|
|
| (3 intermediate revisions by the same user not shown) |
| Line 1: |
Line 1: |
| {{Short description|Injury}} | | {{Short description|A condition where cerebrospinal fluid leaks from the brain or spinal cord}} |
| {{Infobox medical condition (new) | | {{Infobox medical condition |
| | name = Cerebrospinal fluid leak | | | name = Cerebrospinal fluid leak |
| | synonyms = CSF leak | | | synonyms = CSF leak |
| | image =
| | | field = [[Neurology]], [[Neurosurgery]], [[Otolaryngology]] |
| | alt =
| | | symptoms = [[Headache]] (worse when upright), [[nausea]], [[neck stiffness]], [[tinnitus]], [[clear nasal discharge]] (CSF rhinorrhea), [[ear drainage]] (CSF otorrhea), [[photophobia]] |
| | caption =
| | | complications = [[Meningitis]], [[brain herniation]], persistent neurological deficits |
| | pronounce =
| | | onset = Sudden or gradual |
| | field = | | | duration = Varies; may be acute or chronic |
| | symptoms = | | | types = Spontaneous or traumatic (including post-surgical) |
| | complications = | | | causes = Head trauma, spinal tap, surgery, spontaneous (idiopathic), [[connective tissue disorders]] (e.g., [[Marfan syndrome]], [[Ehlers–Danlos syndrome]]) |
| | onset = | | | risks = Trauma, prior spine or sinus surgery, certain genetic conditions |
| | duration = | | | diagnosis = [[MRI]] with contrast, [[CT myelography]], beta-2 transferrin test (for fluid analysis), nasal endoscopy |
| | types = | | | differential = [[Sinusitis]], [[migraine]], [[allergic rhinitis]], [[intracranial hypotension]] |
| | causes = | | | prevention = Use of atraumatic needles in lumbar puncture, avoiding unnecessary spinal taps or trauma |
| | risks = | | | treatment = Bed rest, hydration, [[epidural blood patch]], surgical repair if persistent |
| | diagnosis = | | | medication = [[Caffeine]] for symptom relief, [[antibiotics]] if infection suspected |
| | differential = | | | prognosis = Good with appropriate management; persistent leaks can lead to serious complications |
| | prevention = | | | frequency = Rare; spontaneous CSF leaks estimated at ~5 per 100,000 annually |
| | treatment = | | | deaths = Rare; may occur from complications such as meningitis if untreated |
| | medication = | |
| | prognosis = | |
| | frequency = | |
| | deaths = | |
| }} | | }} |
| A '''cerebrospinal fluid leak''' ('''CSF leak)''' is a medical condition where the [[cerebrospinal fluid]] (CSF) in the [[human brain|brain]] or [[spinal cord]] leaks out of one or more holes or tears in the arachnoid and [[dura mater]].<ref>{{MedlinePlusEncyclopedia|001068|CSF leak}}</ref><ref>{{EMedicine|article|338989|Cerebrospinal Fluid Leak Imaging}}</ref> A spinal CSF leak can also be caused by meningeal diverticula or CSF-venous fistula not associated with an epidural leak.<ref name=":0">{{Cite journal|last=Kranz|first=Peter G.|last2=Luetmer|first2=Patrick H.|last3=Diehn|first3=Felix E.|last4=Amrhein|first4=Timothy J.|last5=Tanpitukpongse|first5=Teerath Peter|last6=Gray|first6=Linda|date=2015-12-23|title=Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension|journal=American Journal of Roentgenology|volume=206|issue=1|pages=8–19|doi=10.2214/AJR.15.14884|pmid=26700332|issn=0361-803X}}</ref> <ref name=":1">{{Cite journal|last=Kranz|first=Peter G.|last2=Amrhein|first2=Timothy J.|last3=Gray|first3=Linda|date=December 2017|title=CSF Venous Fistulas in Spontaneous Intracranial Hypotension: Imaging Characteristics on Dynamic and CT Myelography|journal=AJR. American Journal of Roentgenology|volume=209|issue=6|pages=1360–1366|doi=10.2214/AJR.17.18351|issn=1546-3141|pmid=29023155}}</ref><ref name=":2" /> | | A '''cerebrospinal fluid leak''' (CSF leak) is a medical condition where the [[cerebrospinal fluid]] (CSF) escapes from the [[subarachnoid space]] surrounding the [[brain]] and [[spinal cord]]. This can occur due to a tear or hole in the [[dura mater]], the outermost layer of the [[meninges]]. |
|
| |
|
| CSF leaks are often further classified according to the cause. An [[iatrogenesis|iatrogenic]] or traumatic CSF leak has an identified cause such as a [[lumbar puncture]] (noted by a [[post-dural-puncture headache]]), [[surgery]] or [[physical trauma]]; while a [[spontaneous cerebrospinal fluid leak]] has an unknown cause. CSF leaks are associated with heritable connective tissue disorders including [[Marfan Syndrome|Marfan syndrome]] and [[Ehlers Danlos Syndrome|Ehlers-Danlos syndrome]].<ref>{{cite journal |last1=Reinstein |first1=E |last2=Pariani |first2=M |last3=Bannykh |first3=S |last4=Rimoin |first4=D |last5=Schievink |first5=WI |title=Connective tissue spectrum abnormalities associated with spontaneous cerebrospinal fluid leaks: a prospective study. |journal=European Journal of Human Genetics |volume=21 |date=April 2013 |issue=4 |pages=386–390 |doi=10.1038/ejhg.2012.191 |pmid=22929030|pmc=3598315 }}</ref>
| | ==Causes== |
| | Cerebrospinal fluid leaks can be caused by a variety of factors, including: |
|
| |
|
| ==Signs and symptoms==
| | * '''Trauma''': Head injuries or spinal injuries can lead to tears in the dura mater. |
| The most common symptom of a CSF leak is a fast-onset, extremely painful [[orthostatic headache]] or [[thunderclap headache]].<ref>{{Cite news|url=https://www.mayoclinic.org/diseases-conditions/thunderclap-headaches/symptoms-causes/syc-20378361|title=Thunderclap headaches - Symptoms and causes|work=Mayo Clinic|access-date=2018-08-01|language=en}}</ref>
| | * '''Surgical procedures''': Certain [[neurosurgery|neurosurgical]] or [[spinal surgery|spinal surgeries]] may inadvertently cause a CSF leak. |
| | * '''Spontaneous leaks''': These occur without any apparent cause and may be related to underlying connective tissue disorders. |
| | * '''Increased intracranial pressure''': Conditions that increase pressure within the skull can lead to CSF leaks. |
|
| |
|
| Patients with a spinal leak may suffer [[intracranial hypotension]] (low CSF pressure) because the body cannot replenish the [[Cerebrospinal fluid|CSF]] fast enough to keep pace with the leak. As a result, the brain may sag inside the skull and into the [[foramen magnum]], which is visible (and measurable) with an [[MRI]] of the brain. Patients with a cranial leak are more likely to suffer [[intracranial hypertension]] (high CSF pressure), and are at risk of [[meningitis]]. Some patients with either a cranial or spinal leak can fluctuate between high and low CSF pressure.
| | ==Symptoms== |
|
| | The symptoms of a cerebrospinal fluid leak can vary depending on the location and severity of the leak. Common symptoms include: |
| While high CSF pressure can make lying down unbearable, low CSF pressure due to a leak can be relieved by [[supine position|lying flat on the back]].<ref name=":3">{{Cite web|url=https://www.cedars-sinai.edu/Patients/Programs-and-Services/Neurosurgery/Centers-and-Programs/Cerebrospinal-Fluid-Leak/CSF-Leak-A-Curable-Cause-of-Headache.aspx|title=CSF Leak: A Curable Cause of Headache|website=www.cedars-sinai.edu|language=en|access-date=2018-08-01}}</ref>
| |
|
| |
|
| Other symptoms of a CSF leak can include [[neck pain]], [[photophobia]], [[dizziness]], [[gait]] disturbances, [[tinnitus]], [[visual]] disturbances, [[brain fog]], [[nausea]], fluid dripping from the nose or ears, and a metallic taste in the mouth. An untreated CSF leak can result in [[coma]] or death.<ref>{{Cite web|url=https://www.researchgate.net/publication/266253177|title=Headache Secondary to Intracranial Hypotension, Schievink, W and Deline, C|website=www.researchgate.net|language=en|access-date=2018-09-22}}</ref>
| | * '''Headache''': Often described as a positional headache, worsening when upright and improving when lying down. |
| | | * '''Nasal drainage''': Clear, watery fluid draining from the nose, especially when bending forward. |
| Movement disorders are uncommon in spontaneous CSF leaks but occasionally can be one of the major components of the clinical presentation.<ref>{{Cite journal|last=Mokri|first=Bahram|date=December 2014|title=Movement disorders associated with spontaneous CSF leaks: a case series|journal=Cephalalgia: An International Journal of Headache|volume=34|issue=14|pages=1134–1141|doi=10.1177/0333102414531154|issn=1468-2982|pmid=24728303}}</ref>
| | * '''Tinnitus''': Ringing in the ears. |
| | * '''Hearing loss''': Changes in hearing, often due to pressure changes in the ear. |
| | * '''Neck stiffness''': Due to irritation of the meninges. |
|
| |
|
| ==Diagnosis== | | ==Diagnosis== |
| CSF leaks are frequently misdiagnosed by [[physicians]] as [[migraine]], [[Chiari malformation]], [[dysautonomia]] or [[conversion disorder]].
| | Diagnosing a CSF leak involves a combination of clinical evaluation and diagnostic tests. These may include: |
| | |
| Routine imaging assessment should begin with contrast-enhanced brain MRI with sagittal reformats. <ref name=":0" /><ref name=":2">{{Cite journal|last=Kranz|first=Peter G.|last2=Gray|first2=Linda|last3=Malinzak|first3=Michael D.|last4=Amrhein|first4=Timothy J.|date=2019-11-01|title=Spontaneous Intracranial Hypotension: Pathogenesis, Diagnosis, and Treatment|journal=Neuroimaging Clinics of North America|series=Minimally Invasive Image-Guided Spine Interventions|language=en|volume=29|issue=4|pages=581–594|doi=10.1016/j.nic.2019.07.006|pmid=31677732|issn=1052-5149}}</ref> Brain MRI should be assessed for signs of SEEPS <ref name=":3" />:
| |
| | |
| * Subdural fluid collections
| |
| * Enhancement of the meninges
| |
| * Engorgement of venous structures
| |
| * Pituitary swelling
| |
| * Sagging of the brain
| |
| | |
| For suspected spinal CSF leaks, spine imaging should be used to guide treatment. <ref name=":2" />
| |
| | |
| Other [[Medical imaging|imaging]] can be helpful in diagnosing a CSF leak, and in identifying its location, typically using a [[CT scan]] or an [[Magnetic resonance imaging|MRI scan]]. A [[Myelography|myelogram]] can be used to more precisely identify the location of a CSF leak by injecting a dye to further enhance the imaging. However, CSF leaks are frequently not visible on imaging.
| |
| | |
| For patients with recalcitrant spontaneous intracranial hypotension and no leak found on conventional spinal imaging, digital subtraction myelography, CT myelography and dynamic myelography (a modified conventional myelography technique) should be considered to rule out a CSF-venous fistula.<ref>{{Cite journal|last=Schievink|first=Wouter I.|last2=Moser|first2=Franklin G.|last3=Maya|first3=M. Marcel|last4=Prasad|first4=Ravi S.|date=June 2016|title=Digital subtraction myelography for the identification of spontaneous spinal CSF-venous fistulas|journal=Journal of Neurosurgery. Spine|volume=24|issue=6|pages=960–964|doi=10.3171/2015.10.SPINE15855|issn=1547-5646|pmid=26849709|doi-access=free}}</ref> <ref name=":1" /> In addition, presence of a hyperdense paraspinal vein should be investigated in imaging as it is highly suggestive of a CSF venous fistula.<ref>{{Cite journal|last=Clark|first=Michael S.|last2=Diehn|first2=Felix E.|last3=Verdoorn|first3=Jared T.|last4=Lehman|first4=Vance T.|last5=Liebo|first5=Greta B.|last6=Morris|first6=Jonathan M.|last7=Thielen|first7=Kent R.|last8=Wald|first8=John T.|last9=Kumar|first9=Neeraj|last10=Luetmer|first10=Patrick H.|date=January 2018|title=Prevalence of hyperdense paraspinal vein sign in patients with spontaneous intracranial hypotension without dural CSF leak on standard CT myelography|journal=Diagnostic and Interventional Radiology (Ankara, Turkey)|volume=24|issue=1|pages=54–59|doi=10.5152/dir.2017.17220|issn=1305-3612|pmc=5765931|pmid=29217497}}</ref>
| |
|
| |
|
| Fluid dripping from the nose ([[Cerebrospinal fluid rhinorrhoea|CSF rhinorrhoea]]) or ears (CSF otorrhea) should be collected and tested for the protein Beta-2 transferrin which would be highly accurate in identifying CS fluid and diagnosing a cranial CSF leak.<ref>{{Cite journal|last=O'Cearbhaill|first=Roisin M.|last2=Kavanagh|first2=Eoin C.|date=March 2018|title=Beta-2 Transferrin and IR|journal=Journal of Vascular and Interventional Radiology: JVIR|volume=29|issue=3|pages=439|doi=10.1016/j.jvir.2017.10.002|issn=1535-7732|pmid=29455884}}</ref>
| | * '''Imaging studies''': [[MRI]] or [[CT scan]] can help visualize the site of the leak. |
| | * '''Beta-2 transferrin test''': A laboratory test that detects the presence of CSF in nasal or ear fluid. |
| | * '''Intrathecal fluorescein''': A dye injected into the CSF to help identify the leak site during imaging. |
|
| |
|
| ==Treatment== | | ==Treatment== |
| Symptomatic treatment usually involves [[analgesics]] for both cranial and spinal CSF leaks. [[Caffeine]] and short-term [[bed rest]] can alleviate symptoms of low CSF pressure, while elevated rest and [[acetazolamide]] can alleviate symptoms of high CSF pressure.
| | Treatment for a cerebrospinal fluid leak depends on the cause and severity of the leak. Options include: |
| | |
| Sometimes a CSF leak will heal spontaneously. Otherwise, symptoms may last months or even years. An [[epidural blood patch]] is the typical treatment for a CSF leak, where up to 20 [[Cubic centimetre|cubic centimeters]] of the patient's blood is drawn, then injected into either the [[lumbar]] or [[cervical spine]], close to the known or suspected site of the leak. [[Fibrin glue]] patching is an alternative where blood patching is unsuccessful. If the site of the leak is known, [[neurosurgical]] repair of the [[dura mater]] is an option.
| |
|
| |
|
| Surgery to treat a CSF-venous fistula in CSF leak patients is highly effective. <ref>{{Cite journal|last=Wang|first=Timothy Y.|last2=Karikari|first2=Isaac O.|last3=Amrhein|first3=Timothy J.|last4=Gray|first4=Linda|last5=Kranz|first5=Peter G.|date=2020-03-01|title=Clinical Outcomes Following Surgical Ligation of Cerebrospinal Fluid-Venous Fistula in Patients With Spontaneous Intracranial Hypotension: A Prospective Case Series|journal=Operative Neurosurgery (Hagerstown, Md.)|volume=18|issue=3|pages=239–245|doi=10.1093/ons/opz134|issn=2332-4260|pmid=31134267|doi-access=free}}</ref>
| | * '''Conservative management''': Bed rest, hydration, and caffeine intake to reduce symptoms and allow the leak to heal naturally. |
| | * '''Epidural blood patch''': A procedure where a small amount of the patient's blood is injected into the epidural space to seal the leak. |
| | * '''Surgical repair''': In cases where conservative measures fail, surgical intervention may be necessary to repair the dura mater. |
|
| |
|
| The use of [[antibiotics]] to [[preventive healthcare|prevent]] meningitis in those with a CSF leak due to a [[skull fracture]] is of unclear benefit.<ref>{{cite journal |last1=Ratilal |first1=BO |last2=Costa |first2=J |last3=Pappamikail |first3=L |last4=Sampaio |first4=C |title=Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. |journal=The Cochrane Database of Systematic Reviews |date=28 April 2015 |issue=4 |pages=CD004884 |doi=10.1002/14651858.CD004884.pub4 |pmid=25918919}}</ref> | | ==Prognosis== |
| | The prognosis for individuals with a cerebrospinal fluid leak varies. Many leaks resolve with conservative treatment, but some may require surgical intervention. Early diagnosis and treatment are crucial to prevent complications such as [[meningitis]]. |
|
| |
|
| ==References== | | ==Related Pages== |
| {{reflist}}
| | * [[Meninges]] |
| | * [[Intracranial pressure]] |
| | * [[Neurosurgery]] |
| | * [[Spinal cord]] |
|
| |
|
| == External links == | | == External links == |
| Line 86: |
Line 78: |
| | ICD10CM = {{ICD10CM|G96.0}} | | | ICD10CM = {{ICD10CM|G96.0}} |
| }} | | }} |
|
| |
| [[Category:Spinal cord]] | | [[Category:Spinal cord]] |
| [[Category:Brain disorders]] | | [[Category:Brain disorders]] |
| [[Category:Central nervous system disorders]] | | [[Category:Central nervous system disorders]] |
| {{dictionary-stub1}} | | [[Category:Neurology]] |
| == Cerebrospinal_fluid_leak ==
| | [[Category:Medical conditions]] |
| <gallery>
| | {{nt}} |
| File:CSF_circulation.png|Diagram of cerebrospinal fluid circulation
| |
| File:1316_Meningeal_LayersN.jpg|Meningeal layers of the brain
| |
| File:MRI_of_human_brain_with_type-1_Arnold-Chiari_malformation_and_herniated_cerebellum.jpg|MRI showing type-1 Arnold-Chiari malformation
| |
| File:Spinal_needles.jpg|Various types of spinal needles
| |
| File:Epidural_blood_patch.svg|Diagram of an epidural blood patch procedure
| |
| </gallery>
| |
A condition where cerebrospinal fluid leaks from the brain or spinal cord
| Cerebrospinal fluid leak
|
|
|
| Synonyms
|
CSF leak
|
| Pronounce
|
N/A
|
| Specialty
|
N/A
|
| Symptoms
|
Headache (worse when upright), nausea, neck stiffness, tinnitus, clear nasal discharge (CSF rhinorrhea), ear drainage (CSF otorrhea), photophobia
|
| Complications
|
Meningitis, brain herniation, persistent neurological deficits
|
| Onset
|
Sudden or gradual
|
| Duration
|
Varies; may be acute or chronic
|
| Types
|
Spontaneous or traumatic (including post-surgical)
|
| Causes
|
Head trauma, spinal tap, surgery, spontaneous (idiopathic), connective tissue disorders (e.g., Marfan syndrome, Ehlers–Danlos syndrome)
|
| Risks
|
Trauma, prior spine or sinus surgery, certain genetic conditions
|
| Diagnosis
|
MRI with contrast, CT myelography, beta-2 transferrin test (for fluid analysis), nasal endoscopy
|
| Differential diagnosis
|
Sinusitis, migraine, allergic rhinitis, intracranial hypotension
|
| Prevention
|
Use of atraumatic needles in lumbar puncture, avoiding unnecessary spinal taps or trauma
|
| Treatment
|
Bed rest, hydration, epidural blood patch, surgical repair if persistent
|
| Medication
|
Caffeine for symptom relief, antibiotics if infection suspected
|
| Prognosis
|
Good with appropriate management; persistent leaks can lead to serious complications
|
| Frequency
|
Rare; spontaneous CSF leaks estimated at ~5 per 100,000 annually
|
| Deaths
|
Rare; may occur from complications such as meningitis if untreated
|
A cerebrospinal fluid leak (CSF leak) is a medical condition where the cerebrospinal fluid (CSF) escapes from the subarachnoid space surrounding the brain and spinal cord. This can occur due to a tear or hole in the dura mater, the outermost layer of the meninges.
Cerebrospinal fluid leaks can be caused by a variety of factors, including:
- Trauma: Head injuries or spinal injuries can lead to tears in the dura mater.
- Surgical procedures: Certain neurosurgical or spinal surgeries may inadvertently cause a CSF leak.
- Spontaneous leaks: These occur without any apparent cause and may be related to underlying connective tissue disorders.
- Increased intracranial pressure: Conditions that increase pressure within the skull can lead to CSF leaks.
Symptoms[edit]
The symptoms of a cerebrospinal fluid leak can vary depending on the location and severity of the leak. Common symptoms include:
- Headache: Often described as a positional headache, worsening when upright and improving when lying down.
- Nasal drainage: Clear, watery fluid draining from the nose, especially when bending forward.
- Tinnitus: Ringing in the ears.
- Hearing loss: Changes in hearing, often due to pressure changes in the ear.
- Neck stiffness: Due to irritation of the meninges.
Diagnosis[edit]
Diagnosing a CSF leak involves a combination of clinical evaluation and diagnostic tests. These may include:
- Imaging studies: MRI or CT scan can help visualize the site of the leak.
- Beta-2 transferrin test: A laboratory test that detects the presence of CSF in nasal or ear fluid.
- Intrathecal fluorescein: A dye injected into the CSF to help identify the leak site during imaging.
Treatment[edit]
Treatment for a cerebrospinal fluid leak depends on the cause and severity of the leak. Options include:
- Conservative management: Bed rest, hydration, and caffeine intake to reduce symptoms and allow the leak to heal naturally.
- Epidural blood patch: A procedure where a small amount of the patient's blood is injected into the epidural space to seal the leak.
- Surgical repair: In cases where conservative measures fail, surgical intervention may be necessary to repair the dura mater.
Prognosis[edit]
The prognosis for individuals with a cerebrospinal fluid leak varies. Many leaks resolve with conservative treatment, but some may require surgical intervention. Early diagnosis and treatment are crucial to prevent complications such as meningitis.
Related Pages[edit]
External links[edit]
