Cerebrospinal fluid leak
A cerebrospinal fluid leak is a medical condition where the cerebrospinal fluid that surrounds the brain and spinal cord leaks out of one or more holes or tears in the dura mater. A CSF leak is classed as either spontaneous, having no known cause, or nonspontaneous where it is attributed to an underlying condition. Causes of a primary CSF leak are those of trauma including from an accident or intentional injury, or arising from a medical intervention known as iatrogenic. A basilar skull fracture as a cause can give the sign of CSF leakage from the ear, nose or mouth. A lumbar puncture can give the symptom of a post-dural-puncture headache.
A cerebrospinal fluid leak can be either cranial or spinal, and these are two different disorders. A spinal CSF leak can be caused by one or more meningeal diverticula or CSF-venous fistulas not associated with an epidural leak. A spontaneous spinal cerebrospinal fluid leak may occur sometimes in those with predisposing heritable connective tissue disorders including Marfan syndrome and Ehlers–Danlos syndromes. A loss of CSF greater than its rate of production leads to a decreased volume inside the skull known as intracranial hypotension.
Any CSF leak is most often characterized by orthostatic headaches, which worsen when standing, and improve when lying down. Other symptoms can include neck pain or stiffness, nausea, vomiting, dizziness, fatigue, and a metallic taste in the mouth. A CT myelography scan can identify the site of a cerebrospinal fluid leakage. Once identified, the leak can often be repaired by an epidural blood patch, an injection of the patient's own blood at the site of the leak, a fibrin glue injection, or surgery.
A spontaneous CSF leak is a rare condition, affecting at least one in 20,000 people and many more who go undiagnosed every year. On average, the condition develops at age 42, and women are twice as likely to be affected. Some people with a sCSF leak have a chronic leak despite repeated patching attempts, leading to long-term disability due to pain and being unable to be upright, and surgery is often needed. The symptoms of a spontaneous CSF leak were first described by German neurologist Georg Schaltenbrand in 1938 and by American neurologist Henry Woltman of the Mayo Clinic in the 1950s.
Classification
Cerebrospinal fluid leaks are classified into two distinct disorders: cranial leaks, and spinal leaks. Where there has been no preceding surgery or medical procedure that may have caused a CSF leak it is called a spontaneous CSF leak.Cranial leak
Cranial leaks occur in the head, and in some of these cases, CSF can leak from one side of the nose, or from the ear. Intracranial hypertension is often associated with a spontaneous cranial CSF leak, rarely reported with a spinal leak.Spinal leak
The vast majority of CSF leaks are spinal. Spinal leaks occur when one or more holes form in the dura along the spinal cord. There are three types of spontaneous spinal CSF leaks. A spinal leak typically causes spontaneous intracranial hypotension.Spontaneous intracranial hypotension
Spontaneous intracranial hypotension refers to lower than normal CSF volume due to a leak of CSF at the level of the spine.Spontaneous intracranial hypotension is an important cause of longstanding headaches. Other symptoms can include nausea, blurred vision, coma, and dementia. SIH is typically secondary to a spontaneous spinal CSF leak. Cranial CSF leaks do not cause SIH. While this symptom can be referred to as intracranial hypotension, the intracranial pressure may be normal, with the underlying issue instead being low CSF volume, in this case a sCSFL may be referred to as CSF hypovolemia.
Signs and symptoms
Spinal CSF leaks
The most common symptom of a spinal CSF leak is a fast-onset, extremely painful orthostatic headache. This headache is usually made worse by standing and typically becomes prominent throughout the day, with the pain becoming less severe when lying down. Orthostatic headaches can become chronic and disabling to the point of incapacitation. Some people will develop headaches that begin in the afternoon. This is known as second-half-of-the-day headache. This may be an initial presentation of a spontaneous CSF leak or appear after treatment such as an epidural patch, and likely indicates a slow spinal CSF leak. While high CSF pressure can make lying down unbearable, low CSF pressure due to a leak can be relieved by lying flat on the back.About 50% of people with a spinal CSFL experience neck pain or stiffness, nausea, and vomiting.
Other symptoms of a CSF leak include photophobia, dizziness and vertigo, gait disturbances, tinnitus, facial numbness or weakness, visual disturbances, brain fog or difficulties with concentration, neuralgia, fatigue, fluid dripping from the nose or ears.
Aural symptoms are also present in many cases of intracranial hypotension due to CSF leak; including muffled hearing, pulsatile tinnitus, hearing loss. Less common symptoms include double vision or tremor.
Movement disorders are uncommon in spontaneous CSF leaks but occasionally can be one of the major components of the clinical presentation.
Some cases of chronic intracranial hypotension due to CSF leak may present as personality changes, altered behaviors and impairment of executive functions, similar to behavioral-variant frontotemporal dementia as the frontal and temporal lobes are affected by downward sagging due to reduced intra-cranial pressures.
An untreated CSF leak can result in coma or death as late stage findings as the brainstem herniates through the skull base or foramen magnum.
Cranial CSF leaks
Cranial leaks occur in the skull. Symptoms often include a watery discharge including CSF from one side of the nose, or from the ear. There may also be a metallic taste in the mouth.Causes
A spontaneous spinal CSF leak refers to any CSF leak that has not been preceded by a surgical or other medical procedure. Later evidence suggests that these leaks result from either a discogenic pathology, such as microspur, osteophyte or spinal disc herniation that pierces the dura like a knife, connective tissue disorder, or spinal drainage problems.A cerebrospinal fluid leak can be a rare complication of an anterior cervical discectomy and fusion. One study suggested a CSF leak to follow from 0.5% of operations. Another study suggests a CSF leak to follow from 1% of operations. In most of these cases repair is successful.
Discogenic causes
The most common cause of an intractable sCSF leak is discogenic, either from a spinal disc herniation, osteophyte or microspur on the disc or vertebral body. "Recent radiological and microsurgical investigations revealed that a calcified, degenerative bony microspur is often the culprit lesion in cases of intractable CSF leaks. Arising from the level of the intervertebrate disk space, these microspurs pierce the ventral dura and produce a slit-like defect a few millimeters in length. These microspurs and the associated CSF leak have to be localized exactly, and then they are amenable to surgical treatment."Connective tissue theory
Various scientists and physicians have suggested that sCSFLs may be the result of an underlying connective tissue disorder affecting the spinal dura. It may also run in families and be associated with aortic aneurysms and joint hypermobility.Up to two thirds of those affected demonstrate some type of generalized connective tissue disorder. Marfan syndrome, Ehlers–Danlos syndrome, and autosomal dominant polycystic kidney disease are the three most common connective tissue disorders associated with sCSFLs. Roughly 20% of patients with a sCSFL exhibit features of Marfan syndrome, including tall stature, hollowed chest, joint hypermobility and arched palate. However, no other Marfan syndrome presentations are shown.
Spinal drainage theory
Some studies have proposed that issues with the spinal venous drainage system may cause a CSF leak. According to this theory, dural holes and intracranial hypotension are symptoms caused by low venous pressure in the epidural space. When leg muscles pump blood towards the heart, and pressure in the inferior vena cava vein becomes negative, the network of epidural veins is overdrained, causing CSF to be aspirated into the epidural space. True leaks can form at weak points in the spinal meninges. Therefore, the observed CSF hypotension is a result of CSF hypovolemia and reduced epidural venous pressure.Other causes
Cranial CSF leaks result from intracranial hypertension in the vast majority of cases. The increased pressure causes a rupture of the cranial dura mater, leading to a CSF leak and intracranial hypotension. Patients with a nude nerve root, where the root sleeve is absent, are at increased risk for developing recurrent CSF leaks. Lumbar disc herniation has been reported to cause CSF leaks in at least one case. Degenerative spinal disc diseases cause a disc to pierce the dura mater, leading to a CSF leak.CSF leaks can result from a lumbar puncture procedure.
Complications
Several complications can occur as a result of sCSFLS including decreased cranial pressure, brain herniation, infection, blood pressure problems, transient paralysis, and coma. The primary and most serious complication of a spontaneous cerebrospinal fluid leak is spontaneous intracranial hypotension, where pressure in the brain is severely decreased. This complication leads to the hallmark symptom of severe orthostatic headaches.People with cranial CSF leaks, the rarer form, have a 10% risk of developing meningitis per year. If cranial leaks last more than seven days, the chances of developing meningitis are significantly higher. Spinal CSF leaks cannot result in meningitis due to the sterile conditions of the leak site. When a CSF leak occurs at the temporal bone, surgery becomes necessary in order to prevent infection and repair the leak. Orthostatic hypotension is another complication that occurs due to autonomic dysfunction when blood pressure drops significantly. The autonomic dysfunction is caused by compression of the brainstem, which controls breathing and circulation.
Low CSF volume can cause the cerebellar tonsil position to descend, which can be mistaken for Chiari malformation; however when the CSF leak is repaired the tonsil position often returns to normal in this "pseudo-Chiari" condition. A further, albeit rare, complication of CSF leak is transient quadriplegia due to a sudden and significant loss of CSF. This loss results in hindbrain herniation and causes major compression of the upper cervical spinal cord. The quadriplegia dissipates once the patient lies supine. An extremely rare complication of sCSFL is third nerve palsy, where the ability to move one's eyes becomes difficult and interrupted due to compression of the third cranial nerve.
There are documented cases of reversible frontotemporal dementia and coma. Coma due to a CSF leak has been successfully treated by using blood patches and/or fibrin glue and placing the person in the Trendelenburg position. Empty sella syndrome, a bony structure that surround the pituitary gland, occurs in CSF leak patients.