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Jyothsna BP, Kumar KV, Unni NV, Praveen G, Shejoy JP, Prasannan B. Spontaneous Cerebrospinal Fluid Rhinorrhea in End Stage Renal Disease. Indian J Nephrol 2021; 31:296-298. [PMID: 34376948 PMCID: PMC8330654 DOI: 10.4103/ijn.ijn_372_19] [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] [Received: 11/16/2019] [Revised: 02/16/2020] [Accepted: 04/24/2020] [Indexed: 11/30/2022] Open
Abstract
We report a case of spontaneous cerebrospinal fluid (CSF) rhinorrhea in a patient on maintenance hemodialysis. There was no previous history of trauma or surgery. Secondary hyperparathyroidism due to progression of chronic kidney disease (CKD) and a rise in intracranial pressure resulted in spontaneous cerebrospinal fluid rhinorrhea. He underwent endoscopic endonasal repair with theco-peritoneal shunt; CSF leak stopped completely and the patient is doing well on one year follow up.
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Affiliation(s)
| | | | | | | | - Joshua P Shejoy
- Department of Neurosurgery, Aster Medcity, Kochi, Kerala, India
| | - Bipi Prasannan
- Department of Nephrology, Aster Medcity, Kochi, Kerala, India
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Abstract
Introduction Cerebrospinal fluid (CSF) rhinorrhea is the result of a bony defect at the skull base with disruption of the arachnoid, dura mater, and sinonasal mucosa that leads to an active CSF leak and flow of clear fluid from the nose. The endoscopic repair of CSF leaks and skull defects have been used by an increasing number of surgeons and is the standard of care for repairing CSF leaks. Materials and methods We conducted a retrospective study of all cases of CSF leaks managed via the endonasal endoscopic approach from 2010 to 2020 at a tertiary referral hospital of King Fahad Specialist Hospital, Dammam (KFSH-D). Results Over 10 years, 61 procedures were performed on a total of 56 patients (average age, 39.9 years) with 26 spontaneous CSF leaks and 30 traumatic CSF leaks. The leak sites were frontal bone in 14% of the cases, the roof of the ethmoid in 25%, the cribriform plate of ethmoid in 39%, and the walls of sphenoid sinus in 21%; multiple site defects were found in eight patients. The defect was localized by high-resolution computed tomography (CT) of the paranasal sinuses and skull base and magnetic resonance imaging (MRI) in all patients. CT cisternography, intrathecal fluorescein injection, and topical application of fluorescein dye were used in patients as required. A combination of free grafts and flaps materials were used in most patients. A middle and inferior turbinate graft was used in 12 patients, a septal cartilage graft in 18 patients, and a pedicled nasoseptal flap in 12 patients. The success rate was 92% after the first closure attempt. A recurrence of CSF leaks was observed in four patients. The mean hospitalization time was 6.5 days. The postoperative follow-up period ranged from one year to 10 years with a mean postoperative follow-up time of three years. Conclusions The endonasal endoscopic approach is the current standard of care for repairing most CSF leaks and skull base defects. We have had an excellent experience with endonasal endoscopic CSF leak repair, with high success rates and low morbidity. Our results support the effectiveness and safety of this technique and should encourage otolaryngologists to apply the procedure in cases of CSF leak.
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Affiliation(s)
- Rawan F Bubshait
- Otolaryngology - Head and Neck Surgery, King Fahad Specialist Hospital, Dammam, SAU
| | - Ali A Almomen
- Otolaryngology - Head and Neck Surgery, King Fahad Specialist Hospital, Dammam, SAU
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Do Most Patients With a Spontaneous Cerebrospinal Fluid Leak Have Idiopathic Intracranial Hypertension? J Neuroophthalmol 2020; 39:487-495. [PMID: 30747786 DOI: 10.1097/wno.0000000000000761] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The association between cerebrospinal fluid (CSF) leaks at the skull base and raised intracranial pressure (ICP) has been reported since the 1960s. It has been suggested that spontaneous CSF leaks might represent a variant of idiopathic intracranial hypertension (IIH). We review the evidence regarding the association between spontaneous CSF leaks and IIH, and the role of ICP in the pathophysiology of nontraumatic skull base defects. We also discuss the management of ICP in the setting of CSF leaks and IIH. EVIDENCE ACQUISITION References were identified by searches of PubMed from 1955 to September 2018 with the terms "idiopathic intracranial hypertension" and "cerebrospinal fluid leak." Additional references were identified using the terms "pseudotumor cerebri," "intracranial hypertension," "benign intracranial hypertension," and by hand search of relevant articles. RESULTS A CSF leak entails the egress of CSF from the subarachnoid spaces of the skull base into the surrounding cavitary structures. Striking overlaps exist regarding demographic, clinical, and radiological characteristics between IIH patients and those with spontaneous CSF leaks, suggesting that some (if not most) of these patients have IIH. However, determining whether a patient with spontaneous CSF leak may have IIH may be difficult, as signs and symptoms of raised ICP may be obviated by the leak. The pathophysiology is unknown but might stem from progressive erosion of the thin bone of the skull base by persistent pulsatile high CSF pressure. Currently, there is no consensus regarding the management of ICP after spontaneous CSF leak repair when IIH is suspected. CONCLUSIONS IIH is becoming more widely recognized as a cause of spontaneous CSF leaks, but the causal relationship remains poorly characterized. Systematic evaluation and follow-up of patients with spontaneous CSF leaks by neuro-ophthalmologists will help clarify the relation between IIH and spontaneous CSF leaks.
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Bidot S, Levy JM, Saindane AM, Narayana KM, Dattilo M, DelGaudio JM, Mattox DE, Oyesiku NM, Peragallo JH, Solares CA, Vivas EX, Wise SK, Newman NJ, Biousse V. Spontaneous Skull Base Cerebrospinal Fluid Leaks and Their Relationship to Idiopathic Intracranial Hypertension. Am J Rhinol Allergy 2020; 35:36-43. [DOI: 10.1177/1945892420932490] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The association between spontaneous skull base cerebrospinal fluid (CSF) leaks and idiopathic intracranial hypertension (IIH) has been suggested, but its significance remains unclear. Objective To estimate the prevalence of IIH in spontaneous skull base CSF leak patients. Methods Systematic collection of demographics, neuro-ophthalmic and magnetic resonance imaging evaluation of spontaneous skull base CSF leak patients seen pre- and post-leak repair in one neuro-ophthalmology service. Patients with preexisting IIH were diagnosed with definite IIH if adequate documentation was provided; otherwise, they were categorized with presumed IIH. Classic radiographic signs of intracranial hypertension and bilateral transverse venous sinus stenosis were recorded. Results Thirty six patients were included (age [interquartile range]: 50 [45;54] years; 94% women; body mass index: 36.8 [30.5;39.9] kg/m2), among whom six (16.7%, [95% confidence interval, CI]: [6.4;32.8]) had a preexisting diagnosis of definite or presumed IIH. Of the remaining 30 patients, four (13.3%, 95%CI: [3.8;30.7]) had optic nerve head changes suggesting previously undiagnosed IIH, while one was newly diagnosed with definite IIH at initial consultation. One out of 29 patients with normal findings of the optic nerve head at presentation developed new onset papilledema following surgery (3.4%, 95%CI: [0.1;17.8]) and was ultimately diagnosed with definite IIH. Overall, the prevalence of definite IIH was 19.4% (95%CI: [8.2;36.0]). Conclusion Striking demographic overlap exists between IIH patients and those with spontaneous CSF leak. Definite IIH was present in approximately 20% of our patients. However, its true prevalence is likely higher than identified by using classic criteria. We therefore hypothesize that an active CSF leak serves as an auto-diversion for CSF, thereby “treating” the intracranial hypertension and eliminating characteristic signs and symptoms at initial presentation.
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Affiliation(s)
- Samuel Bidot
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Joshua M. Levy
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Amit M. Saindane
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia
| | - Kannan M. Narayana
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - Michael Dattilo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - John M. DelGaudio
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Douglas E. Mattox
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nelson M. Oyesiku
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jason H. Peragallo
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
| | - C. Arturo Solares
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Esther X. Vivas
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Sarah K. Wise
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Nancy J. Newman
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
- Department of Neurological Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia
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The forgotten foramina: a study of the anterior cribriform plate. Surg Radiol Anat 2015; 37:835-40. [DOI: 10.1007/s00276-015-1471-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
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Emanuelli E, Milanese L, Rossetto M, Cazzador D, d'Avella E, Volo T, Baro V, Denaro L, Gioffrè G, Borsetto D, Martini A. The endoscopic endonasal approach for cerebrospinal fluid leak repair in the elderly. Clin Neurol Neurosurg 2015; 132:21-5. [PMID: 25746317 DOI: 10.1016/j.clineuro.2015.02.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Revised: 02/11/2015] [Accepted: 02/16/2015] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Cerebrospinal fluid (CSF) rhinorrhea can lead to CNS infections, carrying significant morbidity and mortality, especially in the elderly. Endoscopic endonasal surgery is a validated technique in the repair of anterior skull base CSF leaks. The aim of this study is to assess diagnostic management, surgical technique and clinical outcome in a consecutive series of elderly patients. METHODS Patients older than 65 years treated for anterior skull base CSF leaks through endoscopic endonasal surgery between 2003 and 2014 were retrospectively reviewed. All patients underwent preoperative nasal endoscopy, laboratory and radiological assessment. In doubtful cases endoscopic exploration was performed after intrathecal fluorescein (IF) injection. Patients were discharged between 3 and 4 days after surgery, and the endoscopic follow-up ranged from 3 to 24 months. RESULTS 20 patients (age range 65-92) presented with 10 spontaneous and 10 traumatic/iatrogenic CSF leaks. In 40% of patients formal rhinoscopy and radiological assessment did not localize the CSF leak and IF injection was performed. IF enabled the identification of the skull base defect in all cases, with no adverse effects. In 11 cases the dura was repaired with fascia lata graft. All patients had successful endoscopic repair of the CSF fistula with no complications nor recurrences during follow-up. CONCLUSION Endoscopic endonasal surgery is a minimally invasive procedure for CSF leak treatment. In our experience, IF injection proved safe and efficient in detecting skull base defects not identified by preoperative imaging. Endoscopic endonasal surgery proved effective and reliable also in elderly patients, with short hospitalization times and no morbidity.
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Affiliation(s)
- Enzo Emanuelli
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Laura Milanese
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy.
| | - Marta Rossetto
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Diego Cazzador
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Elena d'Avella
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Tiziana Volo
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Valentina Baro
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Luca Denaro
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Giorgio Gioffrè
- Department of Neuroscience, University of Padua, via Giustiniani, 5, 35128 Padua, Italy
| | - Daniele Borsetto
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
| | - Alessandro Martini
- Operative Unit of Otolaryngology and Otosurgery, Department of Neuroscience, University of Padua, Via Giustiniani, 2, 35128 Padua, Italy
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Ayberk G, Yaman ME, Ozveren MF. Symptomatic spontaneous pneumocephalus after spinal fusion for spondylolisthesis. J Clin Neurosci 2010; 17:934-6. [DOI: 10.1016/j.jocn.2009.10.033] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2009] [Revised: 10/20/2009] [Accepted: 10/25/2009] [Indexed: 10/19/2022]
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Habu M, Niiro M, Toyoshima M, Kawano Y, Matsune S, Arita K. Transethmoidal meningoencephalocele involving the olfactory bulb with enlarged foramina of the lamina cribrosa--case report. Neurol Med Chir (Tokyo) 2009; 49:269-72. [PMID: 19556738 DOI: 10.2176/nmc.49.269] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 3-year-old girl presented with a transethmoidal meningoencephalocele manifesting as recurrent rhinorrhea. Initially, she developed meningitis, but after treatment she experienced rhinorrhea. Two months later, she again presented with rhinorrhea. Neuroimaging studies revealed a small protrusion (15 mm x 10 mm) at the roof of the ethmoidal sinus. Nasal endoscopy confirmed the diagnosis of meningoencephalocele. The operative findings revealed a small hole in the left olfactory bulb, which had descended into an enlarged foramen along with the arachnoid membrane. The left olfactory bulb was removed, and the enlarged foramina of the lamina cribrosa were covered with a frontal pericranial flap. The defect in the bone was very small, but contributed to the development of meningitis and leakage of the cerebrospinal fluid. Basal cephalocele should be considered in a patient with recurrent rhinorrhea and intracranial infections, even in the absence of any apparent anomaly.
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Affiliation(s)
- Mika Habu
- Department of Neurosurgery, Kagoshima University, Graduate School of Medicine and Dental Sciences, Kagoshima, Japan.
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Cleper R, Goldenberg-Cohen N, Kornreich L, Krause I, Davidovits M. Neurologic and ophthalmologic complications of vascular access in a hemodialysis patient. Pediatr Nephrol 2007; 22:1377-82. [PMID: 17487512 DOI: 10.1007/s00467-007-0491-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2007] [Revised: 03/12/2007] [Accepted: 03/16/2007] [Indexed: 11/26/2022]
Abstract
Patients on long-term hemodialysis undergo multiple interventions, including insertion of central catheters and arteriovenous anastomoses for creation of vascular access. The need for high-flow vessels to maintain hemodialysis efficiency leads to wear on the central veins and consequent stenosis and occlusion. In addition to local signs of impaired venous drainage, abnormal venous flow patterns involving the upper chest, face, and central nervous system might develop. We describe the first pediatric case of devastating intracranial hypertension presenting with visual loss in the eye contralateral to a high-flow vascular access in a patient on long-term hemodialysis. The literature on this rare complication of hemodialysis is reviewed.
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Affiliation(s)
- Roxana Cleper
- Department of Pediatric Nephrology, Schneider Children's Medical Center of Israel, Petah Tiqwa 49202, Israel.
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