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Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
Csf leak and antibiotic.
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Csf leak and antibiotic.

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Neurosurgery.

Neurosurgery.

Published in: Health & Medicine, Business
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  • 1. Role of Prophylactic Antibiotic In Traumatic Cranial CSF leak Dr.Saurav Singh Hamal MBBS (Nepalgunj Medical College). Medical Officer (ANIAS).
  • 2. CSF leak Introduction • CSF leak :- - It refers to any disruption of arachnoid and dura mater that allows CSF to escape to an extradural space. - The most common manifestation are Rhinorrhoea and Otorrhoea, and rarely spinal leakage.
  • 3. • Galen accurately described CSF rhinorrhea in 2nd Century • 1826 – C. Miller described Rhinorrhea in a hydrocephalic child . •In 1889 St Clair Thompson coined the term Rhinorrhoea in a report descrbing a group of patient with spontaneous CSF leak. •In 1923 Grant first proposed closing a traumatic dural defect.(Profuse bleeding foiled his proposal of surgical repair. •In 1926 Dandy first reported a 1st succesful operative repair of a CSF leak. • Dohlman, Wigand and others pioneered operative repair. History
  • 4. Classification of CSF leak :- In 1937 Cairns offered 1st classification dividing it into :- 1.Acute 2. Delayed 3.Traumatic 4. Operative 5.Spontaneous. Ommaya later classified into :- 1.Traumatic : - a.Accidental b. Iatrogenic. 2.Nontraumatic : - a.High pressure leak ; tumors, hydrocephalus. b. Normal pressure leak ; congenital, focal atrophy.
  • 5. • Trauma is the most common cause of Cranial CSF leak and postraumatic CSF leak occur in 2-3 % of patient with head injury. •Traumatic CSF leak involve nasal pathway in 80% of case and aural pathways in 20%. • Postraumatic CSF leak are uncommon in young children and rare below 2years of age due to flexibility of skull bone, cartilaginous ethmoid and poor development of frontal and ethmoid sinus. •Clinical symptoms of Cranial CSF leak includes : -Frank rhinorrhoea and Otorrhoea. - Intermittent leaks, apparent with change in posture. - Anosmia( when cribriform plate involved). - Risk of meningitis associated in 2-50% of untreated case, and risk is increased with duration of CSF leak. Pneumococcus is the main organism revealed. In a review of 122 cases of posttraumatic CSF meningitis was reported in 3% of case when the leak was treated within 1 week and 23 % when the leak persistent beyond 1 week. Overview Of Traumatic CSF leak:-
  • 6. Relevant Anatomy • http://emedicine.medscape.com/article/861126-overview#a04 •The most common anatomic sites of cerebrospinal fluid (CSF) leaks are the areas of congenital weakness of the anterior cranial fossa and areas related to the type of surgery performed. •According to data from 53 patients with different causes of CSF rhinorrhea, 39% of leaks occurred in the region of the cribriform plate and air cells of the ethmoid sinus; in 15% of leaks, the fistula extended to the frontal sinus; and in another 15%, the leak was in the area of the sella turcica and sphenoid sinus.
  • 7. Management of CSF Otorrhea/Rhinorrhea The management of CSF leaks after trauma remains somewhat controversial. The literature is sparse, and generally consists of observational studies. However, some general guidelines are supported by large numbers of retrospectively reviewed patients. Diagnosis:- History:- Clear, water-like, unilateral discharge -Flow may change with alterations in posture and Valsalva -When supine, may have postnasal drip -Cessation of flow associated with headache -May occur after coughing or sneezing. CSF Otorrhoea and Rhinorrhoea:-
  • 8. Investigations:- • CSF as compare to nasal secretion has a central area of blood with outer ring or halo.(Halo Sign). • Glucose testing. CSF glucose is low compared to serum glucose. • Beta 2 transferrin assay. This marker is very specific to CSF. However, the test is expensive and results may take several days to a few weeks to receive. Most leaks will have closed before the results are available, making this a poor test. Beta-2 Transferrin First used in 1979 Acta Otolaryngol. 1979 Mar-Apr;87(3-4):366-9. Protein used in iron transport Beta-1 Serum, nasal secretions, tears, saliva. Beta-2 CSF, perilymph and aqueous humor.
  • 9. Imaging 1. CT Scan :- High resolution CT (1mm) with coronal cuts. 2. CT cisternography 3. MRI cisternography 4. Intrathecal Fluorescein
  • 10. Treatment:- A-Nonsurgical or medical measure:- 1.Place the patient at bed rest with the head elevated. The basic concept is to decrease intracranial pressure, which in turn should decrease the rate of leakage. This same technique is used for management of mild ICP increases after head injury. 2. Stool softener, increase fluids, especially drinks with caffeine, can help slow or stop the leak and may help with headache pain. 3.Consider Cough medication , diuretics(Acetazolamide), 4.Consider prophylactic antibiotics carefully. The clinician must balance the likelihood of meningitis with the possibility of selecting resistant bacteria. If the likelihood of contamination is low and the patient is immunocompetent, antibiotics may not be needed. 5.Ear drops are probably not necessary. They may confuse the picture when gauging resolution of the CSF leak.
  • 11. 6. Lumbar Drain:- Two ways to drain a.By pressure – set drain at certain level above patient’s ear/ventricles – e.g. 10cm, therefore any pressure greater than 10cm H2O will drain. b.By volume – 10 cc/hr and reclamp (20 cc/hr of CSF produced, 150mL total volume) • Drain should not be raised above the level of the ventricles . 7.Wait :- wait and watch for spontaneous resolution of csf leak. Brodie and Thompson et al- 820 T-bone fractures/122 CSF leaks Spontaneous resolution with conservative measures. 95/122 (78%): within 7 days, 21/122(17%): between 7-14 days 5/122(4%): Persisted beyond 2 weeks.
  • 12. B.Surgical Management:- • Indications: – 1.Extensive intracranial injury 2.Intraoperative identification – 3.Do not respond to conservative measures 4.Recurrent meningitis – 5.Some authors suggest that non-operative repair of spontaneous leak is rarely permanent. Type of repair:- – 1.Intracranial/Open – 2.Extracranial/Endoscopic
  • 13. •Controversial role of antibiotic. •Most controversy start from 2 metaanalysis performed at a year difference. •Brodie 1997 – meta-analysis of traumatic leaks Meningitis occur in 2.5% cases(6/237) treated with antibiotics, And in 10% Cases(9/87) not treated with antibiotics. • In 1998 Villalobos et al have conducted a metaanalysis and found that antibiotic failed to lower the infection rate. However, critiques of these meta-analyses point out that neither of these studies included an extensive review of the literature and that the conclusions drawn were based mainly on retrospective and observational studies Do Prophylactic Antibiotics Prevent Meningitis in Posttraumatic CSF Leaks: •Meningitis occur in 2-50% of case of traumatic CSF leak ,10% being average.
  • 14. • Recently a Cochrane Database review was performed to address these deficiencies. The analysis included 208 patients from 4 randomized controlled trials and an additional 2168 patients from 17 nonrandomized controlled trials. - The analysis concluded that the evidence does not support the use of;Prophylactic antibiotics to reduce the risk of meningitis in patients with basilar skull fractures or basilar skull fractures with active CSF leak. •Hoff et al conducted a prospective randomized trial; no patients in either arm got meningitis.
  • 15. • The incidence of posttraumatic meningitis after head trauma ranges from 0.2 - 17.8% and increases significantly in the presence of skull base fracture, pneumocephalus or cerebrospinal fluid (CSF) leak . • 2 studies were performed to conclude role of antibiotics in traumatic CSF leak 1st on head injury patient with skull base fracture. 2nd on patient with skull base fracture and pneumocephalus. • Even in those patients with CSF rhinorrhea or intracranial hemorrhage, prophylactic ceftriaxone (2 grams daily) did not prove to be effective on prevention of meningitis. • In order to cover most of normal flora of air sinus they added azithromycin orally ( It has high csf penetration, mild GI discomfort ,patient tolerance and cost effectiveness) for 1 week along with the ceftriaxone • But despite these measure there was no significant improvement in prevention of Posttraumatic meningitis. Trialsjournal.com. A comparative study conducted in Iran.
  • 16. • Proponents argue that meningitis is bad enough to warrant the use of prophylactic antibiotics despite data which don’t show their high efficacy. • Opponents feel that they are ineffective and lead to colonization by more serious flora, and bacterial resistance. E.g-In a ICU Setup rampant use of prophylactic antibiotic for traumatic meningitis led to death of 8 patient due to resistant klesbsiella spp. Are antibiotics Really Needed?
  • 17. Conclusion:- • Choice of use and not to use Antibiotics solely depends on individual case and on doctor managing the case of Cranial CSF leak:. • Some common indication may be: - Perioperative antibiotics. - Active rhinosinusitis. - Immunocompromised patient. - Compound fracture. “When in doubt , Do without”.
  • 18. References:- • ( G.Michael lemole Barrow neurological institute St joseph hospital). • http://www.otohns.net • Trialsjournal.com. • http://regionstraumapro.com
  • 19. • Thank You.

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