This document discusses traumatic cranial CSF leaks, including their history, classification, causes, symptoms, diagnosis, and management. It focuses on the controversial role of prophylactic antibiotics. While earlier meta-analyses suggested antibiotics may reduce meningitis risk, a 2011 Cochrane review found no evidence to support their use. Proponents argue they may still be warranted given the risks of meningitis, while opponents feel they are ineffective and could increase antibiotic resistance. The conclusion is that the choice to use antibiotics depends on the individual case and managing physician's assessment.

1. Dr.Saurav Singh Hamal
MBBS (Nepalgunj Medical College).
Medical Officer (ANIAS).
Role of Prophylactic Antibiotic
In Traumatic Cranial CSF leak

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 it occurs 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. 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:-

7. 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.

8. Imaging
1. CT Scan :- High resolution CT (1mm) with coronal cuts.
2. CT cisternography
3. MRI cisternography
4. Intrathecal Fluorescein

9. 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.
5.Ear drops are probably not necessary.

10. 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.

11. 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

12. •Controversial role of antibiotic.
•Most controversy start from 2 metaanalysis
performed at a year difference.
Do Prophylactic Antibiotics Prevent Meningitis in Posttraumatic CSF
Leaks:
•Meningitis occur in 2-50% of case of traumatic
CSF leak ,10% being average.
1.Brodie h et al 1997 USA
Prophylactic antibiotics for posttraumatic
cerebrospinal fluid fistulae.
Arch Otolaryngol Head Neck
Surg 1997;123:749-52.
2.Villalobos T et al 1998 USA
Antibiotic prophylaxis after basilar skull
fractures
Clin Infect Dis 1998;27:364-9.

13. Author Patient group Study type Key result Weakness
Brodie H 6 studies with data
analysis of incidence
of meningitis
resulting from
posttraumatic CSF
leak .
324 patient of whom
237 were receiving
antibiotic and 87 did
not.
Meta Analysis 2.5% of those
receiving antibiotic
developed
meningitis
compared to 10%
of those not
receiving.
Only 15 cases
of
meningitis,no
formal review
of quality
paper.No odds
ratio or
confidence
interval
calculated.
Villalobos
T
12 studies with data
allowing analysis of
effectiveness of
antibiotic use in
preventing meningitis
from basilar skull #.
1241 of whom 719
received antibiotic
and 522 did not.
Meta analysis. 1.15 (95% CI 0.68 -
1.94).Odds ratio of
developing meningitis
in untreated Vs
Treated case.
1.34(95%CI 0.75-2.41)
odds ratio of
meningitis risk in
patient with CSF leak.

14. • Recently a Ratilal et al Cochrane Database
review in Aug 2011 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.
Cochrane Database of Systematic Reviews 2011, Issue 8.
Art. No.: CD004884. DOI:
10.1002/14651858.CD004884.pub3
• Santarius and colleagues BMJ 2002;325:1037.2
unconfirmed the myth that prophylactic antimicrobial are
effective in CSF leak the reason put forward are-
1. That commonly used antibiotics such as cephalosporins
penetrate the non-inflamed meninges poorly,
2. That antibiotics are unlikely to eradicate potential
pathogens such as the pneumococci from the upper
respiratory tract.

15. • 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.
Are antibiotics Really Needed?

16. 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”.

17. • Thank You.
• Special thanks to :- Dr Pritam Gurung, Dr Dinesh Thapa,
Dr Susangma Chemjong,Dr Jasmine Shrestha.