Successful Treatment of Spontaneous Cerebrospinal Fluid Rhinorrhea With Endoscopic Third Ventriculostomy and Lumboperitoneal Shunt: A Case Report

Incidental Durotomy Repair in Lumbar Spine Surgery: Institutional Experience and Review of Literature

STUDY DESIGN

: Retrospective Chart Review.

OBJECTIVES

Incidental durotomies (IDs) are common spine surgery complications. In this study, we present a review on the most commonly utilized management strategies, report our institutional experience with case examples, and describe a stepwise management algorithm.

METHODS

A retrospective review was performed of the electronic medical records of all patients who underwent a thoracolumbar or lumbar spine surgery between March 2017 and September 2019. Additionally, a literature review of the current management approaches to treat IDs and persistent postoperative CSF leaks following lumbar spine surgeries was performed.

RESULTS

We looked at 1133 patients that underwent posterior thoracolumbar spine surgery. There was intraoperative evidence of ID in 116 cases. Based on our cohort and the current literature, we developed a progressive treatment algorithm for IDs that begins with a primary repair, which can be bolstered by dural sealants or a muscle patch. If this fails, the primary repair can be followed by a paraspinal muscle flap, as well as a lumbar drain. If the patient cannot be weaned from temporary CSF diversion, the final step in controlling postoperative leak is longterm CSF diversion via a lumboperitoneal shunt. In our experience, these shunts can be weaned once the patient has no further clinical or radiographic signs of CSF leak.

CONCLUSIONS

There is no standardized management approach of IDs and CSF leaks in the literature. This article intends to provide a progressive treatment algorithm and contribute to the development process of a treatment consensus.

Spontaneous Cerebrospinal Fluid Rhinorrhea Secondary to Idiopathic Intracranial Hypertension

The cerebrospinal fluid (CSF) is a physiological fluid that functions to protect the brain tissue and maintain intracranial pressure. Defects between the subarachnoid spaces and other spaces can cause CSF leaks. We report the case of a 37-year-old female with no known past medical history who presented to the emergency department with a history of headaches for two months, nasal drip for 1.5 months, and recurrent fevers. Idiopathic intracranial hypertension was confirmed by cranial magnetic resonance imaging (MRI) and transnasal endoscopic repair of a CSF leak defect, and an abdomen fat graft was performed followed by an Axium navigation-guided right ventriculoperitoneal shunt (VPS).

Bacterial meningitis caused by nontraumatic cerebrospinal fluid rhinorrhea with aqueductal stenosis: A case report

Background:

Nontraumatic cerebrospinal fluid (CSF) rhinorrhea associated with aqueductal stenosis is rare. The resulting CSF leakage may cause bacterial meningitis, and appropriately timed surgical treatment should be considered.

Case Description:

A 28-year-old woman with obstructive hydrocephalus secondary to aqueductal stenosis presented with intermittent nasal discharge. CSF rhinorrhea was suspected, but she refused surgery. During the course of conservative treatment, she developed meningitis. Exacerbation of hydrocephalus and CSF rhinorrhea was suspected, and the patient underwent endoscopic third ventriculostomy after recovery from meningitis. Postoperatively, ventricular size decreased and CSF leakage completely resolved. There was no recurrence of hydrocephalus or rhinorrhea.

Conclusion:

Patients with intermittent CSF rhinorrhea due to exacerbation of hydrocephalus are at high risk for bacterial meningitis. Appropriately timed surgical treatment results in a favorable outcome.

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.

[A case of spontaneous middle cranial fossa cerebrospinal fluid leak presenting as recurrent bacterial meningitis]

A 19-year-old man with a history of Chiari type I malformation was admitted to our hospital two times within a 2-month period because of bacterial meningitis. Cerebrospinal fluid (CSF) analysis showed neutrophilic pleocytosis and hypoglycorrhachia. During the second admission, we became aware of hearing loss on the right since age 15 years. High-resolution temporal bone CT showed soft tissue opacification of the right epitympanum and external auditory canal. Tissue biopsy resulted in CSF otorrhea and pneumocephalus. CT cisternography revealed a temporal bone CSF leak. Brain MRI showed a dural defect localized to the anterior petrous apex. Using a combined middle cranial fossa-transmastoid approach, the dural defect and associated arachnoid granulations were located along the superior side of the greater petrosal nerve and repaired. A CSF leak without underlying pathology, such as trauma, surgery, or congenital abnormality, is defined as spontaneous. Spontaneous CSF leak should be considered as a cause of recurrent bacterial meningitis even when CSF otorrhea and fluid behind the tympanic membrane are clinically absent.