Short review/perspective: Critical early treatment of infections including meningitis and/or ventriculitis due to recurrent postoperative lumbar cerebrospinal fluid leaks, lumbar drains, or intracranial devices/implants

Abstract

Background: Early treatment of cerebrospinal fluid (CSF) infections, including meningitis and/or ventriculitis (MV) is critical to minimize morbidity/mortality. Infections/MV are typically attributed to; recurrent postoperative lumbar CSF fistulas with drainage through the skin (12.2-33.3%), lumbar drains, and/or various intracranial devices (i.e. external ventricular drains, intracranial pressure monitors).

Methods: Lumbar MR examinations best document recurrent postoperative dural fistulas with subcutaneous extension leading to leaking wounds; the longer these leaks persist, the greater the risk of CSF infection and MV. Classical cranial MR findings of MV due to prior lumbar surgery, lumbar drains or multiple intracranial devices include; ventricular debris, ependymal enhancement, hydrocephalus, extra-axial fluid collections, infarcts (arteritis/ventriculitis), abscesses, and granulomas.

Results: Surgery for recurrent postoperative lumbar CSF leaks typically warrant wound reexploration with direct sutured-dural repairs, use of muscle patch grafts (avoid fat - it resorbs), fibrin sealants/fibrin glues (FS/FG), lumbar drains, lumboperitoneal and/or pseudomeningocele-peritoneal shunts. For patients who additionally develop meningitis/ventriculitis, one should consider adding intraventricular (IVT) or lumbar intrathecal (IT) antibiotic therapy to routine intravenous antibiotics. Notably, all efforts should be made to avoid the high mortality rates associated with VM (i.e., 13% to 60%).

Conclusion: Recurrent postoperative lumbar CSF leaks (i.e., especially after CSF breaches the skin), lumbar drains, and/or intracranial devices/implants may cause infections including meningitis and ventriculitis (MV). It is critical to recognize and treat these infections/MV early to avoid high morbidity and mortality rates.

Keywords: Cerebrospinal Fluid (CSF) Leaks; Dural Repair; Early Diagnosis; Early Surgery; External Fistulas; External Ventricular Drains; Fibrin Sealant/Fibrin Glues; Infection; Intracranial Pressure Monitors; Lumbar Drain; Lumbar Surgery; Magnetic Resonance Imaging (MR); Meningitis; Muscle Patch Graft; Traumatic Dural Tears (DT); Ventriculitis.