Surgical Management of Traumatic Cerebrospinal Fluid Fistulas with Associated Lesions

Abstract Head trauma is associated with a significant risk of cerebrospinal fluid (CSF) fistula.

Material and Methods:Here we report 22 cases subjected to operative intervention for otorrhea, rhinorrhea and oculorrhea with associated traumatic lesions. Majority of the cases had moderate to severe head trauma with Glascow Coma Scale (GCS) score under 14. The study group includes 11 cases with depression fractures, 6 with epidural hematomas and 4 with tension pneumocephalus.

Results:Rhinorrhea was the most common presenting symptom encountered in 15 cases whereas otorrhea was prominent in 7 and oculorrhea in 2 cases. Two patients having rhinorrhea had also oculorrhea and otorrhea. The patients were operated with unilateral approaches in 12 and bifrontal approaches in 10 of the cases.

ConclusIon:Early surgical intervention should be performed in cases presenting with CSF fistula and associated traumatic lesions without considering conservative management to provide an effective control of associated complications due to CSF fistulas.

Keywords:CSF fistula; oculorrhea; otorrhea; rhinorrhea; surgery; trauma

IntroductionTrauma is the most commonly encountered reason for cerebrospinal fluid (CSF) fistula. Two percent of the head trauma and %20 of the skull base fractures have the risk of traumatic CSF fistula [1,2] About one fifth of CSF fistulas are seen as otorrhea due to middle cranial fossa fractures and the remaining 80% is seen as rhinorrhea secondary to anterior cranial fossa fractures [3,7]. Treatment starts at early recognition and verification of the exact site of leakage since infectious complications are the major causes of morbidity at the acute and subacute stage [1,3,7,9]. Although CSF leaks, particularly mild ones, do resolve spontaneously, some tend to persist and necessitate other treatment modalities including daily lumbar punctures or external lumbar drainage. Despite conservative measures, a portion of CSF leaks do not cease and surgical treatment should be performed. Some of the CSF fistula patients require urgent surgical repair due to associated pathologies [5,10,11]. This group is unique in that the cases are usually subjected to moderate or severe head trauma requiring surgery due to associated lesion together with rhinorrhea, oculorrhea or otorrhea which tends to persist. Although there are conservative measures advocated for the definitive treatment, appropriate timing of surgery is also crucial to prevent complications particularly in fractures involving sinuses.In the present study, we report our indications for urgent surgical repair of traumatic CSF fistulas via the anterior and middle cranial fossa with a specific interest on associated traumatic lesions like depression fractures, epidural hematomas or tension pneumocephalus.