Skull Base Cerebrospinal Fluid Fistulas: A Comprehensive Diagnostic Algorithm

Abstract

For patients with skull base CSF fistulas, a graduated diagnostic approach with emphasis on confirmation of leak by beta2-transferrin analysis and precise localization by high-resolution computed tomography is both efficacious and cost effective.

Diagnosis and treatment of cerebrospinal fluid rhinorrhea following accidental traumatic anterior skull base fractures

“…Starting with the simplest diagnostic tool and progressing to the most complex appears to be the most efficient and cost-effective route (Table 2). 119 While embarking on the treatment of these fistulas, we must remember that 85% of CSF rhinorrhea cases resulting from head trauma stop spontaneously and that the risk of meningitis is 0.68% in the first 24 hours after injury and increases up to 18.87% in the first 2 weeks after injury. 42,88 Published reviews have not shown that prophylactic treatment with antibiotics makes a difference, and therefore such therapy should be discouraged.…”

“…Very few studies have been done exclusively to assess the accuracy of HRCT in posttraumatic CSF leaks. In a retrospective review of 47 cases of traumatic and nontraumatic CSF leaks visualized on HRCT, Zapalac and colleagues 119 reported a sensitivity and an accuracy of 87% each. Yilmazlar and colleagues 118 reviewed 81 patients who were treated for CSF leakage due to skull base fractures.…”

“…In Fig. 2, we show a modified version of the algorithm provided by Zapalac et al, 119 integrating all the new chemical and imaging tools that would be more suitable and cost effective for the diagnosis of posttraumatic CSF fistulas. Unfortunately, the diagnosis of an occult fistula in a patient who presents with meningitis and without CSF rhinorrhea becomes more difficult, and all effort should be made to find the fistula by using all the imaging studies deemed necessary.…”

Spontaneous CSF Rhinorrhea Our Experience

“…This communication or fistula must involve a breech of the arachnoid and dura matter, the bone of skull base, and the underlying mucosa [1]. CSF rhinorrhea can be classified according to the etiology into traumatic and non-traumatic [2].…”

Cerebrospinal Fluid Leak, Meningocele and Meningoencephalocele

“…In this setting, high resolution CT is the fi rst line imaging technique, having a reported sensitivity ranging from 50% up to 100% (Dietrich et al 1993;Lloyd et al 1994, Zapalac 2002. It is obtained without intrathecal or intravenous contrast agent administration, using thin (1-or 2-mm) contiguous axial and coronal planes.…”