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Original Article
Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea? Jaskaran S. Gosal, Tenzin Gurmey, Gopi K. Kursa, Pravin Salunke, Sunil K. Gupta Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
ABSTRACT Background: Traumatic cerebrospinal fluid (CSF) rhinorrhea is a serious and potentially fatal condition as it may lead to meningitis. As acetazolamide decreases CSF production and hence CSF pressure, it has been proposed that the medication may help in curing CSF rhinorrhea. There is no definitive evidence, however, that acetazolamide is actually beneficial in treating traumatic CSF rhinorrhea. The aim of this study was to determine if the administration of acetazolamide in patients of head trauma with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid‑base and electrolyte changes caused by the drug were also studied. Materials and Methods: We conducted a single center randomized prospective study. Forty‑four patients of head trauma with CSF rhinorrhea were divided into two groups, the experimental group (21 patients) was given acetazolamide; and, the control group (23 patients) did not receive the medication. The median duration of CSF leak in days, and the electrolyte changes observed on administration of the medication were recorded in both the groups. Results: Both the experimental and control groups were well matched in terms of age, sex, mechanism of injury, Glasgow Coma Scale (GCS) and the type of skull fracture. The median duration of CSF leak in the control group was of 4 days and in the study group, of 5 days. Acetazolamide caused significant metabolic acidosis and hypokalemia (as shown by decreased serum pH, serum bicarbonate and serum potassium levels) in the experimental group when compared to the control group. Conclusions: Acetazolamide did not influence the resolution of traumatic CSF rhinorrhea and instead lead to significant metabolic and electrolyte disturbances. Key words: Head injury; CSF rhinorrhoea; acetazolamide
Introduction Cerebrospinal fluid (CSF) rhinorrhea is commonly encountered in patients sustaining a head injury, especially those with basilar skull fractures.[1] Most of these CSF fistulae resolve spontaneously. Some require a longer time to stop and a few may need surgical intervention. Addition of acetazolamide has been suggested in the management of traumatic CSF rhinorrhea.[2] Its usage is justified by the Access this article online Website: www.neurologyindia.com DOI: 10.4103/0028-3886.156280 PMID: xxxxx
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fact that it reduces CSF production by 48%.[3-7] The actual role of acetazolamide in the amelioration of traumatic CSF rhinorrhea is not clear as, till date, very few formal studies have ben conducted investigating its impact in the management of CSF fistulae following head trauma. The purpose of this study was to investigate whether or not the administration of acetazolamide in head trauma patients with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid‑base and electrolyte changes caused by acetazolamide admininstration were also studied.
Materials and Methods In this prospective randomized, clinical trial, we evaluated 44 patients with traumatic CSF rhinorrhea who were referred to the trauma center of a tertiary care hospital over a period of one and a half years. Of these, 21 patients were randomly assigned to the experimental group and
Address for correspondence: Prof. Sunil K. Gupta, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E‑mail: [email protected]
Neurology India / March 2015 / Volume 63 / Issue 2
197
[Downloaded free from http://www.neurologyindia.com on Thursday, May 07, 2015, IP: 61.16.135.116]
Gosal, et al.: Acetazolamide in traumatic CSF rhinorrhea
23 to the control group. The experimental group received acetazolamide while the control group was not administered the medication. Two patients were excluded from the study because they died before a reasonable assessment could be carried out. However, their acid‑base and electrolyte derangements following acetazolaminde admininstration were significant. At follow‑up, the duration of CSF leakage, period of hospitalization, incidence of meningitis, electrolyte and acid base disturbances, number of surgeries and lumbar drainage instituted in both the groups were recorded. The lottery method of simple randomization was used to allocate the patients to both the groups. The patients included in the study were those greater than 5 years of age presenting to the trauma centre with a history of head trauma and diagnosed with acute CSF rhinorrhea. The following types of patients were excluded from the study: Patients less than 5 years of age, patients with a history of remote trauma and delayed (more than 7 days after head trauma) CSF leak, and patients with a large defect at the base of skull that clearly required surgical intervention. The patients in the control group were managed conservatively with a strict bed rest, head elevation of atleast 30 degrees, and avoidance of sneezing, coughing and straining. None of them were administered acetazolamide. The patients in the experimental group were also managed conservatively on the same principles. In addition, acetazolamide (250 mg qid in adults and 8‑30 mg/kg/day in children in divided doses) was also admininstered to them. The approximate duration of conservative management in both the groups was arbitrarily defined as 10 days after which they were taken up for either lumbar drainage or surgery. A complete physical examination of the patients with head trauma was performed to detect any sign of CSF leakage, and a brain CT scan was undertaken immediately after stabilizing the patient. Those who met the inclusion criteria entered the study. With a checklist designed for each patient, we registered and compared the following data between the two groups: The demographic data, the duration of CSF leakage, the incidence of meningitis during admission (based on the presence of headache, fever and neck stiffness), the need for surgical intervention, the need for lumbar drainage and the location of the precise site of CSF leakage. The follow up period was fixed at 90 days from the onset of CSF rhinorrhea and the patients were followed up for upto 3 months in both the groups. The data was entered in SPSS version 16. To determine the correlation between our quantitative data, we used the 198
independent t‑test, Mann‑Whitney test and Fisher’s exact test. For our qualitative data, we used the Chi‑ square test. A P value
Original Article
Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea? Jaskaran S. Gosal, Tenzin Gurmey, Gopi K. Kursa, Pravin Salunke, Sunil K. Gupta Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
ABSTRACT Background: Traumatic cerebrospinal fluid (CSF) rhinorrhea is a serious and potentially fatal condition as it may lead to meningitis. As acetazolamide decreases CSF production and hence CSF pressure, it has been proposed that the medication may help in curing CSF rhinorrhea. There is no definitive evidence, however, that acetazolamide is actually beneficial in treating traumatic CSF rhinorrhea. The aim of this study was to determine if the administration of acetazolamide in patients of head trauma with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid‑base and electrolyte changes caused by the drug were also studied. Materials and Methods: We conducted a single center randomized prospective study. Forty‑four patients of head trauma with CSF rhinorrhea were divided into two groups, the experimental group (21 patients) was given acetazolamide; and, the control group (23 patients) did not receive the medication. The median duration of CSF leak in days, and the electrolyte changes observed on administration of the medication were recorded in both the groups. Results: Both the experimental and control groups were well matched in terms of age, sex, mechanism of injury, Glasgow Coma Scale (GCS) and the type of skull fracture. The median duration of CSF leak in the control group was of 4 days and in the study group, of 5 days. Acetazolamide caused significant metabolic acidosis and hypokalemia (as shown by decreased serum pH, serum bicarbonate and serum potassium levels) in the experimental group when compared to the control group. Conclusions: Acetazolamide did not influence the resolution of traumatic CSF rhinorrhea and instead lead to significant metabolic and electrolyte disturbances. Key words: Head injury; CSF rhinorrhoea; acetazolamide
Introduction Cerebrospinal fluid (CSF) rhinorrhea is commonly encountered in patients sustaining a head injury, especially those with basilar skull fractures.[1] Most of these CSF fistulae resolve spontaneously. Some require a longer time to stop and a few may need surgical intervention. Addition of acetazolamide has been suggested in the management of traumatic CSF rhinorrhea.[2] Its usage is justified by the Access this article online Website: www.neurologyindia.com DOI: 10.4103/0028-3886.156280 PMID: xxxxx
Quick Response Code
fact that it reduces CSF production by 48%.[3-7] The actual role of acetazolamide in the amelioration of traumatic CSF rhinorrhea is not clear as, till date, very few formal studies have ben conducted investigating its impact in the management of CSF fistulae following head trauma. The purpose of this study was to investigate whether or not the administration of acetazolamide in head trauma patients with CSF rhinorrhea was beneficial in decreasing the duration of CSF rhinorrhea. The acid‑base and electrolyte changes caused by acetazolamide admininstration were also studied.
Materials and Methods In this prospective randomized, clinical trial, we evaluated 44 patients with traumatic CSF rhinorrhea who were referred to the trauma center of a tertiary care hospital over a period of one and a half years. Of these, 21 patients were randomly assigned to the experimental group and
Address for correspondence: Prof. Sunil K. Gupta, Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India. E‑mail: [email protected]
Neurology India / March 2015 / Volume 63 / Issue 2
197
[Downloaded free from http://www.neurologyindia.com on Thursday, May 07, 2015, IP: 61.16.135.116]
Gosal, et al.: Acetazolamide in traumatic CSF rhinorrhea
23 to the control group. The experimental group received acetazolamide while the control group was not administered the medication. Two patients were excluded from the study because they died before a reasonable assessment could be carried out. However, their acid‑base and electrolyte derangements following acetazolaminde admininstration were significant. At follow‑up, the duration of CSF leakage, period of hospitalization, incidence of meningitis, electrolyte and acid base disturbances, number of surgeries and lumbar drainage instituted in both the groups were recorded. The lottery method of simple randomization was used to allocate the patients to both the groups. The patients included in the study were those greater than 5 years of age presenting to the trauma centre with a history of head trauma and diagnosed with acute CSF rhinorrhea. The following types of patients were excluded from the study: Patients less than 5 years of age, patients with a history of remote trauma and delayed (more than 7 days after head trauma) CSF leak, and patients with a large defect at the base of skull that clearly required surgical intervention. The patients in the control group were managed conservatively with a strict bed rest, head elevation of atleast 30 degrees, and avoidance of sneezing, coughing and straining. None of them were administered acetazolamide. The patients in the experimental group were also managed conservatively on the same principles. In addition, acetazolamide (250 mg qid in adults and 8‑30 mg/kg/day in children in divided doses) was also admininstered to them. The approximate duration of conservative management in both the groups was arbitrarily defined as 10 days after which they were taken up for either lumbar drainage or surgery. A complete physical examination of the patients with head trauma was performed to detect any sign of CSF leakage, and a brain CT scan was undertaken immediately after stabilizing the patient. Those who met the inclusion criteria entered the study. With a checklist designed for each patient, we registered and compared the following data between the two groups: The demographic data, the duration of CSF leakage, the incidence of meningitis during admission (based on the presence of headache, fever and neck stiffness), the need for surgical intervention, the need for lumbar drainage and the location of the precise site of CSF leakage. The follow up period was fixed at 90 days from the onset of CSF rhinorrhea and the patients were followed up for upto 3 months in both the groups. The data was entered in SPSS version 16. To determine the correlation between our quantitative data, we used the 198
independent t‑test, Mann‑Whitney test and Fisher’s exact test. For our qualitative data, we used the Chi‑ square test. A P value
