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1/25. Successful closure of recurrent traumatic csf rhinorrhea using the free rectus abdominis muscle flap.

    BACKGROUND: We present two patients in whom a free rectus abdominis muscle flap was used to close recurrent traumatic CSF rhinorrhea. CASE DESCRIPTION: CT scan of both patients showed frontal lobe atrophy and porencephaly after contusional hematoma. In the first patient, because the site of CSF leakage was not identified and the patient underwent three unsuccessful attempts to close the fistula using the fascia lata, we treated the patient by unifying all paranasal sinuses and by filling them with a free rectus abdominis muscle flap. In the second patient, CSF rhinorrhea recurred 6 years after closure of the fistula using the fascia lata. The patient underwent separation of a porencephalic cyst from the paranasal sinus and a free muscle flap was placed extradurally, because the CSF pulse pressure in the enlarged left anterior horn eroded the previously repaired fascia lata, resulting in the recurrence of CSF leakage. CONCLUSION: Although duraplasty is the primary procedure for repairing dural fistulas, the vascularized free muscle flap is an alternative method when the location of the fistula is not identified or the patient with recurrent CSF rhinorrhea has severe frontal lobe atrophy and porencephaly.
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2/25. Spontaneous CSF rhinorrhoea due to temporosphenoidal encephalocele.

    A 54-year-old woman was referred with spontaneous cerebrospinal fluid (CSF) rhinorrhoea. CT cisternography revealed a defect in the lateral wall of the left sphenoid sinus, with an anteromedial temperosphenoidal encephalocele associated with contrast leakage into the sinus. Subsequent monitoring showed raised intracranial pressure. Transcranial intradural repair of the encephalocele followed by lumboperitoneal shunt for the high pressure abolished the leakage of cerebrospinal fluid.
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3/25. Spontaneous cerebrospinal fluid rhinorrhea associated with chronic renal failure--case report.

    A 39-year-old woman was admitted with complaints of headache and nasal discharge on the left for 3 months which was later on proved to be cerebrospinal fluid (CSF). Neurological examination found no abnormalities except bilateral papilledema. neuroimaging demonstrated enlargement of the lamina cribrosa foramina through which the olfactory nerves pass, as well as empty sella and cerebral cortical atrophy. Bone mineral densitometry showed osteopenia. CSF Ca and blood parathyroid hormone levels were elevated. CSF pressure was 280 mmH2O. Bilateral frontal craniotomy was performed to expose the anterior fossa. Foraminal enlargement at the lamina cribrosa was confirmed, and islands of extra-osseous calcifications on the arachnoid membrane were identified. The base of the anterior fossa was repaired intradurally with fascial graft and fibrin glue on both sides. No CSF leakage was noted at 1-year follow up. Spontaneous CSF leakage probably resulted from enlargement of the foramina at the lamina cribrosa due to Ca mobilization from bones and pseudotumor cerebri not to the extent of hydrocephalus caused by poor CSF absorption at the arachnoid granulations obliterated by extra-osseous calcareous accumulation.
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4/25. Low-pressure hydrocephalic state complicating hemispherectomy: a case report.

    Low-pressure hydrocephalic state (LPHS) has only recently been described as a distinct clinical entity occurring in patients with bioatrophic lesions of the brain. We report a patient in whom this syndrome developed after subtotal hemispherectomy for intractable epilepsy. methods: A 30-year-old man developed cerebrospinal fluid (CSF) rhinorrhea after subtotal hemispherectomy. After repair of the CSF dural fistula, clinical and radiological features of an LPHS developed. After external ventricular drainage for 26 days, a programmable low-pressure shunt system was instituted. RESULTS: Worsening neurologic status and ventriculomegaly in the face of normal intraventricular pressures is diagnostic of this condition. The clinical status clearly correlated with ventricular size and not ventricular pressure. CONCLUSION: LPHS is a clinically significant perioperative complication that rarely occurs after large brain excisions. Restoration of the baseline brain compliance is critical in the management of this condition.
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5/25. Pseudotumour cerebri, CSF rhinorrhoea and the role of venous sinus stenting in treatment.

    We present a case of pseudotumour cerebri (PTC), which is important as it illustrates the effects of chronically raised CSF pressure, the relationship between PTC and venous sinus obstruction and the successful treatment of PTC using a venous sinus stent. A 38-year-old woman, previously diagnosed with PTC and unsuccessfully treated 10 years previously re-presented with spontaneous CSF rhinorrhoea. Imaging revealed dramatic changes of chronically raised CSF pressure and a defect in the anterior cranial fossa. The CSF leak was corrected surgically and a lumbo-peritoneal shunt inserted to correct a large postoperative subgaleal CSF collection. Direct retrograde cerebral venography (DRCV) demonstrated venous sinus obstruction due to a filling defect. This was associated with a pressure gradient and a high superior sagittal sinus pressure. The venous sinus obstruction was successfully treated with a venous sinus stent and the lumbo-peritoneal shunt was removed. Chronically raised CSF pressure in untreated cases of PTC may cause widespread changes in the skull, which in this case, culminated in a spontaneous CSF leak despite relatively mild headache and visual symptoms. Furthermore, cases of PTC secondary to venous sinus obstruction may be successfully treated using venous sinus stenting. The index of suspicion for venous sinus stenosis or obstruction should be raised in the investigation of patients with PTC.
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6/25. Cerebrospinal fluid leak and meningitis associated with nasal continuous positive airway pressure therapy.

    Clear rhinorrhea is a common symptom in patients with obstructive sleep apnea (OSA) and may worsen with continuous positive airway pressure therapy. Clear rhinorrhea can also be the presenting symptom of cerebrospinal fluid (CSF) leak, which is evidence of a communication between the subarachnoid space and the nasal cavity or sinuses. While CSF leak has been reported to occur with nasal continuous positive airway pressure (nCPAP) therapy following trauma to the skull base, its association with OSA and nCPAP therapy in the absence of trauma has not been previously described. We report two patients with OSA in whom CSF leak developed following the institution of nCPAP therapy. In one patient, the rhinorrhea was complicated by meningitis. Both patients underwent successful repair of their defects. One patient successfully restarted nCPAP therapy, while the other refused it.
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7/25. Cerebrospinal fluid leak from nontumor ear after acoustic neuroma surgery: diagnostic and therapeutic problems.

    An unusual case of CSF leak from the nontumor ear after removal of a 3-cm acoustic neuroma is presented. Prior to tumor removal a ventricular-peritoneal shunt was established because of increased intracranial pressure. After the shunt was clamped the patient twice developed rhinoliquorrhea and underwent in both instances unsuccessful closure of the leak on the tumor side. Finally the leak was established in the nontumor ear, most likely due to sequelae after a hunting accident 20 years before, where a projectile created a defect in the tegmen tympani. The CSF leak was probably provoked by the pressure changes following tumor removal and shunt treatment.
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8/25. Primary spontaneous cerebrospinal fluid rhinorrhea.

    Spontaneous cerebrospinal fluid (CSF) rhinorrhea constitutes only 3% to 4% of CSF fistulas. Nontraumatic, normal pressure CSF fistulas with resultant rhinorrhea, in which no cause can be identified, or primary spontaneous CSF rhinorrhea, is considerably rarer. Presented here are two cases of CSF rhinorrhea of this nature, including the diagnostic workup and treatment. Reviews of literature support laboratory quantitative glucose determination as the most effective and least morbid method for confirming the presence of CSF. iodine-contrast (metrizamide/lohexol) computerized tomographic cisternography has been shown to be the most effective and least morbid method for localizing the fistula. For inactive, intermittent, small, or questionable CSF leaks, radionuclide cisternography has been shown to be more effective in identifying the presence of these leaks, although not necessarily the location. Numerous reports provide evidence to support the use of an extracranial rhinologic approach for surgical repair of the leak, as a more successful yet less morbid procedure than a craniotomy when used appropriately.
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9/25. Intestinal activity visualized on radionuclide cisternography in patients with cerebrospinal fluid leak.

    Several methods are used in conjunction with radionuclide cisternography for detecting cerebrospinal fluid (CSF) rhinorrhea or otorrhea, including positioning of the patient to induce drainage, placing cotton pledgets in the nostrils and ears for scintillation counting, and increasing the CSF pressure within the subarachnoid space. Presented here are three surgically proven cases of CSF leak where intestinal activity was detected at different intervals following the lumbar intrathecal administration of indium-111-DTPA for radionuclide cisternography. We recommend the addition of an abdominal image during radionuclide cisternography for CSF liquorrhea.
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10/25. Tension pneumocephalus.

    Tension pneumocephalus occurs when intracranial air exists under pressure, resulting in neurologic deterioration. The syndrome is precluded by an extracranial-intracranial communication and a difference in extracranial-intracranial pressure with the latter being greater. Although most frequently associated with head trauma, a variety of situations, including an operative sitting position and use of nitrous oxide anesthesia, have been known to contribute to this potentially life-threatening complication. This article will address pathogenesis, assessment parameters, and medical and nursing approaches utilized to reduce and minimize further entrapment of air. A case report will be presented illustrating this condition.
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