Liquorrhea: signs, how to treat

In clinical practice, liquorrhea is diagnosed when the cerebrospinal fluid (liquor cerebrospinalis) for one reason or another goes beyond the cerebrospinal fluid system, where this biological fluid circulates continuously, providing protection to the brain and spinal cord, nutrition to their tissues, and removal of metabolic products.

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Epidemiology

In adult patients with traumatic brain injury, the incidence of nasal cerebrospinal fluid leakage is 1.7-6.5% and is three times more common than cerebrospinal fluid leakage from the ear.

Clinical statistics indicate a higher rate – up to 10% – of post-traumatic cerebrospinal fluid leakage in fractures of the bones of the base of the skull. At the same time, cerebrospinal fluid leakage from the nose accompanies at least 40 cases of fracture of the bones of the facial skull out of 100.

On average, spontaneous nasal cerebrospinal fluid rhinorrhea accounts for 3.5% of all cases of rhinocerebrospinal fluid rhinorrhea.

In neurosurgical and ENT-endosurgical practice, the incidence of cerebrospinal fluid fistulas and postoperative cerebrospinal fluid leaks exceeds 50% and represents a serious problem.

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Causes liquorrhea

Experts associate the main causes of cerebrospinal fluid leakage, as well as risk factors for partial exfusion of cerebrospinal fluid, with fractures and injuries to the spinal column, in which the dura mater of the spinal cord is damaged and post-traumatic spinal cerebrospinal fluid leakage is determined.

There is also post-traumatic basal liquorrhea associated with complications and consequences of traumatic brain injury, in particular, fractures of the bones of the cranial vault (frontal) or its base (ethmoid, temporal, sphenoid, occipital bones).

Depending on the localization of cerebrospinal fluid leakage in TBI, there are such types as nasal liquorrhea, that is, liquorrhea from the nose (rhinoliquorrhea or nasal liquorrhea), and otoliquorrhea - liquorrhea from the ear or aural liquorrhea.

Quite often, the leakage of cerebrospinal fluid outward has an iatrogenic etiology, when postoperative cerebrospinal fluid leakage occurs due to the formation of cerebrospinal fluid fistulas (fistulas) during surgical interventions on the brain, on any of the paranasal sinuses (during the removal of cysts, polyps, tumors), during rhinoplasty, etc.

Among the causes of postoperative ear liquorrhea is the installation of cochlear implants in people with hearing problems. And the development of spinal liquorrhea can complicate the performance of diagnostic and therapeutic lumbar puncture (the code for cerebrospinal fluid leakage during spinal puncture is G97.0) or epidural anesthesia - if the technique for performing these manipulations is not followed.

Symptomatic liquorrhea is observed due to the disruption of the integrity of the cerebral ventricles or subarachnoid cisterns (cisternae subarachnoidales) entering the cerebrospinal fluid system during inflammation of the brain (encephalitis) and its membranes (meningitis). This type of cerebrospinal fluid leak is also characteristic of congenital anomalies in the form of brain hernias - meningocele, and congenital defects of the ear labyrinth, and tumors of the spinal cord and brain (especially in the pituitary gland).

The reasons why non-traumatic - spontaneous liquorrhea from the nose may occur and stop from time to time may be associated with both idiopathic increase in intracranial pressure and defects in the bones of the sphenoid sinus or ethmoid labyrinth, in particular, the ethmoid bone - in cases of a relatively high location of the maxillary sinus.

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Risk factors

According to research data, in addition to neurosurgical or otolaryngological surgical intervention and the listed manipulations, risk factors may include intracranially growing (deep into the subarachnoid space) brain tumors and congenital cysts filled with cerebrospinal fluid.

Also, the presence of hydrocephalus and acromegaly associated with the development of pituitary adenoma; genetically determined anatomical abnormalities of the bone structures of the skull or meninges; empty sella syndrome, as well as hereditary collagenosis, known as Marfan syndrome, play a major role in the development of spontaneously occurring nasal cerebrospinal fluid rhinorrhea.

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Pathogenesis

In bone fractures or operations on the brain and spinal cord, the pathogenesis of liquorrhea is due to the fact that damage to their hard shell can lead to the formation of either a fistula or a hernial sac in the fracture zone (or one with a defect in the closure of a surgical suture). In both cases, the liquor system ceases to be hermetic.

Through the fistula, cerebrospinal fluid freely leaks from the spinal subarachnoid space, and this is spinal cerebrospinal fluid leakage.

Under the influence of intracranial pressure, the hernia perforates, and then the cerebrospinal fluid flows into the epidural space of the spinal canal or leaves the subarachnoid space of the brain filled with cerebrospinal fluid (located under the arachnoid membrane). From there, through the nasal commissure of the brain, the cerebrospinal fluid enters the sinuses and flows out through the nasal passages, and in the case of auricular cerebrospinal fluid - from the external auditory canal.

In addition, for various reasons, the integrity of the cerebrospinal fluid channels of the pia mater of the brain may be disrupted, which increases the risk of spontaneous nasal cerebrospinal fluid leakage.

The higher frequency of cerebrospinal fluid leakage in fractures of the bones of the base of the skull is explained by the localization of cerebrospinal fluid-filled cisterns in the subarachnoid space of this region.

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Symptoms liquorrhea

The first signs of nasal liquorrhea are the release of an almost colorless transparent fluid through one of the nasal passages. The leakage usually intensifies if the head is tilted forward. With otoliquorrhea, cerebrospinal fluid flows more intensively from the ear canals when the head is tilted to the side, and hearing in that ear may decrease.

A pinkish tint to the secreted cerebrospinal fluid indicates the presence of blood in it.

Symptoms of cerebrospinal fluid leakage from the nose can also manifest as a nighttime cough, which is explained by the flow of cerebrospinal fluid into the respiratory tract in a lying position.

Since intracranial pressure may decrease, headaches are not excluded. And intense spinal liquorrhea is accompanied by general dehydration of the body and increased dryness of the skin.

Complications and consequences

What is the danger of liquorrhea? When the liquorrhea volume expires and is not compensated, its resorption, intracranial pressure and blood filling of cerebral vessels decrease, which is fraught with tissue atrophy and damage to brain structures, which lead to functional disorders of the central and autonomic nervous system - up to the development of a terminal condition.

In addition, various types of liquorrhea are characterized by consequences and complications associated with the addition of infection. Thus, in the absence of proper treatment, nasal liquorrhea can lead to meningitis, encephalitis, inflammation of the cerebral ventricles (ependymitis), intracranial air accumulation (pneumocephalus), as well as inflammation of the bronchi and stomach (if the patient swallows the leaking cerebrospinal fluid).

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Diagnostics liquorrhea

Comprehensive diagnostics of liquorrhea includes analysis of the leaking cerebrospinal fluid, as well as a test for the oil stain that remains when a tissue with a sample of fluid secreted from the nose or ear dries.

Instrumental diagnostics are used with the use of rhinoscopy, otoscopy, radiography, CT and MRI of the brain (spinal cord).

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Differential diagnosis

To identify possible rhinitis ( allergic or serous), inflammation of the labyrinth of the inner ear, as well as neoplasms in the brain or paranasal sinuses, differential diagnostics are carried out.

Treatment liquorrhea

Conservative treatment of cerebrospinal fluid rhinorrhea – in a hospital setting, with bed rest (with the head of the bed raised in case of rhino- or otoliquorrhea) – involves taking medications that help reduce intracranial pressure, and for this purpose diuretics (osmotic or loop) are prescribed, as well as acetazolamide derivatives that slow down the production of cerebrospinal fluid – Diacarb or Diumeride (0.25 g per day).

In addition, anti-edema and anti-inflammatory drugs from the corticosteroid group (parenterally), antibiotics from the cephalosporin group (depending on the patient’s condition – parenterally or orally), as well as analgesic and anti-inflammatory drugs from the NSAID group (in tablets or intramuscularly) are used.

If diuretics and Diacarb are insufficiently effective and the cerebrospinal fluid pressure is elevated, a spinal puncture with the installation of lumbar drainage is used.

Surgery may be required for cerebrospinal fluid leakage - post-traumatic, post-operative or spontaneous. And the main tasks of surgical intervention (endoscopic transnasal or transcranial) are to remove the cyst, correct the defect or close the cerebrospinal fluid fistula to stop the leakage of cerebrospinal fluid and restore the hermetic state of the skull.

Prevention

There are no specific means for preventing cerebrospinal fluid leakage in patients, and medical recommendations concern neurosurgical treatment of craniocerebral injuries and techniques for performing operations on the spine, brain, paranasal sinuses, and procedures such as spinal puncture.

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Forecast

With all the negative consequences of cerebrospinal fluid leakage and possible complications of this pathology, it is difficult to predict its outcome. However, treatment of cerebrospinal fluid leakage caused by moderate TBI is successful in two-thirds of cases and is limited to drug therapy.