Cerebrospinal fluid fistula

Cerebrospinal fluid fistula

cerebrospinal fluid leak (CSFL) is a medical condition when the cerebrospinal fluid of a person leaks out of the dura mater.

There is a incomplete sealing of the dura mater and is a major complication of intradural procedures.

Cerebrospinal fluid fistula classification

Cerebrospinal Fluid Fistula Etiology.

see Cerebrospinal fluid fistula diagnosis.

Cerebrospinal fluid fistula complications

Dural closure‘s reinforcement using different new dural sealants plays an important role in prevention. Moreover, the use of neuronavigation systems in skull base and posterior fossa surgery can help to minimize the size of approach and reduce the incidence of CSF leak. New minimally invasive spinal approaches, such as minimally invasive decompression for spinal degenerative disorders or performing selective laminotomy over laminectomy for intradural spinal pathology are very useful techniques to prevent CSF leak in this kind of surgery. In conclusion, although CSF leak remains a risky complication in neurosurgery, its prevention and treatment significantly benefited from advances in biomaterials and surgical technique 1).

see Cerebrospinal fluid fistula treatment.

Ramos-Rincon et al. aimed to analyze research activity on cerebrospinal fluid (CSF) leaks in general and CSF cerebrospinal fluid rhinorrhea and cerebrospinal fluid otorrhea in particular and to identify the main topic clusters in these areas.

They identified all relevant documents, using the medical subject headings (MeSH) term “Cerebrospinal Fluid Leak”, that are indexed in the MEDLINE database between 1945 and 2018. They performed a descriptive bibliometric analysis and analyses of networks and research clusters in order to identify the main topic areas of research.

From 1945 to 2018, a total of 4,130 records were published with the term CSF leak, including 2,821 documents (68.1%) with the term CSF rhinorrhea and 1,040 documents (25.8%) with CSF otorrhea. The number of documents published increased from 10 in 1945-49 to 642 in 2010-14. Articles represented the dominant document type (86.8% of the documents analyzed), while case reports were the main type of study (37.4%). In terms of geographical distribution, researchers from the USA led in the number of signatures (39.1%), followed by those from the UK (7.5%). The most active areas of research in the field were “Postoperative Complications,” “Tomography, X-Ray Computed,” and “Magnetic Resonance Imaging.” The terms “Adults,” “Young Adult,” and “Middle-Aged” were most common in CSF rhinorrhea research; and the terms “Infant,” “Child, Preschool,” “Child,” and “Adolescent” were more common in CSF otorrhea.

Based on these findings, articles and case reports related to “Surgery” and “postoperative complications” associated with the cerebrospinal fluid fistula diagnosis are the main topics of study, highlighting the importance of this document type in advancing knowledge in the field 2).


Rapisarda A, Orlando V, Izzo A, D’Ercole M, Polli FM, Visocchi M, Montano N. New Tools and Techniques to Prevent CSF Leak in Cranial and Spinal Surgery. Surg Technol Int. 2022 Apr 20;40:sti40/1577. Epub ahead of print. PMID: 35443285.

Ramos-Rincon JM, Monjas-Canovas I, Abarca-Olivas J, Gras-Albert JR, Bellinchón-Romero I, Gonzalez-Alcaide G. Research in Cerebrospinal Fluid Leak (Rhinorrhea and Otorrhea): A Bibliometric Analysis From 1945 to 2018. Cureus. 2022 Feb 3;14(2):e21888. doi: 10.7759/cureus.21888. PMID: 35265419; PMCID: PMC8898118.

Obstructive hydrocephalus from posterior fossa tumor risk factors

Obstructive hydrocephalus from posterior fossa tumor risk factors

Saad et al. from the Emory University Hospital surveyed the CNS (Central Nervous System) Tumor Outcomes Registry at Emory (CTORE) for patients who underwent posterior fossa tumor surgery at 3 tertiary-care centers between 2006 and 2019. Demographic, radiographic, perioperative, and dispositional data were analyzed using univariate and multivariate models.

They included 617 patients undergoing PFT resection for intra-axial (57%) or extra-axial (43%) lesions. Gross total resection was achieved in 62% of resections. Approximately 13% of patients required permanent cerebrospinal fluid shunt. Only 31.5% of patients who required pre- or intraop external ventricular drain (EVD) placement needed permanent cerebrospinal fluid shunt. On logistic regression, Tumor size, transependymal edema, use of perioperative external ventricular drain, postoperative intraventricular hemorrhage (IVH), and surgical complications were predictors of permanent CSF diversion. Preoperative tumor size was the only independent predictor of postoperative shunting in patients with subtotal resection. In patients with intra-axial tumors, transependymal flow (P = .014), postoperative IVH (P = .001), surgical complications (P = .013), and extent of resection (P = .03) predicted need for shunting. In extra-axial tumors, surgical complications were the major predictor (P = .022).

The study demonstrates that the presence of preoperative hydrocephalus in patients with PFT does not necessarily entail the need for permanent CSF diversion. Saad et al. reported the major predictive factors for needing a permanent cerebrospinal fluid shunt for obstructive hydrocephalus 1).

Superior tumor extension (into the aqueduct) and failed total resection of tumor were identified as independent risk factors for postoperative hydrocephalus in patients with fourth ventricle tumor 2).

Cully and colleagues analyzed 117 patients and found the following factors to be associated with a higher incidence of postresection hydrocephalus (PRH): age <3 years, midline tumor location, subtotal resection, prolonged EVD requirement, cadaveric dural grafts, pseudomeningocele formation, and CSF infections 3).

Due-Tonnessen and Hleseth found that patients with medulloblastoma and ependymoma had much higher rates of postoperative shunt placement than astrocytomas 4). Kumar and colleagues in a study of 196 consecutive children found age <3 years, tumor histology of medulloblastoma/ependymoma and partial resections were associated with the increased chances of postresection hydrocephalus 5). A study noted that the only modifiable risk factor for the development of PRH was the presence of intraventricular blood in postoperative imaging 6).

Intraventricular blood can cause hydrocephalus either by the “snow globe effect” 7) or by other factors like impaired absorption of CSF by inflammation and fibrosis of the arachnoid granulations caused by blood degradation products 8).

Gopalakrishnan and colleagues noted the following risk factors for PRH: the need for CSF diversion in the pediatric population—children with symptomatology <3 months duration, severe hydrocephalus at presentation, tumor location in the midline, tumor histology, viz. medulloblastoma and ependymoma, use of intraoperative EVD, longer duration of EVD, postoperative meningitis, and pseudomeningocele 9). Similar findings were also reported by Bognar et al. who showed that the presence of EVD and the duration of EVD were associated with a significant increase in the incidence of postresection CSF diversion. In another recent study, Pitsika et al. 10) showed that patients who underwent EVD had a higher rate of postoperative VPS. They also noted a negative correlation between early EVD clamping and VPS indicating that clamping encourages the re-establishment of normal CSF flow when the obstructive tumor is removed 11). From 12).

Choroid plexus cysts (CPCs) are a type of neuroepithelial cysts, benign lesions located more frequently in the supratentorial compartment. Symptomatic CPCs in the posterior fossa are extremely rare and can be associated with obstructive hydrocephalus

Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocelecerebrospinal fluid fistula, and infection. The use of a pre-resection cerebrospinal fluid shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation 13).


Saad H, Bray DP, McMahon JT, Philbrick BD, Dawoud RA, Douglas JM, Adeagbo S, Yarmoska SK, Agam M, Chow J, Pradilla G, Olson JJ, Alawieh A, Hoang K. Permanent cerebrospinal fluid shunt in Adults With Posterior Fossa Tumors: Incidence and Predictors. Neurosurgery. 2021 Nov 18;89(6):987-996. doi: 10.1093/neuros/nyab341. PMID: 34561703; PMCID: PMC8600168.

Chen T, Ren Y, Wang C, Huang B, Lan Z, Liu W, Ju Y, Hui X, Zhang Y. Risk factors for hydrocephalus following fourth ventricle tumor surgery: A retrospective analysis of 121 patients. PLoS One. 2020 Nov 17;15(11):e0241853. doi: 10.1371/journal.pone.0241853. PMID: 33201889; PMCID: PMC7671531.

Cully DJ, Berger MS, Shaw D, Geyer R. An analysis of factors determing the need for ventriculoperitoneal shunts after posterior fossa tumor surgery in children. Neurosurgery 1994;34:402-8.
4) , 8)

Due-Tonnessen B, Helseth E. Management of hydrocephalus in children with posterior fossa tumors: Role of tumor surgery. Pediatr Neurosurg 2007;43:92-6

Kumar V, Phipps K, Harkness W, Hayward RD. Ventriculoperitoneal shunt requirement in children with posterior fossa tumors: An 11-year audit. Br J Neurosurg 1996:10:467-70.

Abraham A, Moorthy RK, Jeyaseelan L, Rajshekhar V. Postoperative intraventricular blood: A new modifiable risk factor for early postoperative symptomatic hydrocephalus in children with posterior fossa tumors. Childs Nerv Syst 2019;35;1137-46.

Tamburrini G, Frassanito P, Bianchi F, Massimi L, Di Rocco C, Caldarelli M. Closure of endoscopic third ventriculostomy after surgery for posterior cranial fossa tumor: The “Snow Globe effect”. Br J Neurosurg 2015;29:386-9.

Gopalakrishnan CV, Dhakoji A, Menon G, Nair S. Factors predicting the need for cerebrospinal fluid diversion following posterior cranial fossa tumor surgery in children. Pediatr Neurosurg 2012;48:93-101

Pitsika M, Fletcher J, Coulter IC, Cowie CJA. A validation study of the modified Canadian preoperative prediction rule for hydrocephalus in children with posterior fossa tumors. J Neurosurg. doi: 10.3171/2021.1.PEDS20887.

Bognar L, Borgulya G, Benke P, Madarassy G. Analysis of CSF shunting procedure requirement in children with posterior fossa tumors. Childs Nerv Syst 2003;19:332-6.

Muthukumar N. Hydrocephalus Associated with Posterior Fossa Tumors: How to Manage Effectively? Neurol India. 2021 Nov-Dec;69(Supplement):S342-S349. doi: 10.4103/0028-3886.332260. PMID: 35102986.

Anania P, Battaglini D, Balestrino A, D’Andrea A, Prior A, Ceraudo M, Rossi DC, Zona G, Fiaschi P. The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review. Neurosurg Rev. 2021 Jun;44(3):1243-1253. doi: 10.1007/s10143-020-01325-z. Epub 2020 Jun 3. PMID: 32494987.

Delayed facial palsy after microvascular decompression for hemifacial spasm

Delayed facial palsy after microvascular decompression for hemifacial spasm

Delayed facial palsy after microvascular decompression for hemifacial spasm can occur even when hemifacial spasms disappear immediately after microvascular decompression, but the patients with delayed facial palsy can fully recover within weeks 1) 2).

The earlier that DFP develops, the shorter will be the time to recovery 3). Results also suggest that arterial hypertension contributes to DFP 4).

Findings suggested that delayed facial palsy after MVD was caused by a re-activation of varicella zoster virus 5).

The etiology of DFP and its association with herpes infection should be further clarified 6).


Lee JM, Park HR, Choi YD, Kim SM, Jeon B, Kim HJ, Kim DG, Paek SH. Delayed facial palsy after microvascular decompression for hemifacial spasm: friend or foe? J Neurosurg. 2018 Aug;129(2):299-307. doi: 10.3171/2017.3.JNS162869. Epub 2017 Sep 1. PMID: 28862543.

Hua Z, Da TY, Hui WX, Tingting Y, Jin Z, Yan Y, Shiting L. Delayed Facial Palsy After Microvascular Decompression for Hemifacial Spasm. J Craniofac Surg. 2016 May;27(3):781-3. doi: 10.1097/SCS.0000000000002521. PMID: 27046467.

Kong CC, Guo ZL, Xu XL, Yu YB, Yang WQ, Wang Q, Zhang L. Delayed Facial Palsy After Microvascular Decompression for Hemifacial Spasm. World Neurosurg. 2020 Feb;134:e12-e15. doi: 10.1016/j.wneu.2019.08.105. Epub 2019 Aug 26. PMID: 31465849.

Liu LX, Zhang CW, Ren PW, Xiang SW, Xu D, Xie XD, Zhang H. Prognosis research of delayed facial palsy after microvascular decompression for hemifacial spasm. Acta Neurochir (Wien). 2016 Feb;158(2):379-85. doi: 10.1007/s00701-015-2652-9. Epub 2015 Dec 11. PMID: 26659255.

Furukawa K, Sakoh M, Kumon Y, Teraoka M, Ohta S, Ohue S, Hatoh N, Ohnishi T. [Delayed facial palsy after microvascular decompression for hemifacial spasm due to reactivation of varicella-zoster virus]. No Shinkei Geka. 2003 Aug;31(8):899-902. Japanese. PMID: 12968493.

Rhee DJ, Kong DS, Park K, Lee JA. Frequency and prognosis of delayed facial palsy after microvascular decompression for hemifacial spasm. Acta Neurochir (Wien). 2006 Aug;148(8):839-43; discussion 843. doi: 10.1007/s00701-006-0847-9. Epub 2006 Jun 29. PMID: 16804640.
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