title: A management algorithm for cerebrospinal fluid leak associated with anterior skull base fractures: detailed clinical and radiological follow-up.
abstract: Detailed outcome data for the management of anterior skull base fractures associated with cerebrospinal fluid (CSF) leakage is lacking. We present detailed follow-up data of a single-center study using a predetermined algorithm for the management of CSF leakage secondary to traumatic fractures. A number of 138 consecutive patients were included in the analysis; all patients underwent high-resolution computed tomography (CT) scanning at time of admission with β(2)-transferrin testing used to confirm CSF leakage. Patients with acute surgical indications were operated as emergent; leaks were repaired at the time of initial surgery in patients with intracranial pressure < 15 cm H(2)O. The remainder of the study population was managed conservatively including use of prophylactic antibiotics; lumbar drainage (LD) catheters were placed in those patients with leakage persisting beyond 48 h. Leaks lasting longer than 5 days underwent microsurgical repair using an intradural bicoronal approach. One-year follow-up assessment included evaluation of neurological status, Glasgow Outcome Scale (GOS), and repeat head CT. Twenty eight patients (26.9%) underwent emergent surgery, 15 of whom had simultaneous CSF leak repair, whereas 76 patients (73.1%) underwent delayed CSF leak repair between days 5 and 14. Postoperative meningitis rate was low (1.9%). Postoperative CSF leak (1.9%) was managed by intradural or transnasal endoscopic operation. Comparable rates of anosmia and frontal lobe hypodensities were seen in the surgical and conservatively managed subgroups. The presented algorithm, utilizing prophylactic antibiotics, trial of LD, acute and/or delayed intradural microsurgery, yields favorable outcomes. Large randomized controlled trials are needed to better define the role of prophylactic antibiotics and to better characterize the optimal timing and approach of surgical repair.
authors.affiliation: Department of Neurosurgery, Medical University Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria. camillo.sherif@meduniwien.ac.at
authors.forename: Camillo
authors.initials: C
authors.lastname: Sherif
authors.forename: Antonio
authors.initials: A
authors.lastname: Di Ieva
authors.forename: Daniel
authors.initials: D
authors.lastname: Gibson
authors.forename: Bita
authors.initials: B
authors.lastname: Pakrah-Bodingbauer
authors.forename: Georg
authors.initials: G
authors.lastname: Widhalm
authors.forename: Irena
authors.initials: I
authors.lastname: Krusche-Mandl
authors.forename: Jozsef
authors.initials: J
authors.lastname: Erdoes
authors.forename: Benjamin
authors.initials: B
authors.lastname: Gilloon
authors.forename: Christian
authors.initials: C
authors.lastname: Matula
mesh_terms: D000328:Adult; D000465:Algorithms; D065634:Cerebrospinal Fluid Leak; D002559:Cerebrospinal Fluid Rhinorrhea / Q000175:diagnosis* / Q000209:etiology / Q000601:surgery*; D006259:Craniocerebral Trauma / Q000150:complications* / Q000401:mortality / Q000601:surgery; D004724:Endoscopy; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D008297:Male; D008581:Meningitis / Q000150:complications / Q000175:diagnosis; D008866:Microsurgery; D012887:Skull Fractures / Q000150:complications* / Q000601:surgery*; D013997:Time Factors; D014057:Tomography, X-Ray Computed