Management of Cerebrospinal Fluid Leaks of the Anterior and Lateral Skull Base

Objectives: Non-traumatic cerebrospinal fluid (CSF) leaks along the anterior or lateral skull base are often secondary to intracranial hypertension. Surgical repair of these bony defects along with resection of an associated encephalocele helps to prevent meningitis. While reconstruction of the skull base is necessary and may be curative in some cases, patients with intracranial hypertension are at increased risk of recurrent CSF leaks at the reconstruction site or elsewhere along the skull base. The goal of this study is to present our treatment algorithm and outcomes in patients who present with a CSF leak.

Methods: This is a prospective, observational study of 38 patients who underwent an endoscopic, endonasal repair of a CSF leak or a combined mastoidectomy and middle cranial fossa craniotomy for treatment of a tegmen tympani CSF leak.

Results: The average body mass index (BMI) was 34.97 kg/m². Twenty-seven (71%) of the patients were obese (BMI > 30 kg/m²). Eighteen patients had intracranial pressures (ICPs) greater than 20 cm H2O. Thirty-seven (97%) patients had closure of the CSF leak at first attempt without recurrence at an average follow-up of 13 months. Nine ventriculoperitoneal shunts were placed to help prevent recurrence.

Conclusions: Closure and prevention of future CSF leaks present many challenges. Risk factors for recurrence include high-volume leaks, CSF opening pressures >20 cm H20, a BMI > 30 kg/m², radiographic signs of intracranial hypertension, and events that impair the absorption of CSF. We discuss our skull base reconstruction techniques and present a treatment algorithm for the management of intracranial hypertension in patients with a CSF leak.