Surgical Outcomes of the Endonasal Endoscopic Approach within a Standardized Management Protocol for Repair of Spontaneous CSF Leaks: A Retrospective Review of 46 Patients

Background: Spontaneous cerebrospinal fluid (CSF) leaks are rare, often delayed in diagnosis, and can precipitate meningitis. Craniotomy is the historical “gold standard” repair. An endonasal endoscopic approach (EEA) offers potentially less invasiveness and lower surgical morbidity than a traditional craniotomy but must yield the same surgical success. A paucity of data exists studying EEA as the primary management for spontaneous CSF leaks.

Methods: We retrospectively reviewed patients undergoing spontaneous CSF leak repairs between July 2010 and August 2018. Standardized management at the authors’ institution is surgical repair with EEA as first-line treatment after radiological diagnosis. Lumbar puncture is performed 24 to 48 hours postoperatively. If opening pressure is >20 cm H₂O, the patient is evaluated for CSF diversion or a trial of acetazolamide, at the provider’s discretion.

Results: Of 46 patients identified, the most common leak etiology was encephalocele (28/46, 60.9%), and the most common location was cribriform/ethmoid (26/46, 55.9%). Forty-three patients underwent EEA alone, and three patients underwent simultaneous EEA/craniotomy. The most common repair strategy was nasoseptal or other pedicled flaps (18/46, 39.1%). Postoperatively, 15 patients received CSF diversion (32.6%), with BMI > 40 kg/m² being the only significant risk factor (OR = 4.35, p = 0.033) for postrepair shunt placement. Two patients underwent repair revision—one because of progressive fungal sinusitis, the other because of recurrent CSF leak. Mean follow-up duration was 15 months.

Discussion: Here we demonstrate a paradigm of EEA repair of spontaneous CSF leaks with postoperative lumbar puncture to identify undiagnosed idiopathic intracranial hypotension and effectively manage the disease without undue recurrence rates. In our cohort, the single significant risk factor predicting postoperative shunt placement was morbid obesity. This has implications for future surgical treatment as obesity levels continue to rise worldwide.