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Rhinology/Allergy

(295) Localization and Treatment of Spontaneous CSF Leaks Without Conclusive Imaging

Monday, October 2, 2023
2:45 PM – 3:45 PM East Coast USA Time
Has Audio

    Presenting Author(s)

  • JL

    Joseph S. Lee, MD

    Resident
    The Ohio State University Wexner Medical Center Department of Otolaryngology
    Columbus, Ohio, United States

    • Co-Author(s)

  • TL

    Thomas Lepley, Other

    The Ohio State University Wexner Medical Center Department of Otolaryngology, USA

  • DP

    Daniel M. Prevedello, MD, MBA

    The Ohio State University, USA

  • DH

    Douglas A. Hardesty, MD

    The Ohio State University, USA

  • Kyle K. VanKoevering, MD

    Associate Professor
    Ohio State University- Department of Otolaryngology, Head and Neck Cancer
    Columbus, Ohio, United States

  • RC

    Ricardo L. Carrau, MD MBA FACS

    Professor
    Department of Otolaryngology-Head and Neck Surgery, Wexner Medical Center at The Ohio State University, Columbus, Ohio, 43210, USA
    columbus, Ohio, USA

    • Senior Author(s)

  • BO

    Bradley Ia Otto, MD

    Director, Division of Rhinology
    The Ohio State University Wexner Medical Center Department of Otolaryngology
    Columbus, OH, United States

Disclosure(s):
Joseph S. Lee, MD: No relevant relationships to disclose.
Kyle K. VanKoevering, MD: No relevant relationships to disclose.


Introduction: Spontaneous cerebrospinal fluid (CSF) leaks are rare but can lead to significant morbidity. This study identifies the most common anatomic subsites of CSF leaks that are not clearly identified on high-resolution computed tomography (HRCT) and details the management of these cases.

Methods: Retrospective chart review of adults treated for spontaneous CSF leaks with inconclusive HRCTs at a tertiary medical center in Ohio from 2012 through 2022 was performed. Demographic data, presenting symptoms, imaging results, and treatment plans were recorded. Descriptive statistical analysis was performed to identify the most common anatomic subsites.

Results: HRCT was unable to identify a source in 23 of 596 patients diagnosed with CSF leaks. The most common presenting symptoms were clear rhinorrhea (100%), headache (52.2%), salty/metallic taste (43.5%), and visual changes (26.1%). None had meningitis or intracranial complications at presentation. 80% were diagnosed with idiopathic intracranial hypertension (IIH) by lumbar puncture (LP) with opening pressure (OP) > 25 cmH2O (mean LP OP 30.8 cmH2O). MRI with constructive interference in steady state (CISS) protocol was obtained in 82.6% of patients and correctly identified a source in 6 cases where HRCT was inconclusive. Imaging demonstrated an empty sella in 78.3%. The most common site of leak was at the cribriform plate (60.9%), followed by the sphenoid sinus (39.1%). Intraoperative intrathecal fluorescein was used in 35.3% of cases. Postoperatively, 52.2% patients received CSF-diverting shunts, and 56.6% were started on acetazolamide. 3 patients developed recurrent leaks within 2 years, all of whom did not have an opening pressure measured or shunt placed during their initial hospitalization.

Conclusions: The most common site of spontaneous CSF leaks was at the cribriform plate followed by the sphenoid sinus. MRI can potentially be used in conjunction with HRCT to more accurately localize the site of CSF leak. Intrathecal fluorescein can be used as a tool intraoperatively when imaging is inconclusive. Failure to manage IIH can potentially lead to recurrent CSF leaks.