Neurosurgery.

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.