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Unusually Delayed Posttraumatic CSF Rhinorrhoea: Case Report

This case report describes an unusually delayed presentation of cerebrospinal fluid (CSF) rhinorrhoea 44 years after a traumatic brain injury. The patient had recurrent bouts of meningitis over the past year before CSF leakage was detected from his nose. Imaging revealed a bone defect in the anterior cranial fossa at the site of the original head injury. The defect was repaired surgically. Delayed CSF leakage many decades after trauma is rare and the mechanism in this case was likely brain atrophy resulting in herniated brain tissue reopening the fistula over time.

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89 views2 pages

Unusually Delayed Posttraumatic CSF Rhinorrhoea: Case Report

This case report describes an unusually delayed presentation of cerebrospinal fluid (CSF) rhinorrhoea 44 years after a traumatic brain injury. The patient had recurrent bouts of meningitis over the past year before CSF leakage was detected from his nose. Imaging revealed a bone defect in the anterior cranial fossa at the site of the original head injury. The defect was repaired surgically. Delayed CSF leakage many decades after trauma is rare and the mechanism in this case was likely brain atrophy resulting in herniated brain tissue reopening the fistula over time.

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© © All Rights Reserved
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Indian Journal of Neurotrauma (IJNT)

171
Case report
2010, Vol. 7, No. 2, pp. 171-172

Unusually delayed posttraumatic CSF rhinorrhoea


KVLN Rao M Ch, Dhaval Shukla M Ch, B Indira Devi M Ch
Department of Neurosurgery, NIMHANS, Bangalore, Karnataka

Abstract: Cerebrospinal fluid (CSF) rhinorrhoea is not uncommon after traumatic brain injury. It
usually occurs within first two days of trauma and subsides spontaneously. Delayed leak beyond
three months of trauma is rare. We describe a case of posttraumatic CSF rhinorrhoea which
presented 44 years after injury.
Keywords: CSF leak; meningitis; trauma

INTRODUCTION previous physician who had treated him for recurrent


meningitis. He never had CSF rhinorrhoea during these
Cerebrospinal fluid (CSF) leak after traumatic brain 44 years. General examination revealed a small scar on
injury (TBI) is not an uncommon phenomenon. CSF left side of forehead. Besides anosmia on left side there
rhinorrhoea is usually apparent during the first 48 hours were no neurological deficits. Clinically CSF rhinorrhoea
in two third of cases after TBI. In the remaining cases it could not be demonstrated. Routine haematological and
is evident within 3 months. However in exceptional biochemical investigation were normal. CT scan of head
cases, CSF rhinorrhoea does not appear even decades with coronal and axial reconstruction revealed a well
after TBI. Such patients often present with recurrent demarcated bone defect in the floor of the anterior cranial
meningitis and a CSF leak is detected during the work fossa at the level of anterior ethmoidal cells on left side.
up for the cause of recurrent meningitis1. The following (Fig 1). MRI of brain revealed the same defect with
report describes a case of delayed CSF rhinorrhoea. herniation of leptomeninges and thin gliotic tissue in
CASE REPORT the nasal cavity (Fig 2). The clinical and radiological
diagnosis was post traumatic CSF rhinorrhoea due to
A 57 years old gentleman was referred to us for evaluation
and treatment of clear water discharge from left nostril
of one year duration. He had suffered three bouts of
meningitis one year back, and was treated in a different
hospital. He did not have CSF rhinorrhoea during any
of these episodes. After treatment of third episode of
meningitis, he developed CSF leak from left nostril. The
leak was exacerbated on lying down on left side and on
sitting. He recollected that he had sustained head injury
at age of 12 years (44 years before onset of CSF Fig 1: CT scan of head coronal (A) and sagittal (B)
rhinorrhoea), when he had fallen down from and tree reconstruction, bone windows showing a bone defect in ACF
and sustained a laceration on left side of his forehead. base at level of anterior ethmoids.
The scalp laceration was sutured primarily. There was
bleeding from nose but he does not remember whether
a clear fluid was also leaking from nose at that time. He
remained conscious and was not hospitalized and hence
he thought this accident as a minor event in his life
which he had almost forgotten, and was not revealed to

Address for correspondence:


Dr. B Indira Devi, Professor
Department of Neurosurgery, National Institute of Mental Health
and Neurosciences (NIMHANS), Bangalore 560029, Karnataka Fig 2: MRI of brain T2W, coronal (A) and sagittal (B)
Phone: 0091 080 26995409 Fax : 0091 080 26631830 acquisition, showing herniating arachnoid and CSF from ACF
Email: [email protected] base to anterior ethmoids and nasal cavity.

Indian Journal of Neurotrauma (IJNT), Vol. 7, No. 2, 2010


172 KVLN Rao, Dhaval Shukla, B Indira Devi

defect in the anterior cranial fossa (ACF) base at get recurrent meningitis several years later. Delayed CSF
ethmoidal cells. A bifrontal craniotomy and intradural rhinorrhoea is reported even 48 years after initial trauma3.
repair of CSF fistula was done. On retracting the left The possible mechanisms of appearance or reappearance
frontal lobe a thin gliotic tissue and arachnoid was seen of CSF leak in such delayed cases is raised intracranial
going through the bone defect. The gliotic tissue and pressure, another trauma, growing skull fracture, and
arachnoid was resected and a bone defect 3.5 X 1.5 cms ascending infections. None of these causes were
was found in the ACF base at the region of anterior responsible in our case. The probable mechanism is our
ethmoidal cell. The margins of the defect were smooth. case is atrophy of the brain resulting in retraction of
The defect was sealed with a piece of temporalis muscle herniated brain tissue leading to opening of fistula. It is
and a bone graft harvested from inner table of frontal difficult to prove whether the defect of the bone was
bone. The base of ACF was covered with fascia lata. A large at the time of initial trauma or it has increased
lumbar drain was inserted after surgery and CSF was over years due to mechanism similar to that of growing
drained for 5 days. Two months after surgery he presented skull fracture in our case. In the reported cases of delayed
again with headaches without fever. An MRI of brain leaks after trauma herniating brain through the defect
showed bilateral chronic subdural haematomas. There was found. This herniation was responsible for initial
was no CSF leak from the repaired site. Chronic subdural cessation of CSF leak and later for maintaining the bone
hematomas were evacuated by burr holes. At follow up, defect by interfering with healing1.
four months after surgery, he was asymptomatic.
In any patient who presents with recurrent meningitis
DISCUSSION a history of TBI, howsoever minor or remote, should be
sought and should be investigated for CSF fistula.
Post traumatic CSF leak often subsides spontaneously.
The mechanism of natural healing is sealing by blood REFERENCES
clot, inflammation, or brain tissue herniation. The
1. Okada J, Tsuda T, Takasugi S, Nishida K, Tóth Z, Matsumoto
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otorrhoea is higher than rhinorrhoea. Such natural after head trauma.
healing mechanisms are not perfect and patients may Surg Neurol 1991; 35:213-7.
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mechanisms of leak within few months are resolution of complications of ethmoid fractures: a “growing fracture”
oedema, absorption of blood clot, contracture of scar, phenomenon.
and necrosis of soft tissues or bone. The incidence of Acta Neurochir (Wien) 1995; 137:164-73.
delayed CSF leak beyond 3 months is 5%, whereas delay 3. B. Schick B, Weber R, Kahle G, Draf W, Lackmann GM.
beyond a year is very rare2. If CSF does not leak within Late manifestation of traumatic lesions of skull base.
months of TBI, the event is often forgotten till patients Skull Base Surgery 1997; 7:77-83.

Indian Journal of Neurotrauma (IJNT), Vol. 7, No. 2, 2010

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