Traumatic cerebrospinal fluid leakage: risk factors and the use of prophylactic antibiotics

Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures

BACKGROUND

Basilar skull fractures (BSF) predispose patients to meningitis because of the possible direct contact of bacteria in the paranasal sinuses, nasopharynx or middle ear with the central nervous system (CNS). Cerebrospinal fluid (CSF) leakage has been associated with a greater risk of contracting meningitis. Antibiotics are often given prophylactically, although their role for preventing bacterial meningitis is not established.

OBJECTIVES

To evaluate the effectiveness of prophylactic antibiotics for preventing meningitis in patients with BSF.

SEARCH STRATEGY

We searched the Cochrane Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 3, 2005), MEDLINE (1966 to September 2005), EMBASE (1974 to June 2005), and LILACS (1982 to September 2005). We also performed an electronic search of meeting proceedings from the American Association of Neurological Surgeons (1997 to September 2005) and handsearched the abstracts of meeting proceedings of the European Association of Neurosurgical Societies (1995, 1999 and 2003).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing any antibiotic versus placebo or no intervention. We also identified non-RCTs to perform a separate meta-analysis to compare results.

DATA COLLECTION AND ANALYSIS

At least two authors independently appraised the quality and extracted the data of each trial.

MAIN RESULTS

Five RCTs and 17 non-RCTs comparing different types of antibiotic prophylaxis with placebo or no intervention in patients with BSF were identified. Most trials presented insufficient methodological detail. All studies included meningitis in their primary outcome. Overall, we evaluated 208 participants from the four RCTs that were considered suitable for inclusion in the meta-analysis. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of the frequency of meningitis, all-cause mortality, meningitis-related mortality, and need for surgical correction in patients with CSF leakage. We performed a subgroup analysis to evaluate the primary outcome in patients with and without CSF leakage. We also completed a meta-analysis of all the identified controlled non-RCTs (enrolling a total of 2168 patients), producing results consistent with the randomised data.

AUTHORS' CONCLUSIONS

Currently available evidence from RCTs does not support prophylactic antibiotic use in patients with BSF, whether there is evidence of CSF leakage or not. Until more research is completed, the effectiveness of antibiotics in patients with BSF cannot be determined because studies published to date are flawed by biases. Large, appropriately designed RCTs are needed.

Endoscopic repair of CSF rhinorrhea: experience of 44 cases

Cerebrospinal fluid (CSF) rhinorrhea is a leakage of fluid from the subarachnoid space to the frontal, sphenoidal or ethmoidal sinuses. CSF rhinorrhea is a known potential complication with significant morbidity and mortality. It may present a significant challenge in diagnosis, localization and management. Study design: series study. Material and method: Between 1993 and 2004, 44 patients with cerebrospinal rhinorrhea were operated on using intranasal endoscopic approach in the University Hospital of the University of Sao Paulo, Medical School. The charts of all patients treated in our hospital were reviewed. Results: Forty-four patients, 16 women (36%) and twenty-eight men (64%), were included in the study. Patients’ ages ranged from 2 to 68 years (mean: 40.3 years). Etiology, site of leakage, diagnosis, technique, cause of failure and follow-up are discussed. Conclusion: The authors concluded that transnasal endoscopic surgery for CSF rhinorrhea had high success rate, low morbidity and stable long-term results.

Rapid, accurate and non-invasive detection of cerebrospinal fluid leakage using combined determination of β-trace protein in secretion and serum

BACKGROUND

beta-Trace protein (Btp) has been proposed as a valuable marker of cerebrospinal fluid (CSF) leakage overcoming the drawbacks of beta-2-transferrin (B-2Tr) determination. However, there is still controversy about the appropriate cut-offs to be used (range 0.35-6 mg/L). The aim of the study was to evaluate cut-offs of Btp determination for detection CSF leakage. Further, we assessed whether the Btp secretion to serum ratio (Btp-sec/ser-ratio) would add diagnostic value.

METHODS

Prospective study in patients with suspected CSF leakage. Quantitative determination of Btp in secretion and serum (Dade-Behring) and qualitative measurement of B-2-Tr in secretion and serum. Results were assessed in view of clinical data. Cut-offs and diagnostic characteristics were determined by ROC analysis.

RESULTS

A total of 176 samples were assessed originating from 105 patients. In 43 samples CSF leakage could be confirmed. Sensitivity of B-2-Tr was 84%, specificity amounted to 100%. The area under the curve (AUC) for Btp-measurement in secretion was 0.98. At a cut-off of 0.68 mg/L, sensitivity was 100% and specificity 91%. At a cut-off of 1.11 mg/L, the specificity was 100% with a sensitivity of 93%. The Btp-sec/ser-ratio has an AUC of 0.99. Combining a 0.68 mg/L cut-off in secretion with a Btp-sec/ser-ratio cut-off of 4.9 reveals a sensitivity of 99% and a specificity of 100%.

CONCLUSIONS

Btp is a rapid and accurate marker for the presence of CSF leakage. Combining measurement of Btp in secretion together with determination of the Btp-sec/ser-ratio enhances the diagnostic characteristics of the Btp assay. Determination of Btp in both serum and secretion is thus recommended.

Comprehensive Algorithm for Skull Base Dural Lesion and Cerebrospinal Fluid Fistula Diagnosis

OBJECTIVES/HYPOTHESIS

Skull base dural lesions and cerebrospinal fluid (CSF) fistulas are potentially vital conditions whose diagnosis can be challenging. The authors' aim was to compose a comprehensive algorithm that combines the most modern diagnostic tools in easily applicable patterns to indicate a possible dural lesion or CSF fistula.

STUDY DESIGN

Prospective clinical study.

METHODS

The authors collected the data of all patients with suspicion of CSF fistula or dural lesion, or both, between January 1999 and December 2002. Beta-trace protein, beta2-transferrin, and endoscopic and laboratory sodium fluorescein tests; high-resolution computed tomography; and magnetic resonance cisternography were used according to the symptoms and etiological factors. The results of the diagnostic tools that were used and intraoperative findings (in case of an operative treatment) were reviewed.

RESULTS

From 1999 to 2002, 236 patients were evaluated because of suspicion of dural lesion or CSF fistula, mostly after head trauma. Pattern I of the algorithm was applied for head trauma in dural lesion or CSF leak assessment, pattern II for postoperative CSF leaks, pattern III for evaluation of spontaneous CSF rhinorrhea, and pattern IV for the assessment of recurrent pneumococcal meningitis related to dural lesions without CSF fistula. By applying the patterns of this algorithm, a dural lesion or CSF leak that was also confirmed intraoperatively was detected in 48 patients.

CONCLUSION

The four patterns of the new diagnostic algorithm described in the present study enable physicians to reliably clarify suspicions of dural lesions and CSF fistulas and aim to help them choose the best possible management. Each pattern uses the optimal combination of CSF tests and radiological imaging to reach a synergistic effect for precisely detecting dural lesions or CSF fistulas. Accordingly, this improves surgical decision-making when necessary.

Extensive Tension Pneumocephalus Complicating Continuous Lumbar CSF Drainage for the Management of CSF Rhinorrhoea

We report a case of tension pneumocephalus developing after a continuous lumbar CSF drain had been inserted for the treatment of CSF rhinorrhoea following translabyrinthine removal of a vestibular schwannoma. Despite conservative management, the patient developed recurrent CSF rhinorrhoea and hydrocephalus requiring explorations of the petromastoid cavity, an external ventricular drain and eventually a lumbar-peritoneal shunt. The prevention and management of pneumocephalus secondary to continuous lumbar CSF drainage is briefly reviewed.

Persistent posttraumatic cerebrospinal fluid leakage

OBJECT

Persistent posttraumatic cerebrospinal fluid (CSF) leakage frequently complicates skull base fractures. Although many CSF leaks will cease without treatment, patients with CSF leaks that persist greater than 24 hours may be at increased risk for meningitis, and many will require surgical intervention. The authors reviewed their 15-year experience with posttraumatic CSF leaks that persisted longer than 24 hours.

METHODS

The authors reviewed the medical records of 51 patients treated between 1984 and 1998 with CSF leaks that persisted for 24 hours or longer after traumatic head injury. In 27 patients (55%) spontaneous resolution of CSF leakage occurred at an average of 5 days posttrauma. In 23 patients (45%) surgery was required to resolve the leakage. Eight patients (16%) with occult CSF leaks presented with recurrent meningitis at an average of 6.5 years posttrauma. Forty-three (84%) patients with CSF leaks sustained a skull fracture, most commonly involving the frontal sinus, whereas parenchymal brain injury or extraaxial hematoma was demonstrated in only 18 patients (35%). Delayed CSF leaks, with an average onset of 13 days posttrauma, were observed in eight patients (16%). Among patients with clinically evident CSF leakage, the frequency of meningitis was 10% with antibiotic prophylaxis, and 21% without antibiotic prophylaxis. Thus, prophylactic antibiotic administration halved the risk of meningitis. A variety of surgical approaches was used, and no significant neurological morbidity occurred. Three (13%) of 23 surgically treated patients required additional surgery to treat continued CSF leakage.

CONCLUSIONS

A significant proportion of patients with CSF leaks that persist greater than 24 hours will require surgical intervention. Prophylactic antibiotic therapy may be effective in this group of patients. Patients with skull base or frontal sinus fractures should be followed to detect the occurrence of delayed leakage. Surgery-related outcome is excellent.

Ascending meningitis secondary to traumatic cerebrospinal fluid leaks

Cerebrospinal fluid (CSF) leakage may cause immediate or delayed complications, such as ascending meningitis and brain abscess, potentially lethal complications that may appear years or decades after the trauma. Thus, the initial treatment of a CSF fistula may decisively influence long-term outcome. In a retrospective study including 1036 consecutive patients presenting with severe cranial trauma from May 1990 to March 1996, we identified 27 patients (2.6%) with CSF fistulas. Patients with a post-traumatic CSF leak were most commonly males between 15 and 40 years involved in a motor vehicle accident. The most common sites of injury were the frontal area and anterior skull base for those patients with rhinorrhea and the temporal bone for those patients with otorrhea. A transcranial repair was used for large cranial base defects (n = 10), while conservative treatment, comprised of bedrest, lumbar drainage, and medications, was used for smaller fistulas (n = 17). Four patients (40%) initially treated with a transcranial repair, and five patients (29%) initially treated conservatively, developed a meningitis. Therefore, neither the conservative approach nor the transcranial repair was able to prevent this considerable incidence of ascending meningitis. We believe that the high incidence of meningitis is not acceptable; thus, we are now evaluating early intervention using endoscopic techniques for the identification and/or repair of post-traumatic fistulas.

CSF rhinorrhoea following treatment with dopamine agonists for massive invasive prolactinomas

OBJECTIVE

The management of CSF rhinorrhoea following dopamine agonist (DA) treatment for invasive prolactinomas is difficult and there is no clear consensus for its treatment. Our objective was therefore to investigate the different treatments for this condition.

DESIGN AND PATIENTS

We examined the case notes of five patients with invasive prolactinomas and CSF rhinorrhoea following DA treatment. The different ways in which this complication had been managed is detailed along with a review of the literature.

RESULTS

Five patients aged 24-67 years (3 male) with massive invasive prolactinomas (serum prolactin 95000-500000 mU/l) eroding the skull base were treated with dopamine agonists (3 bromocriptine, 1 cabergoline and 1 both). CSF rhinorrhoea developed in all patients between 1 week and 4 months after commencing dopamine agonist treatment. In two patients (cases 1 and 4), CSF rhinorrhoea ceased within a few days of stopping bromocriptine but restarted when treatment was resumed. One of these (case 4), a 67-year-old woman had no further treatment and CSF leakage stopped completely. She died of unrelated medical problems 3 years later. In one patient staphylococcus aureus meningitis and pneumocephalus developed as a complication of CSF rhinorrhoea. Three patients had endoscopic nasal surgery to repair the fistula using muscle grafts, and to decompress the pituitary tumour, with success in two. One patient had intracranial surgery and dural repair, which was successful in sealing the leak.

CONCLUSIONS

We suggest that surgery as soon as is feasible is the treatment of choice for the repair of a CSF leak following dopamine agonist treatment. An additional strategy is the withdrawal of dopamine agonist to allow tumour re-growth to stop the leak.

An unusual case of presumed perilymph fistula

Perilymph fistulae have been described for over 30 years and yet there are no universally accepted diagnostic criteria or treatment regimes for them. This paper describes an unusual case of a presumed traumatic perilymph fistula and discusses its treatment and prognosis in relation to previous studies.