Transverse sinus stenting without surgical repair in idiopathic CSF rhinorrhea associated with transverse sinus stenoses: a pilot study
Stéphanie LenckAurélien NouetEimad ShotarSamiya Abi JaoudéPatrick NicholsonKévin PrematCéline CorcyAnne‐Laure BochNader SourourF. TankéréAlexandre CarpentierFrédéric Clarençon
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Abstract:
Based on their clinical and radiological patterns, idiopathic CSF rhinorrhea and idiopathic intracranial hypertension can represent different clinical expressions of the same underlying pathological process. Transverse sinus stenoses are associated with both diseases, resulting in eventual restriction of the venous CSF outflow pathway. While venous sinus stenting has emerged as a promising treatment for idiopathic intracranial hypertension, its efficiency on idiopathic CSF leaks has not been very well addressed in the literature so far. The purpose of this study was to report the results of transverse sinus stenting in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.From a prospectively collected database, the authors retrospectively collected the clinical and radiological features of the patients with spontaneous CSF leakage who were treated with venous sinus stenting.Five female patients were included in this study. Transverse sinus stenoses were present in all patients, and other radiological signs of idiopathic intracranial hypertension were present in 4 patients. The median transstenotic pressure gradient was 6.5 mm Hg (range 3-9 mm Hg). Venous stenting resulted in the disappearance of the leak in 4 patients with no recurrence and no subsequent meningitis during the follow-up (median 12 months, range 6-63 months).According to the authors' results, venous sinus stenting may result in the disappearance of the leak in many cases of idiopathic CSF rhinorrhea. Larger comparative studies are needed to assess the efficiency and safety of venous stenting as a first-line approach in patients with spontaneous CSF rhinorrhea associated with transverse sinus stenoses.Keywords:
Sinus (botany)
Cerebrospinal Fluid Rhinorrhea
Dural venous sinuses
Objectives To report a case of spontaneous cerebrospinal fluid oto-rhinorrhea with recurrent purulent meningitis and to discuss its diagnosis and treatment.Methods The medical history,diagnosis and treatment of a 9-yearold child with spontaneous cerebrospinal fluid oto-rhinorrhea with recurrent purulent meningitis was retrospectively reviewed.Results The child visited a doctor due to four episodes of purulent meningitis.Spontaneous cerebrospinal fluid oto-rhinorrhea was cured by surgery.Conclusions The spontaneous cerebrospinal fluid oto-rhinorrhea in children is rare.Pediatrician should be alert of recurrent purulent meningitis in cerebrospinal fluid oto-rhinorrhea.
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<b><i>Objectives:</i></b> To present a rare case of cerebral venous sinus thrombosis (CVST). <b><i>Clinical Presentation and Intervention:</i></b> A 43-year-old woman presented with coma and was diagnosed as a case of CVST. She recovered in a few days with heparin treatment. Many possible risk factors for CSVT were negative in the patient but intermittent cerebrospinal fluid (CSF) rhinorrhea was accidentally noticed. Cerebral computed tomography and magnetic resonance imaging were done. The patient was diagnosed as having spontaneous intermittent CSF rhinorrhea due to a defect in the base of the skull. <b><i>Conclusions:</i></b> This case showed the importance of being aware that a defect in the base of the skull may lead to intermittent CSF rhinorrhea in patients with CVST.
Cerebrospinal Fluid Rhinorrhea
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Dural venous sinuses
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Brain tumors are the rarest cause of cerebrospinal fluid rhinorrhea. Non-traumatic cerebrospinal fluid rhinorrhea is also a relatively rare condition. It may be misdiagnosed as allergic rhinitis or chronic sinusitis and lead to unsuitable treatment. We described a 34-yearold man who came to our allergy clinic with a chief complaint of clear rhinorrhea from his left nostril with more than four years of duration. Only hypertrophy of left inferior concha was found in the clinical examination. His rhinorrhea aggravated when bending forward. So we were suspicious of CSF rhinorrhea.MRI was done for him and demonstrated a large tumor in the pineal region. The patient underwent surgery with resection of the mass via an infratentorial-supracerebellar approach. This case showed the role of maintaining differential diagnosis for a common complaint; rhinitis which is seen as usual.
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The management of cerebrospinal fluid rhinorrhea has historically plagued the neurosurgeon and the otolaryngologist—head and neck surgeon. Intracranial repair is still favored at many institutions, despite its inherent morbidity. Extracranial nonendoscopic techniques have been previously described but have not gained wide acceptance. More recently, several reports have been published describing a variety of endoscopic techniques in limited patient series used to manage cerebrospinal fluid rhinorrhea. We present our series of 29 patients with cerebrospinal fluid rhinorrhea, treated with endoscopic techniques between December 1989 and June 1993, with follow‐up ranging from 3 to 43 months. This represents the largest reported series to date of patients treated with this technique. Our technique has evolved during this time period but centers around the use of free tissue grafts from various donor sites. The causes of the skull base defects in this series included neurosurgical procedures (9), functional endoscopic sinus surgery (8), and trauma (3). Defects occurred spontaneously in 9 cases. The fovea ethmoidalis and sphenoid sinus were the site in 11 and 12 cases, respectively, and the cribriform plate was involved in 6 cases. Cerebrospinal fluid rhinorrhea was documented by nasal endoscopy with or without intrathecal fluorescein, laboratory studies, computed tomography with or without contrast cisternography, and radioisotope cisternography in various combinations. Resolution of cerebrospinal fluid rhinorrhea was achieved in 22 of 29 patients (75.9%) with one endoscopic procedure and 25 of 29 patients (86.2%) after a second attempt. Four patients required neurosurgical intervention for recurrent cerebrospinal fluid rhinorrhea. Complications were minimal and were related primarily to the original pathology or procedure. Cerebrospinal fluid rhinorrhea can be managed safely and effectively with endoscopic techniques in a majority of cases, and the morbidity of open procedures can be avoided.
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ABSTRACT: There has been a recent renewal of interest in the extracranial repair of cerebrospinal fluid rhinorrhea because of the relatively high morbidity associated with the transcranial approach. The authors describe an extracranial approach that involves packing of the sphenoid and ethmoid sinuses on the side of the CSF leak. A case of successful treatment of CSF rhinorrhea by this method is presented. The extracranial approach may be advantageous for the repair of CSF rhinorrhea and the authors advocate an increase in its utilization by neurosurgeons and otolaryngologists working as a team.
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Radionuclide cisternography (RS) is a highly sensitive, reliable and safe technique used for the confirmation of the presence of cerebrospinal fluid rhinorrhea and the localisation of fistula. The authors describe a patient aged 53 years old with spontaneous cerebrospinal fluid rhinorrhea detected by RS. This kind of rhinorrhea is very rare. After measuring the radioactivity of the nasal wads and examining the RS images, no obvious cause of this rhinorrhea was found. The patient was operated and dura mater cerebroplasty in the anterior cranial fossa was performed. No other cause of rhinorrhea was found during the operation. After the operation the rhinorrhea ceased. The authors report this case because spontaneous rhinorrhea is rare and is well treated by dura mater cerebroplasty.
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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.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.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.
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To summarize our experience in managing cerebrospinal fluid(CSF) rhinorrhea.Twenty-nine cases with cerebrospinal fluid rhinorrhea from 1982 to March of 1997 were reviewed. The duration of CSF rhinorrhea varied from 3 months to 23 years. The ages of the patients ranged from 7 to 72 years.The causes of CSF leak were spontaneous in 18 cases, traumatic in 6 (1 had two accidents and got two different leaking sites) and iatrogenic in 5 cases. Twenty-two cases underwent surgical repair. Overall closure rate was 81.8%. The causes, symptoms and signs, sites of leakage and surgical techniques were analyzed. The classification, diagnosis and treatment of CSF rhinorrhea were discussed.Transnasal extracranial repair undertaken by otorhinolaryngologist got better closure rate(93.8%) in this group. Transnasal endoscopic repair could afford excellent view, facilitate precise tissue graft placement and get better closure rate.
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