J Neurosurg 49:121-123, 1978
Traumatic cerebrospinal fluid fistula simulating tears Case report
KIRAN K. JOSHI, M.S., AND H. ALAN CROCKARD, F.R.C.S.
Department of Neurosurgery, Royal Victoria Hospital, Belfast, Northern Ireland ~" A young child developed delayed cerebrospinal fluid (CSF) rhinorrhea and CSF leak from the eye presenting as tears. The "tears" were CSF which had tracked from the cribriform plate through the ethmoidal air sinuses to the medial aspect of the left orbit. There was marked chemosis and it was considered likely that the tears had leaked through damaged conjunctiva. KEY WORDS cerebrospinal fluid fistula 9 tears, posttraumatic 9 cribriform plate fracture 9 cerebrospinal fluid orbitorrhea 9
C
EREBROSPINAL fluid (CSF) rhinorrhea and otorrhea following fracture of the base of the skull, although common in both children and adults, is rare before 2 years of age. 1 We have recently encountered a case of CSF fistula in the form of pseudo tears in an 8-month-old child following a head injury. Case Report
An 8-month-old girl was transferred from a peripheral hospital to the Regional Neurosurgical Unit at the Royal Victoria Hospital 2 days after she had been injured in an automobile accident. She had been sitting on her mother's knee in the front seat of a car when it was involved in a head-on collision. The child's head struck the dashboard. She sustained two 1-cm lacerations on the left temple and left infraorbital region which bled profusely at the scene of the accident. When the child was admitted to the peripheral hospital she was pale but the
J. Neurosurg. / Volume 49 / July, 1978
bleeding had stopped. She was unconscious but moved all her limbs to painful stimuli; the movements on the right side, however, were much less brisk than those on the left. There was swelling around the left eye extending laterally to the laceration in the left temporal fossa. The left globe was intact but the left pupil was dilated and did not react directly or consensually to light. The right pupil reacted briskly to light and there were complete movements of the right eye. There was right facial weakness as part of the right hemiparesis. General examination did not reveal any other injuries. Plain radiograph of the skull did not disclose any fracture. The hemiparesis was considered to be due to a contusion of the left cerebral hemisphere. The patient was treated intramuscularly with dexamethasone, 4 mg initially and 1 mg every 6 hours. She also received ampicillin, 125 mg every 6 hours, and intravenous fluids. Twelve hours later, the level of consciousness was unchanged. The child
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K. K. Joshi a n d H. A. C r o c k a r d
FIG. 1. Photograph showing exophthalmos, "tears" around the left eye, and complete ophthalmoplegia.
responded to painful stimuli and hemiparesis was still present. The left pupil did not react directly or consensually to light, both fundi were normal. A pulsating exophthalmos developed accompanied by a bruit heard over the left eyeball and in the left temporal fossa. The child was anemic with a hemoglobin level of 5.6 gm%. A blood transfusion was given to correct the anemia and after this the bruit disappeared. She was transferred to the Regional Neurosurgical Unit 48 hours after injury. Examination. The child's clinical condition was stable, but because of the history of the bruit it was considered important to exclude a carotid-cavernous fistula. Percutaneous transfemoral retrograde four-vessel angiography failed to show such a fistula, but there was evidence of left cerebral hemispheric swelling. Over the next few days the left-sided proptosis became more marked and was accompanied by increasing chemosis of the conjunctiva (Fig. 1). Five days after injury CSF was noted escaping from the left nostril. About the same time "tears" flowed from the left eye. However, the "tears" had a high sugar content (as indicated by strong reaction on Dextrostix reagent strips), and it was concluded that the fluid was CSF. Tomography of the anterior cranial fossa revealed fractures involving the ethmoidal air sinuses. In view of these findings and continuing CSF leak, it was decided to explore the fossa at operation. Operation. The anterior fossa was explored through bifrontal osteoplastic flaps. The dura 122
was tense, especially on the left side. The dura was opened on the left side, after ligation of the sagittal sinus. The brain and olfactory bulb were found to be contused and impacted into a fracture 3 cm long running obliquely over the left cribriform plate and ethmoidal air sinuses. The left optic nerve and the optic chiasm were normal. Herniated brain was removed from the fracture site in the cribriform plate. The dural laceration was repaired. Postoperative Course. After the operation there were no "tears" or leak of CSF from the nose. The proptosis subsided in the next 36 to 48 hours. The left pupil remained dilated and did not react directly or consensually to light. The left-sided ptosis and complete ophthalmoplegia persisted, although the child's general condition gradually improved. The child left the hospital 19 days after injury. Three weeks later she was alert and feeding well, and there was an overall improvement in the neurological condition. The left proptosis had resolved, and she could open the eyelid slightly. The pupil was fixed and dilated and there were no left eye movements. Funduscopy now revealed a primary optic atrophy. Right hemiparesis was less marked, with good movement of both arm and leg, but there was an increase in tone. Discussion
Posttraumatic CSF rhinorrhea from the ethmoidal cells is rare in children below the age of 2 years. Caldicott, et al., 1 have attributed this to the fact that the paranasal air sinuses are poorly developed at this age. In our patient the fracture line was seen running across the cribriform plate and the area of the posterior ethmoidal air sinuses. We believe that the CSF tracked down through the dural tear, through the ethmoidal air sinuses into the left orbit and ultimately presented as "tears." The pulsating exophthalmos could be explained on the basis of intracranial pulsations transmitted to the orbital contents. The bruit localized over the left eye is more difficult to explain. The absence of any carotid-cavernous fistula seen on angiography and the fact that the bruit disappeared with correction of the anemia, leads us to conclude that the murmur was functional; J. Neurosurg. / Volume 49 / July, 1978
CSF fistula simulating tears but it is difficult to account for the fact that it was localized over the area of trauma. We have seen one other example in a 5year-old child who had a severe orbital fracture. In this case, however, there was profuse CSF leaking from the nose and there was little or no difficulty with the diagnosis. It may be that the condition is much more common than hitherto considered. It might be useful to routinely test the lacrimal secretions of patients with frontal fossa fractures.
J. Neurosurg. / Volume 49 / July, 1978
Reference
1. Caldicott WJH, North JB, Simpson DA: Traumatic cerebrospinal fluid fistulas in children. J Neurosurg 38:1-9, 1973
Address reprint requests to: H. Alan Crockard, F.R.C.S., Department of Neurosurgery, Royal Victoria Hospital, Belfast BTI2 6BJ, Northern Ireland.
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Traumatic cerebrospinal fluid fistula simulating tears Case report
KIRAN K. JOSHI, M.S., AND H. ALAN CROCKARD, F.R.C.S.
Department of Neurosurgery, Royal Victoria Hospital, Belfast, Northern Ireland ~" A young child developed delayed cerebrospinal fluid (CSF) rhinorrhea and CSF leak from the eye presenting as tears. The "tears" were CSF which had tracked from the cribriform plate through the ethmoidal air sinuses to the medial aspect of the left orbit. There was marked chemosis and it was considered likely that the tears had leaked through damaged conjunctiva. KEY WORDS cerebrospinal fluid fistula 9 tears, posttraumatic 9 cribriform plate fracture 9 cerebrospinal fluid orbitorrhea 9
C
EREBROSPINAL fluid (CSF) rhinorrhea and otorrhea following fracture of the base of the skull, although common in both children and adults, is rare before 2 years of age. 1 We have recently encountered a case of CSF fistula in the form of pseudo tears in an 8-month-old child following a head injury. Case Report
An 8-month-old girl was transferred from a peripheral hospital to the Regional Neurosurgical Unit at the Royal Victoria Hospital 2 days after she had been injured in an automobile accident. She had been sitting on her mother's knee in the front seat of a car when it was involved in a head-on collision. The child's head struck the dashboard. She sustained two 1-cm lacerations on the left temple and left infraorbital region which bled profusely at the scene of the accident. When the child was admitted to the peripheral hospital she was pale but the
J. Neurosurg. / Volume 49 / July, 1978
bleeding had stopped. She was unconscious but moved all her limbs to painful stimuli; the movements on the right side, however, were much less brisk than those on the left. There was swelling around the left eye extending laterally to the laceration in the left temporal fossa. The left globe was intact but the left pupil was dilated and did not react directly or consensually to light. The right pupil reacted briskly to light and there were complete movements of the right eye. There was right facial weakness as part of the right hemiparesis. General examination did not reveal any other injuries. Plain radiograph of the skull did not disclose any fracture. The hemiparesis was considered to be due to a contusion of the left cerebral hemisphere. The patient was treated intramuscularly with dexamethasone, 4 mg initially and 1 mg every 6 hours. She also received ampicillin, 125 mg every 6 hours, and intravenous fluids. Twelve hours later, the level of consciousness was unchanged. The child
121
K. K. Joshi a n d H. A. C r o c k a r d
FIG. 1. Photograph showing exophthalmos, "tears" around the left eye, and complete ophthalmoplegia.
responded to painful stimuli and hemiparesis was still present. The left pupil did not react directly or consensually to light, both fundi were normal. A pulsating exophthalmos developed accompanied by a bruit heard over the left eyeball and in the left temporal fossa. The child was anemic with a hemoglobin level of 5.6 gm%. A blood transfusion was given to correct the anemia and after this the bruit disappeared. She was transferred to the Regional Neurosurgical Unit 48 hours after injury. Examination. The child's clinical condition was stable, but because of the history of the bruit it was considered important to exclude a carotid-cavernous fistula. Percutaneous transfemoral retrograde four-vessel angiography failed to show such a fistula, but there was evidence of left cerebral hemispheric swelling. Over the next few days the left-sided proptosis became more marked and was accompanied by increasing chemosis of the conjunctiva (Fig. 1). Five days after injury CSF was noted escaping from the left nostril. About the same time "tears" flowed from the left eye. However, the "tears" had a high sugar content (as indicated by strong reaction on Dextrostix reagent strips), and it was concluded that the fluid was CSF. Tomography of the anterior cranial fossa revealed fractures involving the ethmoidal air sinuses. In view of these findings and continuing CSF leak, it was decided to explore the fossa at operation. Operation. The anterior fossa was explored through bifrontal osteoplastic flaps. The dura 122
was tense, especially on the left side. The dura was opened on the left side, after ligation of the sagittal sinus. The brain and olfactory bulb were found to be contused and impacted into a fracture 3 cm long running obliquely over the left cribriform plate and ethmoidal air sinuses. The left optic nerve and the optic chiasm were normal. Herniated brain was removed from the fracture site in the cribriform plate. The dural laceration was repaired. Postoperative Course. After the operation there were no "tears" or leak of CSF from the nose. The proptosis subsided in the next 36 to 48 hours. The left pupil remained dilated and did not react directly or consensually to light. The left-sided ptosis and complete ophthalmoplegia persisted, although the child's general condition gradually improved. The child left the hospital 19 days after injury. Three weeks later she was alert and feeding well, and there was an overall improvement in the neurological condition. The left proptosis had resolved, and she could open the eyelid slightly. The pupil was fixed and dilated and there were no left eye movements. Funduscopy now revealed a primary optic atrophy. Right hemiparesis was less marked, with good movement of both arm and leg, but there was an increase in tone. Discussion
Posttraumatic CSF rhinorrhea from the ethmoidal cells is rare in children below the age of 2 years. Caldicott, et al., 1 have attributed this to the fact that the paranasal air sinuses are poorly developed at this age. In our patient the fracture line was seen running across the cribriform plate and the area of the posterior ethmoidal air sinuses. We believe that the CSF tracked down through the dural tear, through the ethmoidal air sinuses into the left orbit and ultimately presented as "tears." The pulsating exophthalmos could be explained on the basis of intracranial pulsations transmitted to the orbital contents. The bruit localized over the left eye is more difficult to explain. The absence of any carotid-cavernous fistula seen on angiography and the fact that the bruit disappeared with correction of the anemia, leads us to conclude that the murmur was functional; J. Neurosurg. / Volume 49 / July, 1978
CSF fistula simulating tears but it is difficult to account for the fact that it was localized over the area of trauma. We have seen one other example in a 5year-old child who had a severe orbital fracture. In this case, however, there was profuse CSF leaking from the nose and there was little or no difficulty with the diagnosis. It may be that the condition is much more common than hitherto considered. It might be useful to routinely test the lacrimal secretions of patients with frontal fossa fractures.
J. Neurosurg. / Volume 49 / July, 1978
Reference
1. Caldicott WJH, North JB, Simpson DA: Traumatic cerebrospinal fluid fistulas in children. J Neurosurg 38:1-9, 1973
Address reprint requests to: H. Alan Crockard, F.R.C.S., Department of Neurosurgery, Royal Victoria Hospital, Belfast BTI2 6BJ, Northern Ireland.
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