Endoscopic management of traumatic cerebro-spinal fluid rhinorrhea Y R Yadav, Vijay Parihar, Shailendra Ratre, Yatin Kher Department of Neurosurgery NSCB (Government) Medical College Jabalpur MP India 482003 Recipient of Charak award (IMA MP state 2011) Chairman fellowship program of one week brain and spine endoscopic training www.neuroendoscopyjbp.org Executive member of Neurological surgeons society of India E mail yadavyr@yahoo.co.in, yadramyr@yahoo.com, Web site www.yadavyr.com Tel: +91 9893711193, +91 761 2673644.  

Endoscopic management of traumatic cerebro-spinal fluid rhinorrhea Introduction: Communication between the intracranial subarachnoid space and the sinonasal mucosa.

Traumatic CSF Rhinorrhea Accidental trauma Surgical trauma Early Within 7 days Delayed

S. No MRI cisternography CT cisternography HR CT Nasal endoscopy with or without fluorescene Radionucleotide cisternography Advantages Useful in active or inactive leak Slow-flow and diffusion-weighted may have a role in active CSF leaks FLAIR Could demonstrate herniation of meninges, brain tissue and CSF. Useful in multiple fractures Useful in active leak Can differentiate contrast material from sclerotic sinus walls, dense insipissated sinus secretions and blood. Good for bone Can show dehiscence When all investigation fail to show leak When CSF leak is suspected (CSF collection not possible) 48- or 72-hour scans are possible with In111 and are useful in the detection of intermittent leaks. Multiple site

S. No MRI cisternography CT cisternography HR CT Radionucleotide cisternography Limitations Bone Invasive Problem in detecting small amount of diluted contrast from bone . Detects the fluid poorly. Multiple defects or fractures (which one is leaking) Not widely available. Unable to localize exact site ( Only as screening when diagnosis is in question) False-positive ( 33%) as isotope can be absorbed into the circulatory system and can contaminate extracranial tissue.

Primary investigations: Combined modalities of CT and MRI have a higher sensitivity and specificity. Getting two investigations is not cost-effective. CT cisternography in these circumstances offers an acceptable method.

Conservative management: Most of the traumatic CSF rhinorrhea can be managed by observation for 7-10 days Up to 2 to 4 weeks after trauma or operation. Early surgery in subgroup:

Early surgery group (or subgroup with increased risk of meningitis Fractures close to midline (more CSF pressure and less chances of brain plugging opening) Fracture displacement > 1 cm, Delayed leak or intermittent leak Profuse leak (sphenoid sinus, petrous) Encephalocele or a meningocele protruding through the bony defect which disallows the healing process. Penetrating injury Comminuted fracture

Operative management: Surgery is indicated to prevent complications if conservative management fails. 3-11% risk of meningitis in first 3 weeks 10% annually Risk more in early period

Advantages of endoscopic technique: Easy access, precision and accuracy Success rate of 90% in the first attempt About 95-98% after a second attempt.

Indication for endoscopic approach Difficult for large defect, lateral recess of frontal and sphenoid sinus especially for beginners. Best suited for small defects in sphenoid sinus, cribriform plate, anterior and posterior ethmoid sinus

Head elevation Nasal cavity towards surgeon

Types of grafts or flaps and repair techniques: At least 5 mm mucosa removal in all directions of defect. Removal of any bony projections for better graft placement and graft take up. Types of grafts or flaps and repair techniques: Free tissue, Vascularized flap Composite grafts ((involves more than one type of tissue). The Bath plug technique The button technique

Overlay and underlay; relation to skull bone Overlay technique, the graft is placed extracranially Underlay technique, the graft is placed between dura and bone. Intradural Combined techniques can be used.

Multilayer closure for large defects The fibrin plug to stabilize the fat graft Layers of Gelfoam or Surgicel should separate graft from packing to avoid avulsion Packing of gauze or balloon impregnated with an antibiotic ointment

Post operative care: Bed rest for 3-5 days with head elevation. Peri operative prophylactic antibiotics? Avoid nose blowing, sneezing and Valsalva maneuvers. Sneezing by open mouth Stool softeners to avoid straining.

Results: over 90% success Careful in leveling success Recurrences may occur very late (80 months in Gassner et al series)

Lumbar drain indication: Recurrent Persistent leaks Associated with hydrocephalus. Large skull defects with meningoceles.

Complications of Repair Meningitis, Chronic headache, Pneumocephalus, Intracranial hematomas, Frontal lobe abscess. Recurrence.

Recurrence: Extensive skull base defects, Multiple sites of leaks Lateral sphenoid leaks, Frontal sinus with extension superiorly and laterally Raised ICP, Diabetes mellitus Elevated body mass index, (> 30) Middle-aged obese female

Based on Yadav YR, Parihar V, Janakiram N, Pande S, Bajaj J, Namdev H. Endoscopic management of cerebro-spinal fluid rhinorrhea. Asian journal of Neurosurgery. Ahead of print, DOI:10.4103/1793-5482.145101 Yadav YR, Parihar V, Kher Y. Complication  avoidance and its management in endoscopic neurosurgery. Neurol India 2013;61:217-25. Yadav YR, Parihar V, Ratre S, Iqbal M. Microneurosurgical skills training. J Neurol Surg A Cent Eur Neurosurg 2015 Apr 27. [Epub ahead of print] DOI: 10.1055/s-0034-1376190

Thankful to my teachers

Thankful to my colleagues