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Cerebrospinal Fluid Leak - Causes for Leakage, Associated Symptoms, Diagnosis, and Treatment

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A Cerebrospinal Fluid (CSF) leak occurs when a hole or tears in the meningeal layers results in neurological problems.

Written by

Dr. Jayasree S

Medically reviewed by

Dr. Abhishek Juneja

Published At August 26, 2022
Reviewed AtDecember 28, 2023

What Is a Cerebrospinal Fluid Leak?

Cerebrospinal Fluid or CSF is a fluid that protects and nourishes the brain and spinal cord. It is rich in glucose and proteins. The brain and spinal cord are covered with multiple membranes called meninges. CSF fills the spaces between these layers and suspends the brain in a fluid environment. It cushions and protects the brain and spinal cord, as these structures are delicate vital organs. Out of the three layers of the meninges, the dura mater is the outermost layer. When there is a tear or hole in the dura, the CSF may leak out. CSF leak may cause several symptoms, the major one being agonizing headaches.

What Are the Causes of Cerebrospinal Fluid Leakage?

Under normal conditions, the brain is floating in a pool of CSF. However, when there is a hole through which CSF leaks out, the brain tends to sag inside the skull. The sagging brain pressures the nerves, blood vessels, and the meningeal layers. This is the apparent reason behind all the symptoms and neurological issues associated with a CSF leak. The following are the possible causes of CSF leakage:

  • Medical procedures like spinal tapping (lumbar puncture), where a needle is inserted into the spinal column to draw out a sample of the CSF for laboratory examinations.

  • Spinal surgeries might create holes in the dura, leading to a CSF leak.

  • Epidural injections, where an injection is done right into the spinal column to effect anesthesia for various surgical procedures. The needle puncture may lead to a CSF leak.

  • Spontaneous CSF leak due to unknown reasons.

  • A bone spur or calcified vertebra creates a hole in the dura.

  • Formation of an enlarged nerve root sleeve cyst.

  • Rarely, a fistula may form, connecting the CSF chamber to adjacent veins, and fluid may drain into the vein.

  • Individuals affected by certain genetic disorders such as polycystic kidney disease (clusters of cysts in the kidney, a rare genetic disorder), Marfan syndrome (a genetic disorder affecting connective tissues), and Ehlers-Danlos syndrome (inherited disorder affecting blood vessels, joints, and skin) may suffer CSF leak.

  • A leak may start from a torn and weak area of the dura. It may be due to a repeated sprain or pull to one’s back in infrequent stretching, lifting heavy weights, falls, motor vehicle accidents, and occasions like riding on a roller coaster, which could strain the vertebra.

  • Extensive drainage of CSF happens due to significant trauma and head injury. This is due to skull fractures and disruption of meninges, leading to fluid leaks through the nose and ears. This is a medical emergency requiring urgent care.

What Are the Signs and Symptoms of Cerebrospinal Fluid Leak?

CSF leakage brings down the pressure inside the head (intracranial hypotension). The associated symptoms or indicators of CSF are:

  • Headaches are often described as a feeling of pull or pressure from the head towards the neck.

  • The intensity of the headache can range from a mild ache to severely debilitating pain.

  • Pain worsens when someone is in an upright position and gets better while lying flat on the back. It begins by standing or sitting upright continuously for about fifteen minutes. And seem to improve after lying down for about fifteen to thirty minutes.

  • Pain and stiffness in the neck.

  • Nausea.

  • Discomfort with light and sound.

  • Dizziness and vertigo (sense of imbalance).

  • Problems with hearing (caused by otorrhea, spinal fluid drainage from the eardrum), and a constant ringing in the ear.

  • Brain fog.

  • Some may experience pain in the face and the area between the shoulder blades.

  • Numbness on the face, altered taste, and vision problems.

  • When there is a heavy leak of CSF, one might suffer trouble with walking, muscle weakness, loss of consciousness, and end up in a coma stage.

How Is a Cerebrospinal Fluid Leak Diagnosed?

Since headache is the clinical presentation for several neurological conditions, it is hard to conclude as CSF leaks. The most obvious sign is the clinical presentation of the symptoms, especially the positional headache. Imaging studies are the best way to diagnose a CSF leak. The doctor may order:

  • Computed Tomography (CT) Scan: It helps to look for areas of leak and damage. It is also used to rule out bleeding inside the brain. If there is an extensive leak of CSF, one should look for fractures in the skull that require immediate attention.

  • Magnetic Resonance Imaging (MRI): helps pin down the point of the CSF leak. In addition, it can show some specific findings associated with CSF leakage, such as; subdural fluid collections, sagging of the brain, accumulation of fluid around the site of leakage in the spine, an enlarged pituitary gland, meningeal enhancement, or enlarged veins inside the head.

  • Myelography Procedure: In this procedure, a substance called contrasting dye is injected into the spinal canal to trace the path of leakage on a CT scan or X-ray.

What Is the Treatment for a Cerebrospinal Fluid Leak?

  • Most of the time, patients spontaneously recover from the symptoms caused by intracranial hypotension, such as headache and dizziness. Initially, doctors advised bed rest with caffeine and fluid intake to alleviate the headaches. Other treatment strategies involve:

  • An epidural blood patch successfully clogs the area of the tear or hole to stop further leakage. One injects the patient’s blood into the space outside the dura membrane. This blood forms a clot in the leaking spot and plugs it shut.

  • A fibrin patch is also used as an injection at the site of the leak to seize it.

  • If none work, one can opt for a surgical repair of the torn dura through stitches, clips, or other materials that can seal the tear. Surgery is the first treatment choice when there is extensive fluid drain due to trauma-related fractures.

  • Following the treatment, the patient should rest and avoid activities that may increase the pressure inside the head (intracranial pressure), such as lifting weights, straining, bending, and tilting.

What Are the Long-Term Conditions Associated With Cerebrospinal Fluid Leak?

Complications:

  • Tension pneumocephalus and meningitis occur when air enters the spaces around the brain.

  • Bleeding or subdural hematomas on the brain’s surface.

Side Effects:

  • Neck stiffness.

  • Low-grade headache.

  • Ringing in the ear or tinnitus.

Conclusion:

A CSF leak and associated headaches are often misdiagnosed as migraine, sinusitis, or other headaches. In most cases with CSF leaks, patients heal without medical attention. If the site of the leak is identified by appropriate testing, there are multiple ways to resolve the issue. Occasionally, a CSF leak may cause life-threatening infections of the meninges and brain. Therefore, one should seek expert care at the earliest for maximum recovery and the best outcomes.

Dr. Abhishek Juneja
Dr. Abhishek Juneja

Neurology

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