Fístula Liquórica Esfenoidal Espontânea ­ relato de caso / Spontaneous sphenoidal liquor fistula - Case report

Introdução: fístula liquórica rinogênica é uma comunicação do espaço subaracnóideo com a fossa nasal ou seios paranasais, decorrentes a um defeito anatômico da dura-máter, osso e mucosa. As fístulas liquóricas nasais espontâneas são eventos raros, cerca de 3%, com possíveis complicações deletérias e uma causa definida. Relato de caso: o caso relatado é de paciente de 47 anos, com queixa de cefaleia de forte intensidade, diagnosticado com fístula liquórica esfenoidal espontânea. Conclusão: o otorrinolaringologista tem importante papel em realizar o diagnóstico e assistir o paciente com fístula liquórica rinogênica.

Introduction: rhinoid cerebrospinal fluid fistula is a communication of the subarachnoid space with the nasal fossa or paranasal sinuses, due to an anatomical defect of the dura mater, bone and mucosa. Spontaneous nasal fluid fistulas are rare events, about 3%, with possible deleterious complications and a definite cause. Case report: the case reported is a 47-year-old patient complaining of severe headache, diagnosed with spontaneous sphenoidal cerebrospinal fluid fistula. Conclusion: has an important role in the diagnosis and assistance of cases with rhinoid cerebrospinal fluid fistula.

Spontaneous cerebrospinal fluid fistula in the clivus.

INTRODUCTION: Spontaneous cerebrospinal fluid (CSF) fistulas are infrequent and only 10 cases in the literature have been located in the clivus. We describe two new cases of CSF fistulas in this site and review the literature. CASE REPORT: The first patient was a 52-year-old woman referred to our centre for intermittent rhinorrhea that had been diagnosed after an episode of meningitis. The second case was a 69-year-old man who was visited for rhinorrhea of one-year duration; he also developed meningitis during the preoperative study. In both cases, the spontaneous CSF fistula was diagnosed by beta-2-transferrin testing, CT scan and MRI. We performed an endonasal endoscopic transsphenoidal approach and used free grafts and vascularized flaps to close the clival defect. Treatment was successful in both cases. DISCUSSION: The physiopathology of spontaneous CSF fistulas remains unknown. Possible explanations given to date in this location are pulsatility of the basilar artery, repeated Valsalva maneuvers and Marfan's disease, the two latter also related to CSF fistulas in other locations. Closure of a CSF leak towards the nasal cavity is mandatory due to potential complications. Our results support the endoscopic transsphenoidal approach using free grafts and/or pediculated flaps as a good alternative to open surgery.

Spontaneous submucosal sphenoidal fistula discovered intraoperatively. A case report.

BACKGROUND AND IMPORTANCE: Skull base spontaneous cerebrospinal fluid fistulas have been recently recognized as secondary to pseudotumor cerebri. In most cases, they occur in the ethmoid region and the sphenoid bone which is much less affected. Regardless of their etiology, the clinical manifestation of skull base fistulas is usually the same and includes a rhinorrhea and less frequently an otorrhea. We report a case of a cryptic sphenoid cerebrospinal fluid fistula discovered intraoperatively during the excision of a pituitary ACTH-secreting microadenoma (2mm in diameter). CLINICAL PRESENTATION: A 54-year-old female was admitted to our neurosurgery department for Cushing's disease due to a pituitary microadenoma. Six months prior to admission, she complained of severe fatigue, polyphagia and weight gain. Clinical examination revealed central obesity with a body mass index of 45kg/m(2) and other symptoms suggestive of Cushing's disease. Hormonal tests and a MR scan revealed a pituitary ACTH-secreting microadenoma. During the operative procedure via a transnasal approach, her nasal and sphenoid sinus mucosa appeared unusually edematous. After removal of the latter in order to approach the sellar floor, a millimetric hole in the bone at the level of the optic groove was visualized which let out cerebrospinal fluid under pressure without interruption. The microadenoma was macroscopically completely removed without any cerebrospinal fluid coming from the pituitary surgical cavity. The closing procedure of the sphenoid groove millimetric opening was performed by injecting fibrin glue and a lumbar drain was placed indwelling for four days. CONCLUSION: This case report describes a cryptic sphenoid submucosal cerebrospinal fluid fistula in a patient with Cushing's syndrome. This type of case raises the question of the natural evolution of the skull base cerebrospinal fluid fistula from its formation to an externalization such as rhinorrhea.