- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
- Department of Otolaryngology, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
DOI:10.4103/2152-7806.131105Copyright: © 2014 Matsubara T This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Matsubara T, Akutsu H, Tanaka S, Yamamoto T, Ishikawa E, Matsumura A. A case of spontaneous cerebrospinal fluid rhinorrhea: Accurate detection of the leak point by magnetic resonance cisternography. Surg Neurol Int 19-Apr-2014;5:54
How to cite this URL: Matsubara T, Akutsu H, Tanaka S, Yamamoto T, Ishikawa E, Matsumura A. A case of spontaneous cerebrospinal fluid rhinorrhea: Accurate detection of the leak point by magnetic resonance cisternography. Surg Neurol Int 19-Apr-2014;5:54. Available from: http://sni.wpengine.com/surgicalint_articles/a-case-of-spontaneous-cerebrospinal-fluid-rhinorrhea-accurate-detection-of-the-leak-point-by-magnetic-resonance-cisternography/
Background:Spontaneous cerebrospinal fluid (CSF) rhinorrhea is a rare entity. The accurate preoperative localization of the leak point is essential for planning surgical treatment, but is sometimes difficult. To localize the leak point, magnetic resonance cisternography (MRC) is the method of choice, but its effectiveness remains unclear.
Case Description:A 34-year-old mildly obese female experienced spontaneous CSF rhinorrhea after an attack of bronchial asthma. High-resolution computed tomography (CT) failed to reveal the leak point, while MRC demonstrated an arachnoid herniation at the olfactory cleft. The patient underwent endoscopic endonasal repair of the CSF leak with success. There has been no recurrence of CSF rhinorrhea for 14 months after surgery followed by the administration of acetazolamide.
Conclusion:We report a rare case of spontaneous CSF rhinorrhea associated with benign intracranial hypertension, in which the leak point was successfully detected by MRC. The CSF leak was completely repaired by minimally invasive endoscopic endonasal surgery. MRC may be a reliable method for detecting CSF leak points.
Keywords: Benign intracranial hypertension, endoscopic endonasal surgery, leak point, magnetic resonance cisternography, spontaneous cerebrospinal fluid rhinorrhea
The term spontaneous cerebrospinal fluid (CSF) rhinorrhea has been applied to describe the nasal discharge of CSF unrelated to trauma, surgery, malformation, or tumor.[
To localize the leak point, numerous techniques have been used, including plain skull radiography, pluridirectional tomography, intraoperative injection of fluorescein dye, positive contrast studies, and radionuclide cisternography, however, these methods have some limitation to accurately detect leaks. In general, computed tomography (CT) cisternography has been considered the most reliable and accurate method of diagnosing CSF rhinorrhea, however, this technique is invasive and is contraindicated in patients with elevated ICP.[
We report here on a patient with spontaneous CSF rhinorrhea associated with benign intracranial hypertension (BIH) and originating at the cribriform plate, in which the leak point was successfully detected by MRC, resulting in complete repair via minimally invasive endoscopic endonasal surgery.
A 34-year-old female suddenly experienced marked rhinorrhea from the left nostril, with no history of trauma. She had been having intermittent headache. She had been coughing due to bronchial asthma for one month and was taking medication including steroid hormone inhalation. The diagnosis of CSF rhinorrhea was made based on clinical findings and a glucose-oxidase test. The patient's physical examination revealed mild obesity (BMI 34.1 kg/m2), but no signs of meningitis, visual disturbance, or olfactory dysfunction. High-resolution CT revealed enlargement of the sella turcica and broad thinning of the bony wall of both the sphenoid sinus and ethmoid sinus, including the cribriform plate [
Magnetic resonance cisternography (MRC) reveals an extracranial extension of cerebrospinal fluid (CSF) space as a small pouch protruding into the left olfactory cleft (a,b). Arachnoid herniation is indicated by soft tissue isointense strands of tissue intermingled with CSF signal intensity probably through the osteodural defect at the olfactory cleft (b, arrowhead). Note that the empty sella is depicted (c, arrow). MRC taken one week after surgery reveals the arachnoid herniation diminishing with a solid mass (abdominal fat) (d,e, blue arrowhead)
The patient underwent endoscopic endonasal repair of the CSF leak via the left nostril. During the surgery, arachnoid herniation was observed at the olfactory cleft, precisely as demonstrated by the preoperative MRC [
After the surgery, lumbar drain management was carried out for one week. ICP monitoring revealed that the patient's mean ICP was 22-23 cmH2O. Furthermore, a sudden impulse of elevated ICP over 36 cmH2O (B wave) was found (BIH). Thus, acetazolamide was administered to decrease CSF production. At the time of writing, 14 months after surgery, there has been no recurrence of CSF rhinorrhea [Figure
Over the past two decades, open transcranial approaches for the repair of CSF rhinorrhea have been replaced by a minimally invasive endoscopic endonasal approach. Improved cosmetics, olfaction preservation, and reduced morbidity are the main reasons for this preference for endoscopic repairs.[
In the present patient, preoperative MRC precisely identified the location of the CSF leak, which made it possible to perform minimally invasive endoscopic surgery, avoiding a craniotomy and damage the olfactory nerve. If we had chosen conventional transcranial repair, the leak point would have been covered with a pericranial flap over the olfactory nerve and would therefore not be seen directly. The endoscopic endonasal approach made it possible to directly visualize the skull base defect and facilitated direct repair of the leak point.
Accurate localization of the CSF leak is essential for planning surgical treatment.[
Focusing the topic to spontaneous CSF rhinorrhea, CT is not sufficient compared with that following trauma especially in localizing CSF leak point, based on the following reasons. First, patients with a spontaneous CSF leak naturally lack skull fracture, which is usually present in traumatic patients and can be detected by high-resolution CT (accuracy 92%, sensitivity 92%, specificity 100%).[
In contrast, the efficacy of MRC in localizing spontaneous CSF rhinorrhea compared with other types of CSF rhinorrhea has not yet been fully evaluated. Only one previous study showed the efficacy of MRC: Schuknecht et al. demonstrated spontaneous intermittent CSF rhinorrhea in 27 patients; MRC was correct in 93.3% of cases, CT cisternography in 62.5%, and CT in 50%.[
In conclusion, the present clinical course suggested that MRC was effective for revealing the precise CSF leak point in a patient with spontaneous CSF rhinorrhea and thereby making it possible to perform less invasive endoscopic endonasal surgery. We believe that significant number of patients may be unreported, in whom MRC can provide more information to identify the leak point than CT, and endoscopic surgery was available. Further studies are needed to determine the usefulness of MRC in localizing the leak point of spontaneous CSF rhinorrhea.
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