What are Cerebrospinal Fluid (CSF) Leaks and Treatments?
BDS (Bachelor of Dental Surgery), 10 years of experience
What is the meaning of Cerebrospinal Fluid (CSF) Leaks?
Cerebrospinal fluid (CSF) leak is seen when there is a hole or tear in the membranes that surround the brain and spinal cord, causing the clear fluid that surrounds and cushions these organs to escape. The spinal cord is a thin, long, tubular soft tissue structure that is surrounded by the backbones known as vertebrae. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord. It cushions the brain and spinal cord from injury, and also delivers nutrition to the brain, and acts as a waste removal system of the brain. In this article, we will be discussing in detail CSF leaks and their treatments.
- What are the types of CSF Leaks?
- What are the causes of CSF Leaks?
- What are the risk factors for CSF Leaks?
- What are the symptoms of CSF Leaks?
- How to diagnose CSF Leaks?
- What are the treatments for CSF Leaks?
- What are the complications of CSF Leaks?
- What are the side effects of CSF Leak treatments?
- How to care after CSF Leak treatments?
- What is the cost of CSF Leak treatment in India?
What are the types of CSF Leaks?
CSF leaks can be of two types:
- Spinal CSF leaks: This type of CSF leak can occur anywhere in the spinal column.
- Cranial CSF leaks: This type of CSF leak can occur anywhere in the skull.
What are the causes of CSF Leaks?
The cases of cranial CSF leaks are:
- Increase of pressure in the brain
- Injury to the head
- Disorders of the inner ear
- Shunt (a hollow tube placed surgically in the brain to allow the drainage of CSF) not functioning well
The causes of spinal CSF are:
- Head or spine injury ( Know more about- What is Skull Base Surgery? )
- Lumbar puncture or spinal tap (insertion of a needle into the spinal canal for collecting the CSF for diagnostic purposes)
- Epidural injection (injection given for relief of pain) given during labor and delivery
- Dura mater (outermost layer of the brain and spinal cord) abnormalities
- History of spine surgery
- Bone spurs or growths along the spine. ( Know more about- What is Brain Cancer Treatment? )
- Abnormal connections between veins and dura mater (known as CSF-venous fistulas)
Other causes may include:
- Coughing
- Sneezing
- Lifting of heavy objects
- Straining to pass stools
- Exercise
- Stretching
- A fall
- Spontaneous CSF leak (no known cause)
What are the risk factors for CSF Leaks?
The following factors may increase the risk of developing cranial CSF leaks:
- Obesity
- High blood pressure
- More commonly seen in women
- Head injury ( Know more about- What is Brain Injury? )
- History of previous surgery on or around the skull
- Tumor at base of the skull
- Inner ear abnormalities
- Skull base abnormalities
- Obstructive sleep apnea (sleep-related breathing disorder)
The following factors may increase the risk of developing spinal CSF leaks:
- History of previous surgery on or around the spine
- Connective tissue disorders like Ehlers-Danlos syndrome (an inherited disorder primarily affecting the skin, blood vessels, and joints) or Marfan syndrome (an inherited disorder primarily affecting the eyes, heart, bones, and blood vessels)
What are the symptoms of CSF Leaks?
The symptoms of cranial CSF leaks are:
- Drainage of clear fluid from the nose or ear (usually on one side)
- Loss of hearing
- Meningitis (inflammation of the brain and spinal cord membranes)
- Metallic taste in the mouth
The symptoms of spinal CSF leaks are:
- Headache, that usually:
- This leads to pain at the back of the head
- Improves on lying down
- Worsens on standing up
- Is triggered or worsened by straining or coughing
- May start suddenly, known as a thunderclap headache
- Shoulder or neck pain
- Ringing in the ears (tinnitus)
- Dizziness
- Nausea
- Vomiting
- Changes in vision
- Changes in hearing
- Changes in behavior
How to diagnose CSF Leaks?
Cranial CSF leak diagnosis:
- Physical examination: The doctor examines the nose and ears closely, along with any other symptoms that may be seen. The patient may be asked to lean forward to see if there is any nasal discharge. If present, the discharge may be collected and sent to the laboratory for further examination. The patient’s medical history is also noted.
- CT myelography: This test uses a CT scan (an imaging test used to obtain clear images of the internal organs of the body) and a contrast dye to locate the CSF leaks which may be present anywhere in the skull base.
- Tympanometry: The fluid in the middle ear is tested in this procedure to check for CSF. ( Know more about- What is Tympanoplasty? )
- MRI with gadolinium: This is an imaging test that uses a contrast agent called gadolinium to highlight the abnormalities in the brain. This helps in locating the source of the CSF leak.
Spinal CSF leak diagnosis:
- Physical examination: The doctor checks the patient physically, which includes checking the flexibility of the joints. The medical history of the patient is noted.
- Myelography: This method uses subtraction fluoroscopy (a test done for the visualization of the blood vessels), a CT scan or MRI scan (imaging tests to obtain clear images of the internal organs by the body), and a contrast dye for locating CSF leaks. The exact location of the CSF leak can be pointed out by using this method.
- MRI with gadolinium: This is an imaging test done using a contrast agent known as gadolinium, to help in highlighting the abnormalities in the brain or spine that result from a CSF leak.
- Radioisotope cisternography: This test is done for measuring the CSF pressure, and then injecting a chemical into the space that surrounds the spinal cord. Images of the area are then taken many times within 24 hours. These images help in tracking the flow of the CSF, which will be abnormal in case of an active spinal CSF leak.
- Lumbar puncture (spinal tap): A needle is placed in the spinal column for measuring the pressure of the CSF inside the spinal column.
What are the treatments for CSF Leaks?
The various treatment modalities for CSF leaks include:
Conservative treatment:
- In case of some cranial CSF leaks, like those caused due to trauma, conservative treatment alone can help in treating the condition.
- Conservative treatment includes:
- Bed rest for up to two weeks
- Elevation of the head of the bed
- Taking prescribed stool softeners to prevent straining during bowel movements
- Staying hydrated
- Saline infusions
- Avoid sneezing, coughing, blowing of the nose
- Avoid heavy lifting
Epidural blood patch:
- A sample of the patient’s blood is taken and then injected into the spinal canal.
- The blood cells cause clot formation, which creates a patch that covers the area of CSF leakage.
Sealant:
- A special sealant may be used alone or mixed with the patient’s blood.
- This mixture is then injected into the spinal canal of the patient.
- This covers the hole and stops the leakage of CSF.
Surgery:
- Some CSF leaks, like spontaneous cranial CSF, may require surgery.
- Surgery is done only if other treatment options do not work, and the exact site of the CSF leak is not known.
- Surgery may involve repairing the CSF leak using stitches (sutures) or grafts, which are made from natural or synthetic patches of fat or muscles.
Trans-venous embolization:
- This is a new, minimally-invasive type of treatment for CSF leaks.
- This is a catheter-based (a catheter is a thin hollow tube used to drain the urine from the bladder) procedure done for CSF-venous fistulas, which is direct communication between the spinal subarachnoid space (space present in the spine) and the epidural veins (network of interconnecting veins present in the outer part of the spinal canal).
- It involves using glue to shut the fistula from inside the culprit vein.
What are the complications of CSF Leaks?
The complications of CSF leaks include:
- Meningitis
- Tension pneumocephalus (air enters the spaces that surround the brain)
- Stroke (blood supply to the brain stops)
- Coma
- Brain herniation (dislocation of the brain tissue within the skull) ( Know more about- What is Brain Aneurysm Surgery? )
What are the side effects of CSF Leak treatments?
The side effects of the treatments done for CSF leaks could include:
- Cranial aerosoles (a pocket of gas formed inside the skull if the fluid drains too quickly)
- Infections
- Meningitis
- Abscess (pus) formation
How to care after CSF Leak treatments?
Following CSF leak repair one can take the following care:
- Avoid lifting heavy objects
- Avoid twisting, stretching, and bending
- Avoid straining while having a bowel movement
- Use a prescribed stool softener
- Avoid sneezing and coughing. If you must do so, do it with your mouth open
- Avoid using a straw
- Avoid blowing your nose
- Try and keep your back straight during all movements
What is the cost of CSF Leak treatments in India?
The total cost of CSF leak treatments in India can range from around INR 50,000 to INR 6,70,000, depending on the type of treatment done. However, many prominent hospitals and doctors in India specialize in CSF leak treatments. But the cost varies across different hospitals.
If you are coming from abroad, apart from the cost of CSF leak treatments, there will be an additional cost of living in a hotel and the cost of local travel. So, total cost of CSF leak treatments in India comes from a total of INR 65,000 to INR 9,00,000.
We hope that we could answer all your questions regarding CSF leaks and their treatments through this article.
If you need more information about CSF leaks, you can contact a Neurosurgeon.
We only aim to provide you with information through this article. We do not recommend any medication or treatment to anyone. Only a qualified doctor can give you the best advice and correct treatment plan.
