Historical Perspective

First reported in the 17th century.

Dandy in 20th century, reported first successfulrepair utilizing a bifrontal craniotomy forplacement of a fascia lata graft.

Extracranial approaches introduced mid-20thcentury.

Endoscopic approaches were introduced andpopularized in the 1980s and early 1990s.

                                                                                                                                                                                                        

Historical Perspective

First reported in the 17th century.

Dandy in 20th century, reported first successfulrepair utilizing a bifrontal craniotomy forplacement of a fascia lata graft.

Extracranial approaches introduced mid-20thcentury.

Endoscopic approaches were introduced andpopularized in the 1980s and early 1990s.

                                                                                                                                                                                                        

Dr.Saurav Singh Hamal MBBS (Nepalgunj Medical College).

Medical Officer (ANIAS).

Role of Prophylactic Antibiotic In Traumatic Cranial CSF leak

CSF leak Introduction• CSF leak :-

- It refers to any disruption of arachnoid and dura mater that allows CSF to escape to an extradural space.

- The most common manifestation are Rhinorrhoea and Otorrhoea, and rarely spinal leakage.

• Galen accurately described CSF rhinorrhea in 2nd Century • 1826 – C. Miller described Rhinorrhea in a hydrocephalic child .

•In 1889 St Clair Thompson coined the term Rhinorrhoea in a report descrbing a group of patient with spontaneous CSF leak.

•In 1923 Grant first proposed closing a traumatic dural defect.(Profuse bleeding foiled his proposal of surgical repair.

•In 1926 Dandy first reported a 1st succesful operative repair of a CSF leak.• Dohlman, Wigand and others pioneered operative repair.

History

Classification of CSF leak :-

In 1937 Cairns offered 1st classification dividing it into :-1.Acute 2. Delayed 3.Traumatic 4. Operative 5.Spontaneous.

Ommaya later classified into :-1.Traumatic : - a.Accidental b. Iatrogenic.

2.Nontraumatic : - a.High pressure leak ; tumors, hydrocephalus.

b. Normal pressure leak ; congenital, focal atrophy.

• Trauma is the most common cause of Cranial CSF leak and it occurs in 2-3 % of patient with head injury.

•Traumatic CSF leak involve nasal pathway in 80% of case and aural pathways in 20%.

• Postraumatic CSF leak are uncommon in young children and rare below 2years of age due to flexibility of skull bone, cartilaginous ethmoid and poor development of frontal and ethmoid sinus.

•Clinical symptoms of Cranial CSF leak includes :-Frank rhinorrhoea and Otorrhoea.- Intermittent leaks, apparent with change in posture.- Anosmia( when cribriform plate involved).- Risk of meningitis associated in 2-50% of untreated case, and risk is increased with duration of CSF leak. Pneumococcus is the main organism revealed.

In a review of 122 cases of posttraumatic CSF meningitis was reported in 3% of case when the leak was treated within 1 week and 23 % when the leak persistent beyond 1 week.

Overview Of Traumatic CSF leak:-

Management of CSF Otorrhea/RhinorrheaThe management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients.

Diagnosis:-History:- Clear, water-like, unilateral discharge

-Flow may change with alterations in posture and Valsalva-When supine, may have postnasal drip-Cessation of flow associated with headache-May occur after coughing or sneezing.

CSF Otorrhoea and Rhinorrhoea:-

Investigations:- • CSF as compare to nasal secretion has a central area of blood

with outer ring or halo.(Halo Sign).

• Glucose testing. CSF glucose is low compared to serum glucose. 

• Beta 2 transferrin assay. This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks to receive. Most leaks will have closed before the results are available, making this a poor test.

Beta-2 TransferrinFirst used in 1979

Acta Otolaryngol. 1979 Mar-Apr;87(3-4):366-9.

Protein used in iron transport Beta-1

Serum, nasal secretions, tears, saliva.Beta-2

CSF, perilymph and aqueous humor.

Imaging1. CT Scan :- High resolution CT (1mm) with coronal cuts.

2. CT cisternography

3. MRI cisternography

4. Intrathecal Fluorescein

Treatment:-

A-Nonsurgical or medical measure:- 1.Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury.

2. Stool softener, increase fluids, especially drinks with caffeine, can help slow or stop the leak and may help with headache pain. 3.Consider Cough medication , diuretics(Acetazolamide).

4.Consider prophylactic antibiotics carefully.

5.Ear drops are probably not necessary.

6. Lumbar Drain:-Two ways to drain

a.By pressure – set drain at certain level above patient’s ear/ventricles – e.g. 10cm, therefore any pressure greater than 10cm H2O will drain.

b.By volume – 10 cc/hr and reclamp (20 cc/hr of CSF produced, 150mL total volume)

• Drain should not be raised above the level of the ventricles .

7.Wait :- wait and watch for spontaneous resolution of csf leak. Brodie and Thompson et al- 820 T-bone fractures/122 CSF leaks Spontaneous resolution with conservative measures.

95/122 (78%): within 7 days, 21/122(17%): between 7-14 days5/122(4%): Persisted beyond 2 weeks.

B.Surgical Management:-• Indications:

1.Extensive intracranial injury 2.Intraoperative identification3.Do not respond to conservative measures 4.Recurrent meningitis5.Some authors suggest that non-operative repair of spontaneous leak is rarely permanent.

Type of repair:-– 1.Intracranial/Open – 2.Extracranial/Endoscopic

•Controversial role of antibiotic.•Most controversy start from 2 metaanalysis performed at a year difference.

Do Prophylactic Antibiotics Prevent Meningitis in Posttraumatic CSF Leaks:•Meningitis occur in 2-50% of case of traumatic CSF leak ,10% being average.

1.Brodie h et al 1997 USA Prophylactic antibiotics for posttraumatic cerebrospinal fluid fistulae.Arch Otolaryngol Head Neck Surg 1997;123:749-52.

2.Villalobos T et al 1998 USA Antibiotic prophylaxis after basilar skull fracturesClin Infect Dis 1998;27:364-9.

Author Patient group Study type Key result Weakness

Brodie H 6 studies with data analysis of incidence of meningitis resulting from posttraumatic CSF leak .324 patient of whom 237 were receiving antibiotic and 87 did not.

Meta Analysis 2.5% of those receiving antibiotic developed meningitis compared to 10% of those not receiving.

Only 15 cases of meningitis,no formal review of quality paper.No odds ratio or confidence interval calculated.

Villalobos T

12 studies with data allowing analysis of effectiveness of antibiotic use in preventing meningitis from basilar skull #.1241 of whom 719 received antibiotic and 522 did not.

Meta analysis. 1.15 (95% CI 0.68 - 1.94).Odds ratio of developing meningitis in untreated Vs Treated case.

1.34(95%CI 0.75-2.41) odds ratio of meningitis risk in patient with CSF leak.

• Recently a Ratilal et al Cochrane Database review in Aug 2011 was performed to address these deficiencies. The analysis included 208 patients from 4 randomized controlled trials and an additional 2168 patients from 17 nonrandomized controlled trials.

- The analysis concluded that the evidence does not support the use of Prophylactic antibiotics to reduce the risk of meningitis in patients with basilar skull fractures or basilar skull fractures with active CSF leak.

Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD004884. DOI: 10.1002/14651858.CD004884.pub3

• Santarius and colleagues BMJ 2002;325:1037.2 unconfirmed the myth that prophylactic antimicrobial are effective in CSF leak the reason put forward are-

1. That commonly used antibiotics such as cephalosporins penetrate the non-inflamed meninges poorly,

2. That antibiotics are unlikely to eradicate potential pathogens such as the pneumococci from the upper respiratory tract.

• Proponents argue that meningitis is bad enough to warrant the use of prophylactic antibiotics despite data which don’t show their high efficacy.

• Opponents feel that they are ineffective and lead to colonization by more serious flora, and bacterial resistance.

Are antibiotics Really Needed?

Conclusion:-• Choice of use and not to use Antibiotics solely depends on individual case

and on doctor managing the case of Cranial CSF leak:.• Some common indication may be:- Perioperative antibiotics.- Active rhinosinusitis.- Immunocompromised patient.- Compound fracture.

“When in doubt , Do without”.

• Thank You.• Special thanks to :- Dr Pritam Gurung, Dr Dinesh Thapa, Dr Susangma Chemjong,Dr Jasmine Shrestha.