Persistent CSF Rhinorrhoea, Pneumocephalus, and Recurrent Meningitis Following Misdiagnosis of Olfactory Neuroblastoma
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Abstract:
A 41-year-old female patient was admitted with streptococcal meningitis on a background of 5-month history of CSF rhinorrhoea. Imaging revealed an extensive skull base lesion involving the sphenoid and ethmoid sinuses, the pituitary fossa with suprasellar extension and bony destruction. Histological examination of an endonasal transethmoidal biopsy suggested a diagnosis of olfactory neuroblastoma. A profuse CSF leak occurred and the patient developed coliform meningitis. A second endonasal endoscopic biopsy was undertaken which demonstrated the tumour to be a prolactinoma. Following endonasal repair of the CSF leak and lumbar drainage, she developed profound pneumocephalus. The patient underwent three further unsuccessful CSF leak repairs. Definitive control of the CSF leak was finally achieved through a transcranial approach with prolonged lumbar drainage. This case illustrates some of the potentially devastating complications which can occur as a consequence of complex skull base lesions. A multidisciplinary approach may be required to successfully manage such cases.Keywords:
Pneumocephalus
Cribriform plate
Cerebrospinal fluid leak
Clivus
Lateral recess
Arachnoiditis
Pneumocephalus is common after neurosurgical and sinus procedures, but also after traumatic skull base fractures. An elderly lady presented after a fall with epistaxis and progressive consciousness decline. CT showed a cribriform plate fracture and severe pneumocephalus involving the extradural, subdural, intraventricular, and posterior fossa compartments. It was postulated the “epistaxis” comprised bloodstained CSF, which allowed air to enter the subarachnoid/subdural space, by means of a dehiscence in the skull base, creating a CSF fistula.
Pneumocephalus
Cribriform plate
Subarachnoid space
Subdural space
Skull fracture
Sinus (botany)
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Pneumocephalus
Cribriform plate
Fossa
Cribriform
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Pneumocephalus is common after neurosurgical and sinus procedures, but also after traumatic base of skull fractures. An elderly woman presented after a fall with epistaxis, confusion, and progressive conscious decline. CT showed a right-sided cribriform plate fracture and severe pneumocephalus involving the extradural, subdural, intraventricular, and posterior fossa compartments. It was postulated the "epistaxis" was a blood-stained CSF leak, which allowed the intracranial pressure to drop, encouraging air to enter the subarachnoid/subdural space by means of a dehiscence in the skull base, creating a CSF fistula.
Pneumocephalus
Cribriform plate
Subdural effusion
Subdural space
Subarachnoid space
Skull fracture
Sinus (botany)
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Two patients were found with delayed intracerebral tension pneumocephalus 5 and 12 months later, following head injury. Simple skull X-ray showed a large air-containing cyst in the left frontal lobe in both cases. Dural repairs were done through an intradural approach via single frontal craniotomy. Basal skull fracture with dural tear at cribriform plate of ethmoid bone and intracerebral cyst filled with air were found during operation. Their deteriorated consciousness became clear post-operatively. Plain computed tomography was a very useful instrument in determining the location of the gas collection, fracture site, and tension on the brain.
Pneumocephalus
Cribriform plate
Frontal bone
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Clivus
Cribriform plate
Orbit (dynamics)
Tuberculum sellae
Sphenoid bone
Sinus (botany)
Ethmoid sinus
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We evaluated the utility of a three-dimensional (3-D) endoscopic system for skull base surgery. We performed a retrospective case series in a tertiary care medical center. Thirty-six patients underwent skull base (nonpituitary) resections via 3-D endoscopic system. Fifteen patients (42%) were operated for excision of malignant tumors, 19 (53%) for excision of benign lesions, and 3 (8.3%) for skull base reconstruction. The tumors involved the cribriform plate (n = 13), sphenoid sinus and planum (n = 17), clivus (n = 7), and sella (n = 7). Complete tumor resection was achieved in 31 patients and subtotal resection in two. Five patients (14%) had postoperative complications. There was one case of meningitis, and there were no cases of cerebrospinal fluid leak. The surgeon's ability to recognize anatomic structures at the skull base was evaluated using the 3-D and two-dimensional systems. The 3-D technique was superior to the conventional technique for identification of the sella, carotid prominence, optic prominence, cribriform plate, sphenoid, and fovea ethmoidalis. The two systems were equal for detection of the turbinates, clivus, maxillary, ethmoids, and frontal sinuses. Endoscopic skull base surgery with stereoscopic viewing is feasible and safe. Further studies are required to evaluate the advantage of binocular vision in skull base surgery.
Clivus
Cribriform plate
Cerebrospinal fluid leak
Endoscopic endonasal surgery
Cribriform
Sinus (botany)
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ABSTRACT Objective To report a rare case of delayed spontaneous cerebrospinal fluid (CSF) leak through clival region in the sphenoid sinus. Case report A 35-year-old female presented to our outdoor clinic with watery right nasal discharge for past 2 months, which increased on bending forward. Her medical history, general physical and neurological examinations were unremarkable. High-resolution computed tomographic scan and magnetic resonance cisternography were performed and suggestive of defect in right cribriform plate and right sphenoid sinus. Endoscopic repair was done but same symptoms occurred after 1 month. Repeat magnetic resonance imaging showed fistula in the lateral wall of right sphenoid sinus. Revision endoscopic transnasal CSF rhinorrhea repair was done. Lumbar subarachnoid drain was left in place for 5 days. No recurrence was noted at 12-week follow-up. Conclusion Endoscopic transnasal approach is the best modality of treatment for midline skull base defects. Delayed leaks can present from previously weak areas and all the doubtful areas must be examined during surgery. How to cite this article Mohindra S, Mohindra S, Joshi K, Sodhi HS. Delayed Spontaneous Cerebrospinal Leak through Clival Recess: Emphasis on Technique of Repair. Clin Rhinol An Int J 2017;10(1):42-44.
Lateral recess
Cribriform plate
Sinus (botany)
Cerebrospinal Fluid Rhinorrhea
Ethmoid sinus
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Cribriform plate
Pneumocephalus
Cribriform
Ethmoid bone
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Clivus
Cribriform plate
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Pneumocephalus
Cribriform plate
Cerebrospinal fluid leak
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