J Neurol Surg B Skull Base 2013; 74 - A190
DOI: 10.1055/s-0033-1336313

Occult Increased Intracranial Pressure in Spontaneous Cerebrospinal Fluid Leak

Maria Koutourousiou 1(presenter), Esther Vivas 1, Srinivas Chivukula 1, Juan Fernandez-Miranda 1, Eric Wang 1, Barry Hirsch 1, Carl Snyderman 1, Paul Gardner 1
  • 1Pittsburgh, PA, USA

Objective: Spontaneous cerebrospinal fluid (CSF) leak may be associated with increased intracranial pressure (ICP), complicating the management of these patients.

Methods: We retrospectively reviewed the medical files of 36 patients who presented with spontaneous rhinorrhea (n = 17) or otorrhea (n = 19) since October 2004, and who were treated with endoscopic endonasal surgery (EES) or middle fossa craniotomy (MFC), respectively. Congenital extensive skull base bone defects and postsurgical and post-traumatic CSF leaks were excluded from this study. Postoperative ICP, body mass index (BMI), and the need of ventriculoperitoneal (VP) shunt placement were evaluated and analyzed. Obesity was defined as BMI > 30.

Results: Besides headache in eight patients (22.2%) and nausea/vomiting/dizziness in six (16.7%), none of the patients with CSF leak presented with signs or symptoms of increased ICP (balance or visual problems, optic atrophy, papilledema, diplopia). Occult increased ICP was diagnosed in 36.1% of patients by direct measurement of CSF pressure. Cases with spontaneous rhinorrhea (n = 17) showed a female predominance (82.3%) with obesity in 58.8%. All were treated with EES combined with lumbar drain (LD) placement in eight cases. Following EES, eight patients (47%, all of them with BMI above normal) were diagnosed with increased ICP (mean, 30.2 cm H2O; range, 27-36 cm H2O) requiring placement of a VP shunt. Among the cases with spontaneous otorrhea (n = 19), there was a slight female predominance (57.9%) with obesity in 57.9%. MFC was accompanied by LD placement in 12 patients. Following MFC, five patients (29.4%, 60% of them obese) had evidence of increased ICP (mean, 26.7 cm H2O; range, 23-35 cm H2O) and were all treated with VP shunt placement.

Conclusion: Evaluation of ICP following surgery for repair of spontaneous CSF leak can reveal occult intracranial hypertension. VP shunting should be considered for the definitive treatment of these patients.