CSF (CerebroSpinal Fluid) Leakage

What is a CSF Leak?

CSF leak is when the cerebrospinal fluid (fluid around the brain and spine) leaks out somewhere. This can occur due to head trauma, after surgeries around the brain/sinuses/ear/skull or from procedures that cause an opening into the spinal fluid (e.g., spinal tap (lumbar puncture)). CSF (Cerebral/Spinal Fluid) leaks can occur spontaneously as well. Because the CSF is under pressure - we are constantly making new fluid - the fluid will leak out of the CSF (brain and spinal cord) space and will continue until it is stopped by a procedure.

What are the Symptoms of a CSF Leak?

Many times, there are no symptoms in a CSF Leak. The most common symptoms of a CSF leak include a watery drainage from the nose (most commonly one side) or a salty taste in the back of the throat. This salty taste represents the cerebral spinal fluid that leaks in the back of the throat. Some patients may present with a meningitis (infection around the brain). This occurs because the bacteria can get from the nose into the brain or go from the nose into the ear and from there into the brain.

If the source of the CSF leak is the ear, the fluid goes into the space behind the ear drum down the Eustachian tube to the back of the nose (nasopharynx) and into the back of the throat. If the leak accumulates behind the ear drum and a tube is placed in the ear drum, it can lead to a persistent leakage of spinal fluid through the tube.

What is the Problem With Having a CSF Leak?

The main problem is the connection that is created between the brain and the outside creates a channel for bacteria to get through and cause an infection. An infection around the brain (meningitis) is a life-threatening infection.

Who Gets a CSF Leak?

Around the head, there are 4 main categories of patients who develop CSF leaks.

1. People who have had skull base tumor surgeries (e.g., acoustic neuroma, meningioma, other tumors) and the CSF fluid can leak through the area of the surgery and drain into the ear.

2. People who have had nose or sinus surgery which caused a break in the bone of the skull base (floor of the brain) and leakage comes through the opening.

3. People who have had CSF (spinal fluid) leak after ear surgery where the bone separating the ear/mastoid from the brain is opened and the dura (covering of the brain) is injured.

4. People who get spontaneous CSF leakage. This can occur in patients around the ear or the sinuses. It can be congenital in some patients (i.e., they have an abnormally open channel between the spinal fluid space and the ear). Or, it can be acquired, which most commonly occurs in patients who are heavier than their ideal body weight.

What Is Done to Diagnose CSF (Cerebral Spinal) Leaks Around the Ear or Sinuses?

The first step is to make sure there is a leakage of CSF (cerebral spinal) fluid and to find from where it is coming. This is done by performing some scans (most commonly CT and MRI). Sometimes, these studies have to be performed with contrast injected into the cerebral spinal fluid (CSF) space. This allows the specialist to see where the contrast material leaks through. This is more useful for the sinuses and not used as much for the ear. The leaks coming around the ear tend to be slower and may not show up on these studies.

Other studies are when a radionuclide is injected into the cerebral spinal space and an absorbent material is placed in the back of the nose. After a few hours, the absorbent material is removed and tested.

Finally, if the fluid can be collected, it is sent for a beta-2-transferrin test (a protein unique to the spinal fluid).

Procedure

The procedure to repair the leakage of spinal fluid depends on the source of the leakage. Most of the sources of leakage around the ear and sinuses can be repaired using minimally invasive approaches using microscopes or endoscopes. Sometimes, a craniotomy (opening of the skull) has to be performed in conjunction with a neurosurgeon.

If the leak occurs immediately after surgery, the treatment of choice is to place a lumbar drain. A lumbar drain is a drain placed into the spinal fluid space in the lower back which will slowly remove fluid from the spinal fluid space. The drain will usually be in place for 3-5 days. Reducing the spinal fluid pressure and placement of pressure in the area of the surgery (using packing or a dressing) is often enough to stop a leakage right after surgery.

Leaks that are persistent for long periods of time after surgery or are spontaneous require repair of the source of the leak with surgery.

CSF Leaks Around the Ear

Leaks around the ear are treated depending on the location of the source of the leak and the patient's medical status.

1. If the source of the leak is around the mastoid bone (the bone behind the ear), the surgery requires removal of some of the bone behind the ear to find the source of the leak. The leak is then stopped by using tissue, fat, and a special tissue glue (Tisseal). The patients generally require an overnight stay in the hospital.

For a video of the surgery, click below. Please note this is a surgical video and the images may be too graphic for some viewers.

2. If the source of the CSF leak is from the top of the space behind the ear drum (middle ear) or from the petrous apex (towards the center of the head), the repair requires a craniotomy (opening the skull) and the use of tissue and glue. Sometimes, a lumbar drain has to be placed. The patient generally stays about 3-4 days after surgery in the hospital.

3. Rarely, if the patient is very ill and cannot undergo a procedure under general anesthesia, a short (15 minute) procedure under local anesthesia can be performed to block the eustachian tube. This prevents the CSF leak from having access to bacteria and the back of the nose. This will prevent meningitis but can cause a problem which is filling the middle ear (space behind the ear drum) with fluid which causes some hearing loss and plugging sensation.

Treatment of CSF Leaks Around the Sinuses

The best treatment for CSF leaks around the sinuses is using an endoscopic approach. The area of the leak may need to be identified by injecting a dye (fluorescin) into the spinal fluid. A special filter is used to see the green color of the leak in the nose. A variety of flaps can be performed to plug the leakage spot. Sometimes, a lumbar drain is placed to improve the chances of stopping the leak.

Why Come to UCI If you Have a CSF Leak?

Dr. Djalilian is one of a few surgeons in the U.S. with an extensive experience in treatment of spontaneous CSF leaks around the ear. He is in the process of publishing his results of treatment of this condition over the past 8 years using his minimally invasive approaches. Our skull base team has extensive experience with leaks after surgeries in treatment of skull base tumors which requires tight closure of the spinal fluid spaces to prevent CSF leakage.

To Make an Appointment with Dr. Djalilian our expert in the treatment of CSF Leaks around the ear or Dr. Bhandarkar, our expert in the treatment of sinus CSF leaks, please Call 714-456-7017 or click here to request an appointment via the web.

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