Non-traumatic cerebrospinal fluid rhinorrhea: diagnosis and management

Abstract

Background: Although the majority of cerebrospinal (CSF) fistulas in the anterior skull base are traumatic in nature, the minority is non-traumatic or primary. Non-traumatic CSF leak can be a diagnostic and treatment challenge.

Patients and methods: We describe the diagnosis, modified methods of localization, and surgical repair of a series of nine patients who presented with non-traumatic CSF rhinorrhea and were managed between July 2000 and October 2002.

Results: Eight patients were managed via an endoscopic approach and one patient through an intracranial approach. The RI/T2-FLAIR test was used for localization of the site of the leak. The test confirmed the site of CSF leak in 6 patients. Successful repair of CSF rhinorrhea was achieved in 7 of 8 patients with a single endoscopic procedure; one patient required two procedures after a re-leak 18 months following the first repair.

Conclusion: Non-traumatic CSF rhinorrhea is a relatively rare condition and occurs secondary to different etiologies. Among multiple techniques available for localization, MRI/FLAIR is effective, but requires further evaluation and polishing. In the absence of a large skull base lesion or tumor, endoscopic repair of CSF fistula carries a high success rate with a high margin of safety and low morbidity rate.

Figure 1

Distribution of the patients according to the site and the etiology of the lesions.

Figure 2

(A) Overlay technique for small defect repair (<3mm); (B) Underlay technique for large defect repair (>3mm).

Figure 3

MRI/FLAIR imaging of non-traumatic CSF rhinorrhea for sphenoid lesions: (A) MRI T2-weighted image of spontaneous CSF rhinorrhea of the right sphenoid sinus; (B) FLAIR imaging of the same patient, notice the nulling signal of the CSF.

Figure 4

CT-cisternography revealing CSF agress from right cribriform area.

Figure 5

Diagnosis and management of non-trumatic CSF rhinorrhea. F.E., Fovea ethmoidalis; C.F.P. cribriform plate.