Diagnostic Challenging Time: A Systematic Review Focusing on Clinical and Pathological Features

Post-traumatic meningitis is a dreadful condition that presents additional challenges, in terms of both diagnosis and management, when compared with community-acquired cases. Post-traumatic meningitis refers to a meningeal infection causally related to a cranio-cerebral trauma, regardless of temporal proximity. The PICO (participants, intervention, control, and outcomes) question was as follows: "Is there an association between traumatic brain injury and post-traumatic meningitis?" The present systematic review was carried out according to the Preferred Reporting Items for Systematic Review (PRISMA) standards. Studies examining post-traumatic meningitis, paying particular attention to victims of traumatic brain injury, were included. Post-traumatic meningitis represents a high mortality disease. Diagnosis may be difficult both because clinical signs are nonspecific and blurred and because of the lack of pathognomonic laboratory markers. Moreover, these markers increase with a rather long latency, thus not allowing a prompt diagnosis, which could improve patients' outcome. Among all the detectable clinical signs, the appearance of cranial cerebrospinal fluid (CSF) leakage (manifesting as rhinorrhea or otorrhea) should always arouse suspicion of meningitis. On one hand, microbiological exams on cerebrospinal fluid (CSF), which represent the gold standard for the diagnosis, require days to get reliable results. On the other hand, radiological exams, especially CT of the brain, could represent an alternative for early diagnosis. An update on these issues is certainly of interest to focus on possible predictors of survival and useful tools for prompt diagnosis.

Analysis and Clinical Importance of Skull Base Fractures in Adult Patients with Traumatic Brain Injury

Aims and Objectives:

Basal skull fracture (BSF) is rare in head injury (HI) patients and occasionally goes unnoticed which may lead to cerebrospinal fluid (CSF) fistula. With changing trends in HI, there is a need to reassess incidence and pattern of BSF pattern, CSF leak, meningitis, and management protocol, especially in this part of the world where detailed literature is lacking.

Subjects and Methods:

We closely followed adult patients admitted with BSF in our institute between January 2013 and December 2014. Associated clinical features were recorded. In case of CSF leak, detailed CSF study was done and patients were managed accordingly. Patients with persistent CSF leak were managed surgically.

Results:

During the study period, 194 of 5041 HI patients had evidence of BSF (3.85%). BSF was most commonly associated with moderate-to-severe HI (73.19%). About 81.44% patients were male and 29.9% were <30 years. Most common cause was road traffic accident (84.54%). Isolated anterior cranial fossa (ACF) fracture was most common (50%). About 63.92% patients had raccoon eyes. Forty-three patients had CSF leak with CSF rhinorrhea being more common. Culture of only 5 patients suggested bacterial meningitis. CSF leak lasted for more than 10 days in 8 patients, of which 4 patients required surgical repair.

Conclusions:

BSF is rare in victims of HI. It is more common in young adult males. ACF fractures are most common in our setup. Clinical signs of BSF are supportive but not definitive; high resolution computed tomography head is gold standard to detect BSF. CSF leak is rare and most of the cases can be managed conservatively. Leak persisting more than 7–10 days has high risk of developing meningitis and likely to need surgical intervention.

Infection Prevention in the Neurointensive Care Unit: A Systematic Review

Hospital-acquired infections are common in neurointensive care units. We sought to review interventions which may reduce infection rates in neurocritically ill populations. We conducted a systematic review of studies targeting adult patients in neuro-intensive care units (neuro-ICUs) with an intervention designed to prevent ICU-acquired infections. Our outcome of interest was change in the prevalence or rates of infection between active and control arms of these studies. We excluded studies based on the following criteria: no English full-text version available; pediatric population; non-neurosciences ICU population; pre- or intraoperative methods to prevent infection; lack of discrete data for infection rates/prevalence; studies that were purely observational in nature and did not test an intervention; and studies performed in resource limited settings. We initially retrieved 3716 results by searching the following databases: PubMed/MEDLINE, EMBASE via Ovid, and Cochrane CENTRAL via Ovid. No date or language limits were used in the search. Computerized deduplication was conducted using EndNote followed by a confirmatory manual review resulting in 3414 citations. An additional 19 manuscripts were identified through review of references. The screening process followed a standard protocol, using two screeners at the title/abstract level to determine relevance and at the full-text level to determine eligibility for inclusion. The 3427 titles/abstracts were independently screened by two board-certified neurointensivists to determine relevance for full-text review, and 3248 were rejected. The remaining 179 abstracts were reviewed in full text using predetermined inclusion/exclusion criteria. Ultimately, 75 articles met our inclusion criteria and were utilized in the final analysis. The reviewed literature highlights the need for collaborative, multi-disciplinary, and multi-pronged approaches to reduce infections. Rates of VRI, SSI, VAP, CAUTI, and CLABSI can approach zero with persistence and a team-based approach.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

Management of Spontaneous CSF Rhinorrhea: An Institutional Experience

Introduction  Cerebrospinal fluid (CSF) rhinorrhea is the leakage of CSF through nasal cavity, due to abnormal communication between the arachnoid membrane and nasal mucosa. Middle-age (fourth to fifth decade) group, female gender, and obesity (body mass index > 40) are the most commonly reported risk-factors for this rare entity. In this study, we present our single center experience of spontaneous CSF rhinorrhea discussing important clinicoradiological aspects in preoperative evaluation and nuances in the endoscopic repair technique. Material and Methods  A retrospective study conducted for 43 spontaneous CSF rhinorrhea patients admitted between Jan 2011 to Jan 2018 at our tertiary care center. All patients underwent endoscopic repair of the defect depending upon their site of leak. Results  Mean age in our study was 36.7 ± 12.3 years (range: 9-62 years). Average BMI in males was found lower (28.7) as compared with females (32). Most common site of CSF leak was cribriform plate ( n  = 32, 74.4%) and Planum was found to be the least common site ( n  = 1, 2.3%) of CSF leak. Intraoperatively, 23 (53.5%) patients showed high-flow leak. Intrathecal injection of fluorescein dye was used to identify the site of CSF leakage in 15 cases (34.8%). The overall success rate of primary endoscopic repair in our study was 95.3%. Conclusion  Spontaneous CSF rhinorrhea occurs secondary to elevated intracranial pressure, with a predilection for obese females in fourth to fifth decade. Individualized tailored surgical approach depending upon the site, size, and flow-variety of the defect forms the cornerstone of management.

Recurrent meningitis in children: etiologies, outcome, and lessons to learn

PURPOSE

Recurrent meningitis in children is a rare condition. However, its early recognition is important in order to prevent serious complications. This study aims to review cases of recurrent meningitis in children.

METHODS

This is a retrospective study that included children diagnosed with recurrent meningitis and who were followed at child neurology clinic at the Jordan University Hospital from January 2001 to June 2017.

RESULTS

Thirteen patients were included (nine males and four females). Age of first episode of meningitis ranged from 2 months to 9.5 years. The delay in diagnosis of the underlying cause after the first episode ranged from 6 months to 2.5 years. Underlying causes included inner ear malformation in one patient, skull fractures in two, and dermal sinuses (thoracic spinal and occipital dermal sinus) in two patients. No identifiable cause was found in eight patients. Streptococcus pneumoniae was identified in four (31%) patients, Staphylococcus aureus in two (15%), and no organism was isolated in seven (54%). Three patients (23.1%) developed neurological sequel including developmental delay, limb spasticity, and epilepsy. Two patients had sensorineural hearing loss related to meningitis, and two patients had sensorineural hearing loss mostly related to their original disease.

CONCLUSION

A detailed history, examination, and thorough investigations are necessary to determine the underlying cause of recurrent meningitis. In addition, in patients with positive CSF bacterial culture, finding the underlying etiology is very likely.

Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

Background  The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods  Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results  Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture ( n  = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions  Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

Recurrent CSF Rhinorrhea Misdiagnosed as Chronic Allergic Rhinitis with Subsequent Development of Bacterial Meningitis

INTRODUCTION

Cerebrospinal fluid (CSF) rhinorrhea results from an abnormal communication of the dura mater to the nasal mucosa. The majority of cases of CSF rhinorrhea are the result of trauma or surgery involving the skull base. Spontaneous CSF rhinorrhea is a rare clinical entity with increased risk of ascending infection. Delay in diagnosis places the patient at risk of developing meningitis.

CASE PRESENTATION

A 36-year-old African American female with significant medical history of obesity and hypertension presented to the emergency department with headache, altered level of consciousness, fever, and neck stiffness. Previously, the patient was diagnosed with chronic allergic sinusitis by multiple providers. Physical exam findings and laboratory tests were consistent with bacterial meningitis. The patient was admitted and started on appropriate antibiotic therapy. The patient continued to complain of persistent unilateral clear nasal drainage. The initial report from the computerized tomography scan of the sinuses indicated findings consistent with chronic sinusitis. Magnetic resonance imaging of the orbits revealed findings consistent with CSF rhinorrhea. Otolaryngology was consulted for surgical intervention.

CONCLUSION

Suspected CSF rhinorrhea should prompt immediate biochemical and radiologic evaluation and surgical consultation. CSF rhinorrhea places patients at risk of developing bacterial meningitis.

Contemporary Trends in the Management of Posttraumatic Cerebrospinal Fluid Leaks

The objective of this review is to provide an overview on the diagnosis and management of traumatic cerebrospinal fluid (CSF) leaks. This comprehensive review explores controversies associated with the management of CSF leaks as well as a review of the most contemporary literature. The scope of this article covers both traumatic CSF leaks of the middle and anterior cranial fossae.