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Cerebrospinal fluid

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Cerebrospinal fluid

  1. 1. Journal club
  2. 2. CEREBROSPINAL FLUID: IMPLICATIONSIN ORAL AND MAXILLOFACIAL SURGERYM. Todd Brandt, W. Scott Jenkins, Tirbod T Fattahi, Richard H Haug.JOMS 2002; 60: 1049-1056.
  3. 3. Introduction CSF is an essential component of the nervous system. Serves as cushion, lubrication for cerebral hemisphere and meningeal layer. CSF fistula and leaks are documented in variety situation trauma, skull base surgery, functional endoscopy, spontaneous. Galen in 2nd century AD, first documented the description of CSF fistula(rhinorrhea) First correlation of CSF rhinorrhea with craniomaxillary trauma was made in 17th century by Bidloo & Elder. CSF fistula is serious potential fetal condition, successful management requires through understanding of pertinent anatomy & path physiology. This article reviews the anatomy & path physiology of CSF , clinical significance of CSF fistula , highlights on etiology and management of CSF leaks seen in OMFS.
  4. 4. Anatomy Choroid plexus Lateral ventricle CSF is formed in the Third ventricle choroid plexus Forth ventricle around the lateral ventricle and lesser amount by 3rd & 4th ventricle. Partly by arachnoid villi with rate of 0.35- 0.40ml/min.
  5. 5. Lateral ventricles Intra ventricular foramina Monroe foramina Circulation & absorption of 3rd ventricles CSF Cerebral aqueduct of midbrain 4th ventricles laterally medially Foramina Luschka Foramina Magendie Sub arachinoid space Central canal of spinal cord Superolateral surface of cerebrum Subarachnoid space around spinal cord &Arachoid granulations Inferior surface of cerebrum cauda equinaSuperior sagittal sinus Tentorial notch Veins of spinal cord
  6. 6. Physiology CSF termed as third circulation. Clear fluid bathing the brain & meninges produced on daily basis in ventriculocisternal portion of nervous system. In adult avg intracranial volume is 1700ml, CSF makes about 5- 10% volume (50-160 ml). Rate of formation is 20-22ml/hr or 500ml/day or 0.35-0.40 ml/min. CSF as a whole is renewed 4-5 times a day. In recumbent position intra cranial pressure is 8-12 mm Hg or 110-150 mm H2O (ie equilibrium to capillary pressure) Autoregulation maintains the intracranial pressure irrespective of ↑ arterial pressure. Co2 has profound effect on the CSF pressure. Hyperventilation: rapid ↓ in Pco2, ↑ pH & ↓ the CSF pressure.
  7. 7. Function of CSF:1. Serves as water cushion for brain & spinal cord protect from blunt force trauma.2. Provides the media to support the nervous system in closed bony cavity and protect by countercoup mechanism.3. No lymphatic channels in nervous system , serves to remove the cerebral metabolic waste.4. Active transport & passive diffusion allows exchange of electrolyte and fluid between plasma & extracellular space around choroid cell.
  8. 8. Various constituent of CSF. Constituents CSF Serum Nasal secretionOsmolarity 295 295 277(mOsm/L)Na (mEQ/L) 140 140 150K (mEQ/L) 2.5-3.5 3.3-4.8 12-41Cl (mEQ/L) 120-130 100-106 119-125Glucose (mg/100ml) 58-90 80-120 14-32Albumine (of total 50-75% 55% 57%protein)Total protein (mg/dL) 5-45 6-8.4 335-636IgG (mg/100ml) 3.5 1140 51B2 Transferrin 15 0 0
  9. 9. Incidence of CSF leak CSF not common in all the trauma. Reports suggests 80% CSF leaks are direct results of trauma ( craniomaxillary trauma- naso-orbito-ethmoidal #, postrior table frontal sinus #, skull base #) closed head injury with basilar skull # and CSF leaks range from 2%-30%. 16% occurs secondary to surgery (iatorgenic nasal, paranasal, skull base surgery, functional endoscopic procedure) remaining 4% spontaneous in origin(hydrocephalus, brain tumor, congenital anomaly) Pediatric population presents with lower CSF leaks as facial skeletal development not reached the maturation & sinus pneumatization is incomplete,
  10. 10. Patho-physiology It presents as CSF Rhinorrhea or CSF otorrhea. most of times, occurs through anterior cranial fossa as at this region dura is tightly adhered to thin bone of cribriform plate and roof of ethmoid. factors affecting nature of leak- Disruption of arachinoid & dura laceration, tear in periosteum & mucosa. Degree of displacement of bony fragments. Intracranial pressure Increased production of CSF
  11. 11. ClassificationOmmaya classification system for CSF leak (1964)Traumatic (80-90%) Non-traumatic (10-20%)Accidental (Cranimaxillofacial fractures) High pressure leaks 1. Tumors 2. Hydrocephalous 3. Benign intracranial hypertensionIatrogenic (neurosurgical & functional Normal pressure leaksendoscopic procedures) 1. Congenital anomaly 2. Focal atrophy 3. Osteomyelitic erosion
  12. 12. EvaluationClinical presentation Clinical/Laboratory Imaging identification1. Otorrhea (25%), Clinical- 1) Plane radiographs , CT rhinorrhea (68%) 1) Reservoir sign scans: disruption of bony2. High suspicious 2) Target sign (ring test) architecture, air or fluid level, with epistasis, 3) Altered ICP causes headaches. tumor masses. pharyngorrhea, 4) Low pressure- headache to be 2) Cysternography : hemotympanum relieved by staining or a. non radioactive dyes- , battels sign, performing Valsalva Methylene blue, phenol post traumatic movement . sulfonphthalein, flurescin. serous otitis 5) High pressure- headache b. Radioactive agent- media. relieved by release of CSF eg Indium 11diethyleen3. CSF leaks should lumbar puncture triaminic penta acetic acid be assumed until Laboratory- (DPTA), technetium 99m- ruled out. 1) Glucose CSF conce ≥ plasma DPTA. 2) ↓Protein & K+ level c. Combination of imaging 3) β2 transferrin along with contract medium (metrizamide)
  13. 13. Clinical management- Conservative medical approach Surgical intervention
  14. 14. Conservative medical approach Strict bed rest Head elevation 35 ° -45° Instruction to avoid activity that ↑ ICP (coughing, nose blowing, sneezing, straining) Stool softener Acetazolamide (↓ CSF production ) Incidence of meningitis is 3%-50% and mortality associated with post traumatic meningitis is 10% Antibiotic prophylaxis is not recommended Clemenza et al
  15. 15. Protocol for surgical intervention Spontaneous closure of CSF fistulas within 48 hrs = 68%, 1 week = 85%. With reduction of craniofacial fracture CSF leaks resolve spontaneously During reduction any suspicion regarding posterior frontal table, orbito-ethmoidal #, fistulas are obliterated with galeal flap or fat. If conservative management of facial # to slow the leak with 72 hr, lumbar subarachnoid drain placed ( if no indication for craniotomy) Persistent leak > 8days despite of subarachnoid lumbar drain, craniotomy is require to repair the CSF fistula. Surgery can be performed extra cranially ( endoscopic or transfacial) intracranially (craniotomy)
  16. 16. Patient selection for surgical repair Complication of CSF fistula – tension meningitis, pneumocele. ↓ Incidence of meningitis (9%), {post traumatic meningitis organism asso. Pneumococcous species} Repair of basal dural tear can prevent meningitis (Teasdaie & Jennett) Classification of compound skull fracture by Sakas et al  I- Cribiform  II- Fronto-ethmoidal  III- lateral frontal  IV- complex(any combiantion of above). Type I are more prone fro infection than type II & III (near to sagittal midline are prone for infection) Large fracture with max bone displacement (> 1 cm any plane . Patient with transient rhinorrhea >8 days high risk of meningitis.
  17. 17. A. Lumbar drain- First indwelling catheter was reported in 1963. these are subarachnoid lumbar drain effectively reduce the hydrostatic pressure. Drains are kept for 4-10 days, drains CSF about 150 ml /day. Risk of meningitis ↑ up to 10% when lumbar drains violate the subarachnoid space. procedure may also present with complications like transient lumbar nerve root irritation, CSF overdraining leading temporary neurological decline.
  18. 18. B. Intracrainal repair- Dandy 1926, first described intracranial repair of CSF fistula. CraniotomyAdvantage-  Direct visualization of dural tear.  Allows inspection of adjacent t brain injury  Preferred when extracranial approach has failed.Disadvantage-  Asomia  Intracranial hemorrahge  Brain edema  Skull base exposure  Brain retraction
  19. 19. C. Extracranial repair- Dohlman 1948, first extra cranial approach for CSF fistula repair. Appproaches- External ehtmoid-sphenoidal (medial orbital incision, dissect orbital content posteriorly to gain ethmoidal labyrinth, fistula repair can be done with fascial late, muscle, fibrin glue) Transmastoid (with high speed bur mastoid air cells are removed) Transseptosphenoidal (trans nasal route),
  20. 20. D. Endoscopic repair Overall success 98%, Can address ethmoidal roof, cribiform plate, sphenoidal defects Recommended when defect is < 1 cm.Disadvantage- Limited visualization Possible cerebral damage.
  21. 21. Post operative care Patient going for the surgical repair shunts are kept at adjacent to direct repair Shunts are kept appro 4-10 days Antibiotic prophylaxis for the patient with higher risk of meningitis, preexisting sinusitis, compound skull base fracture with gross contamination. Nafcillin, gentamicin, cephazolin excellent choice. Surgical pack with antibiotic is kept to reduce bacterial endotoxin.
  22. 22. Thank you…

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