The Role of Diamox and High-Volume Lumbar Puncture for Treatment of Iatrogenic Postoperative Cerebrospinal Fluid Leak

Introduction: Iatrogenic cranial cerebrospinal fluid (CSF) leaks after skull base surgery remain a challenging, albeit common, management issue for both neurosurgeons and otolaryngologists. Unlike traumatic CSF leaks which typically resolve with conservative measures, iatrogenic CSF leaks tend to be refractory to these techniques. This study is focused on the safety and proof of concept of a strategy employing acetazolamide with high-volume lumbar puncture as a treatment option for postoperative CSF leak.

Methods: We conducted an exploratory study of six patients who were given acetazolamide therapy after developing iatrogenic cerebrospinal fluid leak following craniotomy or transsphenoidal approach for tumor resection from July 2018 to July 2019. Patients who presented with CSF leaks on clinical exam were started on acetazolamide 250 mg three times a day for 10 days and underwent a high-volume lumbar puncture (30–40 mL of CSF). These patients were given strict instructions to avoid the Valsalva maneuvers/strenuous activity and maintain head of bed elevated for 2 weeks. These patients were followed up in clinic postoperatively by otolaryngology and neurosurgery to assess for the presence of CSF leak at 10 and 30 days postoperatively.

Results: At our institution, six patients were randomly assigned to acetazolamide therapy after they developed iatrogenic cerebrospinal fluid leak secondary to after craniotomy or transsphenoidal surgery for tumor resection. Table 1 shows a summary of patient demographics. The average age of patients was 40.8 years. Five patients were female, and one was male.

Four patients, three of who had previously undergone transsphenoidal surgery and the fourth a pterional craniotomy for a planum meningioma, presented postoperatively with CSF leak from the nare. They were admitted for an average of 3 days after undergoing high-volume lumbar puncture and adhering to strict CSF leak precautions. The remaining two patients had previously undergone craniotomy for skull-base tumor resection and presented with CSF leak from the EVD site in one instance and from the incision in the second patient. The patient leaking CSF rom the EVD site had their incision oversewn and was started on acetazolamide, and the latter was managed similarly but also additionally underwent a high-volume lumbar puncture. They were both discharged from clinic without complication. CSF profiles, gram stains, and cultures were monitored and followed up for 5 days to rule out meningitis. All six patients had resolution of their CSF leak on clinical exam at their interval follow-up appointments. No patients experienced serious complications or permanent neurological deficits.

Conclusion: The use of acetazolamide with concomitant high-volume lumbar puncture is a safe and effective management strategy for treating iatrogenic postoperative CSF leak in skull-base neurosurgery. It is a novel approach to managing these complex patients who helps avoid prolonged hospital stays associated with lumbar drainage and can obviate the need for additional surgery.

 

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No conflict of interest has been declared by the author(s).