Download PDF
J Neurol Surg B Skull Base
DOI: 10.1055/a-2300-4130
Original Article

Spontaneous Clival Leaks and Their Management

Katti Blessi Sara
1   Department of Otorhinolaryngology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
,
Garima Upreti 
2   Department of Otorhinolaryngology, All India Institute of Medical Sciences Rajkot, Rajkot, Gujarat, Rajkot, India
,
Habie Thomas
1   Department of Otorhinolaryngology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
,
Ajay Philip
1   Department of Otorhinolaryngology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
,
Rajan Sundaresan
1   Department of Otorhinolaryngology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
,
Edmond Jonathan Gandham
3   Department of Neurosurgery, Christian Medical College Vellore, Vellore, Tamil Nadu, India
,
Regi Thomas 
1   Department of Otorhinolaryngology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
› Author Affiliations
› Further Information
    Permissions and Reprints

Abstract

Introduction Cerebrospinal fluid (CSF) leaks through the nasal cavity occurrence has a rising trend, of which primary spontaneous leak is 6 to 40% of all the CSF leaks. The most common site of CSF leak is ethmoid roof where the bone is thinner in the entire skull base. Clivus being the hard bone is a rare site for spontaneous leak. We present a case series from a single quaternary care center of this rare occurrence and study its reason and management strategy.

Materials and Methods A retrospective surgical audit over a period of 10 years of all patients diagnosed with CSF rhinorrhea was done. A PubMed search was conducted with keywords of CSF leak, CSF rhinorrhea, spontaneous CSF rhinorrhea, clival leak, and clivus to identify the literature and these articles were compiled and their management reviewed.

Results and Analysis A total of 100 patients underwent surgical management for spontaneous CSF leak, of which there were 5 patients who had spontaneous CSF rhinorrhea from the clivus. There were four female patients; four patients had high body mass index. The most common site of leak was mid-clivus and surgical technique employed was multilayer dural plasty with a nasoseptal flap and measures were taken to reduce the intracranial pressure intra-operatively and postoperatively.

Conclusion Spontaneous clival leak is a rare entity with mid and lower clivus being the common site. A combined approach by ENT and neurosurgeons results in best outcome for the patients.

Keywords

spontaneous clival leaks - clivus - spontaneous CSF rhinorrhea - IIH


Publication History

Received: 20 September 2024

Accepted: 28 March 2024

Accepted Manuscript online:
05 April 2024

Article published online:
03 May 2024

© 2024. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Beckhardt RN, Setzen M, Carras R. Primary spontaneous cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg 1991; 104 (04) 425-432
    CrossrefPubMedGoogle Scholar
  • 2 Wise SK, Schlosser RJ. Evaluation of spontaneous nasal cerebrospinal fluid leaks. Curr Opin Otolaryngol Head Neck Surg 2007; 15 (01) 28-34
    CrossrefPubMedGoogle Scholar
  • 3 Ommaya AK, Di Chiro G, Baldwin M, Pennybacker JB. Non_traumatic cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry 1968; 31: 214-225
    CrossrefPubMedGoogle Scholar
  • 4 Shugar JMA, Som PM, Eisman W, Biller HF. Non-traumatic cerebrospinal fluid rhinorrhea. Laryngoscope 1981; 91 (01) 114-120
    CrossrefPubMedGoogle Scholar
  • 5 Keshri A, Jain R, Manogaran RS, Behari S, Khatri D, Mathialagan A. Management of spontaneous CSF rhinorrhea: an institutional experience. J Neurol Surg B Skull Base 2019; 80 (05) 493-499
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Hatch JL, Schopper H, Boersma IM. et al. The bone mineral density of the lateral skull base and its relation to obesity and spontaneous CSF leaks. Otol Neurotol 2018; 39 (09) e831-e836
    CrossrefPubMedGoogle Scholar
  • 7 Shetty PG, Shroff MM, Fatterpekar GM, Sahani DV, Kirtane MV. A retrospective analysis of spontaneous sphenoid sinus fistula: MR and CT findings. AJNR Am J Neuroradiol 2000; 21 (02) 337-342
    PubMedGoogle Scholar
  • 8 Hooper AC. Sphenoidal defects–a possible cause of cerebrospinal fluid rhinorrhoea. J Neurol Neurosurg Psychiatry 1971; 34 (06) 739-742
    CrossrefPubMedGoogle Scholar
  • 9 Khairy S, Almubarak AO, Aloraidi A, Alahmadi KOA. Canalis basalis medianus with cerebrospinal fluid leak: rare presentation and literature review. Br J Neurosurg 2019; 33 (04) 432-433
    CrossrefPubMedGoogle Scholar
  • 10 Haetinger RG, Navarro JAC, Liberti EA. Basilar expansion of the human sphenoidal sinus: an integrated anatomical and computerized tomography study. Eur Radiol 2006; 16 (09) 2092-2099
    CrossrefPubMedGoogle Scholar
  • 11 Abuzayed B, Tanriover N, Gazioglu N, Akar Z. Extended endoscopic endonasal approach to the clival region. J Craniofac Surg 2010; 21 (01) 245-251
    CrossrefPubMedGoogle Scholar
  • 12 Ramos A, García-Uría J, Ley L, Saucedo G. Transclival cerebrospinal fluid fistula in a patient with Marfan's syndrome. Acta Neurochir (Wien) 2007; 149 (07) 723-725 , discussion 725
    CrossrefPubMedGoogle Scholar
  • 13 Berdahl JP, Fleischman D, Zaydlarova J, Stinnett S, Allingham RR, Fautsch MP. Body mass index has a linear relationship with cerebrospinal fluid pressure. Invest Ophthalmol Vis Sci 2012; 53 (03) 1422-1427
    CrossrefPubMedGoogle Scholar
  • 14 Banks CA, Palmer JN, Chiu AG, O'Malley Jr BW, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg 2009; 140 (06) 826-833
    CrossrefPubMedGoogle Scholar
  • 15 Coiteiro D, Távora L, Antunes JL. Spontaneous cerebrospinal fluid fistula through the clivus: report of two cases. Neurosurgery 1995; 37 (04) 826-828
    CrossrefPubMedGoogle Scholar
  • 16 Seth R, Rajasekaran K, Benninger MS, Batra PS. The utility of intrathecal fluorescein in cerebrospinal fluid leak repair. Otolaryngol Head Neck Surg 2010; 143 (05) 626-632
    CrossrefPubMedGoogle Scholar
  • 17 Placantonakis DG, Tabaee A, Anand VK, Hiltzik D, Schwartz TH. Safety of low-dose intrathecal fluorescein in endoscopic cranial base surgery. Neurosurgery 2007; 61 (3, Suppl): 161-165 , discussion 165–166
    PubMedGoogle Scholar
  • 18 Ozturk K, Karabagli H, Bulut S, Egilmez M, Duran M. Is the use of topical fluorescein helpful for management of CSF leakage?. Laryngoscope 2012; 122 (06) 1215-1218
    CrossrefPubMedGoogle Scholar
  • 19 Saafan ME, Ragab SM, Albirmawy OA. Topical intranasal fluorescein: the missing partner in algorithms of cerebrospinal fluid fistula detection. Laryngoscope 2006; 116 (07) 1158-1161
    CrossrefPubMedGoogle Scholar
  • 20 Bidot S, Saindane AM, Peragallo JH, Bruce BB, Newman NJ, Biousse V. Brain imaging in idiopathic intracranial hypertension. J Neuroophthalmol 2015; 35 (04) 400-411
    CrossrefPubMedGoogle Scholar
  • 21 Seth R, Rajasekaran III K, Luong A, Benninger MS, Batra PS. Spontaneous CSF leaks: factors predictive of additional interventions. Laryngoscope 2010; 120 (11) 2141-2146
    CrossrefPubMedGoogle Scholar
  • 22 Maralani PJ, Hassanlou M, Torres C. et al. Accuracy of brain imaging in the diagnosis of idiopathic intracranial hypertension. Clin Radiol 2012; 67 (07) 656-663
    CrossrefPubMedGoogle Scholar
  • 23 Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology 2013; 81 (13) 1159-1165
    CrossrefPubMedGoogle Scholar
  • 24 Sannareddy RR, Rambabu K, Kumar VE, Gnana RB, Ranjan A. Endoscopic management of CSF rhinorrhea. Neurol India 2014; 62 (05) 532-539
    CrossrefPubMedGoogle Scholar
  • 25 Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Laryngoscope 2017; 127 (09) 2011-2016
    CrossrefPubMedGoogle Scholar
  • 26 Murtagh FR, Quencer RM, Poole CA. Extracranial complications of cerebrospinal fluid shunt function in childhood hydrocephalus. AJR Am J Roentgenol 1980; 135 (04) 763-766
    CrossrefPubMedGoogle Scholar
  • 27 Calcaterra TC. Extracranial surgical repair of cerebrospinal rhinorrhea. Ann Otol Rhinol Laryngol 1980; 89 (2, Pt 1): 108-116
    CrossrefPubMedGoogle Scholar
  • 28 Yadav YR, Pande S, Raina VK, Singh M. Lumboperitoneal shunts: review of 409 cases. Neurol India 2004; 52 (02) 188-190
    PubMedGoogle Scholar
  • 29 Cooper JR. Migration of ventriculoperitoneal shunt into the chest. Case report. J Neurosurg 1978; 48 (01) 146-147
    CrossrefPubMedGoogle Scholar
  • 30 Browd SR, Ragel BT, Gottfried ON, Kestle JRW. Failure of cerebrospinal fluid shunts: part I: obstruction and mechanical failure. Pediatr Neurol 2006; 34 (02) 83-92
    CrossrefPubMedGoogle Scholar
  • 31 Aktas U, Yilmazlar S, Ugras N. Anatomical restrictions in the transsphenoidal, transclival approach to the upper clival region: a cadaveric, anatomic study. J Craniomaxillofac Surg 2013; 41 (06) 457-467
    CrossrefPubMedGoogle Scholar
  • 32 Lund VJ, Stammberger H, Nicolai P. et al; European Rhinologic Society Advisory Board on Endoscopic Techniques in the Management of Nose, Paranasal Sinus and Skull Base Tumours. European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base. Rhinol Suppl 2010; 22: 1-143
    PubMedGoogle Scholar
  • 33 Fujii K, Chambers SM, Rhoton Jr AL. Neurovascular relationships of the sphenoid sinus. A microsurgical study. J Neurosurg 1979; 50 (01) 31-39
    CrossrefPubMedGoogle Scholar
  • 34 Lockwood AH, Quencer RM, Page LK. CSF rhinorrhea from a transclival meningocele demonstrated with metrizamide CT cisternography. Case report. J Neurosurg 1980; 53 (04) 553-555
    CrossrefPubMedGoogle Scholar
  • 35 Turanzas FS, Lobato RD, León PG, Gómez PA. CSF rhinorrhea from a transclival meningocele demonstrated by MR. Acta Neurochir (Wien) 1996; 138 (05) 595-596
    CrossrefPubMedGoogle Scholar
  • 36 Al-Shurbaji AA, Abu-Salma ZA. Spontaneous cerebrospinal fluid rhinorrhea through clival defect. Neurosciences (Riyadh) 2005; 10 (03) 232-234
    PubMedGoogle Scholar
  • 37 Ahmad FU, Sharma BS, Garg A, Chandra PS. Primary spontaneous CSF rhinorrhea through the clivus: possible etiopathology. J Clin Neurosci 2008; 15 (11) 1304-1308 DOI: 10.1016/j.jocn.2006.10.012.
    CrossrefPubMedGoogle Scholar
  • 38 Akyuz M, Arslan G, Gurkanlar D, Tuncer R. CSF rhinorrhea from a transclival meningocele: a case report. J Neuroimaging 2008; 18 (02) 191-193
    CrossrefPubMedGoogle Scholar
  • 39 Elrahman HA, Malinvaud D, Bonfils NA, Daoud R, Mimoun M, Bonfils P. Endoscopic management of idiopathic spontaneous skull base fistula through the clivus. Arch Otolaryngol Head Neck Surg 2009; 135 (03) 311-315
    CrossrefPubMedGoogle Scholar
  • 40 Van Zele T, Kitice A, Vellutini E, Balsalobre L, Stamm A. Primary spontaneous cerebrospinal fluid leaks located at the clivus. Allergy Rhinol (Providence) 2013; 4 (02) e100-e104
    CrossrefPubMedGoogle Scholar
  • 41 Tandon V, Garg K, Suri A, Garg A. Clival defect causing primary spontaneous rhinorrhea. Asian J Neurosurg 2017; 12 (02) 328-330 DOI: 10.4103/1793-5482.144202.
    Article in Thieme ConnectPubMedGoogle Scholar
  • 42 Zanabria-Ortiz R, Domínguez-Báez J, del Toro A, Lazo-Fernández E, Sánchez-Medina Y, Robles-Hidalgo E. Rinorraquia secundaria a meningocele transclival. A propósito de un caso y revisión de la literatura. Neurocirugia (Astur) 2015; 26 (06) 292-295 DOI: 10.1016/j.neucir.2015.02.008. [Internet]
    CrossrefPubMedGoogle Scholar
  • 43 Hayashi Y, Iwato M, Kita D, Fukui I. Spontaneous cerebrospinal fluid leakage through fistulas at the clivus repaired with endoscopic endonasal approach. Surg Neurol Int 2015; 6 (01) 106
    CrossrefPubMedGoogle Scholar
  • 44 Pagella F, Pusateri A, Matti E. et al. Endoscopic Management of Spontaneous Clival Cerebrospinal Fluid Leaks: Case Series and Literature Review. World Neurosurg 2016; 86: 470-477 DOI: 10.1016/j.wneu.2015.11.026. [Internet]
    CrossrefPubMedGoogle Scholar
  • 45 Codina Aroca A, Gras Cabrerizo JR, De Juan Delago M, Massegur Solench H. Spontaneous cerebrospinal fluid fistula in the clivus. Eur Ann Otorhinolaryngol Head Neck Dis 2017; 134 (06) 431-434
    CrossrefPubMedGoogle Scholar
  • 46 Asad S, Peters-Willke J, Brennan W, Asad S. Clival Defect with Primary CSF Rhinorrhea: A Very Rare Presentation with Challenging Management. World Neurosurg 2017; 106: 1052.e1-1052.e4 DOI: 10.1016/j.wneu.2017.07.011. [Internet]
    CrossrefPubMedGoogle Scholar
  • 47 Karli R, Yildirim U. Endoscopic management of spontaneous cerebrospinal fluid fisstula caused by clival defect. J Craniofac Surg 2018; 29 (06) e604-e606 https://pubmed.ncbi.nlm.nih.gov/30067524/ cited 2020Sep9 [Internet]
    CrossrefPubMedGoogle Scholar
  • 48 Chen GY, Ma L, Xu ML. et al. Spontaneous cerebrospinal fluid rhinorrhea: A case report and analysis. Medicine (Baltimore) 2018; 97 (05) e9758
    CrossrefPubMedGoogle Scholar
  • 49 Nogueira JF, Woodworth BA, Stamm A, Silva ML. A Primary Clival Defect: Endoscopic Binostril Approach With Nasal Septal Flap Closure and Preservation of Septal Integrity. Ear Nose Throat J 2019; 98 (05) E24-E26
    CrossrefPubMedGoogle Scholar