A Multidisciplinary Approach to Treating Spontaneous CSF Leaks
Date: December 11, 2009
Johns Hopkins Sinus Center surgeons believe there's nothing "spontaneous" about so-called spontaneous cerebrospinal fluid (CSF) leaks, where fluid seeps from the brain for no apparent reason. Such leaks put patients at risk for sever headaches and meningitis. Physicians have long known that rising intracranial pressure may help create leaks. Now, a multidisciplinary team is developing protocols to better monitor rising pressures, especially in postsurgical patients.
"Historically, repairs for Spontaneous CSF leaks have had a worse track record than leaks caused by accident or trauma. The problem could be high intracranial pressure. Perhaps this puts them at higher risk for the surgical repair to fail," says Doug Reh, medical director of Otolaryngology-Head and Neck Surgery atJohns Hopkins Health Care & Surgery Center at Green Spring Station.
The few previous studies measuring CSF pressure in leak patients used static measurements such as lumbar punctures. But Reh wanted to use and study continuous monitoring, because pressures constantly change throughout the day, affected by everything from a sneeze to sitting up in a hospital bed.
Reh was introduced by Sinus Center Director Andrew Lane to two colleagues already working on the problem, and who had come up with a constant monitoring technique that Lane used with his postoperative CSF leak patients. David Solomon and Abhay Moghekar, co-directors of the Center for Cerebrospinal Fluid Disorders, developed in 2007 a method for monitoring CSF levels in patients with pseudotumor cerebri, a disorder marked by increased CSF pressures that can, unchecked, rob vision. Their technique, which involves a catheter threaded into the spine and an external pressure monitor, has yielded more accurate readings and more effective treatments. "We're guided now to a great degree by the information we get from our pressure monitoring," says Solomon, adding that, in some cases of consistently high readings, medications, or shunts to lower CSF levels can save vision.
With patients taking part in the team's study of intracranial pressure in spontaneous CSF leak repair outcomes, Solomon begins monitoring them the night before surgery to establish a baseline. The catheter stays in until three days after surgery, then a follow-up reading is taken (CSF pressures are lowered by allowing CSF drainage via the lumbar drain for the first few days after surgery in order to allow the leak repair to seal).
"If I see transient elevations in their intracranial pressure that might interfere with my repair, we can work with our neurologists and neurosurgeons to treat this and give them a better chance of success," says Reh, a sinusitis expert and surgeon who teams with neurosurgeon Gary Gallia on spontaneous CSF cases.
With additional study patients coming from Lane, Howard Francis, Masaru Ishii and others, Reh says they're amassing data on physical issues that may correlate with higher CSF pressure levels. Gallia notes the study "will really gice us data identifying patients at risk for a recurrent leak down the road." Obesity is one potential factor; others such as sleep apnea are also being studied. "We're also looking at variables such as oxygen saturation and respiratory variations," says Reh.
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