Dr.Saurav Singh HamalMBBS (Nepalgunj Medical College).Medical Officer (ANIAS).Role of Prophylactic AntibioticIn Traumatic Cranial CSF leak
CSF leak Introduction• CSF leak :-- It refers to any disruption ofarachnoid and dura mater thatallows CSF to escape to anextradural space.- The most commonmanifestation are Rhinorrhoeaand Otorrhoea, and rarelyspinal leakage.
• Galen accurately described CSF rhinorrhea in 2ndCentury• 1826 – C. Miller described Rhinorrhea in ahydrocephalic child .•In 1889 St Clair Thompson coined the term Rhinorrhoeain a report descrbing a group of patient with spontaneousCSF leak.•In 1923 Grant first proposed closing a traumatic duraldefect.(Profuse bleeding foiled his proposal of surgicalrepair.•In 1926 Dandy first reported a 1st succesful operativerepair of a CSF leak.• Dohlman, Wigand and others pioneered operative repair.History
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.
• Trauma is the most common cause of Cranial CSF leak and it occurs in 2-3 % ofpatient with head injury.•Traumatic CSF leak involve nasal pathway in 80% of case and aural pathways in20%.• Postraumatic CSF leak are uncommon in young children and rare below 2years of agedue to flexibility of skull bone, cartilaginous ethmoid and poor development of frontaland 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 withduration of CSF leak. Pneumococcus is the main organism revealed.In a review of 122 cases of posttraumatic CSF meningitis was reported in 3% of casewhen the leak was treated within 1 week and 23 % when the leak persistent beyond 1week.Overview Of Traumatic CSF leak:-
Management of CSF Otorrhea/RhinorrheaThe management of CSF leaks after traumaremains somewhat controversial. The literatureis sparse, and generally consists of observationalstudies. However, some general guidelines aresupported by large numbers of retrospectivelyreviewed patients.Diagnosis:-History:- Clear, water-like, unilateral discharge-Flow may change with alterations inposture and Valsalva-When supine, may have postnasal drip-Cessation of flow associated with headache-May occur after coughing or sneezing.CSF Otorrhoea and Rhinorrhoea:-
Investigations:-• CSF as compare to nasal secretion has a central area of bloodwith outer ring or halo.(Halo Sign).• Glucose testing. CSF glucose is low compared to serumglucose.• Beta 2 transferrin assay. This marker is very specific to CSF.However, the test is expensive and results may take severaldays to a few weeks to receive. Most leaks will have closedbefore the results are available, making this a poor test.Beta-2 TransferrinFirst used in 1979Acta Otolaryngol. 1979 Mar-Apr;87(3-4):366-9.Protein used in iron transportBeta-1Serum, nasal secretions, tears, saliva.Beta-2CSF, perilymph and aqueous humor.
Imaging1. CT Scan :- High resolution CT (1mm) with coronal cuts.2. CT cisternography3. MRI cisternography4. Intrathecal Fluorescein
Treatment:-A-Nonsurgical or medical measure:-1.Place the patient at bed rest with the head elevated. The basic concept is to decreaseintracranial pressure, which in turn should decrease the rate of leakage. This sametechnique is used for management of mild ICP increases after head injury.2. Stool softener, increase fluids, especially drinks with caffeine, can help slow or stopthe leak and may help with headache pain.3.Consider Cough medication , diuretics(Acetazolamide).4.Consider prophylactic antibiotics carefully.5.Ear drops are probably not necessary.
6. Lumbar Drain:-Two ways to draina.By pressure – set drain at certain level above patient’sear/ventricles – e.g. 10cm, therefore any pressure greater than10cm 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 theventricles .7.Wait :- wait and watch for spontaneousresolution of csf leak.Brodie and Thompson et al- 820 T-bonefractures/122 CSF leaks Spontaneous resolutionwith conservative measures.95/122 (78%): within 7 days,21/122(17%): between 7-14 days5/122(4%): Persisted beyond 2 weeks.
B.Surgical Management:-• Indications:1.Extensive intracranial injury 2.Intraoperative identification3.Do not respond to conservative measures 4.Recurrent meningitis5.Some authors suggest that non-operative repair of spontaneous leak israrely permanent.Type of repair:-– 1.Intracranial/Open– 2.Extracranial/Endoscopic
•Controversial role of antibiotic.•Most controversy start from 2 metaanalysisperformed at a year difference.Do Prophylactic Antibiotics Prevent Meningitis in Posttraumatic CSFLeaks:•Meningitis occur in 2-50% of case of traumaticCSF leak ,10% being average.1.Brodie h et al 1997 USAProphylactic antibiotics for posttraumaticcerebrospinal fluid fistulae.Arch Otolaryngol Head NeckSurg 1997;123:749-52.2.Villalobos T et al 1998 USAAntibiotic prophylaxis after basilar skullfracturesClin Infect Dis 1998;27:364-9.
Author Patient group Study type Key result WeaknessBrodie H 6 studies with dataanalysis of incidenceof meningitisresulting fromposttraumatic CSFleak .324 patient of whom237 were receivingantibiotic and 87 didnot.Meta Analysis 2.5% of thosereceiving antibioticdevelopedmeningitiscompared to 10%of those notreceiving.Only 15 casesofmeningitis,noformal reviewof qualitypaper.No oddsratio orconfidenceintervalcalculated.VillalobosT12 studies with dataallowing analysis ofeffectiveness ofantibiotic use inpreventing meningitisfrom basilar skull #.1241 of whom 719received antibioticand 522 did not.Meta analysis. 1.15 (95% CI 0.68 -1.94).Odds ratio ofdeveloping meningitisin untreated VsTreated case.1.34(95%CI 0.75-2.41)odds ratio ofmeningitis risk inpatient with CSF leak.
• Recently a Ratilal et al Cochrane Databasereview in Aug 2011 was performed to addressthese deficiencies. The analysis included 208 patientsfrom 4 randomized controlled trials and an additional2168 patients from 17 nonrandomized controlledtrials.- The analysis concluded that the evidence does notsupport the use of Prophylactic antibiotics to reducethe risk of meningitis in patients with basilar skullfractures or basilar skull fractures with active CSF leak.Cochrane Database of Systematic Reviews 2011, Issue 8.Art. No.: CD004884. DOI:10.1002/14651858.CD004884.pub3• Santarius and colleagues BMJ 2002;325:1037.2unconfirmed the myth that prophylactic antimicrobial areeffective in CSF leak the reason put forward are-1. That commonly used antibiotics such as cephalosporinspenetrate the non-inflamed meninges poorly,2. That antibiotics are unlikely to eradicate potentialpathogens such as the pneumococci from the upperrespiratory tract.
• Proponents argue that meningitis is bad enough to warrant the use of prophylacticantibiotics despite data which don’t show their high efficacy.• Opponents feel that they are ineffective and lead to colonization by more seriousflora, and bacterial resistance.Are antibiotics Really Needed?
Conclusion:-• Choice of use and not to use Antibiotics solely depends on individual caseand 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”.
• Thank You.• Special thanks to :- Dr Pritam Gurung, Dr Dinesh Thapa,Dr Susangma Chemjong,Dr Jasmine Shrestha.