Imaging of Cerebrospinal Fluid Rhinorrhea and Otorrhea

Diagnostic efficacy of contrast-enhanced fluid-attenuated inversion recovery (FLAIR) imaging in idiopathic cerebrospinal fluid rhinorrhea

We report a case of a 50-year-old woman in which contrast-enhanced fluid-attenuated inversion recovery (FLAIR) was used for the diagnosis of idiopathic cerebrospinal fluid rhinorrhea. The pre- and postcontrast FLAIR subtraction images showed a contrasted protrusion of the right olfactory cleft canal, highlighting the potential practicality and effectiveness of using pre- and postcontrast FLAIR subtraction images in diagnosing idiopathic cerebrospinal fluid rhinorrhea, in conjunction with conventional high-resolution computed tomography and magnetic resonance cisternography. The successful diagnosis of cerebrospinal fluid rhinorrhea allowed for treatment through endoscopic nasal surgery to close the fistula with a positive clinical outcome.

Reliability of High-resolution Gadolinium-enhanced MR Cisternography and Gasket-seal Technique for Management of Anterior Skull Base Defects

PURPOSE

Precise preoperative localization of anterior skull base defects is important to plan surgical access, increase the success rate and reduce complications. A stable closure of the defect is vital to prevent recurrence of cerebrospinal fluid (CSF) rhinorrhea. The purpose of this retrospective case series was to evaluate the reliability of a new high-resolution gadolinium-enhanced compressed-sensing SPACE technique (CS T1 SPACE) for magnetic resonance (MR) cisternography to detect cerebrospinal fluid leaks of the anterior skull base and to assess the long-term success rate of the gasket-seal technique for closure of skull base defects.

METHOD

All patients with spontaneous or postoperative cerebrospinal fluid rhinorrhea and defects of the anterior skull base presenting to the Departments of Otorhinolaryngology and Neurosurgery between 2019 and 2020, receiving a computed tomography (CT) cisternography and MR cisternography (on a 3T whole-body MR scanner using a 64-channel head and neck coil) with CS T1 SPACE sequence and closure of the defect with the gasket-seal technique, were enrolled in the study. For the cisternography, iodinated contrast agent (15 ml Solutrast 250 M®), saline (4 mL) mixed with a 0.5 mL of gadoteridol was injected into the lumbar subarachnoid space.

RESULTS

A total of four patients were included in the study and MR cisternography with CS T1 SPACE sequence was able to precisely localize CSF leaks in all patients. The imaging results correlated with intraoperative findings. All defects could be successfully closed with the gasket-seal technique. The mean follow-up was 35.25 months (range 33-37 months).

CONCLUSION

MR cisternography with CS T1 SPACE sequence could be a promising technique for precise localization of CSF leaks and the gasket-seal technique resulted in good closure of the CSF fistula in this case series.

Combined surgical repair and venous sinus stenting for patients with skull base encephaloceles secondary to dural venous sinus stenosis

BACKGROUND

Chronically elevated intracranial pressure (ICP) seen in idiopathic intracranial hypertension (IIH) can cause the development of skull base encephaloceles and cerebrospinal fluid (CSF) leaks. Surgical repair and ventriculoperitoneal shunt (VPS) placement are mainstays of treatment. Venous sinus stenting (VSS) is a newly accepted treatment modality. The goal of this study was thus to determine if VSS can be used to treat symptoms and prevent recurrence after surgical encephalocele repair.

METHODS

Retrospective chart review of patients that had surgical repair of encephaloceles followed by VSS for symptomatic stenosis with elevated pressure gradient.

RESULTS

A total of 13 patients underwent a combined encephalocele repair and VSS. Seventy-two percent were female; 46% had headaches, 69% pulsatile tinnitus, and 92% CSF rhinorrhea or otorrhea. One had seizures. Mean lumbar opening pressure was 23.3 ± 2.6 cm H2O; the average sagittal-to-jugular pressure gradient was 12.7 ± 1.8 cmH2O and was elevated in all patients. Four patients had middle fossa craniotomy for repair of tegmen defect (one bilateral); one had a retrosigmoid craniotomy for repair of a sigmoid plate defect. Eight had an endoscopic endonasal repair for sphenoid or cribriform plate encephalocele. There were no VSS procedural complications or complications associated with dual antiplatelet therapy. One patient had meningitis after endoscopic repair that was treated with antibiotics. One patient had recurrence of both CSF leak and venous stenosis adjacent to the stent requiring repeat repair and VSS. There was no further recurrence.

CONCLUSION

In patients with dural sinus stenosis and encephaloceles requiring repair, VSS can be performed safely within weeks of surgery for relief of symptoms, resolution of underlying pathology, and prevention of CSF leak recurrence.

An Elusive Diagnosis: Delays in Treatment and Opportunities for Improvement in Temporal Encephalocele and CSF Leak

Objective

Symptoms of temporal encephalocele or cerebrospinal fluid (CSF) leak causing middle ear effusion or otorrhea can be nonspecific and mistaken for other common diagnoses, leading to delays in diagnosis, failed treatments, and a risk of meningitis. This study sought to investigate the association between symptomatology and time to definitive surgical management.

Study Design

Retrospective cohort.

Setting

Single tertiary care academic medical center.

Patients

Adults treated surgically for temporal encephalocele or CSF leak. Revision cases were excluded.

Interventions

Chart review was performed to identify pertinent symptoms at presentation. Multivariable regression was performed to analyze the association between symptoms and time to definitive management.

Main Outcome Measures

Otologic and related symptoms present prior to middle cranial fossa (MCF). Time between symptom onset and surgical treatment.

Results

Thirty-four patients had symptoms present a median of 15.5 months (interquartile range, 8-35 months; range, 1 month to 12 years) prior to surgery. The most common symptoms were subjective hearing loss in the affected ear (76.5%) and aural fullness (73.5%). Otorrhea was present in 55.9%, and 42.9% had a history of otorrhea after myringotomy with or without tube insertion. Meningitis occurred in 5 patients (14.7%). Only the absence of otalgia was statistically significantly associated with decreased time between symptoms onset and surgery (P = 0.01).

Conclusions

Encephalocele and CSF leak were most commonly associated with aural fullness and hearing loss. Medical treatment for presumed Eustachian tube dysfunction or chronic ear disease were commonly observed. Patients had symptoms for a median of almost 1 and a half years prior to surgical management.

Frailty in middle cranial fossa approach for encephalocele or cerebrospinal fluid leak repair

Objective

The modified 5-item frailty index (mFI-5) is a concise, comorbidity-based risk stratification tool that can predict adverse outcomes after surgery. The goal of this study was to understand the frailty of patients undergoing surgery for temporal encephalocele or cerebrospinal fluid (CSF) leak and the utility of mFI-5 for predicting increased post-operative outcomes.

Methods

A retrospective review of adults with temporal encephalocele or CSF leak who underwent middle cranial fossa (MCF) approach craniotomies with or without mastoidectomy from January 2015 through August 2021 at a tertiary care academic medical center was performed. Patients who underwent additional surgeries or extended surgical approaches were excluded. The mFI-5 was calculated for all patients. Demographic and clinical data were obtained from the medical record.

Results

Thirty-six patients underwent 40 MCF approach craniotomies for temporal encephalocele or CSF leak, including three revision cases and one patient with sequential bilateral operations. Mean age was 54.1 ± 10.8 years, and 66.7% were female. In the univariable regression analysis, mFI-5 score, age, and procedure time use were significantly associated with increased hospital length of stay (LOS) but not increased intensive care unit (ICU) LOS. Anesthesia time and lumbar drain were significantly associated with increased hospital LOS and ICU LOS, and they remained significantly associated with increased hospital LOS in the multivariable model.

Conclusion

Frailty is associated with increased hospital LOS stay among patients undergoing MCF approach for CSF leak or encephalocele. Reducing anesthesia time and avoiding lumbar drain use are potentially modifiable risk factors that can reduce the LOS and associated costs.

Level of Evidence

4.

[Diagnostic value of computed tomographic cisternography and magnetic resonance hydrography in cerebrospinal fluid rhinorrhea]

Objective:To evaluate the accuracy of preoperative computed tomographic cisternography（CTC） and magnetic resonance hydrography（MRH）in the diagnosis of cerebrospinal fluid（CSF） rhinorrhea. Methods:Retrospective analysis was made on the data of 38 patients diagnosed as cerebrospinal rhinorrhea who completed preoperative HRCT, CTC and MRH examinations in the Department of Otolaryngology Head and Neck Surgery of Tianjin Huanhu Hospital from October 2016 to January 2022. The diagnostic accuracy of preoperative imaging examinations was compared according to the leak location found during operation. Results:Among all the 38 cases with CSF rhinorrhea, the detection rates of HRCT, CTC, and cranial MRH were 31.58%, 89.47%, and 60.53%, respectively. The accuracy of CTC was significantlyhigher than that of MRH （ χ²=8.49, P=0.007）, and the accuracy of MRH was significantly higher than that of HRCT （χ²=6.41, P=0.01）. Subgroup analyses were performed according to the precise positioning of cerebrospinal fluid rhinorrhea leakage. In patients with cerebrospinal fluid rhinorrhea located in ethmoid sinus, the accuracy of CTC（80.95% vs. 14.29%，P<0.01）and MRH（52.38% vs. 14.29%，P=0.02）were significantly higher than that of HRCT, but the accuracy but the difference between CTC and MRH between CTC and MRH was not statistically significant （P=0.10）. The accuracy of CTC was significantly higher than that of MRH （100.00% vs. 61.54%, P=0.04） and HRCT （100.00% vs. 53.85%, P<0.01） in patients with CSF rhinorrhea located in sphenoid sinus. However, there was no significant difference in the accuracy between MRH and HRCT （ P=1.00）. However, There was no significant difference in the accuracy of CTC, MRH and HRCT in patients with cerebrospinal fluid rhinorrhea located in frontal sinus. The accuracy of CTC and MRH was 84.62% and 57.69% respectively in 26 patients who failed to detect a CSF rhinorrhea by HRCT, and the difference was not statistically significant（χ²=4.59, P=0.06）. Conclusion:The comprehensive application of the multiple imaging methods has important guiding significance for the accurate treatment and prognosis evaluation. CTC and MRH could improve the accuracy of the localization diagnosis of cerebrospinal fluid rhinorrhea.

CT Cisternogram Findings in Idiopathic Cerebrospinal Fluid Leaks with Emphasis on Long Term Management

To study the various computed tomography (CT) cisternogram findings in idiopathic cerebrospinal fluid (CSF) leaks and the long term treatment modalities after surgical repair of idiopathic CSF leaks. This was a descriptive study conducted among 25 patients in MCV memorial ENT trust hospital, Pollachi between May 2014 and May 2020 amongst patients who underwent CT cisternogram for unilateral or bilateral spontaneous rhinorrhea with or without associated headache, visual disturbances and papilloedema diagnosed to be idiopathic CSF leak by investigations. These patients then underwent CSF leak repair and postoperatively were managed with weight reduction, low salt diet and diuretic therapy. Post surgery these patients were followed up for a period of 12 months and were evaluated on the basis of presence or absence of headache, rhinorrhea and papilloedema at the end of 1st month, 3rd month, 6th month and 1 year and data was collected. CT cisternogram findings were evaluated by proportion method and evaluation of long term management was done using proportion and repeated measures ANOVA for all patients. Evidence of the presence of previously mentioned CT cisternogram or contrast MRI findings at the end of 1 year of post-surgical treatment was recorded where patients were willing for the same. CT Cisternography was done for all patients and 72% patients had empty sella appearance while 28% had partially empty sella. Other findings included perioptic filling, optic blunting and arachnoid pits which were found in 11(44%), 8(32%) and 12(48%) of patients respectively. Only 3(12%) out of 25 patients had an encephalocoele. The commonest site of leak in CT cisternography was the cribriform plate (52%) followed by lateral recess of sphenoid (48%). None of the patients had multiple sites of leak in CT cisternography. On follow up post surgery maximum resolution of symptoms was found at the end of 12 months where 23 out of 25 patients improved. In our study, out of 25 only 5 patients agreed to undergo post diuretic therapy MRI scan out of which 2 patients had partially empty sella and 3 had normal sella indicating resolution of BIH. CT cisternography is an important investigation which aids in the diagnosis of CSF rhinorrhea due to idiopathic intracranial hypertension (IIH). The medical management of IIH post surgery such as weight reduction, salt restriction and diuretic therapy is also crucial to prevent recurrence of symptoms.

Le Fort III fractures: An approach to resuscitation and management

Introduction

Le Fort fractures occur in approximately 20% of facial fractures and result from a high velocity/force mechanism of injury. In those rare 20% occurrences, the Le Fort III fractures are the least common and are highly associated with injuries of the cervical spine, intracranial, and internal neck structures.

Importance

This makes them difficult to manage and requiring a definitive sequence of resuscitation and thorough secondary and tertiary surveys thereafter. The morbidity and mortality of these severe fractures is high but with appropriate resuscitation and adequate stabilization of the fracture, this may be improved on and lowered.

Case presentation

A male sustaining multiple stabs to the face presents to a level one trauma emergency unit haemodynamically unstable/abnormal with a threatened airway and stridor. Discussion: This case report walks through step-by-step the management approaches at each stage thereby assessing and managing the outcomes of each diagnosis.

Conclusion

Le Fort III fractures are rare but critical injuries that require intensive resuscitation and a multidisciplinary approach to achieve wholistic and appropriate management of these patients. Adequate initial resuscitation and stabilization of fractures may improve the morbidity and mortality of these sever injuries.

•

Le Fort fractures result from a high velocity/force mechanism of injury, and those rare 20% occurrences, the Le Fort III fractures are the least common and are highly associated with injuries of the cervical spine, intracranial, and internal neck structures.

•

A male sustaining multiple stabs to the face presents haemodynamically unstable/abnormal with a threatened airway and stridor.

•

Le Fort III fractures require intensive resuscitation and a multidisciplinary approach to achieve wholistic and appropriate management of these patients through airway securing, CT scan, and theatre to plate the fractures.

Hagiwara M, Policeni B, Juliano AF, Agarwal M, Burns J, Dubey P, Friedman ER, Gule-Monroe MK, Jain V, Lam K, Patino M, Rath TJ, Shian B, Subramaniam RM, Taheri MR, Zander D, Corey AS. ACR Appropriateness Criteria® Sinonasal Disease: 2021 Update

This article presents guidelines for initial imaging utilization in patients presenting with sinonasal disease, including acute rhinosinusitis without and with suspected orbital and intracranial complications, chronic rhinosinusitis, suspected invasive fungal sinusitis, suspected sinonasal mass, and suspected cerebrospinal fluid leak. CT and MRI are the primary imaging modalities used to evaluate patients with sinonasal disease. Given its detailed depiction of bony anatomy, CT can accurately demonstrate the presence of sinonasal disease, bony erosions, and anatomic variants, and is essential for surgical planning. Given its superior soft tissue contrast, MRI can accurately identify clinically suspected intracranial and intraorbital complications, delineate soft tissue extension of tumor and distinguish mass from obstructed secretions.The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Surgical Repair of Skull Base CSF Leaks after Cisternography Diagnosis: Analysis of Validity and Surgical Outcome and Impact on Future Treatment Strategies

Skull base cerebrospinal fluid (CSF) leaks can lead to severe complications and require appropriate diagnosis and treatment. Cisternography is applied when exact localization via conventional imaging is not successful. The present study is aimed at identifying factors with potential impact on radiological results and surgical success. Cisternography followed by surgical repair due to skull base CSF leaks was performed in 63 cases between 2002 and 2020. The clinical and radiological findings were analyzed retrospectively. The etiology of CSF leaks was traumatic in 30.2%, spontaneous in 36.5%, and iatrogenic in 33.3%. The sensitivity of cisternography was 87.9%. Spontaneous CSF leaks tended to be diagnosed less frequently via cisternography and were significantly less frequently localized intraoperatively. The median postoperative follow-up period was 34 months. The primary surgical success rate was 79.4%, with a significantly higher success rate for lateral than for anterior skull base defects. Surgical failure tended to be lower in iatrogenic and higher in traumatic defects. Cisternography proved to be a highly sensitive method to localize skull base CSF leaks and can be recommended for advanced diagnostics. Iatrogenic leaks seemed to be more likely to have a favorable surgical outcome, whereas traumatic leaks tended to have a lower surgical success rate.

[The value of magnetic resonance hydrography in the localization of fistula in patients with cerebrospinal fluid rhinorrhea]

Objective:To evaluate the application value of magnetic resonance hydrography in determine the leak location of patients with cerebrospinal fluid rhinorrhea. Methods:Clinical data of 58 patients with cerebrospinal fluid rhinorrhea treated in Tianjin Huanhu Hospital from February 2015 to February 2021 were analyzed retrospectively. The leak position was judged by three methods: nasal sinus coronal CT, magnetic resonance hydrography and magnetic resonance hydrography combined with nasal sinus coronal CT. The consistency of the leak position among groups determined by different imageological examination pre-operation was compared with the real leak position found during the operation. Results:The positive rate of magnetic resonance hydrography combined with coronal CT in paranasal sinuses（91.4%） was significantly higher than that of magnetic resonance hydrography（74.1%）（P>0.05）. The positive rate of magnetic resonance hydrography（74.1%） was higher than that of CT（43.1%）（P>0.01）. Conclusion:The comprehensive application of imaging examination technology has important clinical guiding significance for the correct diagnosis of cerebrospinal fluid rhinorrhea. Magnetic resonance hydrography combined with coronal CT of paranasal sinus can effectively find the leak location, which was suggested as the first choice for preoperative localization of cerebrospinal fluid rhinorrhea.

Usefulness of imaging studies for diagnosing and localizing cerebrospinal fluid rhinorrhea: A systematic review and meta-analysis

OBJECTIVES

To evaluate the usefulness of diagnosis by imaging studies for the localization of cerebrospinal fluid rhinorrhea.

METHODS

PubMed, SCOPUS, Embase, Web of Science, and Cochrane library databases were searched up to July 2021. True and false positive and negative data were collected along with the characteristics of each study. Methodological quality was assessed using the QADAS-2 tool.

RESULTS

Sixteen studies involving 472 patients were included. The diagnostic odds ratio of imaging studies was 13.6195 (95% confidence interval [7.4756; 24.8129]; I² = 28.1%). The area under the summary receiver operating characteristic curve was 0.712. Sensitivity, specificity, negative predictive value, and positive predictive value were 0.8507 ([0.7773; 0.9029]; 72.1%), 0.7827 ([0.6865; 0.8556], 26.8%), 0.5828 ([0.4398; 0.7132]; 67.4%), and 0.9407 ([0.8935; 0.9678]; 59.1%), respectively. In subgroup analysis, there were significant differences in sensitivity (computed tomography, 0.7421; computed tomography cisternography, 0.8872; magnetic resonance imaging, 0.8365; magnetic resonance cisternography, 0.8565; and intrathecal gadolinium magnetic resonance cisternography, 0.9307; radionuclide cisteronography, 0.7097; p  =  0.0481), and negative predictive value among imaging modalities (computed tomography, 0.3028; computed tomography cisternography, 0.4848; magnetic resonance imaging, 0.4658; magnetic resonance cisternography, 0.7465; and intrathecal gadolinium magnetic resonance cisternography, 0.8611, and radionuclide cisteronography, 0.5263; p  =  0.0046). There were no significant differences among imaging modalities in specificity, positive predictive value, or diagnostic odds ratio (p > 0.05).

CONCLUSION

Imaging studies can be used in the diagnosis of cerebrospinal fluid rhinorrhea. Gadolinium magnetic resonance cisternography showed the highest diagnostic accuracy. Also, magnetic resonance cisternography showed fair diagnostic accuracy without intrathecal injection. This article is protected by copyright. All rights reserved.

[Surgical management of 27 cases with temporal bone cerebrospinal fluid leakage]

Objective:To study the clinical manifestations and surgical treatment of temporal bone cerebrospinal fluid leakage. Methods:The clinical data of twenty seven cases with temporal bone cerebrospinal fluid leakage were analyzed retrospectively. Different surgical procedures were adopted according to the location of the leak and the hearing status of the affected ear.If the leakage location was clear before surgery, direct repair was performed via mastoid path or middle cranial fossa path with or without mastoid abdominal fat packing.For patients with unclear leak, large lesion or intractable CEREBROspinal fluid leakage of temporal bone, subtotal petrosal resection and abdominal fat packing were performed.Subtotal temporal bone resection and abdominal fat packing were performed for patients with cochlear involvement. Results:In this study, cases of temporal bone CSF leakage including 13 cases of inner ear malformation; 5 cases secondary to head trauma or previous surgery,5 cases of idiopathic intracranial hypertension or meningocele, 2 cases of langerhans histiocytosis in the temporal bone and 2 cases of inner ear inflammation. High resolution CT （HRCT） of temporal bone showed bone defect of inner auditory canal with vestibular communication in 13 patients with inner ear malformation.The temporal bone HRCT of the remaining 14 patients showed bone defects in the middle cranial fossa or posterior cranial fossa, while MRI of the temporal bone showed meningeal continuity interruption with cerebrospinal fluid inflow into the temporal bone or meningoencephalocele in 12 patients. The 26 patients were followed up from 6 months to 6 years. 1 patient lost follow-up.Meningitis recurred in only 1 patient with inner ear malformation, and subtotal resection of rock bone plus abdominal fat packing was performed.Postoperative hearing was preserved or improved in 7 patients.None of the patients had serious complications, and only 1 patient developed HB Grade Ⅱ facial paralysis after vestibular obliteration, and the facial paralysis recovered within one week. Conclusion:Temporal bone cerebrospinal fluid leakage is relatively rare. Surgical intervention should be taken as early as possible when conservative treatment is failure. Preoperative HRCT and MRI examination are necessary for the localization of the leakage, and individualized surgical approaches can be adopted according to the location of the leakage and the features of the lesion.

Management of cerebrospinal fluid leak: the importance of multidisciplinary approach

Cerebrospinal fluid (CSF) leak remains a rare condition, characterized by serious complications and potentially fatal. According to different etiologies, CSF leaks may be classified into two main categories: traumatic and spontaneous. Spontaneous fistulas seem to be mainly related to obesity and idiopathic intracranial hypertension. Diagnosis is both clinical and radiological. During the last three decades, surgical treatment has mostly shifted to endonasal endoscopic approach, which widely demonstrated to be more effective than invasive intracranial ones. Post-operative complications, long-term sequelae and hospital stay are strongly reduced thanks to endoscopic approach. The diagnosis and treatment of CSF leaks represent a difficult and challenge task. The main effort seems to be related to the precise localization of the leak. An accurate assessment of both predisposing factors and comorbidities is mandatory in case of spontaneous leaks. However, a clinical multidisciplinary evaluation as well as treatment, is essential to decrease the rate of failure of surgery. The presence of a dedicated instruments, the Skull Base Team, the knowledge of reconstructive materials and techniques represents a decisive result in therapeutical management even if for each patient an effective therapeutic algorithm can be obtained considering the correct leak detection and characteristics. In conclusion the strict teamwork with neurosurgeons, neuroradiologists, ophtalmologists will enable the development also of innovative biomaterials, which could spread and standardize multi-layer techniques, nowadays still related to surgeon preferences.

Special MRI Techniques to Suss out Spontaneous Cerebrospinal Fluid Leaks

Anterior skull base cerebrospinal fluid (CSF) fistulas result from skull base osteodural defects, allowing subarachnoid space CSF to escape into pneumatized cavities such as the paranasal sinuses and nasal fossa. Precise localization, characterization, and effective treatment of CSF leaks is essential to prevent meningitis, treatment failure, or recurrence. Advances in magnetic resonance imaging have improved radiologists' ability to localize and characterize anterior skull base CSF fistulas. This article reviews new imaging techniques enabling diagnostic location of CSF fistulas, with an emphasis on magnetic resonance imaging-based techniques.

Spontaneous cerebrospinal fluid leaks of the temporal bone - clinical features and management outcomes

OBJECTIVE

METHODS: A retrospective cohort study over seven-years from 2013 to 2020 was conducted at five tertiary referral centres. Patients identified with biochemically confirmed spontaneous cerebrospinal fluid leaks of the temporal bone manifesting as middle ear fluid with no other obvious cause were included. Demographics (age, gender, body-mass-index), symptomatology, past medical history, examination, investigation (biochemical and radiological), management and outcomes were recorded.

RESULTS

90 adult patients with spontaneous cerebrospinal fluid otorrhoea were identified. Right sided leaks were most common (58%), and a majority of the cohort overweight (mean body-mass-index = 29.2 kg/m²). Unilateral hearing loss was the commonest presenting symptom (81%). Two patients presented to hospital with meningitis presumed secondary to spontaneous cerebrospinal fluid otorrhoea. Over half (54%) of patients were observed who tended to be older (mean age of 71 years vs 62 years) whilst the remainder underwent surgical repair with middle-fossa craniotomy the most common approach (87%). Eight patients managed surgically had recurrent leaks (21%).

CONCLUSIONS

This is one of the largest cohorts of spontaneous cerebrospinal fluid otorrhoea reported in the literature and reiterates the importance for clinicians to have a high index of suspicion for this condition in patients presenting with a unilateral middle ear effusion, especially in those who are overweight. Surgical intervention carries a risk of recurrence and further studies are needed to determine the risk of intra-cranial infection in order to guide management.

High-Resolution Gadolinium-Enhanced MR Cisternography Using Compressed-Sensing T1 SPACE Technique for Detection of Intracranial CSF Leaks

In patients with CSF rhinorrhea, accurate identification of the CSF leakage site is crucial for surgical planning. We describe the application of a novel gadolinium-enhanced high-resolution 3D compressed-sensing T1 SPACE technique for MR cisternography and compare findings with CT cisternography and intraoperative results. In our pilot experience with 7 patients, precise detection of CSF leaks was feasible using compressed-sensing T1 SPACE, which appeared to be superior to CT cisternography.

Middle Cranial Fossa Repair of Temporal Bone Spontaneous CSF Leaks With Hydroxyapatite Bone Cement

OBJECTIVES

To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks.

STUDY DESIGN

Retrospective cohort study.

METHODS

Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded.

RESULTS

The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1-9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short-term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long-term CSF leak recurrences with an average (SD) follow-up of 13.5 (12.9) months (range 0.25-46 months).

CONCLUSIONS

MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:624-632, 2021.

Pseudo-Cerebrospinal Fluid Leaks of the Anterior Skull Base: Algorithm for Diagnosis and Management

Objective  Pseudo-cerebrospinal fluid (CSF) leaks are a rare cause of unilateral, watery rhinorrhea. We proposed a step-wise approach to evaluate these cases. Design  It involves a single-center retrospective cohort study. Setting  The setting is that of a tertiary academic medical center. Participants  Ten patients with diagnosis of pseudo-CSF leak over a 21-year period were evaluated using our proposed algorithm that includes computed tomography, magnetic resonance imaging, nasal endoscopy, β-2 transferrin, intrathecal fluorescein, and surgical exploration of the anterior cranial base. Main Outcome Measures  The occurrence of intracranial infection and resolution of the symptoms were evaluated at a mean follow-up of 94.4 months. Results  Eight patients had history of skull base fracture or surgery. In all patients computed tomography, magnetic resonance imaging, and nasal endoscopy did not show signs of CSF leak. Beta-2 transferrin testing was performed in five patients, being negative in all of them. Intrathecal fluorescein was performed in seven patients, being negative in five and inconclusive in two. Surgical exploration was performed in five patients, definitively ruling out CSF leak. Six patients were treated with intranasal ipratropium, resolving the symptoms in all cases. Conclusion  The presented algorithm provides a step-wise approach for patients with unilateral watery rhinorrhea, allowing to safely ruling out CSF leak.

Investigation of Skull-Based Cerebrospinal Fluid Leak Repair: A Single-Institution Comprehensive Study of 116 Cases Over 10 Years

BACKGROUND

Cerebrospinal fluid (CSF) leaks have been historically difficult to diagnose and treat because their cause can widely vary. There are insufficient diagnostic predictors and no clinically accepted standards for their treatment. This large institutional study reports on the diagnosis, management, and outcomes of patients presenting with CSF leak over 10 years and aims to identify potential comorbidities and risk factors for primary and recurrent leaks.

METHODS

Patients diagnosed with CSF leak from 2007 to 2017 were analyzed retrospectively. The data included medical history, body mass index, surgical treatment, and postoperative outcomes.

RESULTS

A total of 116 cases were identified. The location of leaks was 91 CSF rhinorrhea and 28 CSF otorrhea (3 both). The average BMI for females was greater than that of males (P = 0.01). Causes of leak were 64 noniatrogenic, 47 iatrogenic, and 9 traumatic. A total of 108 patients underwent surgical treatment. Sixty-nine were treated by endoscopic approaches, 42 involved open approaches, and 83 involved the placement of a lumbar drain. Eighteen patients had a ventriculoperitoneal shunt and 6 had a lumbar-peritoneal shunt. A total of 78 patients (72.22%) had an associated encephalocele with the CSF leak. The average length of stay was 7.73 days (0.76). The average length of follow-up was 1.58 years (0.22). The primary repair rate was 80.17% (n = 93) and the overall repair outcome was 99.14% (n = 115).

CONCLUSIONS

The overall CSF repair outcome was 99.14% over 10 years at a single institution. Despite this high percentage, CSF leaks continue to be a complex problem and require vigorous multidisciplinary work with close follow-up and use of multiple imaging strategies.

Detection of Cerebrospinal Fluid Leaks: Is There a Radiologic Standard of Care? A Systematic Review

INTRODUCTION

Diagnosis of cerebrospinal fluid (CSF) leaks traditionally involves laboratory testing of markers and appropriate imaging. Surgical localization can be difficult, and the inability to accurately localize skull base defects leads to increased rates of repair failure and complications. Many imaging techniques localizing and identifying CSF leaks have been proposed. Comparisons of current and investigational imaging techniques used to localize CSF leaks are reviewed.

METHODS

A comprehensive and systematic search through PubMed, Scopus, and reference lists from relevant articles was completed to identify literature on sensitivities of different imaging methods for localization and detection of CSF leaks. Prospective, retrospective, and case series published since 1995 that addressed imaging techniques for CSF leaks confined to the skull base were included. Sensitivities of each major imaging technique proposed were recorded and analyzed.

RESULTS

In total, 133 studies initially were screened from 2125 studies on preliminary search. Of these, 38 studies were included based on inclusion criteria. Studies were segregated by imaging modality. A total of 1000 patients with CSF leaks subsequently were evaluated.

CONCLUSIONS

Although radionuclide cisternography has been the historical standard, recent imaging techniques have emerged considering the low sensitivity. Computed tomography cisternography with contrast also has low sensitivity, even in active leaks. Although high-resolution computed tomography is commonly the initial study of choice, magnetic resonance imaging methods, particularly 3-dimensional imaging, may prove to be a more sensitive study of choice. Computed tomography/magnetic resonance imaging combination methods may show promise in localizing CSF leaks. Stratifying by status and etiology may be an important determinant. Further studies investigating various imaging techniques for localizing CSF leaks are needed.

Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach

Cerebrospinal fluid (CSF) leaks are extracranial egress of CSF into the adjacent paranasal sinus or tympanomastoid cavity due to an osteodural defect involving skull base. It can be due to a multitude of causes including accidental or iatrogenic trauma, congenital malformations and spontaneous leaks. Accurate localization of the site of the leak, underlying causes and appropriate therapy is necessary to avoid associated complications. In this paper relevant anatomy, clinical diagnosis, imaging modalities and associated findings are discussed along with a brief mention about management.

Spontaneous cerebrospinal fluid rhinorrhea: A case report and analysis

INTRODUCTION

Spontaneous cerebrospinal fluid leakage is usually caused by developmental abnormalities and is rare, accounting for approximately 5% of the cases of cerebrospinal fluid (CSF) leakage. To the best of our knowledge, clival dysplasia-caused CSF rhinorrhea has never been reported in the neurosurgical field.

CONCLUSION

Spontaneous cerebrospinal fluid rhinorrhea is often treated by surgery, and a transsphenoidal approach repair is the main surgical method used, offering the advantages of less trauma, fewer complications, rapid postoperative recovery, and low recurrence rate.

Frontoethmoidal Schwannoma with Exertional Cerebrospinal Fluid Rhinorrhea: Case Report and Review of Literature

BACKGROUND

Frontoethmoidal schwannomas are rare. No case manifesting exertional cerebrospinal fluid (CSF) rhinorrhea has ever been reported to the best of our knowledge.

CASE DESCRIPTION

In this report, we describe an extremely rare case of frontoethmoidal schwannoma extending through the olfactory groove with exertional CSF rhinorrhea as the initial symptom. A 50-year-old woman was presented to our clinic for frequent nasal discharge on exertion. A postcontrast computed tomographic scan demonstrated heterogeneously enhanced tumor from the anterior cranial fossa to the anterior ethmoid sinus. A gadolinium-enhanced T1-weighted magnetic resonance image revealed a well-defined heterogeneously enhanced tumor situated in the midline anterior cranial fossa and anterior ethmoid sinus. After the resection, the defect of the right anterior skull base was reconstructed with a fascia graft and adipose tissue taken from the abdomen, as well as a pedicle periosteum flap. A histologic examination revealed the tumor as schwannoma. Her rhinorrhea completely resolved. She regained her sense of smell and taste 1 month after the operation.

CONCLUSION

According to previous reports, olfactory groove, and paraolfactory groove/periolfactory groove schwannomas can be divided into 4 types: subfrontal, nasoethmoidal, frontoethmoidal, and ethmofrontal. Among them, a frontoethmoidal schwannoma can manifest exertional CSF rhinorrhea as an initial symptom.

Tau protein as a possible marker of cerebrospinal fluid leakage in cerebrospinal fluid rhinorrhoea: A pilot study

Introduction

The management of posttraumatic cerebrospinal fluid (CSF) rhinorrhoea remains a clinical challenge. Cerebrospinal fistula is a dural defect responsible for possible CSF leakage into the contiguous air-filled cavities located at the skull base. The risk of central nervous system infection in these conditions is severe and can be life threatening. Consequently, a specific CSF biomarker might be used in case of difficult diagnosis of CSF rhinorrhoea. CSF Tau protein is a neuronal protein, commonly assessed for diagnosis of Alzheimer Disease (AD). The aim of this study was to determine whether the Tau protein could be a relevant marker of CSF leakage.

Materials and methods

Tau protein measurement was performed by enzyme-linked immunosorbent assay in 13 patients with CSF leakage (CSF rhinorrhoea group), and 8 patients with spontaneous aqueous rhinorrhoea (non-CSF leakage group). The serum concentration of Tau protein was measured by ELISA in both CSF rhinorrhoea group and non-CSF leakage group.

Results

In patients with CSF leakage, CSF Tau protein median concentration was 479 ng/L (197 - 2325 ng/L). On the other hand, the Tau protein concentration was below the lower limit of quantification (LLoQ) (< 87 ng/L) in non-CSF leakage group. Serum Tau protein concentration by ELISA was also below LLoQ (< 87 ng/L) for all subjects.

Conclusion

ELISA measurement of Tau protein in rhinorrhoea fluid may be a reliable and relevant marker for detecting the presence of CSF in the nasal discharge and sign the existence of a CSF leakage.