Spontaneous Spinal Cerebrospinal Fluid Leak: Review and Management Algorithm

Clinical Findings, Radiological Characteristics, and Treatment Options of Spontaneous and Secondary Intracranial Hypotension: A Single-Center Experience in Turkey

Introduction  Intracranial hypotension can occur for many reasons, including trauma, surgery, congenital defects, or spontaneous rupture of the dura mater. Symptoms appear long before cerebrospinal fluid (CSF) leaks are diagnosed. Treatment procedures include a variety of conservative and invasive techniques appropriate to the nature of the etiological cause and the severity of the disease. In this cross-sectional study, we aimed to investigate the clinical and imaging features and treatment options of intracranial hypotension patients and to compare them in terms of different etiologies. Methods The data from intracranial hypotension patients were analyzed retrospectively. Symptomatology, neurological findings, and radiological features were compared between patients with spontaneous intracranial hypotension (SIH) and those with secondary causes. Radiological outcomes of conservative treatment and epidural blood patch (EBP) were also evaluated for both groups. Results Of the 30 patients, 23 were female. In 14 of the patients (46.6%), a possible cause of CSF leakage was detected. Compared to intracranial hypotension patients with a secondary cause, SIH patients complained of posterior neck and shoulder pain more frequently (p=0.014, p=0.006). MRI features did not differ significantly when the two groups were compared (p>0.05). The first and sixth-month follow-up MRIs of patients treated with EBP or a conservative approach showed similar improvement rates (p=0.788). Conclusions There was no significant difference in radiological recovery time between conservative treatment and EBP in patients with intracranial hypotension. Radiological recovery times are similar in patients with secondary intracranial hypotension and SIH.

Innovations in the Treatment of Spinal Cerebrospinal Fluid Leaks

Spontaneous spinal cerebrospinal fluid (CSF) leaks are uncommon but can be neurologically debilitating. When initial treatments fail, definitive repair or closure of the leak is indicated. Depending upon the type of leak present, innovative strategies for their treatment have been developed. Among them are open surgical techniques using a transdural approach for the closure of ventral CSF leaks, minimally invasive tubular techniques for the reduction and repair of lateral meningeal diverticula, and endovascular embolization of CSF-venous fistulas. Illustrative cases demonstrating the indications for and implementation of these techniques are provided.

Cranial and Spinal Cerebrospinal Fluid Leaks: Foundations of Identification and Management

Cerebrospinal fluid (CSF) leaks may occur at the skull base or along the spinal column and can cause a variety of debilitating neurological symptoms for patients. Recognizing the potential presence of a CSF leak and then identifying its source are necessary for accurate diagnosis and definitive treatment. A standardized workflow can be followed for successful leak localization, which often requires several diagnostic studies, and for definitive leak treatment, which can range from minimally invasive, needle-based approaches to a variety of surgical corrections. This review paper provides an overview of epidemiology, pathophysiology, and diagnostic workup for CSF leaks and introduces available treatment options. An illustrative case of a skull base CSF leak demonstrating diagnosis and surgical correction is provided.

Progressive superficial siderosis despite complete remission of intracranial hypotension symptoms following epidural patching: Case report

Spontaneous intracranial hypotension (SIH) commonly results from ventral spinal cerebrospinal fluid (CSF) leaks and epidural patches are advocated as first-line treatment. Complications such as superficial siderosis can arise but have previously been reported only in the context of long-term persistent, ongoing, CSF leak and SIH. We report a case of a patient with SIH from a ventral spinal CSF leak that was treated with epidural patching and experienced complete resolution of SIH. Four years later SIH symptoms recurred, and brain magnetic resonance imaging unexpectedly showed the interval accumulation of hemosiderin pigmentation on the cerebellum and brainstem during the period when the patient was without symptoms of SIH. This case uniquely demonstrates the progression of superficial siderosis despite the apparent resolution of SIH. Our findings suggest two divergent pathophysiological outcomes from spinal ventral dural tear: (1) CSF loss causing SIH; and (2) persistent low-level bleeding arising from the spinal dural tear leading to superficial siderosis. These divergent pathophysiologies had a discordant response to epidural patching. Epidural patching successfully treated the SIH but did not prevent the progression of superficial siderosis, indicating that some patients may require more than epidural patching despite symptom resolution. This case highlights the need for post-treatment monitoring protocols in patients with ventral spinal CSF leaks and SIH and raises important questions about the adequacy of epidural patching in certain SIH cases arising from ventral spinal CSF leak.

Cerebral venous thrombosis caused by spontaneous intracranial hypotension due to spontaneous spinal cerebrospinal fluid leakage in the high cervical region: a case report

Spontaneous intracranial hypotension (SIH) may lead to cerebral venous thrombosis (CVT). This case report describes the diagnostic and treatment processes used for a patient with CVT caused by SIH due to spontaneous spinal cerebrospinal fluid (CSF) leakage in the high cervical region. Clinical data were collected from a 37-year-old man with an initial symptom of spontaneous posterior cervical pain. The diagnostic and treatment processes of SIH-induced CVT were described. A magnetic resonance imaging (MRI) study showed superior sagittal sinus thrombosis, and a lumbar puncture revealed a low initial CSF pressure of less than 60 mmH2O. The patient underwent anticoagulation and fluid rehydration therapies. No abnormalities were observed in the thoracic MRI scan, but a cervical MRI scan revealed a spontaneous CSF leak. An epidural blood patch with autologous blood was performed, and symptoms completely resolved 3 days after the procedure. This report proposes a diagnostic procedure for detecting rare cases of SIH-induced CVT, thereby preventing future misdiagnoses and delayed treatment. When a patient presenting with CVT in conjunction with intracranial hypotension has no history of trauma or piercing, SIH caused by spontaneous spinal CSF leakage should be considered as a potential cause of secondary low intracranial pressure. For detection of CSF leaks at rare sites, an MRI of the whole spine rather than a localized MRI of the spine needs to be performed to avoid misdiagnosis. An epidural blood patch should be performed as soon as possible as it may shorten the length of hospitalization and improve prognosis.

Cut-off value for β-trace protein (β-TP) as a rapid diagnostic of cerebrospinal fluid (CSF) leak detection

Objective

To find an adequate cut-off point for beta trace protein (β-TP) in nasal secretion (NS) and validate this diagnostic test with a large sample of patients. Likewise, we evaluated β-TP test efficacy to confirm the cerebrospinal fluid (CSF) leakage closure after treatment.

Methods

We performed a retrospective analysis with 207 samples from 162 patients with suspected CSF leakage received in the Hospital Universitario Virgen de la Arrixaca between 2010 and 2016. Twenty-five samples were included in the control group. Samples were obtained from NS through a swab to determine β-TP using a nephelometry-based assay. Sensitivity, specificity, and area under the curve (AUC) for β-TP in NS were assessed using the receiver operator characteristic (ROC) analysis.

Results

Using imaging techniques, the diagnosis of CSF leak was confirmed in 57 patients (35.19%), while 105 had a negative diagnosis (64.81%). Patients with CSF leakage had significantly higher β-TP values in NS (16.07 ± 16.94 mg/L, p < .001) than the control group (0.33 ± 0.12 mg/L) and patients without CSF leakage (0.61 ± 2.34 mg/L). Applying a 1 mg/L cut-off point resulted in 96.5% sensitivity and 97.1% specificity. Positive and negative predictive values (PPV and NPV) at this cut-off were 94.9% and 98.6%, respectively. Finally, this cut-off point yields a test efficacy for CSF leak diagnosis of 97% (95% CI 92.9-98.9).

Conclusion

Our study has established a 1 mg/L β-TP concentration in NS as a cut-off point for CSF leakage diagnosis with high sensibility and specificity. These results suggest that β-TP analysis could be useful to check CSF leak resolution.

Level of Evidence

4.

Continuous Epidural Saline Infusion for the Treatment of Spontaneous Intracranial Hypotension

OBJECTIVE

Spontaneous intracranial hypotension (SIH) is an increasingly recognized cause of orthostatic headache, but treatment strategies remain controversial. The epidural blood patch is a well-known and widely used treatment in patients with conservative treatment-resistant SIH, but symptoms may not improve even after multiple epidural blood patches, and resistant patients suffer from a lack of appropriate treatment options. Therefore, this study assessed the safety and efficacy of continuous epidural saline infusion (CESI) for SIH treatment.

METHODS

CESI was performed in 11 consecutive patients affected by conservative treatment-resistant SIH. Patient characteristics were obtained by reviewing medical records retrospectively. Headache intensity was assessed using the numerical rating scale (NRS), and changes in NRS before and after treatment were recorded.

RESULTS

The average treatment period for CESI was 21.3 ± 9.6 days, and the average follow-up period was 35.0 ± 30.2 months. CESI was without major complications or mortality, and no infections occurred, even without prophylactic antibiotics. The median NRS score before treatment was 10 points, improving to 5 points 1 day after infusion (P < 0.05), 2 points 1 week after infusion (P < 0.05), and 0 points at 3 months after infusion and the final follow-up. No patients have since experienced recurrence of orthostatic headaches.

CONCLUSIONS

CESI appears to be a safe and well-tolerated procedure for SIH. Further experience may demonstrate this technique to be a viable treatment option for SIH.

Spontaneous Cerebrospinal Fluid Rhinorrhea and Otorrhea: A Case Report and Literature Review

Spontaneous cerebrospinal fluid (CSF) leak is a condition that commonly presents with unilateral watery drainage from the nose or ear, tinnitus, and stuffy ears or hearing loss. Spontaneous CSF rhinorrhea and otorrhea together are rare. A 64-year-old woman presented at our department with complaints of clear watery rhinorrhea and hearing loss on the right side persisting for 10 months. Imaging and surgery were used to diagnose the condition. Through surgical treatment, she was eventually cured. Review of the literature has shown that patients with both nasal and aural CSF leaks are rare. When a patient presents with both unilateral watery drainage from both the nose and ear, a diagnosis of CSF rhinorrhea and otorrhea should be considered. This case report will benefit clinicians by providing more information to assist with diagnosing the disease.

Full Endoscopic Repair of Spontaneous Ventral Cerebrospinal Fluid Leaks in the Spine: Systematic Review of Surgical Treatment Options and Illustrative Case

BACKGROUND

Spontaneous spinal cerebrospinal fluid (CSF) leaks are a rare entity that can lead to intracranial hypotension and associated headaches, meningismus, and patient debility. Surgical treatment may be necessary for patients who do not respond to conservative management. Surgical repair of CSF leaks located in the ventral thoracic spine traditionally require an invasive, open approach.

METHODS

We describe the case of a patient with a ventral thoracic spontaneous spinal CSF leak associated with a ventral bony osteophyte successfully treated with spinal endoscopy. We also provide a systematic review of the literature to better understand outcomes of this approach.

RESULTS

A total of 55 patients were included in the systematic review. The study designs found in the literature review included case reports (66.7%), retrospective cohorts (22.2%), and prospective cohorts (11.1%). Of the studies reporting data, 50% of studies stated they used an open posterior approach to the dural defect, while 37.5% reported using an open anterior approach to the pathology. Only 1 (12.5%) study reported using an endoscope. Most studies (62.5%) used primary closure of the dura in their technique, while 37.5% reported using a local tissue graft (fat or muscle) or a dural sealant for their closure technique, and 25% of studies reported using a dural substitute for their closure technique. Overall mean clinical follow-up was 19.8 months.

CONCLUSIONS

The endoscopic approach described here for treatment of this rare entity allows for removal of bony spicules/osteophytes and dural repair without the morbidity associated with traditional open dorsolateral or ventrolateral approaches.

Lumbar epidural blood patch: An effective treatment for intracranial hypotension

Background:

The literature has demonstrated the efficacy of lumbar epidural blood patch (LEBP) in the management of spontaneous intracranial hypotension (SIH). However, the underlying pathophysiology of such management remains unclear. In this study, we aim to evaluate the utility of LEBP injections in the management of SIH and develop a potential management algorithm used in the triage and management of SIH patients.

Methods:

We retrospectively examined the clinical case notes of 14 patients with SIH (age: 25–69 years) who were managed with LEBP injections during the year of 2016–2021. We evaluated the presenting symptoms of each selected patient and radiological findings as well as treatment outcomes. Our aim is to evaluate the effectiveness of LEBP in the treatment of SIH patients through follow-up clinical and imaging assessment.

Results:

About 93% of patients describe the presence of headache at presentation, while 43% describe it as being of an orthostatic nature. All patients demonstrated typical findings on magnetic resonance imaging brain. Treatment success assessed through symptomatic improvement and radiological resolution was found in 85% of our patients at a 2-month interval.

Conclusion:

LEBP injection is an effective method of management in patients with a diagnosis of SIH. It should be considered in all SIH patients irrespective of whether a “dural leak” can be localized through radiological investigations.

Cerebrospinal fluid leak postnasopharyngeal swab for SARS-CoV-2 testing: A case report

Background:

Due to the SARS-CoV-2 virus pandemic and its rapid spread worldwide, an early and effective detection strategy was the nasopharyngeal reverse transcription polymerase swab tests, a procedure still performed today. A relatively safe procedure when done correctly, however, one of the rare complications reported in the literature includes a cerebrospinal fluid (CSF) leak.

Case Description:

A 69-year-old female patient presented to the emergency department with clear fluid rhinorrhea, clinically diagnosed with a CSF fistula after a SARS-CoV-2 nasopharyngeal swab. Resulting computed tomography and magnetic resonance images did not report any abnormalities; however, persistence of clear fluid rhinorrhea obligated pharmacological treatment without resolution, requiring insertion of a lumbar catheter to achieve clinical resolution.

Conclusion:

It is essential to train staff to correctly administer nasopharyngeal swabs and thus reduce the rate of complications, as well as early recognition of symptoms and signs of CSF fistula.