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  • Controlling intracranial hypertension key to repairing spontaneous cerebrospinal fluid leaks

    By Michael Vaphiades, DO
    Neuro-Ophthalmology/Orbit

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    This prospective study found that the majority of spontaneous cerebrospinal fluid (CSF) leaks are secondary to intracranial hypertension but that treatment of elevated intracranial pressure (ICP) in combination with endoscopic repair can be very successful.

    The authors prospectively evaluated 46 patients (average age, 51 years) with 56 spontaneous CSF leaks who presented over five years to one otolaryngologist. Twenty-one of these patients presented with recurrence of their CSF leak following previous endoscopic and/or open approaches performed by other physicians. Seventy-eight percent of the 46 patients were obese (average body mass index, 35.6).

    Fifty-two CSF leaks (93 percent) were successfully repaired on the first attempt. With secondary repair, all CSF leaks were closed at the last clinical follow-up at an average of 93 weeks. The authors attributed the four occurrences of primary repair failure to elevated ICP after discontinuation of acetazolamide in three individuals.

    Opening pressures via lumbar puncture averaged 24.3 ± 8.3 cm H2O, which increased significantly to 32.3 ± 9.0 cm H2O following closure of the skull base defect. Management of intracranial hypertension included acetazolamide or permanent CSF diversion, which included five revisions of failed pre-existing shunts.

    Among the patients who presented with recurrence following previous surgical interventions at outside institutions, failure to control or recognize intracranial hypertension occurred in all 21 subjects. All patients in this group had documented elevated ICP on opening pressure and/or monitoring following repair at the authors’ institution.

    The authors say this study demonstrates that spontaneous CSF leaks are more common in the presence of obesity and female gender, which is consistent with previous reports in the literature. Overall, clinical presentation and radiologic findings were similar to previously reported data.

    They also note that this is the first cohort of spontaneous CSF leak patients to report the frontal sinus posterior table as the most common site of involvement.