Dr. Amanj Burhan Special neurosurgeon 4/17/2020 1 4/17/2020 3 CSF leak Traumatic Accident 4/17/2020 Non traumatic Iatrogenic 4 TUMOR High pressure HYDROCEPHALUS Non traumatic OSTEOMYELITIC ERROSION Normal pressure FOCAL ATROPHY CONGENITAL ANOMALIES 4/17/2020 5 Traumatic Non traumatic 2% of head injury Rare Age Irrespective Adult , middle age Sex Irrespective Female 2 : 1 male Acute ( within 48 hours ) Insidious 1 week 70% Years Few drops Profuse Laterality Unilateral ( usually) Variable Aerocele 20% Unusually Anosmia 80% Rare Head ache Uncommon Common Risk of infection High 25-50% Low Incidence Onset Duration Amount of leakage 4/17/2020 6 4/17/2020 7 4/17/2020 8 4/17/2020 9 Diagnosis 1-identification of CSF by 1. CSF is clear like water 2. not excoriate the nose 3.salty taste 4/17/2020 12 • Biochemical tests : – sugar more than 30 mg/ dl , false positive 60% present , negative test very useful to exclude csf , – beta 2 transferrin – trace protein( more sensitive ) 4/17/2020 13 2. Site of fistula localization A. Plain X ray : 20% helpful B. CT Scan to rule out hydrocephlaus and neoplasm , non contrast CT for bony abnormality ,contrast CT to identify leaking site associated with adjacent abnormal brain paranchyma C. Water soluble contrast CT cisternography ( wsctc) used when site of leak not localized by CT , multiple bony defect to identify active leaking site D. MRI : T2 prone position : 4/17/2020 14 4/17/2020 15 4/17/2020 16 Treatment of traumatic CSF leak • 1. duration of conservative management before surgery • Most stops spontaneously • Indication of surgery in first 2 weeks a) Not decreased rate of leak ( one week) b) Decreased initially and then continue for more than 10 – 12 days c) Meningitis d) Special cases : extensive skull fracture involving frontal air sinuses and during operation of compound skull fracture when dural tear discovered 4/17/2020 17 2.Antibiotics : • Send for C/S • Start broad spectrum antibiotics • Change antibiotics according to the result of the C/S • Repeat C/S every 48 hour for one week 4/17/2020 18 • Approaches of surgery : • Intracranial Intradural approach ( procedure of choice ) • Intracranial Extradural approach • Extra cranial Trans nasal approach 4/17/2020 19 • Treatment of non traumatic type • Treatment of the cause – Tumor : removal – Hydrocephalus : shunt 4/17/2020 20 4/17/2020 21