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Spontaneous and idiopathic CSF leak in the infrasellar, clival region
Author(s): ,
S. De Vleeschouwer
Affiliations:
University Hospital Leuven, Neurosurgery, Leuven, Belgium
,
W. Backaert
Affiliations:
UZLeuven, Otorhinolaryngology, Leuven, Belgium
L. Van Gerven
Affiliations:
UZLeuven, Otorhinolaryngology, Leuven, Belgium
EANS Academy. De Vleeschouwer S. Oct 21, 2018; 225715; EP4002
Steven De Vleeschouwer
Steven De Vleeschouwer
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Abstract
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Introduction:
The vast majority of CSF leaks through skull base defects occur in a postoperative or posttraumatic setting or more rarely are related to intracranial hypertension and/or encephalocoeles. Spontaneous and idiopathic clival CSF leaks without clearly predisposing pathology are extremely rare. We present the unusual case of a spontaneous infrasellar, clival CSF leak, leading to a life-treatening bacterial meningitis.

Case report:
A 66-yr old man with a history of pulmonary tuberculosis 45 years ago, presented with a fulminant pneumococcal meningitis for which sedation, intubation, ventilation and antibiotic therapy had to be installed. After weaning and putting upright of the patient, a clear CSF leak through the left nostril was clinically confirmed. CT and MRI demonstrated CSF in the extensively pneumatized left sphenoidal sinus. An endoscopic, endonasal, transsphenoidal exploration after intrathecal fluoresceine injection revealed an infra-to retrosellar, clival breach and linear dural tear. Inlay plugging with autologous muscle graft and onlay covering with a mucosal flap (middle turbinate) were efficient to close the defect.

Discussion:
In literature, idiopathic clival defects with a spontaneous CSF leak are notoriously scarce. Meningitis is most frequent presentation and potentially life-treatening complication in these patients. Endoscopic, endonasal and possibly transsphenoidal repair is the contemporary mainstay of the treatment. The ultimate average success rate is above 85% but many patients experience a recurrence which can appear up to 9 years after index presentation.

Conclusion:
An idiopathic clival defect causing a spontaneous CSF leak is an extremely rare but potentially life-treatening condition, warranting timely endoscopic, endonasal repair.
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