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