Spontaneous cerebrospinal fluid leak and idiopathic intracranial hypertension

Cerebrospinal Fluid Leak Presenting as Headache: A Case Report

Headache is a common chief complaint among patients. When presented with this chief complaint, clinicians often form a differential diagnosis of common etiologies, including dehydration, increased stressors, and medication side effects. However, a skillful clinician must always be vigilant of rare etiologies presenting with common chief complaints. Here, we present a rare case of a cerebrospinal fluid leak in a young female presenting with primary symptoms of headache, neck stiffness, and vision changes.

Peri-operative management of endoscopic endonasal cerebrospinal fluid leak repair: an international survey

PURPOSE

Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts.

METHODS

A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion.

RESULTS

The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001).

CONCLUSION

Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency.

Opioid Prescribing Patterns Following Lateral Skull Base Spontaneous Cerebrospinal Fluid Leak Repair

OBJECTIVE

To characterize the opioid prescribing patterns for and requirements of patients undergoing repair of spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Adults with lateral skull base sCSF leaks who underwent repairs between September 1, 2014, and December 31, 2020.

MAIN OUTCOME MEASURE

Mean morphine milligram equivalents (MMEs) of opioids dispensed to inpatients and prescribed at discharge, additional pain control medications dispensed, and outpatient additional opioid requests were compared between groups.

RESULTS

Of 78 patients included, 46 (59%) underwent repair via a transmastoid (TM), 6 (7.7%) via a middle cranial fossa (MCF), and 26 (33.3%) via a combined TM-MCF approach. Inpatients received a mean of 21.3, 31.4, and 37.6 MMEs per day during admission for the TM, MCF, and combined TM-MCF approaches, respectively ( p = 0.019, ηp 2 = 0.101). Upon discharge, nearly all patients (n = 74, 94.9%) received opioids; 27.3, 32.5, and 37.6 MMEs per day were prescribed after the TM, MCF, and TM-MCF approaches, respectively ( p = 0.015, ηp 2 = 0.093). Five (6.4%) patients requested additional outpatient pain medication, after which three were prescribed 36.7 MMEs per day. Patients with idiopathic intracranial hypertension required significantly more inpatient MMEs than those without (41.5 versus 25.2, p = 0.02, d = 0.689), as did patients with a history of headaches (39.6 versus 23.6, p = 0.042, d = 0.684).

CONCLUSIONS

Patients undergoing sCSF leak repair via the MCF or TM-MCF approaches are prescribed more opioids postoperatively than patients undergoing the TM approach. Patients with a history of headaches or idiopathic intracranial hypertension might require more opioids postoperatively.

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.

Multiple skull base defects in the setting of spontaneous cerebrospinal fluid rhinorrhea; a dual institution view

PURPOSE

Idiopathic intracranial hypertension (IIH) is a condition of high cerebrospinal fluid (CSF) pressure that presents with CSF leak. The implications of multiple skull base defects (SBD) and associated synchronous CSF leaks have not been previously explored.

MATERIALS AND METHODS

A dual institutional case-control study examined multiple SBD's and encephaloceles on the risk of CSF leak and postoperative failures post-repair. IIH patients with CSF leaks and IIH controls without leaks were selected retrospectively. Chi square analysis evaluated for statistically significant alterations in probability with CSF leak development.

RESULTS

192 patients were selected with 108 IIH controls and 84 spontaneous CSF leak cases. Signs and symptoms for IIH controls and CSF leak cases respectively were pulsatile tinnitus (60.2 % and 29.8 %), headaches (96.3 % and 63.1 %), papilledema (74.1 % and 12.5 %), visual field defects (60.8 % and 13 %) (p < 0.001). Encephalocele formation in controls was 3.7 % compared to cases at 91.6 % (p < 0.001). Multiple SBD's in controls compared cases was 0.9 % and 46.4 % respectively (p < 0.001). Subgroup analysis of CSF leak cases showed 15 patients with two CSF leak repairs due to a recurrence. 27 (39.1 %) single leak cases had multiple SDB's while 12 (80 %) recurrent leaks had multiple SDB's (p = 0.004).

CONCLUSIONS

Patients with radiographic evidence of multiple SBD's and encephaloceles represent a high-risk population with a propensity for CSF leaks. Secondary SBD's are common in patients with spontaneous CSF rhinorrhea and higher in patients with a recurrence.

Transverse Venous Sinus Stenosis in Patients With Nasal Cerebrospinal Fluid Leak and Idiopathic Intracranial Hypertension

OBJECTIVE

Spontaneous nasal cerebrospinal fluid (CSF) leaks are frequently linked to idiopathic intracranial hypertension (IIH). The objectives of our study were: (1) to determine the rate of transverse venous sinus stenosis (TVSS) in patients with spontaneous nasal CSF leak and in patients with IIH without CSF (controls), and (2) to study the correlation between spontaneous nasal CSF leak and brain imaging features.

STUDY DESIGN

A multicenter retrospective case-control study.

SETTING

Six French tertiary hospitals.

METHODS

Patients with spontaneous nasal CSF leaks and patients with IIH without nasal CSF leaks (controls) were included. The transverse venous sinus patency was analyzed by magnetic resonance imaging to identify possible stenosis or hypoplasia.

RESULTS

Thirty-two patients with spontaneous nasal CSF leaks and 32 controls were included. TVSS was significantly more frequent in patients with spontaneous nasal CSF leaks than in controls (p = .029). Univariate analysis indicated that TVSS (odds ratio, OR: 4.2; 95% confidence interval, CI [1.352-14.915]; p = .017) and arachnoid granulations (OR: 3; 95% CI [1.065-8.994]; p = .042) were risk factors for spontaneous nasal CSF leak. In multivariate analysis, TVSS and arachnoid granulations were independent risk factors of nasal CSF leak (OR: 5.577, 95% CI [1.485-25.837], p = .016; and OR: 4.35, 95% CI [1.234-17.756], p = .029, respectively).

CONCLUSION

This multicenter case-control study shows that TVSS is an independent risk factor for CSF leak in patients with IIH. Stenosis management by interventional radiology may be proposed postoperatively to increase the success of IIH surgical treatment or preoperatively to reduce the need for surgery.

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.

Dural sinus narrowing in patients with spontaneous anterior skull base cerebrospinal fluid leak

Objectives

Current evidence suggests a link between idiopathic intracranial hypertension (IIH) and spontaneous cerebrospinal fluid (sCSF) leak, as well as between IIH and dural venous sinus (DVS) narrowing. However, there are limited data linking DVS narrowing and sCSF leak. This study aims to determine the prevalence of DVS narrowing in patients with sCSF leak.

Methods

A retrospective review of all patients with sCSF leak that presented to a tertiary academic center from 2008 to 2019. Preoperative imaging was independently reviewed by two neuroradiologists to evaluate for DVS narrowing. Available literature was used to estimate the prevalence of DVS narrowing in the general population to allow for comparison. Data were analyzed using Exact binomial test.

Results

Analysis of 25 patients with appropriate imaging revealed the majority were women (21/25, 84%) with a mean age of 51.89 years (SD 13.96). The majority of these patients were found to have narrowing of the DVS (20/25, 80%). In patient with sCSF leaks, there was a significantly higher proportion of patients with DVS narrowing compared with published literature examining this condition in the general population (80% vs. 40%, CI 0.59-0.93, p < .001).

Conclusion

The prevalence of DVS narrowing in patients with sCSF leaks is substantial and likely greater than the general population. Moreover, there appears to be narrowing in most patients with sCSF leak. Preoperative radiological evaluation of the DVS using MR venography may be useful in patients with sCSF leaks as DVS stenosis may be an underdiagnosed etiology. Further study is needed to evaluate this.

Level of Evidence

IV.

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.

Matched Cohort Study of Radiographic Superior Semicircular Canal Dehiscence and Tegmen Dehiscence and Obstructive Sleep Apnea

OBJECTIVE

To report the frequency of radiographic superior semicircular canal dehiscence (SSCD) and tegmen dehiscence in patients with and without obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective matched cohort study.

SETTING

Tertiary care center.

PATIENTS

Adults with OSA and fine-cut computed tomographic scans including the temporal bone were matched to patients without OSA by age, sex, and type of computed tomography (protocol, scanner type, slice thickness). Ears with otologic surgery or temporal bone tumors were excluded.

MAIN OUTCOME MEASURES

Prevalence of SSCD and tegmen dehiscence assessed by two independent reviewers.

RESULTS

The average body mass index of the OSA patients was 29.2 kg/m 2 with an average apnea-hypopnea index of 36.8. The control group had an average body mass index of 26.2 kg/m 2 . Of the 352 temporal bones, 34 (9.7%) had SSCD in the OSA cohort versus 37 (10.5%) in the control group ( p > 0.05). Seven OSA patients (25.6% of those with SSCD) had bilateral SSCD versus 8 controls (27.6% of those with SSCD; p > 0.05). The majority (87.3%) of dehiscences involved the temporal lobe, with the remaining involving the superior petrosal sinus or both. Of the 352 OSA ears, 90 (25.6%) had a tegmen dehiscence versus 95 (27.0%) in the control group ( p > 0.05). Neither group had a laterality preference for SSCD or tegmen dehiscence.

CONCLUSION

The prevalence of radiographic SSCD and tegmen dehiscences in OSA patients does not significantly differ from age- and sex-matched controls. This is in contrast to a previous case-control study finding patients with symptomatic SSCD to have higher rates of OSA. This may suggest that the effect size of OSA on SSCD prevalence may be limited despite OSA being a risk factor for elevated intracranial pressure.

Idiopathic Intracranial Hypertension: Implications for the Otolaryngologist

Idiopathic intracranial hypertension (IIH) is a triad of headaches, visual changes, and papilledema in the absence of a secondary cause for elevated intracranial pressure. There is an association with obesity, and the incidence is rising in parallel with the obesity epidemic. Sometimes these patients present to an otolaryngologist with complaints like tinnitus, dizziness, hearing loss, and otorrhea or rhinorrhea from cerebrospinal fluid leak. IIH diagnosis in conjunction with neurology and ophthalmology, including neuroimaging and lumbar puncture with opening pressure, is key to managing of this condition. Otolaryngologists should recognize IIH as a possible diagnosis and initiate appropriate referrals and treatment.

Treatment, Outcome, and Relapse of Spontaneous and Nonspontaneous Cerebrospinal Fluid Leak

Cerebrospinal fluid (CSF) leak can be spontaneous or nonspontaneous. The management options include conservative treatments, blood patch, and surgical repairs. We compared clinical symptoms, image findings, management options, hospitalization, and relapse rates among different causes of CSF leaks. Eighty-one patients were recruited: 20 with spontaneous and 61 with nonspontaneous CSF leaks. Nonspontaneous causes included lumbar puncture, surgery, and trauma. Surgery sites comprised sphenoid, spine, skull base, and calvaria. Spontaneous CSF leak came from the sphenoid or spine. Age, gender, body mass index, initial symptoms, hospitalization, treatment courses, and recurrence rates showed no difference between the groups. The spontaneous group had higher CSF accumulations on their MRIs. MRI pachymeninge enhancement showed the highest sensitivity (78.6%) for intracranial hypotension. Meningitis occurred in 1/3 of sphenoid, skull base, and calvarian surgeries. Earlier reoperation was correlated with shorter hospitalization (r = 0.651), but the recurrence rates were similar. Longer intervals between surgery and CSF leak encouraged reoperation. Among the spontaneous spine and lumbar puncture-related CSF leaks, 57.1% of them responded to 4 days of conservative treatment. Among the trauma-related CSF leaks, 90.9% of them required surgical repair. The demographic data and symptoms were similar in various groups of CSF leak. The symptom onset durations and treatment strategies were different. However, the recurrence rates were similar.

Ventriculoperitoneal Shunt Alone for Cerebrospinal Fluid Rhinorrhea With Neuroendocrine Alterations in Idiopathic Intracranial Hypertension: A Case Report and Literature Review

Spontaneous skull base cerebrospinal fluid (CSF) leaks due to idiopathic intracranial hypertension (IIH) are a rare entity. Patients often present with CSF rhinorrhea, recurrent meningitis, chronic headache, and visual defects, while few patients have been reported to present with neuroendocrine alterations. Endonasal endoscopic repair is the first-line treatment for these leaks at present. However, the relatively high risk of recurrence remains the main cause of reoperation because of elevated intracranial pressure (ICP) after endoscopic surgery and absence of postoperative ICP management. A shunting procedure may stop CSF leakage or relieve symptoms in complex cases, and this is presently well-known as the last-line therapy for CSF liquorrhea. We describe a 29-year-old woman with spontaneous CSF rhinorrhea and neuroendocrine alterations due to IIH, and with no previous history of trauma, tumor, or nasal surgery. The bone defect in the skull base became implicated when the site of the leak was detected by cranial magnetic resonance imaging and computed tomography (CT). The patient was successfully managed via ventriculoperitoneal shunt (VPS) alone without endoscopic repair, and neuroendocrine alterations resolved after the shunting procedure.

Imaging of Acquired Skull Base Cerebrospinal Fluid Leaks

Acquired skull base cerebrospinal fluid (CSF) leaks can result from trauma, tumors, iatrogenic causes, or may be spontaneous. Spontaneous skull base CSF leaks are likely a manifestation of underlying idiopathic intracranial hypertension. The initial assessment of rhinorrhea or otorrhea which is suspected to be due to an acquired skull base CSF leak requires integration of clinical assessment and biochemical confirmation of CSF. Imaging with high-resolution CT is performed to locate osseous defects, while high-resolution T2w MRI may detect CSF traversing the dura and bony skull base. When leaks are multiple or if samples of fluid cannot be obtained for testing, then recourse to invasive cisternography may be necessary.

Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study

OBJECTIVE

Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

METHODS

From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting.

RESULTS

Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3-9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6-63 months).

CONCLUSIONS

According to the authors' results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.

Venous sinus stenting after repair of skull base spontaneous cerebrospinal fluid leaks: A single-center retrospective cohort series with case-control analysis

BACKGROUND

Management of idiopathic intracranial hypertension (IIH) is recommended after surgical repair of spontaneous cerebrospinal fluid leaks (sCSF-leaks) of the skull base for prevention of recurrence.

PURPOSE

To assess the feasibility of venous sinus stenting, a treatment commonly used for the treatment of IIH associated with intracranial venous sinus stenosis (VSS), after sCSF-leaks closure.

MATERIALS AND METHODS

A single-center cohort series of consecutive patients who underwent sCSF-leak closure was retrospectively analyzed. Stenting was considered either for leak recurrence or in prophylactic manner after repair in patients with VSS as confirmed by cerebral venous imaging. Leak recurrence, need for new repair or adjunctive treatment of IIH, meningitis, and stenting complications were determined at the last follow-up. Cases who had prophylactic stenting were compared to historical controls before stenting option.

RESULTS

Twenty-two patients had intracranial venous stenting after sCSF-leak closure. Their median age was 58 years (Q1=45; Q3=68), BMI=31 kg.m^-2 (Q1=27; Q3=36), and female rate=85%. The overall rate of successful repair after stenting was 95% (95% CI = 87-100%) at a median follow-up of 2.4 years (Q1=1.2; Q3=3.3). Adjunctive treatment for IIH was needed in 4 patients (4/22, 18%) including 2 patients without leak recurrence. No meningitis, permanent morbidity or mortality was observed after stenting. Compared to 18 controls, cases had significantly less recurrence (P = 0.03), and a trend for less adjunctive treatment for IIH (P = 0.06).

CONCLUSIONS

Our study suggests that stenting might be a valid option for prevention of sCSF-leak recurrences after repair in patients with intracranial venous sinus stenosis.

Modified Transpterygoid Approach to Sphenoid Meningoencephaloceles: A Shorter Run for a Longer Slide

OBJECTIVES

Cerebrospinal fluid (CSF) leaks and meningoencephaloceles originating in the lateral recess of the sphenoid sinus can be challenging. The traditional transpterygoid approach through the pterygopalatine fossa (PPF) is time consuming and places important structures at risk, which can lead to significant morbidity. We report a multi-institutional experience using a simplified, endoscopic modified transpterygoid approach (MTPA), which spares the PPF contents in the management of lateral sphenoid sinus meningoencephaloceles and CSF leaks.

STUDY DESIGN

Multi-Institutional, Retrospective Case Series.

METHODS

Patients with lateral sphenoid recess CSF leaks and meningoencephaloceles between 2014 and 2020 who underwent the MTPA at two academic medical centers were identified. Repair techniques and outcomes were evaluated.

RESULTS

Thirty-three patients underwent the MTPA for management. Skull base reconstruction was performed using a free mucosal graft (24/33, 72.7%), nasoseptal flap (4/33, 12.1%), bone grafts (3/33, 9.1%), and abdominal fat grafts (2/33, 6.1%). Lumbar drains and perioperative intracranial pressure measurements were routinely employed. Postoperative complications were uncommon and included three patients (9.7%) with temporary V2 anesthesia, one patient (3.2%) with prolonged V2 anesthesia, and one patient (3.2%) with subjective dry eye, all of which resolved at 9 months postoperatively. There were no recurrent CSF leaks resulting in a 100% success rate. Average follow-up was 13 months.

CONCLUSION

The MTPA reduces morbidity and greatly simplifies access to the lateral sphenoid sinus for the management of CSF leaks and meningoencephaloceles, without compromising exposure. This technique avoids the need for extensive PPF dissection and should be considered for the management of benign lesions involving the lateral sphenoid sinus.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Spinal CSF-Venous Fistulas in Morbidly and Super Obese Patients with Spontaneous Intracranial Hypotension

BACKGROUND AND PURPOSE

Spinal CSF-venous fistulas are increasingly recognized as the cause of spontaneous intracranial hypotension. Here, we describe the challenges in the care of patients with CSF-venous fistulas who are morbidly or super obese.

MATERIALS AND METHODS

A review was undertaken of all patients with spontaneous intracranial hypotension and a body mass index of >40 who underwent digital subtraction myelography in the lateral decubitus position to look for CSF-venous fistulas.

RESULTS

Eight patients with spontaneous intracranial hypotension with a body mass index  of >40 underwent lateral decubitus digital subtraction myelography. The mean age of these 5 women and 3 men was 53 years (range, 45 to 68 years). Six patients were morbidly obese (body mass indexes = 40.2, 40.6, 41, 41.8, 45.4, and 46.9), and 2 were super obese (body mass indexes = 53.7 and 56.3). Lumbar puncture showed an elevated opening pressure in 5 patients (26.5-47 cm H₂O). The combination of an elevated opening pressure and normal conventional spine imaging findings resulted in a misdiagnosis (midbrain glioma and demyelinating disease, respectively) in 2 patients. Prior treatment included surgical nerve root ligation for suspected CSF-venous fistula in 3 patients. Digital subtraction myelography demonstrated a CSF-venous fistula in 6 patients (75%). Rebound high-pressure headache occurred in all 6 patients following surgical ligation of the fistula, and papilledema developed in 3.

CONCLUSIONS

In our series, opening pressure was generally elevated in patients with morbid or super obesity. The yield of identifying CSF-venous fistulas with digital subtraction myelography in this patient population can approach that of the nonobese patient population. These patients may be at higher risk of developing rebound high-pressure headaches and papilledema.

An update on idiopathic intracranial hypertension in adults: a look at pathophysiology, diagnostic approach and management

Idiopathic intracranial hypertension is a neurological syndrome determined by a rise in intracranial pressure without a detectable cause. Course and prognosis may be changeable, requiring a multidisciplinary approach for its diagnosis and management. Although its precise pathogenesis is still unknown, many studies have been carried out to define the possible causal and associated factors, such as retinoids, steroid hormones, body mass index and recent weight gains, cytokines and adipokines levels. The clinical presentation can be variable including chronic headache, disturbance of vision, diplopia and tinnitus. Even if papilloedema is considered the most specific sign, it could not be observed in more than 5% of patients during the evaluation of the fundus oculi. Neuroradiological signs acquire greater importance in patients who do not present papilloedema and may suggest the diagnosis of idiopathic intracranial hypertension. Other assessments can be useful in the diagnostic process, such as optical coherence tomography, visual evoked potentials, ocular ultrasonography and fundus fluorescein angiography and autofluorescence. Nonetheless, cerebrospinal fluid pressure measurement is required to establish a definite diagnosis. Management may be different, since surgical procedures or lumbar punctures are often required when symptoms develop rapidly leading to a loss of visual function. Apart from these cases, patients can be treated with a pharmacological approach and low-calorie diet, but they also need to be monitored over time since relapses years later are not uncommon.

Role of Adjunct Treatments for Idiopathic CSF Leaks After Endoscopic Repair

OBJECTIVE

A higher incidence of recurrent cerebrospinal fluid (CSF) leaks has been reported with idiopathic CSF leaks. A growing number of institutions advocate for routine use of intracranial pressure-lowering adjunct treatments after endoscopic repair. We report our results in a patient cohort in which only symptomatic patients are subjected to further testing and treatment.

STUDY DESIGN

Retrospective review.

METHODS

A retrospective review of patients who underwent endoscopic transnasal repair of idiopathic CSF rhinorrhea was performed at the University of Miami, Florida, from July 2010 to July 2017. The database was queried for demographical data, surgical details, radiological findings, and postoperative outcomes. Only patients with greater than a 12-month follow-up were included.

RESULTS

Thirty-three patients underwent endoscopic repair of an idiopathic CSF leak. Twenty-six (79%) were females, with an average age of entire study population being 48 years. The average body mass index (BMI) of the cohort was 33 kg/m² , with 89% being overweight (BMI > 25 kg/m² ). The skull base defect was found to be mainly at the cribriform plate (64%) and sphenoid sinus (30%). Endoscopic repair was performed successfully as a single repair in 32 patients (97%). The average follow-up was 47 months. Postoperative adjunct medications were used on four patients (12%) with symptomatic idiopathic intracranial hypertension.

CONCLUSION

Endoscopic repair of idiopathic CSF leaks was found to have a high rate of success in our study. Postoperatively, only four patients required additional measures to medically reduce symptomatic intracranial hypertension. Routine postoperative adjunct treatments are unnecessary and may expose patients to adverse long-term side effects.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:41-47, 2021.