• Logo
  • SBMUJournals

A Multidisciplinary Technique Using Endonasal Endoscopic Approach with Intrathecal Fluorescin Under Neuronavigation Guidance in Patients with Cerebrospinal Fluid Leak

Afsoun Seddighi, Amir Nikouei, Amir Saied Seddighi




Background: Cerebrospinal fluid (CSF) is contained in an anatomic space, including cerebral ventricles and subarachnoid spaces and cisterns of brain and spine. Distraction of normal anatomy of any containing parts of this system will result in CSF leakage which could be associated with morbidity and mortality with variable degrees. In this study, we aimed to present 3 patients with history of blunt head trauma, who presented with delayed CSF leak and underwent endonasal endoscopic approach under image guided surgery using neuronavigation system with fluorescein illumination.

Case Presentation: Three patients were referred to neurosurgery department of Shohada Tajrish Hospital with previous history of blunt head trauma, complained from CSF rhinorrhea. They underwent thin slice Computed Tomography scan and received intrathecal fluorescein for better visualization of leakage source under live endonasal endoscopic approach, using image guided neuronavigation technology. Autologous fat tissue and fascia was used to seal the leakage site. Clinical and imaging follow up at post-operative state as well as 1st, 2nd, 4th and 8th week revealed no post-operative complications and repeated CSF leakage.

Conclusion: CSF rhinorrhea indicates abnormality in bony structure of skull base and is a major threat for ascending microbial infections and subsequent meningitis. Thus, identification of leakage site(s) and accurate surgical repair is necessary. We experienced a multidisciplinary approach which showed excellent results and no post-operative complications. Multidisciplinary approach with combination of endonasal endoscopic view under neuronavigation system improves accuracy and will minimize post-operative complications.



Cerebrospinal fluid leak; Skull base fracture; Intrathecal fluorescein; Endonasal endoscopic approach; Neuronavigation


- Milhorat TH. The third circulation revisited. J Neurosurg. 1975;42(6):628-45.

- Williams MA, Razumovsky AY. Cerebrospinal fluid circulation, cerebral edema, and intracranial pressure. Current Curr Opin Neurol. 1993;6(6):847-53.

- Brinker T, Stopa E, Morrison J, Klinge P. A new look at cerebrospinal fluid circulation. Fluids Barriers CNS. 2014;11(1):10.

- Yang Z, Wang B, Wang C, Liu P. Primary spontaneous cerebrospinal fluid rhinorrhea: a symptom of idiopathic intracranial hypertension? J Neurosurg. 2011;115(1):165-70.

- Zlab MK, Moore GF, Daly DT, Yonkers AJ. Cerebrospinal fluid rhinorrhea: a review of the literature. Ear Nose Throat J. 1992;71(7):314-7.

- Bluebond-Langner R, Rodriguez ED. Application of skeletal buttress analogy in composite facial reconstruction. Craniomaxillofac Trauma Reconstr. 2009;2(01):019-25.

- Banks CA, Palmer JN, Chiu AG, O'malley BW, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Sur. 2009;140(6):826-33.

- Olabinri EO, Ogbole GI, Adeleye AO, Dairo DM, Malomo AO, Ogunseyinde AO. Comparative analysis of clinical and computed tomography features of basal skull fractures in head injury in southwestern Nigeria. J Neurosci Rural Pract. 2015;6(2):139.

- Pérez MA, Bialer OY, Bruce BB, Newman NJ, Biousse V. Primary spontaneous cerebrospinal fluid leaks and idiopathic intracranial hypertension. J Neuroophthalmol. 2013;33(4):330.

- Schick B, Weber R, Kahle G, Draf W, Lackmann GM. Late manifestations of traumatic lesions of the anterior skull base. Skull Base. 1997;7(02):77-83.

- Ohwaki K, Yano E, Ishii T, Takanashi S, Nakagomi T. Symptom predictors of cerebrospinal fluid leaks. Can J Neurol Sci. 2008;35(04):452-7.

- Mantur M, Łukaszewicz-Zając M, Mroczko B, Kułakowska A, Ganslandt O, Kemona H, et al. Cerebrospinal fluid leakage—Reliable diagnostic methods. Clin Chim Acta. 2011;412(11):837-40.

- Arrer E, Meco C, Oberascher G, Piotrowski W, Albegger K, Patsch W. β-Trace protein as a marker for cerebrospinal fluid rhinorrhea. Clin Chem. 2002;48(6):939-41.

- Arjmand Y, Torkian P, Keipourfard A. Radiologic Evaluation of Patients with Glioblastoma Multiforme who Initially Presented with Ischemic Stroke: A Case Series. American Journal of Medical Case Reports. 2017;5(1):8-11.

- Mostafa BE, Khafagi A, Morcos JJ. Combined HRCT and MRI in the detection of CSF rhinorrhea. Skull Base. 2004;14(03):157-62.

- Dandy WE. Pneumocephalus (intracranial pneumocele or aerocele). Arch Surg. 1926;12:949–82.

- Wigand ME. Transnasal ethmoidectomy under endoscopical control. Rhinology. 1981;19(1):7-15.

- Nikouei A, Seddighi A, Seddighi AS. The Results of Image Guided Surgery Using Neuronavigation in Resection of Cerebral Gliomas in Eloquent Cortical Areas.

Arch Phys Med Rehabil. 2016;97(10):e69-70.

- Seddighi A, Seddighi AS, Nikouei A, Mohseni G. NS-06 Image Guided Surgery Using Neuronavigation System in Resection of Cerebral Gliomas Involving Eloquent Cortical Areas in Pediatric Population. Neuro Oncol. 2016;18(suppl 3):iii128-.

DOI: https://doi.org/10.22037/icnj.v4i3.18462


  • There are currently no refbacks.