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Colantonio M, Dionne C. Cerebrospinal Fluid Leak Presenting as Headache: A Case Report. Cureus 2024; 16:e64683. [PMID: 39015218 PMCID: PMC11251748 DOI: 10.7759/cureus.64683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2024] [Indexed: 07/18/2024] Open
Abstract
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.
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Affiliation(s)
- Mark Colantonio
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
| | - Christopher Dionne
- Internal Medicine, West Virginia University School of Medicine, Morgantown, USA
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Saltagi AK, Saltagi MZ, Kedo M, Shah MV, Nelson RF. Management of Fallopian Canal Spontaneous CSF Leaks, Implications of Elevated Intracranial Pressure: Case Report and Systematic Review of the Literature. Otol Neurotol 2024; 45:215-222. [PMID: 38361289 DOI: 10.1097/mao.0000000000004107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
OBJECTIVES Describe the diagnosis and management of a spontaneous cerebrospinal fluid leak (sCSF-L) through the facial nerve fallopian canal and determine the role of intracranial hypertension (IH). STUDY DESIGN Retrospective case study and systematic review of the literature. METHODS Reviewed patient characteristics, radiographic findings, and management of the facial nerve canal CSF leak and postoperative IH. Conducted systematic literature review according to the PRISMA guidelines for surgical management and rates of IH. RESULTS A 50-year-old female with bilateral tegmen defects and temporal encephaloceles underwent left middle cranial fossa (MCF) repair. Intraoperative CSF egressed from the temporal bone tegmen defects. Facial nerve decompression revealed CSF leak from the labyrinthine segment. A nonocclusive temporalis muscle plug was placed in the fallopian canal, and tegmen repair was completed with bone cement. A ventriculoperitoneal shunt was placed for IH. Postoperative facial nerve function and hearing were normal. A total of 20 studies met inclusion criteria with a total of 25 unique patients. Of 13 total adult cases of fallopian canal CSF leak, there is a 46% recurrence rate, and 86% of patients had documented IH when tested. CONCLUSIONS Fallopian canal CSF leaks are rare and challenging to manage. Assessment of intracranial hypertension and CSF diversion is recommended along with MCF skull base repair to preserve facial nerve function and conductive hearing.
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Affiliation(s)
| | | | | | - Mitesh V Shah
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, IN
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Cumpston EC, Sualeh AH, Totten DJ, Nelson RF. Immediate CPAP Use after Skull Base Reconstruction with Hydroxyapatite Bone Cement. Otol Neurotol 2023; 44:e577-e582. [PMID: 37464456 DOI: 10.1097/mao.0000000000003964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement. STUDY DESIGN Prospective cohort study. SETTING Tertiary academic medical center. PATIENTS Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022. INTERVENTIONS CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT). MAIN OUTCOME MEASURES Postoperative skull base defects on CT, pneumocephalus, or intracranial complications. RESULTS The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m 2 . Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively. CONCLUSION Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.
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Affiliation(s)
- Evan C Cumpston
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana
| | - Ali H Sualeh
- Indiana University School of Medicine, Indianapolis, Indiana
| | - Douglas J Totten
- Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis, Indiana
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Poczos P, Cihlo M, Zadrobílek K, Jandura J, Čelakovský P, Adamkov J, Kostyšyn R, Česák T. The Need for Emphasis on Intracranial Hypertension Management in Spontaneous Skull Base Meningoencephaloceles. World Neurosurg 2023; 172:e574-e580. [PMID: 36716857 DOI: 10.1016/j.wneu.2023.01.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To provide an analysis of patients with spontaneous skull base meningoencephaloceles (MECs) to determine whether definitive surgical treatment requires management of elevated intracranial pressure (ICP). METHODS Data of 10 subjects with spontaneous MECs were collected and retrospectively evaluated. Measurement of ICP, prior interventions, treatment with acetazolamide, and characteristics of long-term elevated ICP, among others, were analyzed. Our own indications for cerebrospinal fluid (CSF) diversion and use of postoperative external lumbar drain were analyzed as well. RESULTS The sphenoid region was the most common location of MECs. CSF leak was diagnosed in all subjects. The most common graphical signs of elevated ICP were empty sella and arachnoid pits, both of which were present in 90% of cases. Lumbar puncture with opening pressure measurement was performed in 7 patients. Ventriculoperitoneal shunt insertion was indicated in 4 cases before skull base repair and in 2 cases after skull base repair. Two postoperative CSF leaks were managed with external lumbar drain and subsequent shunt installation. CONCLUSIONS Spontaneous MECs are often associated with CSF leak. ICP assessment should be a standard of care to ensure successful operative repair of MECs. Insertion of a CSF diversion device must be considered where direct or indirect signs of intracranial hypertension are present.
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Affiliation(s)
- Pavel Poczos
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia; Department of Anatomy, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia.
| | - Miroslav Cihlo
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Karel Zadrobílek
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Jiří Jandura
- Department of Diagnostic Radiology, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Petr Čelakovský
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Jaroslav Adamkov
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Roman Kostyšyn
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
| | - Tomáš Česák
- Department of Neurosurgery, University Hospital Hradec Králové, Faculty of Medicine in Hradec Králové, Charles University, Hradec Králové, Czechia
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Abstract
OBJECTIVES Describe the diagnosis and management of lateral skull base (LSB) cerebrospinal fluid (CSF) leaks originating from the lateral ventricle. STUDY DESIGN Retrospective case review. SETTING Tertiary referral academic center. PATIENTS Patients with CSF leaks with direct communication to the lateral ventricle on preoperative imaging. INTERVENTION Surgical repair via the middle cranial fossa (MCF) approach. MAIN OUTCOME MEASURES CSF leak patient characteristics (age, sex, body mass index [BMI]) and postoperative course (complications and CSF leak resolution) were collected. RESULTS Three patients had CSF leaks from the lateral ventricle and all patients demonstrated encephalomalacia of the temporal lobe on preoperative imaging. Encephalomalacia resulted from trauma in one case (age 5) and neurodegeneration in two cases (age 77 and 84). BMI ranged from 16.3 to 26.6 mg/kg2 and follow-up ranged from 4 to 21 months. Two patients presented with preoperative meningitis and all patients had resolution of CSF leaks after MCF repair. With the exception of the higher rate of meningitis, patient presentations did not differ from other spontaneous CSF leaks through middle fossa defects. There were no minor or major postoperative complications. CONCLUSIONS CSF leaks from the lateral ventricle represent a rare subset of LSB CSF leaks and can occur in non-obese patients secondary to temporal lobe encephalomalacia. The MCF approach allows for repair of the dura and skull base in this cohort of patients with high-flow CSF leaks and loss of brain parenchyma.
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Kumar A, Shah J, Melmed K, Pacione D, Lieberman S, Lewis A. Meningitis in the Setting of Frontoethmoidal and Temporal Meningoencephaloceles. Neurohospitalist 2021; 11:183-184. [PMID: 33791067 DOI: 10.1177/1941874420958839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This is a patient with multiple meningoencephaloceles which resulted in bacterial meningitis and subsequent status epilepticus. We identify impressive imaging findings demonstrating herniation of the meninges from nasal and bitemporal skull base defects possibly as a result of intracranial hypertension.
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Affiliation(s)
- Arooshi Kumar
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA
| | - Jugal Shah
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Kara Melmed
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Donato Pacione
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
| | - Seth Lieberman
- Department of Otolaryngology, NYU Langone Medical Center, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY, USA.,Department of Neurosurgery, NYU Langone Medical Center, New York, NY, USA
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Abstract
Otalgia, otorrhea and hearing loss are the most common ear-related symptoms that lead to the consultation of an otolaryngologist. Furthermore, balance disorders and affections of the cranial nerve function may play a role in the consultation. In large academic centres, but also in primary care, the identification of rare diseases of the middle ear and the lateral skull base is essential, as these diseases often require interdisciplinary approaches to establish the correct diagnosis and to initiate safe and adequate treatments. This review provides an overview of rare bone, neoplastic, haematological, autoimmunological and infectious disorders as well as malformations that may manifest in the middle ear and the lateral skull base. Knowledge of rare disorders is an essential factor ensuring the quality of patient care, in particular surgical procedures. Notably, in untypical, complicated, and prolonged disease courses, rare differential diagnoses need to be considered.
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Affiliation(s)
- Nora M. Weiss
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie
„Otto Körner“ der Universitätsmedizin Rostock,
Deutschland
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Abboud H, Kharbouch H, Arkha Y, Choukri M. Cerebrospinal fluid fistula in a patient with chronic constipation related to an autonomic dysfunction and revealed by bacterial meningitis - A case report. Surg Neurol Int 2020; 11:194. [PMID: 32754365 PMCID: PMC7395540 DOI: 10.25259/sni_147_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/26/2020] [Indexed: 12/29/2022] Open
Abstract
Background: Cerebrospinal fluid (CSF) fistula represents a rare neurosurgical entity that can be defined as a communication between the subarachnoid space and nasal fossa or less commonly the ear cavity. It can be spontaneous without an evident etiology or secondary following a skull base surgery or trauma. The early diagnosis of spontaneous forms remains a challenge as clinical signs (e.g., unilateral rhinorrhea) can be absent or neglected by patients and can result in meningitis. Case Description: Here, we report the case of a 31-year-old man with chronic constipation complicated by chronic intracranial hypertension, and resulting in rhinorrhea with bacterial meningitis. The etiological assessment of chronic constipation retained an autonomic dysfunction with sympathetic hyperactivity (e.g., pure autonomic failure) as an underlying cause. Beta-2 transferrin testing associated with cerebral magnetic resonance imaging and computed tomography scan confirmed the diagnosis and localization of the fistula at the cribriform plate. The patient underwent an endoscopic endonasal approach with a repair of fistula. He presented with recurrent rhinorrhea 17 months later which required a surgical revision along with CSF diversion with a ventriculoperitoneal shunt. Conclusion: Although rare, autonomic dysfunction can result in chronic constipation in young patients, with intermittent or permanent intracranial hypertension, leading to CSF leaks. The early identification and treatment of the underlying etiology may prevent severe complications and improve the management and outcome of CSF fistula patients.
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Affiliation(s)
- Hilal Abboud
- Department of Neurosurgery, Al-Ghassany Hospital, Fez
| | - Hanane Kharbouch
- Department of Cardiovascular Diseases, Mohamed V University Hospital
| | - Yasser Arkha
- Faculty of Medicine, Mohamed V University, Rabat, Morocco
| | - Mohamed Choukri
- Department of Neurosurgery, Paris Descartes University Hospital, Paris, France
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