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PubMed2003

Cerebrospinal fluid rhinorrhea: pathophysiological aspects and treatment.

The treatment of cerebrospinal fluid rhinorrhea is a challenge and requires a therapeutic strategy in order to reduce the risk of meningitis. The localization of the fistula is not always easy and direct surgical repair requires major operation with an outcome not always successful. In many patients, an alteration of CSF pressure and/or dynamics may be associated to the rhinorrhea, making its spontaneous or surgical closure difficult. In a series of 81 patients affected by rhinorrhea, we have studied the CSF pressure and dynamics and tried to stop the fistula by using a temporary or permanent CSF drainage. This procedure was able to cure the fistula in 54 cases, while a direct surgical repair was required in 12 patients. In 13 cases both the procedures were required. Two patients refused any treatment. These results indicate that the study of the CSF pressure and dynamics may help to understand physiopathology of the CSF rhinorrhea and that the CSF drain (temporary or permanent) can be a simple way of definitively curing the CSF fistula in the majority of patients suffering from rhinorrhea.

Cerebrospinal Fluid Rhinorrhea↗
PubMed2002

Cerebrospinal fluid fistula as a consequence of war head injury.

Cerebrospinal fluid (CSF) fistula as a consequence of brain missile injury and following infectious complications has been recognized for years. Different methods of treatment have been advocated. Missiles used in war cause extensive destruction of the skull and brain as a result of their high kinetic energy. On its transfer through the skull, such high kinetic energy causes fractures called "discontinuous fractures," which are distant from the entry wound and not related to the fracture of the vault. The role of the timely diagnosis of CSF fistulas and their early repair in the management of these wounds is emphasized. Data on 312 patients with missile injuries of the brain inflicted during the war in Croatia were retrieved and analyzed, with special reference to the complications of CSF fistulas and infection. Forty-five patients developed CSF fistula, 15 (33%) of them at the wound site, 23 (51%) as CSF rhinorrhea, and seven (15%) as CSF otorrhea. Six patients developed infectious complications. The presented strategy and operative approach resulted in a low incidence of infectious complications in the study series.

Adolescent↗
PubMed2003

Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery.

OBJECTIVES/HYPOTHESIS: The incidence of cerebrospinal fluid (CSF) leak following trans-sphenoidal surgery ranges from 0.5% to 15.0%. Factors predicting which patients are likely to develop postoperative leaks and optimal management of these patients are poorly defined. The objective was to determine 1) the incidence of CSF leak following trans-sphenoidal surgery; 2) demographic or intraoperative factors associated with postoperative leaks; 3) techniques and efficacy of postoperative leak management at Oregon Health and Science University, (Portland, OR). STUDY DESIGN: Retrospective chart review. METHODS: Two hundred thirty-five trans-sphenoidal surgeries were performed on 216 patients between 1994 and 2001. Follow-up data were available for 217 operations (92.3%) performed on 202 patients (93.5%). RESULTS: Postoperative CSF leaks occurred in 6.0% (13 of 217) of patients. Leaks were more common in the setting of revision surgery versus primary surgery (14.6% vs. 4.0%, P =.0096), nonadenomatous disease versus pituitary adenoma (15.8% vs. 5.1%, P =.059), or if an intraoperative leak occurred (12.7% vs. 2.7%, P =.004). However, on multivariate analysis, only the presence of intraoperative leak (P =.008) and nonadenomatous disease (P =.047) were found to be independently associated with postoperative CSF leak. Size of adenoma was not associated with occurrence of postoperative CSF leak (6.4% for microadenoma vs. 4.2% for macroadenoma) on both univariate and multivariate analysis. There were 13 postoperative CSF leaks: 2 resolved with lumbar drainage and 11 required operative management (three required multiple procedures). Of the three patients who required multiple operations, two had hospital courses complicated by meningitis and postinfectious hydrocephalus and ultimately required ventriculoperitoneal shunts. Endoscopic re-exploration was successful in 87.5% (7 of 8) of cases. CONCLUSIONS: Cerebrospinal fluid leaks following trans-sphenoidal surgery occurred in 6.0% of cases. Nonadenomatous disease and presence of an intraoperative leak were independent predictors of a postoperative leak. Endoscopic re-exploration combined with packing was an effective technique in managing uncomplicated postoperative leaks. In the setting of meningitis and postinfectious hydrocephalus, more invasive techniques such as ventriculoperitoneal shunt may be necessary.

Cerebrospinal Fluid↗
PubMed1988

Effect of propofol on cerebrospinal fluid pressure and cerebral perfusion pressure in patients undergoing craniotomy.

The effects of propofol on cerebrospinal fluid pressure, mean arterial pressure, cerebral perfusion pressure and heart rate were studied during induction, tracheal intubation and skin incision in 23 patients scheduled for elective craniotomy. Premedication consisted of midazolam 0.1 mg/kg intramuscularly and metoprolol 1 mg/kg orally. Measurements were made or derived at time zero and 0.5, 1, 1.5, 2 and 3 minutes after an induction dose of propofol 1.5 mg/kg. A continuous infusion of propofol was started at time zero at a rate of 100 mg/kg/minute. Fentanyl 2 micrograms/kg was added before tracheal intubation, application of the pin head holder and skin incision. Cerebrospinal fluid pressure and mean arterial pressure decreased significantly 2 minutes after propofol alone, by 32% and 10% respectively, while a cerebral perfusion pressure above 70 mmHg was maintained. Heart rate did not change. Propofol combined with moderate dose of fentanyl, obtunded the usual cerebrospinal fluid and arterial pressure responses to intubation and other noxious stimuli. Thus propofol seems to be a suitable intravenous anaesthetic agent for induction and maintenance in neuroanaesthesia.

Anesthesia, Intravenous↗
PubMed1977

Myelin encephalitogenic protein fragments in cerebrospinal fluid of persons with multiple sclerosis.

With a double-antibody radioimmunoassay performed on unconcentrated cerebrospinal fluid, eight of 14 patients in an acute phase of multiple sclerosis had levels of 3.4 to 15.4 ng per milliliter of the P1 fragment (residues 43-88) of myelin encephalitogenic protein. Encephalitogenic protein-P1 was found only in the acute phase and was present in six of seven persons in the first week of an exacerbation and absent in 29 multiple sclerosis patients who were stable or had a gradually progressive course. Six of 117 controls had detectable cerebrospinal fluid encephalitogenic protein-P1. Only in two of these, one with a recent cerebral infarction and one with diabetic nephropathy who was in coma, were the levels in the range encountered in patients in the acute phase of multiple sclerosis. Although not entirely specific for multiple sclerosis, the presence of material in the cerebrospinal fluid of multiple sclerosis patients cross-reacting with encephalitogenic protein-P1 appears to be a characteristic of acute exacerbations.

Adolescent↗
PubMed1994

Straight leg raising test and lumbar cerebrospinal fluid levels of vasoactive intestinal polypeptide and somatostatin in patients with low back pain.

STUDY DESIGN: Straight leg raising was recorded before myelography in 77 patients. At myelography, samples of cerebrospinal fluid were drawn and later analyzed for neuropeptides vasoactive intestinal polypeptide and somatostatin. OBJECTIVES: The study sought to examine correlations, if any, between a positive straight leg raising test and cerebrospinal fluid neuropeptide levels. METHODS: The straight leg raising test was recorded for all patients before a myelography examination was performed because of intractable leg pain symptoms. Forty-seven of the patients were men and 30 were women. Cerebrospinal fluid samples were obtained from all patients upon myelography. Levels of the neuropeptides vasoactive intestinal polypeptide and somatostatin were analyzed in a blind manner by radioimmunoassay, using commercially available radioimmunoassay kits. RESULTS: The results are compatible with previous observations that suggest cerebrospinal neuropeptide levels are altered in conjunction with neural injury or pain syndromes. In the present mixed back pain patient population, which included radicular pain symptoms due to disc herniation and lumbar stenosis, alterations in vasoactive intestinal peptide levels in particular were observed with a positive straight leg raising test. CONCLUSIONS: Nerve root injury, as suggested by a positive straight leg raising test, appears to be neurochemically linked to altered cerebrospinal fluid vasoactive intestinal peptide levels.

Female↗
PubMed2005

Novel dural closure technique using polyglactin acid sheet prevents cerebrospinal fluid leakage after spinal surgery.

OBJECTIVE: Extradural or subcutaneous cerebrospinal fluid (CSF) leakage is a common complication after spinal surgery and is associated with the risks of poor wound healing, meningitis, and pseudomeningocele. Numerous methods to prevent postoperative CSF leakage are available, but pressure-tight dural closure remains difficult, especially with synthetic surgical membranes. The efficacy of a novel dural closure technique was assessed by detecting extradural or subcutaneous CSF leakage on magnetic resonance imaging. METHODS: The novel dural closure technique using absorbable polyglactin acid sheet and fibrin glue and the conventional procedure using only fibrin glue were evaluated retrospectively by identifying extradural or subcutaneous CSF leakage on magnetic resonance imaging scans in the acute (2-7 d) and chronic (3-6 mo) postoperative stages after spinal intradural surgery in 53 patients. RESULTS: The incidence of extradural and subcutaneous CSF leakage was significantly lower (P < 0.05) in the acute (20%) and chronic (0%) stages using polyglactin acid sheet and fibrin glue in 15 patients compared with that in the acute (81%) and chronic (24%) stages using only fibrin glue in 38 patients. One patient in the fibrin glue-only group required repair surgery for cutaneous CSF leakage. CONCLUSION: The combination of polyglactin acid sheet and fibrin glue can achieve water-tight closure after spinal intradural surgery and can minimize the risk of intractable postoperative CSF leakage. This simple, economical technique is recommended for dural closure after spinal intradural surgery.

Adolescent↗
PubMed1981

Cerebrospinal fluid enzymes in neurological diseases.

The activities of adenylate kinase, creatine kinase and lactate dehydrogenase were measured in cerebrospinal fluid and serum from 127 patients admitted to the Department of Neurology. All cerebrospinal fluid samples with hemoglobin greater than 1 mg/l were excluded. Upper reference limits for the enzyme determinations were established, using samples from patients without objective criteria of organic involvement of the nervous system. High enzyme activities did not correlate to any particular group of diseases and were also found in patients without organic brain diseases. We conclude that determination of the three enzymes in cerebrospinal fluid is of limited value in the diagnosis of neurological diseases.

Adenylate Kinase↗
PubMed1989

Cerebrospinal fluid shunts: flow measurements with MR imaging.

The authors describe a technique for determination of shunt patency by quantifying cerebrospinal fluid shunt flow rates with magnetic resonance (MR) imaging. This method uses a modified clinical sequence that is both sensitive to slow flow perpendicular to the imaging plane and capable of achieving oblique angles with a 4-cm field of view. Velocity-dependent phase images were used to quantify flow rates within the shunt. A preliminary study was performed in seven patients with hydrocephalus and cerebrospinal fluid shunts. Two patients were found to have zero flow in the shunt, while the remaining five had flow rates ranging from 4 to 19 mL/h. Results showed that the measurement of flow rates within the shunt lumen with MR imaging is clinically feasible.

Adolescent↗
PubMed1980

Two agarose electrophoretic systems for demonstration of oligoclonal bands in cerebrospinal fluid compared.

Demonstration of oligoclonal bands by electrophoresis of cerebrospinal fluid is an important aid in establishing the diagnosis of multiple sclerosis. Electrophoretic systems vary in their effectiveness in doing so. We compared two systems in this respect. For a thin-layer agarose system, sensitivity was less (47%) than for a high-resolution agarose system (87%). Each system had good specificity (92 and 85%, respectively). Interpretation of electrophoretic patterns for cerebrospinal fluid should be available in clinical laboratories. Further, the best available system should be used for demonstration of oligoclonal bands.

Electrophoresis↗
PubMed1982

K, Cl, and H2O entry in endolymph, perilymph, and cerebrospinal fluid of the rat.

The kinetics of radioactive potassium, chloride, and water entry into endolymph, perilymph, and cerebrospinal fluid were studied after intravenous administration of tracers in anesthetized and nephrectomized rats. Samples of cochlear endolymph, perilymph of scala vestibuli, perilymph of scala tympani, and cisternal cerebrospinal fluid were obtained. The data showed: 1) a rapid turnover of water in endolymph, perilymph, and cerebrospinal fluid, since 3H2O equilibrated with plasma in a few minutes; 2) a slow entry of 42K and 36Cl in perilymph, since 36Cl equilibrated with plasma after 2 h and 42K did not at 6 h; 3) an extremely slow entry of 42K and 36Cl in endolymph, since no equilibrium with plasma was obtained within the 5 h of the experiments. The comparison of the compartmental analysis of our data with the results of other studies using perilymphatic perfusion of tracers indicated that perilymph rather than plasma may be considered as the precursor of endolymph.

Animals↗
PubMed2006

Quantitative analyses of leukemia inhibitory factor in the cerebrospinal fluid in mouse embryos.

Leukemia inhibitory factor contributes to the self-renewal of neural stem cells in the forebrain. Although the existence of endogenous leukemia inhibitory factor in the brain parenchyma has been controversial, the cerebrospinal fluid is known to be another source of leukemia inhibitory factor. No reports of the measurement of leukemia inhibitory factor concentrations in the cerebrospinal fluid, however, exist. In the present study, we determined the leukemia inhibitory factor concentration in cerebrospinal fluid, amniotic fluid, and sera of embryos and dams in mice by enzyme-linked immunosorbent assay. The leukemia inhibitory factor concentrations were found to be constitutively high in the cerebrospinal fluid from embryonic day 11 to embryonic day 17, with a peak on embryonic day 13 and embryonic day 14. These findings correspond to the timing of cortical neuron production in mouse cerebrum.

Age Factors↗
PubMed1981

The electrophoretic demonstration of unique oligoclonal immunoglobulins in cerebrospinal fluid as a diagnostic test for multiple sclerosis.

Polyacrylamide disc gel electrophoresis was performed on unconcentrated cerebrospinal fluid and serum from 132 neurological patients and from 33 patients without neurological disease. The presence of unique, discrete immunoglobulin bands in the gamma-globulin (cathodal) region of the cerebrospinal fluid gel was assessed as a diagnostic test for multiple sclerosis. The procedure exhibited a specificity for multiple sclerosis of 94% and a sensitivity of 72%, and is easier to perform than most of the other published procedures used to demonstrate oligoclonal immunoglobulins in cerebrospinal fluid. It is recommended for use in the clinical chemistry laboratory as a valuable adjunct to the diagnosis of multiple sclerosis.

Humans↗
PubMed1994

Technique to avoid cerebrospinal fluid otorhinorrhea with translabyrinthine removal of acoustic neuroma.

A technique to avoid cerebrospinal fluid otorhinorrhea with translabyrinthine removal of acoustic neuroma is described. Its successful use in 100 consecutive cases with only one incident of cerebrospinal fluid otorhinorrhea suggests that it is an effective technique which has minimal morbidity. Intraoperative and postoperative intravenous antibiotics and the use of bacitracin irrigation during surgery are desirable additions to the technique. The procedure is accomplished in 10 minutes and involves scarifying the tubotympanum and obliteration with fibrous tissue through the facial recess approach. Coupled with obliteration of the petrous apex and mastoid with fat, postoperative CSF otorhinorrhea following translabyrinthine acoustic neuroma removal can be almost complete eliminated.

Cerebrospinal Fluid Otorrhea↗
PubMed1977

Somatostatin in human cerebrospinal fluid.

To determine whether somatostatin is found in the hypothalamus and extrahypothalamic brain, we studied autopsy brain tissue by specific immunoassay. The hypothalamus contained the highest concentration (16.7 +/- 2.4 S.D. pg per microgram of protein), with small amounts in brainstem, cerebral cortex, cerebellum, pineal gland and spinal cord. Cerebrospinal fluid of seven neurologically normal persons also contained somatostatin in concentrations ranging from 15 to 55 pg per milliliter. To determine whether brain disease leads to abnormal cerebrospinal-fluid somatostatin, we examined 30 patients with neurologic disease, of whom 20 of 24 with cord or cerebral disease had concentrations above the highest normal level. The wide variety of diseases with somatostatin elevation suggests nonspecific leakage from damaged brain tissue. Cerebrospinal-fluid somatostatin may provide a good index of brain damage. Although correlated statistically with cerebrospinal-fluid protein, somatostatin concentration in five of 24 cases exceeded the upper limit of normal by 3 S.D. while protein was normal.

Adolescent↗
PubMed1980

Varicella-zoster-associated encephalitis: detection of specific antibody in cerebrospinal fluid.

Varicella-zoster (VZ) antibody measured by indirect immunofluorescence was used to identify patients with encephalitis due to VZ virus. In 15 of 16 (94%) patients with VZ infection and clinical evidence of central nervous system involvement, VZ antibody was present at a titer of 1:2 or greater in cerebrospinal fluid. In contrast, no VZ antibody was detected in the cerebrospinal fluid of seven patients with VZ infections without clinical signs of central nervous system involvement, nor was any detected in the cerebrospinal fluid of 25 patients with malignant or demyelinating disease or encephalitis due to other viral or toxic agents. All of these patients had detectable serum VZ antibody. Thus, in this study the presence of detectable VZ antibody in cerebrospinal fluid measured by indirect immunofluorescence seemed to correlate with clinical evidence of central nervous system involvement due to this virus.

Antibodies, Viral↗
PubMed1999

Antifungal activity of cerebrospinal fluid against Cryptococcus neoformans and Candida species.

The effect of human cerebrospinal fluid (CSF) on the growth of Cryptococcus neoformans and Candida species was tested in RPMI-1640. CSF alone was highly fungistatic for both yeasts and inhibited growth in a concentration-dependent manner. Unlike human serum, CSF did not collaborate with fluconazole for killing C. neoformans. Molecular sieve fractionation of CSF on a G-200 Sephadex column yielded a highly antifungal fraction with a molecular weight around 66 kDa. On SDS-PAGE this fraction migrated as a major and a minor band corresponding to the mobility of bovine serum albumin. These novel findings suggest that CSF contains a factor(s) that provides resistance to the growth of C. neoformans or Candida species.

Animals↗
PubMed1994

Detection and sequencing of rotavirus VP7 gene from human materials (stools, sera, cerebrospinal fluids, and throat swabs) by reverse transcription and PCR.

Human rotavirus RNAs from stool samples, sera, cerebrospinal fluids, and throat swabs of 15 children with rotavirus gastroenteritis were detected and serotyped by reverse transcription and PCR. The reverse transcription-PCR method may allow us to consider rotavirus infections in other parts of the body in addition to the gastrointestinal tract. Moreover, sequence analysis of the VP7 gene was performed on seven samples (one stool, two serum, three cerebrospinal fluid, and 1 throat swab sample). There were no appreciable differences in viral sequences between samples from cerebrospinal fluids, sera, or stools.

Acute Disease↗