Original Article

Neurosurgical Review

, Volume 35, Issue 2, pp 227-238

First online:

A management algorithm for cerebrospinal fluid leak associated with anterior skull base fractures: detailed clinical and radiological follow-up

  • Camillo SherifAffiliated withDepartment of Neurosurgery, Medical University ViennaDepartment of Neurosurgery, KA Rudolfstiftung Email author 
  • , Antonio Di IevaAffiliated withDepartment of Neurosurgery, Medical University ViennaCentre for Anatomy and Cell Biology, Department of Systematic Anatomy, Medical University of Vienna
  • , Daniel GibsonAffiliated withDepartment of Radiology, Dartmouth-Hitchcock Medical Center
  • , Bita Pakrah-BodingbauerAffiliated withDepartment of Neurosurgery, KA Rudolfstiftung
  • , Georg WidhalmAffiliated withDepartment of Neurosurgery, Medical University Vienna
  • , Irena Krusche-MandlAffiliated withDepartment of Traumatology, Medical University Vienna
  • , Jozsef ErdoesAffiliated withDepartment of Traumatology, Medical University Vienna
  • , Benjamin GilloonAffiliated withDepartment of Radiology, Dartmouth-Hitchcock Medical Center
  • , Christian MatulaAffiliated withDepartment of Neurosurgery, Medical University Vienna

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Detailed outcome data for the management of anterior skull base fractures associated with cerebrospinal fluid (CSF) leakage is lacking. We present detailed follow-up data of a single-center study using a predetermined algorithm for the management of CSF leakage secondary to traumatic fractures. A number of 138 consecutive patients were included in the analysis; all patients underwent high-resolution computed tomography (CT) scanning at time of admission with β2-transferrin testing used to confirm CSF leakage. Patients with acute surgical indications were operated as emergent; leaks were repaired at the time of initial surgery in patients with intracranial pressure < 15 cm H2O. The remainder of the study population was managed conservatively including use of prophylactic antibiotics; lumbar drainage (LD) catheters were placed in those patients with leakage persisting beyond 48 h. Leaks lasting longer than 5 days underwent microsurgical repair using an intradural bicoronal approach. One-year follow-up assessment included evaluation of neurological status, Glasgow Outcome Scale (GOS), and repeat head CT. Twenty eight patients (26.9%) underwent emergent surgery, 15 of whom had simultaneous CSF leak repair, whereas 76 patients (73.1%) underwent delayed CSF leak repair between days 5 and 14. Postoperative meningitis rate was low (1.9%). Postoperative CSF leak (1.9%) was managed by intradural or transnasal endoscopic operation. Comparable rates of anosmia and frontal lobe hypodensities were seen in the surgical and conservatively managed subgroups. The presented algorithm, utilizing prophylactic antibiotics, trial of LD, acute and/or delayed intradural microsurgery, yields favorable outcomes. Large randomized controlled trials are needed to better define the role of prophylactic antibiotics and to better characterize the optimal timing and approach of surgical repair.


Anterior skull base fractures Cerebrospinal fluid (CSF) leak Intradural bicoronal approach Microsurgery Traumatic brain injury