eMedicine Specialties > Radiology > Brain/Spine

Cerebrospinal Fluid, Leak: Follow-up

Author: Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR, Professor Emeritus of Radiology, Professor of Clinical Radiology, Louisiana State University Health Sciences Center, New Orleans; Clinical Professor of Radiology, Tulane University School of Medicine; Active Staff, Department of Radiology, University Hospital
Coauthor(s): Enrique Palacios, MD, FACR, Professor of Radiology, Neuroradiology, Tulane University Medical Center, New Orleans; Michael G D'Antonio, MD, Clinical Associate Professor of Radiology, Louisiana State University Health Sciences Center, New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associates, Inc, West Jefferson Medical Center
Contributor Information and Disclosures

Updated: Oct 26, 2009

Intervention

The treatment of cerebrospinal fluid (CSF) leak is primarily surgical. Precise localization of the site of the CSF fistula by using CT, MRI, and cisternographic diagnostic techniques is critical before surgical intervention is done.37 Radiologic interventional procedures are not part of the operative repair of cranial CSF fistulas.

Posttraumatic CSF fistulas persisting beyond 7 days, spontaneous CSF leaks with skull-base defects, increasing pneumocephalus, and meningitis are positive indications for surgical intervention. Extradural endoscopic repair by the otolaryngologist is most helpful in cases needing anterior repair around the cribriform plates. Open craniotomy with intradural repair is necessary for large skull-base defects. The primary goal of surgery is to repair meningeal tears and underlying bone defects.

CSF rhinorrhea or CSF otorrhea

Patients with CSF rhinorrhea or CSF otorrhea are maintained at bedrest in a semisitting Fowler position. They should be instructed to avoid sneezing or coughing, since these actions increase the intracranial pressure and favor persistence of the CSF leak.38,2

CSF leak related to facial fractures or trauma

Preliminary surgical treatment of facial fractures may result in occlusion of the fistula.

Approximately 85% of all posttraumatic fistulas close spontaneously within 7 days.

Pneumocephalus

Rapidly increasing pneumocephalus may result in acute intracranial hypertension requiring the emergency placement of a cranial bone twist-drill hole and the intracranial insertion of a moderately large-bore needle to evacuate the air.

Spontaneous intracranial hypotension syndrome (SIHS)

Frequently, SIHS and persistent orthostatic headache after lumbar punctures can be successfully treated by radiologists or anesthesiologists using a lumbar epidural blood patch.39,40 The cause of the SIHS syndrome should be determined as accurately as possible, and the location of the spinal CSF fistula should be demonstrated by means of MR or isotope cisternography.1 Extradural blood patches are most successful in prolonged or permanent cure of SIHS syndrome and postural headaches when the blood patch is applied at the site of the CSF leak.

Cervical or thoracic spinal CSF fistulas are sometimes effectively treated by using a lumbar blood patch, but successful ablation of the leak occurs less often than with lumbar CSF leak sites.

Occasionally, slow-flow postoperative CSF leaks with lumbar pseudomeningocele have been successfully treated with the aspiration of fluid from the pseudomeningocele and the application of an adjacent extradural blood patch. High-flow CSF fistulas, multiple fistulas, and cervical or thoracic and/or persistent spinal CSF leaks may require surgical meningeal repair.

Sencakova et al41 used 1-3 (or more) extradural lumbar blood patches. They reported early posttreatment improvement in headaches in 90% of patients, but lasting symptom improvement occurred in only 60-75%.

Bedrest, frequent administration of oral fluids, sedation, and analgesic medication are necessary adjuvant treatments.

Epidural blood patch

A trained and knowledgeable radiologist or anesthesiologist can apply an epidural blood patch. Five to 20 mL of freshly drawn unclotted venous blood has been injected into the epidural space, usually in the lumbar region, in literature reports. The injected blood has been demonstrated to extend for several vertebral segments in the epidural space beyond the site of injection. The patient should be kept at bedrest in a decubitus position for at least 2 hours after the epidural blood patch is applied to achieve the maximal effect from the procedure.

 


More on Cerebrospinal Fluid, Leak

Overview: Cerebrospinal Fluid, Leak
Imaging: Cerebrospinal Fluid, Leak
Follow-up: Cerebrospinal Fluid, Leak
Multimedia: Cerebrospinal Fluid, Leak
References
Further Reading
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References

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Keywords

cerebrospinal fluid leak, CSF leak, dural tear, dural leak, CSF rhinorrhea, CSF otorrhea, pneumocephalus, spinal CSF leak, intracranial hypotension, spontaneous intracranial hypotension syndrome, SIHS, traumatic CSF fistula, double-ring sign, lumbar extradural blood patch

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Contributor Information and Disclosures

Author

Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR, Professor Emeritus of Radiology, Professor of Clinical Radiology, Louisiana State University Health Sciences Center, New Orleans; Clinical Professor of Radiology, Tulane University School of Medicine; Active Staff, Department of Radiology, University Hospital
Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, American Society of Spine Radiology, Louisiana State Medical Society, Orleans Parish Medical Society, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Royal Society of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Enrique Palacios, MD, FACR, Professor of Radiology, Neuroradiology, Tulane University Medical Center, New Orleans
Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Michael G D'Antonio, MD, Clinical Associate Professor of Radiology, Louisiana State University Health Sciences Center, New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associates, Inc, West Jefferson Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Lucien M Levy, MD, PhD, Director of Neuroradiology, Professor of Radiology, Department of Radiology, George Washington University Medical Center
Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

C Douglas Phillips, MD, Director of Head and Neck Imaging, Division of Neuroradiology, Weill Medical College of Cornell University/New York Presbyterian Hospital
C Douglas Phillips, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, and Radiological Society of North America
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

L Gill Naul, MD, Professor and Head, Department of Radiology, Texas A&M University College of Medicine; Chair, Department of Radiology, Chief, Section of Magnetic Resonance Imaging, Scott and White Memorial Hospital and Clinic
L Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, and Texas Medical Association
Disclosure: Nothing to disclose.

 
 
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