CSF-leaks-slides-050112 - CSF Leaks CSF Steven Wright M.D...

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Unformatted text preview: CSF Leaks CSF Steven Wright, M.D. Matthew Ryan, M.D. January 5, 2004 CSF Leaks CSF Abnormal communication between the Abnormal subarachnoid space and the tympanomastoid space or nasal cavity. tympanomastoid Presenting symptoms: Middle ear effusion, hearing loss Unilateral rhinorrhea Risk of meningitis is high 2-88% CSF Rhinorrhea CSF Diverse etiology Idiopathic Trauma-Surgical <1% Trauma-Nonsurgical 3% of all closed head injuries 30% of skull base fractures Frontal>Ethmoids>Sphenoids Inflammatory Congenital Neoplasm Testing of Nasal Secretions Testing Beta-2-transferrin is highly sensitive and Beta-2-transferrin specific specific 1/50th of a drop Electronic nose has shown early success Imaging Imaging High resolution CT CT Cisternography MRI Heavily weighted T2 Slow flow MRI MRI cisternography Radionuclide cisternography Intrathecal flourescin Imaging Imaging HRCT Volume averaging Congenital Congenital dehiscences of Spenoid/cribiform niche. niche. Imaging Imaging CT cisternography Currently the optimal Currently imaging modality (85% sensitive) sensitive) Intrathecal Intrathecal administration of iodine, prone 6hrs iodine, 0% for inactive leaks Substantial radiation Substantial exposure exposure ?neurotoxic potential Imaging Imaging MRI cisternography heavily weighted T2 Intrathecal gadolinium Imaging Imaging Slow flow MRI Diffusion weighted Diffusion MRI MRI Fluid motion down to Fluid 0.5mm/sec 0.5mm/sec Ex. MRA/MRV Imaging Imaging Radioisotope cisternography Intrathecal administration of technitium 99m Less spatial resolution and specificity Largely abandoned due to false positive and Largely false negative results false Intrathecal Flourescin Intrathecal 0.1ml of 10% 0.1ml flourescin solution mixed in 10cc of CSF mixed Blue light may Blue enhance the flourescin flourescin Complications are low Treatment of CSF Rhinorrhea Treatment Conservative measures Bed rest/Elev HOB>30 Stool softeners No sneezing/coughing +/- lumbar drains Early failures Assoc with hydrocephalus Recurrent or persistent leaks Treatment of CSF Rhinorrhea Treatment Prophylactic antibiotics: Two conflicting meta-analysis regarding Two basilar skull fractures. basilar Proponents argue less meningitis. Opponents argue organism resistance. Surgical Options Surgical Intracranial Direct visualization Success rates 50-73% Significant morbidity • • • Anosmia Cerebral edema Seizures Surgical Options Surgical Extracranial approach Improved success rates (80%) Significant morbidity Frontal osteoplastic flap/infratemporal Frontal approach approach Endoscopic repair Endoscopic Endoscopic intranasal repair Overall success rates: • 90% 1st attempt • 52-67% for 2nd attempt • Overall 97% Complications: • • • • Meningitis (0.3%) Brain abscess (0.9%) Subdural hematoma (0.3%) Headache (0.3%) Endoscopic techniques Endoscopic Overlay vs Underlay Overlay technique Meta-analysis showed Meta-analysis that both techniques have similar success rates rates Onlay: adjacent Onlay: structures at risk, or if the underlay is not possible possible Surgical Techniques Surgical Use gelfoam and gelfilm (>90%) Use nasal packing (100%) Consider fibrin glue (>50%) Consider lumbar drain for Consider idiopathathic/posttraumatic assoc with increased ICP increased 3-5 days Not required BR, stool softeners, antibiotics CSF Otorrhea CSF Acquired Postoperative (58%) Trauma (32%) Nontraumatic (11%) Spontaneous Bony defect theory Arachnoid granulation theory Temporal bone fractures Temporal Longitudinal 70% Anterior to otic capsule 15-20% facial nerve 15-20% involvement involvement Temporal bone fractures Temporal Transverse 20% High rate of SNHL 50% facial nerve 50% involvement involvement Temporal bone fractures Temporal HRCT will demonstrate the fracture line HRCT and the likely site of CSF leak. and Beta-2-transferrin Treatment Bedrest Elev HOB Stool softeners +/- lumbar drain Temporal bone fractures Temporal Brodie and Thompson et al. 820 T-bone fractures/122 CSF leaks Spontaneous resolution 95/122: within 7 days 21/122: between 7-14 days 5/122: Persisted beyond 2 weeks Temporal bone fractures Temporal Meningitis 9/121 (7%) developed meningitis. A later meta-analysis by the same author later did reveal a statistically significant reduction in the incidence of meningitis with the use of prophylactic antibiotics. with Pediatric temporal bone fractures Pediatric Much lower incidence (10:1, adult:pedi) Undeveloped sinuses, skull flexibility otorrhea>> rhinorrhea Prophylactic antibiotics did not influence Prophylactic the development of meningitis. the Spontaneous CSF otorrhea Spontaneous Congenital Defect Theory: 1) enlarged petrosal fallopian canal 2) patent tympanomeningeal (Hyrtl’s) fissure 3) Comminication of the IAC with the vestibule 3) (Mondini’s dysplasia)-most common (Mondini’s Childhood presentation 82% SNHL 93% Meningitis 83% Mondini Dysplasia Congenital bony defect Congenital Spontaneous CSF otorrhea Spontaneous Arachnoid granulation theory Enlargement of arachnoid villi due to Enlargement congenital entrapments/pressure variations congenital Presentation Unilateral serous otitis media Meningitis (36%) No SNHL or Mondini dysplasia Sites are multiple, floor of the middle fossa Sites most common most Arachnoid Granulation Arachnoid Spontaneous CSF otorrhea Spontaneous Stone et al. HRCT vs. CT cisternography/radionuclide HRCT cisternography. cisternography. HRCT showed bony defects in 71%. 100% intraoperative findings correlated with 100% HRCT. HRCT. HRCT significantly identified more patients HRCT with CSF leak than radionuclide cisternography or CT cisternography. cisternography Surgical approaches Surgical Transmastoid Middle cranial fossa Not ideal for large Not defects (>2cm), multiple defects, or defects that extend anteriorly anteriorly Technically Technically challenging challenging Best exposure Combined approach Technique of closure Technique Muscle, fascia, fat, bone wax, etc.. The success rate is significantly higher for The those patients who undergo primary closure with a multi-layer technique versus those patients who only get single-layer closure. closure. Refractory cases may require closure of Refractory the EAC and obliteration. the Conclusions Conclusions The clinical presentations of CSF leaks The may be very subtle. may The clinician must keep a low threshold for The further testing with Beta-2-Transferrin. further Imaging studies should be performed to Imaging anatomically localize the site. anatomically Success rates may be over 90% with Success proper patient and surgical selection proper ...
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