Aust. N . Z . J . Surg. 1992, 62, 818-820
DELAYED CEREBROSPINAL FLUID RHINORRHOEA: A CASE REPORT BRUCET. STEWART AND ANDREW H. KAYE Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia Post-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a well recognized complication of closed head injury. Most cases occur soon after injury and a delay in presentation of more than 1 month is unusual. A case is reported of CSF rhinorrhoea presenting 15 years after initial trauma which was complicated by meningitis after 12 months. The management of this condition is reviewed.
Key words: cerebrospinal fluid, head injury, rhinnorrhoea.
Introduction Cerebrospinal fluid (CSF) rhinorrhoea has been appreciated as a medical problem since the middle ages, and its association with head injury was first described by Bidloo, a Zurich surgeon, in the seventeenth century. The development of roentgenography allowed underlying fractures to be observed and paved the way for surgical exploration, which was first successfully carried out by Walter Dandy in 1926.2 Since that time this condition has been found to complicate approximately 2% of all unselected head injuries admitted to hospital,'-' and of has been associated with meningitis in !&%'YO
'
case^.^-^ The time of onset of CSF rhinorrhoea is usually within 48 h of injury and a delay beyond 3 months occurs in less than 5% of case^.^-^ Rarely, however, delays of many years may occur, and in such cases the significance of the preceding head injury may not be considered as a factor often resulting in multiple attacks of meningitis until the diagnosis is reached.'%6.9 A case is reported of post-traumatic CSF rhinorrhoea occurring 15 years after the initial head injury. It was precipitated by further minor trauma and persisted for 12 months until repair was effected. The literature regarding this condition and the unusual cases of delayed presentation is briefly reviewed.
Case report A 38 year old farmer was involved in a motor bike accident at the age of 22 in which he sustained a Correspondence: Andrew Kaye, Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Vic. 3050, Australia. Accepted for publication 13 September 1991
closed head injury with brief loss of consciousness and an undisplaced left parietal skull fracture as well as a broken nose. He was hospitalized for 1 week and made an uneventful recovery. Fourteen years later he sustained a blow on the nose from a sheep. This was followed immediately by epistaxis and then by a right nasal watery discharge. The discharge persisted during the next 12 months, was increased by bending or straining and was associated with persistent headaches and malaise. Eventually he developed severe headaches in association with neck stiffness and photophobia, and required hospitalization. A diagnosis of Haemophilis injluenzae meningitis was made on CSF examination obtained by lumbar puncture and he responded to appropriate antibiotics. The diagnosis of CSF rhinorrhoea was suspected and he was transferred to the Royal Melbourne Hospital for neurosurgical opinion. On examination he was anosmic on the right side but otherwise neurologically intact. A computerized tomography (CT) scan of the anterior cranial fossa with coronal images demonstrated a defect in the right cribriform plate and fluid in the posterior ethmoidal air cells (Fig. 1). A nuclear medicine study with [99mTc]-DTPA injected intrathecally showed a large leak on gamma camera images which was confirmed on swab counts in the right nostril. On 8 November 1990 he underwent a right pterional craniotomy with exploration of the anterior cranial fossa. Numerous fine adhesions to the frontal lobe, consistent with recent meningitis, were divided. A brain herniation in a defect in the right cribriform plate was identified. The olfactory nerve was found to be avulsed from the cribriform plate. The brain herniation was amputated and the cribriform plate repaired with crushed muscle and
CEREBROSPINAL FLUID RHINORRHOEA
819
[9y"'Tc]-DTPA and concomitant use of nasal pledgets. This allows for more prolonged observation (up to 24 h) and for attempted precipitation of a leak by positioning or other methods. Any leak occurring during the study will be apparent on radioactive counts of the nasal pledgets even if it does not occur under the gamma camera. In spite of this, false-negative results will still occur when the leak cannot be precipitated. The management of post-traumatic CSF rhinorrhoea remains somewhat controversial especially in the immediate post-injury period. Surgical exploration is generally performed in the presence of an intracranial aerocele, where the leak is heavy or prolonged, or if meningitis complicates the clinical p i c t ~ r e . ~ - ' The , ' ~ difficulty arises in the majority of cases that stop draining spontaneously. The risk of subsequent meningitis in these patients has ranged from 9 to 34Y0"'-~ but a recent study with longer follow-up has shown a cumulative risk that approaches 85% at 10 years. This suggests that a more aggressive surgical approach may be justified. The use of prophylactic antibiotics to reduce the risk, especially from pneumococcal infection, has been suggested but no prospective controlled trial has yet been reported to demonstrate any benefit.I4 Where the onset of CSF rhinorrhoea is delayed the situation is much clearer, and once the diagnosis is confirmed surgical exploration is mandatory as spontaneous closure is unlikely and the risk of meningitis is high.338,'2.'4This point was illustrated in a study by Jamieson and Yelland in Brisbane, where meningitis complicated five of 40 patients presenting within 6 weeks of injury and eight of 10 presenting later.'* The generally accepted explanation for delayed leakage is that the dural defect becomes plugged with brain, as occurred in the present case, granulation tissue or sinus mucosa which seals off the CSF but provides no barrier to the spread of infection. This interposed tissue then prevents natural dural repair and a subsequent, often inconsequential, event then disrupts the temporary seal resulting in rhinorrhoea. Lewin, who commented at length on the poor natural healing characteristics of dura, noted that the ethmoid region was particularly prone to an absence of natural repair whereas concurrent frontal tears would often be well healed at
''
Fig. 1. Coronal CT scan showing a defect in the right cribriform plate (arrow) and fluid in the posterior ethmoidal air cells on that side.
pericranium. The falx was then divided at its lowermost point and the left frontal fossa was explored, with no dural defect being found. He made an uncomplicated recovery from the surgery, and at follow-up 9 months later had no recurrence of rhinorrhoea and was otherwise in good health.
Discussion Delayed onset CSF rhinorrhoea is a rare complication of closed head injury, with over 90% of cases However presenting within 3 months of prolonged delay of up to 34 years has been reported in a case involving penetrating skull injury.' The diagnosis may be suspected by a history of clear nasal discharge which is often precipitated by a further episode of minor trauma, as in this case, though it may be entirely spontaneous. The most common associated symptom is anosmia, which is present in up to 80% of cases especially when the ethmoid area is damaged.3 Confirmation of the diagnosis may be difficult, especially if the leakage is intermittent. Biochemical analysis of the fluid for glucose, protein and chloride has proved ~ n r el i ab l e. ~ , Computerized '. ~ tomography scans with fine cuts of the anterior cranial fossa in both coronal and axial planes may show bony defects and intrathecal contrast media can be used to accurately localize large leaks. However, unless leakage occurs during the relatively short duration of the scan the results may be disappointing. l o The alternative technique is by radionuclide cisternography with intrathecal injection of
''
the time of surgery.' Surgical exploration may be via an intracranial or extracranial approach, although most authors favoured craniotomy which allows visualization of the dural defect, exploration of the entire frontal fossa for defects which may not have been demonstrated pre-operatively , and accurate repair of the dura using fascia1 grafts (pericranium or fascia lata) and crushed muscle. A bifrontal exploration should be performed even if the likely defect has been
STEWART AND KAYE
820
radiologically demonstrated, because multiple abnormalities may be present and a unilateral rhinorrhoea does not uniformly indicate the side of dural defect . 3 In summary, delayed onset CSF rhinorrhoea is a rare complication of head injury, but with potentially fatal sequelae should the diagnosis be overlooked. It should be suspected in anyone developing a clear nasal discharge or bacterial meningitis who has a history of head trauma no matter how remote, and once confirmed either clinically or radiographically requires surgical repair due to the lack of spontaneous closure and the high risk of meningitis supervening. *3s,y
'
References 1 . RUSSELL T. & CUMMINS B. H. (1984) Cerebrospinal fluid rhinorrhea 34 years after trauma: A case report and review of the literature. Neurosurgery 15, 705-6. 2. DANDY W. E. (1926) Pneumocephalus (intracranial pneumatocele or aerocele) Arch. Surg. 12, 949-82. 3. LEWIN W. (1954) Cerebrospinal fluid rhinorrhea in closed head injuries. Br. J . Surg. 42, 1-18. 4. RAFFJ . (1967) Posttraumatic cerebrospinal fluid leaks. Arch. Surg. 95, 648-51. 5 . MINCY J . E. (1966) Posttraumatic cerebrospinal fluid fistula of the frontal fossa. J . Truumu 6 , 618-22.
Aust.
6. WESTMORE G. A. & WHITTAM D. E. (1982) Cerebrospinal fluid rhinorrhea and its management. Br. J . Surg. 69, 489-92. 7. LEECHP. (1974) Cerebrospinal fluid leakage, dural fistulae and meningitis after basal skull fractures. Injury 6, 141-9. V. V . & FRIEDMAN W. H. (1983) 8. PARKJ., STRELZOW Current management of cerebrospinal fluid rhinorrhea. Laryngoscope 93, 1294-300. J. E. 0. & MOUNT L. A. (1970) 9. BRISMAN R., HUGHES Cerebrospinal fluid rhinorrhea. Arch. Neurol. 22, 245-52. E. J . , FORBES G. S. & BROWN M. L. (1980) 10. LANTZ Radiology of cerebrospinal fluid rhinorrhea. AJNR 1, 391-8. 11. FLYNN B. M., BUTLER S. P., QUWN R. J . , MCLAUGHLIN A. F., BAUTOVICH G. J. & MORRISJ. G. (1987) Radionuclide cisternography in the diagnosis and management of cerebrospinal fluid leaks: the test of choice. Med. J . Aust. 146, 82-4. 12. JAMIESONK. G. & YELLAND J . D. N. (1973) Surgical repair of the anterior fossa because of rhinorrhea, aerocele, or meningitis. J . Neurosurg. 39, 328-3 I . 13. ELJAMEL M. S . M. & Fov P. M. (1990) Posttraumatic CSF fistulae the case for surgical repair. Br. J . Neurosurg. 4,479-83. 14. LtVlN S . , NELSON K. E., SPIES H. W. & LEPPER M. H. (1972) Pneumococcal meningitis: the problem of the unseen cerebrospinal fluid leak. Am. J . Med. Sci. 264, 319-27.
N . Z . J . Surg. 1992,62, 820-822
CENTRAL VENOUS THROMBOPHLEBITIS DIAGNOSED BY COMPUTERIZED TOMOGRAPHY SCANNING TIMOTHY KHOR,JIM ANDERSON AND P A U L MCRAE D e p a r t m e n t of Urology a n d R a d i o l o g y , P e r t h , W e s t e r n A u s t r a l i a , A u s t r a l i a
A case is described in which computerized tomography scanning aided in a prompt diagnosis and assessment of an intravenous catheter-induced septic thrombus. Computerized tomography scanning detected gas bubbles within the thrombus, which extended from the right subclavian vein into the superior vena cava, and retrograde propagation of the thrombus into the right internal jugular vein. Computerized tomography scanning also helped in the assessment of the amount of deep tissue swelling present and the competence of the upper repiratory tract.
Key words: computerized tomography, gas bubbles, internal jugular vein, retrograde propagation of septic thrombus, subclavian vein, superior vena cava.
Introduction Central venous thrombophlebitis is a potentially serious complication of central venous catheterization. Before the availability of computerized Comespondence: Dr Timothy Khor, Department of urolo&!y.
Royal Perth Hospital, Perth, WA, Australia. Accepted for publication 18 July 1991
tomography (CT) scanning, the only practical way to see the central veins was by venography. Computerized tomography scanning is less invasive but has the capacity, if intravenous contrast is given, to show intraluminal filling defects which in the right clinical context can be interpreted as thrombophlebitis. A case is reported of intravenous catheterinduced central venous thrombophlebitisin which CT scanning aided in early diagnosis and management.
-
DELAYED CEREBROSPINAL FLUID RHINORRHOEA: A CASE REPORT BRUCET. STEWART AND ANDREW H. KAYE Department of Neurosurgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia Post-traumatic cerebrospinal fluid (CSF) rhinorrhoea is a well recognized complication of closed head injury. Most cases occur soon after injury and a delay in presentation of more than 1 month is unusual. A case is reported of CSF rhinorrhoea presenting 15 years after initial trauma which was complicated by meningitis after 12 months. The management of this condition is reviewed.
Key words: cerebrospinal fluid, head injury, rhinnorrhoea.
Introduction Cerebrospinal fluid (CSF) rhinorrhoea has been appreciated as a medical problem since the middle ages, and its association with head injury was first described by Bidloo, a Zurich surgeon, in the seventeenth century. The development of roentgenography allowed underlying fractures to be observed and paved the way for surgical exploration, which was first successfully carried out by Walter Dandy in 1926.2 Since that time this condition has been found to complicate approximately 2% of all unselected head injuries admitted to hospital,'-' and of has been associated with meningitis in !&%'YO
'
case^.^-^ The time of onset of CSF rhinorrhoea is usually within 48 h of injury and a delay beyond 3 months occurs in less than 5% of case^.^-^ Rarely, however, delays of many years may occur, and in such cases the significance of the preceding head injury may not be considered as a factor often resulting in multiple attacks of meningitis until the diagnosis is reached.'%6.9 A case is reported of post-traumatic CSF rhinorrhoea occurring 15 years after the initial head injury. It was precipitated by further minor trauma and persisted for 12 months until repair was effected. The literature regarding this condition and the unusual cases of delayed presentation is briefly reviewed.
Case report A 38 year old farmer was involved in a motor bike accident at the age of 22 in which he sustained a Correspondence: Andrew Kaye, Department of Neurosurgery, Royal Melbourne Hospital, Parkville, Vic. 3050, Australia. Accepted for publication 13 September 1991
closed head injury with brief loss of consciousness and an undisplaced left parietal skull fracture as well as a broken nose. He was hospitalized for 1 week and made an uneventful recovery. Fourteen years later he sustained a blow on the nose from a sheep. This was followed immediately by epistaxis and then by a right nasal watery discharge. The discharge persisted during the next 12 months, was increased by bending or straining and was associated with persistent headaches and malaise. Eventually he developed severe headaches in association with neck stiffness and photophobia, and required hospitalization. A diagnosis of Haemophilis injluenzae meningitis was made on CSF examination obtained by lumbar puncture and he responded to appropriate antibiotics. The diagnosis of CSF rhinorrhoea was suspected and he was transferred to the Royal Melbourne Hospital for neurosurgical opinion. On examination he was anosmic on the right side but otherwise neurologically intact. A computerized tomography (CT) scan of the anterior cranial fossa with coronal images demonstrated a defect in the right cribriform plate and fluid in the posterior ethmoidal air cells (Fig. 1). A nuclear medicine study with [99mTc]-DTPA injected intrathecally showed a large leak on gamma camera images which was confirmed on swab counts in the right nostril. On 8 November 1990 he underwent a right pterional craniotomy with exploration of the anterior cranial fossa. Numerous fine adhesions to the frontal lobe, consistent with recent meningitis, were divided. A brain herniation in a defect in the right cribriform plate was identified. The olfactory nerve was found to be avulsed from the cribriform plate. The brain herniation was amputated and the cribriform plate repaired with crushed muscle and
CEREBROSPINAL FLUID RHINORRHOEA
819
[9y"'Tc]-DTPA and concomitant use of nasal pledgets. This allows for more prolonged observation (up to 24 h) and for attempted precipitation of a leak by positioning or other methods. Any leak occurring during the study will be apparent on radioactive counts of the nasal pledgets even if it does not occur under the gamma camera. In spite of this, false-negative results will still occur when the leak cannot be precipitated. The management of post-traumatic CSF rhinorrhoea remains somewhat controversial especially in the immediate post-injury period. Surgical exploration is generally performed in the presence of an intracranial aerocele, where the leak is heavy or prolonged, or if meningitis complicates the clinical p i c t ~ r e . ~ - ' The , ' ~ difficulty arises in the majority of cases that stop draining spontaneously. The risk of subsequent meningitis in these patients has ranged from 9 to 34Y0"'-~ but a recent study with longer follow-up has shown a cumulative risk that approaches 85% at 10 years. This suggests that a more aggressive surgical approach may be justified. The use of prophylactic antibiotics to reduce the risk, especially from pneumococcal infection, has been suggested but no prospective controlled trial has yet been reported to demonstrate any benefit.I4 Where the onset of CSF rhinorrhoea is delayed the situation is much clearer, and once the diagnosis is confirmed surgical exploration is mandatory as spontaneous closure is unlikely and the risk of meningitis is high.338,'2.'4This point was illustrated in a study by Jamieson and Yelland in Brisbane, where meningitis complicated five of 40 patients presenting within 6 weeks of injury and eight of 10 presenting later.'* The generally accepted explanation for delayed leakage is that the dural defect becomes plugged with brain, as occurred in the present case, granulation tissue or sinus mucosa which seals off the CSF but provides no barrier to the spread of infection. This interposed tissue then prevents natural dural repair and a subsequent, often inconsequential, event then disrupts the temporary seal resulting in rhinorrhoea. Lewin, who commented at length on the poor natural healing characteristics of dura, noted that the ethmoid region was particularly prone to an absence of natural repair whereas concurrent frontal tears would often be well healed at
''
Fig. 1. Coronal CT scan showing a defect in the right cribriform plate (arrow) and fluid in the posterior ethmoidal air cells on that side.
pericranium. The falx was then divided at its lowermost point and the left frontal fossa was explored, with no dural defect being found. He made an uncomplicated recovery from the surgery, and at follow-up 9 months later had no recurrence of rhinorrhoea and was otherwise in good health.
Discussion Delayed onset CSF rhinorrhoea is a rare complication of closed head injury, with over 90% of cases However presenting within 3 months of prolonged delay of up to 34 years has been reported in a case involving penetrating skull injury.' The diagnosis may be suspected by a history of clear nasal discharge which is often precipitated by a further episode of minor trauma, as in this case, though it may be entirely spontaneous. The most common associated symptom is anosmia, which is present in up to 80% of cases especially when the ethmoid area is damaged.3 Confirmation of the diagnosis may be difficult, especially if the leakage is intermittent. Biochemical analysis of the fluid for glucose, protein and chloride has proved ~ n r el i ab l e. ~ , Computerized '. ~ tomography scans with fine cuts of the anterior cranial fossa in both coronal and axial planes may show bony defects and intrathecal contrast media can be used to accurately localize large leaks. However, unless leakage occurs during the relatively short duration of the scan the results may be disappointing. l o The alternative technique is by radionuclide cisternography with intrathecal injection of
''
the time of surgery.' Surgical exploration may be via an intracranial or extracranial approach, although most authors favoured craniotomy which allows visualization of the dural defect, exploration of the entire frontal fossa for defects which may not have been demonstrated pre-operatively , and accurate repair of the dura using fascia1 grafts (pericranium or fascia lata) and crushed muscle. A bifrontal exploration should be performed even if the likely defect has been
STEWART AND KAYE
820
radiologically demonstrated, because multiple abnormalities may be present and a unilateral rhinorrhoea does not uniformly indicate the side of dural defect . 3 In summary, delayed onset CSF rhinorrhoea is a rare complication of head injury, but with potentially fatal sequelae should the diagnosis be overlooked. It should be suspected in anyone developing a clear nasal discharge or bacterial meningitis who has a history of head trauma no matter how remote, and once confirmed either clinically or radiographically requires surgical repair due to the lack of spontaneous closure and the high risk of meningitis supervening. *3s,y
'
References 1 . RUSSELL T. & CUMMINS B. H. (1984) Cerebrospinal fluid rhinorrhea 34 years after trauma: A case report and review of the literature. Neurosurgery 15, 705-6. 2. DANDY W. E. (1926) Pneumocephalus (intracranial pneumatocele or aerocele) Arch. Surg. 12, 949-82. 3. LEWIN W. (1954) Cerebrospinal fluid rhinorrhea in closed head injuries. Br. J . Surg. 42, 1-18. 4. RAFFJ . (1967) Posttraumatic cerebrospinal fluid leaks. Arch. Surg. 95, 648-51. 5 . MINCY J . E. (1966) Posttraumatic cerebrospinal fluid fistula of the frontal fossa. J . Truumu 6 , 618-22.
Aust.
6. WESTMORE G. A. & WHITTAM D. E. (1982) Cerebrospinal fluid rhinorrhea and its management. Br. J . Surg. 69, 489-92. 7. LEECHP. (1974) Cerebrospinal fluid leakage, dural fistulae and meningitis after basal skull fractures. Injury 6, 141-9. V. V . & FRIEDMAN W. H. (1983) 8. PARKJ., STRELZOW Current management of cerebrospinal fluid rhinorrhea. Laryngoscope 93, 1294-300. J. E. 0. & MOUNT L. A. (1970) 9. BRISMAN R., HUGHES Cerebrospinal fluid rhinorrhea. Arch. Neurol. 22, 245-52. E. J . , FORBES G. S. & BROWN M. L. (1980) 10. LANTZ Radiology of cerebrospinal fluid rhinorrhea. AJNR 1, 391-8. 11. FLYNN B. M., BUTLER S. P., QUWN R. J . , MCLAUGHLIN A. F., BAUTOVICH G. J. & MORRISJ. G. (1987) Radionuclide cisternography in the diagnosis and management of cerebrospinal fluid leaks: the test of choice. Med. J . Aust. 146, 82-4. 12. JAMIESONK. G. & YELLAND J . D. N. (1973) Surgical repair of the anterior fossa because of rhinorrhea, aerocele, or meningitis. J . Neurosurg. 39, 328-3 I . 13. ELJAMEL M. S . M. & Fov P. M. (1990) Posttraumatic CSF fistulae the case for surgical repair. Br. J . Neurosurg. 4,479-83. 14. LtVlN S . , NELSON K. E., SPIES H. W. & LEPPER M. H. (1972) Pneumococcal meningitis: the problem of the unseen cerebrospinal fluid leak. Am. J . Med. Sci. 264, 319-27.
N . Z . J . Surg. 1992,62, 820-822
CENTRAL VENOUS THROMBOPHLEBITIS DIAGNOSED BY COMPUTERIZED TOMOGRAPHY SCANNING TIMOTHY KHOR,JIM ANDERSON AND P A U L MCRAE D e p a r t m e n t of Urology a n d R a d i o l o g y , P e r t h , W e s t e r n A u s t r a l i a , A u s t r a l i a
A case is described in which computerized tomography scanning aided in a prompt diagnosis and assessment of an intravenous catheter-induced septic thrombus. Computerized tomography scanning detected gas bubbles within the thrombus, which extended from the right subclavian vein into the superior vena cava, and retrograde propagation of the thrombus into the right internal jugular vein. Computerized tomography scanning also helped in the assessment of the amount of deep tissue swelling present and the competence of the upper repiratory tract.
Key words: computerized tomography, gas bubbles, internal jugular vein, retrograde propagation of septic thrombus, subclavian vein, superior vena cava.
Introduction Central venous thrombophlebitis is a potentially serious complication of central venous catheterization. Before the availability of computerized Comespondence: Dr Timothy Khor, Department of urolo&!y.
Royal Perth Hospital, Perth, WA, Australia. Accepted for publication 18 July 1991
tomography (CT) scanning, the only practical way to see the central veins was by venography. Computerized tomography scanning is less invasive but has the capacity, if intravenous contrast is given, to show intraluminal filling defects which in the right clinical context can be interpreted as thrombophlebitis. A case is reported of intravenous catheterinduced central venous thrombophlebitisin which CT scanning aided in early diagnosis and management.
-
