Spontaneous Clival Leaks and Their Management

Abstract

Introduction Cerebrospinal fluid (CSF) leaks through the nasal cavity occurrence has a rising trend, of which primary spontaneous leak is 6 to 40% of all the CSF leaks. The most common site of CSF leak is ethmoid roof where the bone is thinner in the entire skull base. Clivus being the hard bone is a rare site for spontaneous leak. We present a case series from a single quaternary care center of this rare occurrence and study its reason and management strategy. Materials and Methods A retrospective surgical audit over a period of 10 years of all patients diagnosed with CSF rhinorrhea was done. A PubMed search was conducted with keywords of CSF leak, CSF rhinorrhea, spontaneous CSF rhinorrhea, clival leak, and clivus to identify the literature and these articles were compiled and their management reviewed. Results and Analysis A total of 100 patients underwent surgical management for spontaneous CSF leak, of which there were 5 patients who had spontaneous CSF rhinorrhea from the clivus. There were four female patients; four patients had high body mass index. The most common site of leak was mid-clivus and surgical technique employed was multilayer dural plasty with a nasoseptal flap and measures were taken to reduce the intracranial pressure intra-operatively and postoperatively. Conclusion Spontaneous clival leak is a rare entity with mid and lower clivus being the common site. A combined approach by ENT and neurosurgeons results in best outcome for the patients.

Keywords: IIH; clivus; spontaneous CSF rhinorrhea; spontaneous clival leaks.

Fig. 1

( A ) The blue arrow shows the endoscopic image of fluorescein through the clival defect. ( B ) The black square box shows the bony defect in the clivus. ( C ) The yellow square shows the bony defect sealed with fat and fascia as an inlay layer. ( D ) Reconstruction with multilayered dural plasty showing reinforcement with nasoseptal flap with green highlighter.

Fig. 2

( A ) Sagittal CT image depicting bony defect in the mid-clivus and basilar artery posterior to the defect. ( B ) The corresponding axial image on T2-weighted MRI showing communication between subarachnoid space and clival bone with basilar artery posteriorly. ( C ) Axial MRI image showing features of IIH—flattening of globe, optic nerve flaring, and tortuosity. CT, computed tomography; IIH, idiopathic intracranial hypertension; MRI, magnetic resonance imaging.