Neurosurgical treatment of traumatic frontobasal CSF fistulae in 300 patients (1967–1989)

Abstract

300 patients with traumatic fronto-basal CSF fistulae were treated neurosurgically from 1967 to 1989, i.e. via a transcranial approach. An additional intracranial space occupying lesion, a direct open endocranium and/or a large basal brain hernia was found in 68%. The following aspects were discussed: progress in establishing the exact anatomical diagnosis, especially neuroradiological advances; questions of the indication for surgery; the problem of the optimal surgical approach. Both the cranial and the rhinological approach have advantages and disadvantages. Their indications only partly coincide, so that the choice of method depends especially on the individual pathology. Advances were made in recent years in terms of neurosurgery as well as of rhinology. The neurosurgical results could be improved, and postoperative complications have become rare after the cranial approach. Besides the optimal choice of the time of operation, the following factors are important: an adequate intracranial debridement; a microsurgical technique entailing as little damage to surrounding tissue as possible and various specially mentioned brain-protective measures. An optimal collaboration between the specialties involved is the basis for further progress. More attention must be paid to endocrinological problems in the future.

Spontaneous closure of traumatic CSF otorrhoea following conservative management

“…The management could be conservative or surgical. Fifty to eighty-five percent of traumatic CSF leaks resolve spontaneously within 7 days, and almost all leaks cease within 6 months of conservative management [6][7][8][9][10][11].…”

“…This includes bed rest with patient in head -up position and avoidance of coughing, sneezing and heavy lifting. Therapeutic reduction of the spinal fluid production using agents such as acetazolamide and frusemide and repeated removal of CSF via lumbar tap or an indwelling catheter has also been tried with minimal success [10][11][12]. Laxatives have been used to decrease raised intracranial pressure associated with bowel movement [7].…”

“…However the period of waiting is arbitrary and this often requires close cooperation between neurosurgeons, neuroradiologist and otolaryngologist. A waiting period between 5 days and 8 weeks has been reported [7][8][9][10][11][12]. Posttraumatic CSF fistulas persisting beyond 7 days, spontaneous CSF leaks with skull-base defects, increasing pneumocephalus, and meningitis are positive indications for surgical intervention.…”

“…Posttraumatic CSF fistulas persisting beyond 7 days, spontaneous CSF leaks with skull-base defects, increasing pneumocephalus, and meningitis are positive indications for surgical intervention. Extracranial and endoscopic repair by the otolaryngologist has been reported, however, open craniotomy with intradural repair is necessary for large skull-base defects [10][11][12][13]. Prophylactic antibiotics used in this patient seem to be the widely accepted practice.…”

Surgical treatment of complex traumatic frontobasal lesions: personal experience in 74 patients

“…13,16,18,24,26,29,30,37,41 According to the authors of these studies, all acute patients underwent surgery for persistent CSF leaks, large comminuted fractures with a suspected dural tear, or perforating injuries.…”