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Cerebrospinal Fluid Leaks

Introduction. Cerebrospinal fluid surrounds and cushions brainPathologic communication with outside world can lead to problemsMultiple etiologies of CSF fistulaeMultiple diagnostic modalitiesTreatment varies and depends on etiologies. History. 2nd Century -- described by GalenMiddle Ages -- ass

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Cerebrospinal Fluid Leaks

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    1. Cerebrospinal Fluid Leaks Michael E. Decherd, MD Byron J. Bailey, MD University of Texas Medical Branch May 26, 1999

    2. Introduction Cerebrospinal fluid surrounds and cushions brain Pathologic communication with outside world can lead to problems Multiple etiologies of CSF fistulae Multiple diagnostic modalities Treatment varies and depends on etiologies

    3. History 2nd Century -- described by Galen Middle Ages -- association made with head trauma 1897 -- Escat describes and treats fistulous EAC

    4. History 1926 -- Dandy describes intracranial repair 1948 -- Dohlman describes extracranial repair 1981 -- Wigand describes endoscopes in repair

    5. Basic Science CSF is essentially an ultrafiltrate of plasma Adult averages 140 mL, renewed three times daily Mostly made in choroid plexus Traverses ventricles, convexities, uptaken by arachnoid villi Normal pressure between 50-180 mm H2O

    6. Classification Terminology not consistent Traumatic Surgical Non-surgical

    7. Classification Non-Traumatic High-pressure Normal-pressure Spontaneous -- poor term but refers to leak with no antecedent history of trauma High-flow versus Low-flow

    8. Epidemiology 80% trauma (non-surgical), 16% surgical, 3-4% non-traumatic Occur in: 3% closed head injuries 9% penetrating head injuries 10-30% basilar skull fractures Meningitis 10-25% of traumatic (non-surgical) CSF leaks Mortality 10%

    9. Diagnosis, General High index of suspicion Rhinorrhea may be of aural source

    10. Diagnosis, History and Physical Suspect with: History of trauma Unilateral rhinorrhea Recurrent meningitis Child with malformatons of otic capsule

    11. Diagnosis, History and Physical May note salty taste Reservoir sign Halo sign Handkerchief test

    12. Diagnosis, Laboratory Glucose Greater than 30 mg/dL generally indicative Can have false-positives and false-negatives Beta-2-Transferrin (Tau-Transferrin) Gold Standard Found in CSF, perilymph, vitreous humor Our lab -- 1 ml of nasal secretions, 1 gold-top tube, 4 days for result

    13. Diagnosis, Radiologic Radionuclide cisternography Test best-suited for ruling in a fistula Pledgets in nose at various points Compare counts to serum Technetium or Indium depending on half-life CT Cisternography MRI adjunctive if encephalocele Fluorescein

    14. Treatment, Non-surgical In order to work body needs to be able to heal itself Chronic fistula probably won’t heal Surgical reduction of fractures may allow spontaneous closure Appropriate if patient can afford to wait

    15. Treatment, Non-surgical Specifics: Elevate head of bed Lumbar drain -- but not too much Avoid sneezing, coughing, straining at stool Anti-hypertensives, analgesics Antibiotics controversial Questionable role of diuretics, fluid restriction

    16. Treatment, Surgical Tailored to individual Intracranial versus extracranial Endoscopic versus microscopic

    17. Treatment, Surgical Specifics: Exposure Grafts/flaps fat, fascia, muscle, cartilage, mucosa simple or composite Biological glue collagen, fibrin, cyanoacrylate Gelfoam, Merocel Postop -- bedrest, similar to medical management

    18. Controversies Antibiotics Intracranial versus extracranial Choice of repair

    19. Complications Meningitis Tension pneumocephalus

    20. Future Developments Refinement of endoscopic techniques More studies of specifics of care Improved biomaterials Improve radiological techniques

    21. Case Study 33 yo WF, chief complaint “runny nose” Comes and goes, usually right side, takes Contac with some relief PMH: thinks she was hospitalized once with “brain infection”, migraines born deaf in left ear fell off seawall after high school prom

    22. Case Study Exam: clear rhinorrhea right nare, ?polyp middle meatus Lab: positive for glucose; beta-2-transferrin pending CT scan Postop -- goofy

    23. Conclusion CSF fistulae arise from a variety of etologies Diagnosis based on physical, laboratory and radiologic techniques Treatment divided into surigical and non-surgical Future holds refinement of existing techniques, development of new ones

    24. Cerebrospinal Fluid Leaks Michael E. Decherd, MD Byron J. Bailey, MD University of Texas Medical Branch May 26, 1999

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