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 fluidic system where the biological fluid circulates unceasingly, providing protection to the brain and spinal cord, feeding their tissues and removing metabolic products.

[1], [2], [3], [4]

Epidemiology

In adult patients with craniocerebral trauma, the frequency of nasal liquorrhea is 1.7-6.5% and is three times more likely to develop cerebrospinal fluid from the ear.

Clinical statistics indicate a higher level - up to 10% - of post-traumatic flow of cerebrospinal fluid in fractures of the skull base bones. In this case, cerebrospinal fluid from the nose is accompanied by at least 40 cases of fracture of the bones of the facial skull of 100.

But the share of spontaneous nasal liquorrhea, on average, accounts for 3.5% of all cases of rhinolics.

In neurosurgical and lorg-endosurgical practice, the frequency of occurrence of cerebrospinal fluid and postoperative liquorrhea exceeds 50% and represents a serious problem.

[5], [6], [7], [8]

Causes of the liquorrhea

The main causes of liquorrhea, as well as the risk factors for partial exfusion of cerebrospinal fluid, experts associate with fractures and injuries of the spine, in which the hard shell of the spinal cord is damaged and the posttraumatic spinal liquorrhea is determined.

Also, post-traumatic basal liquorrhea is associated with  complications and consequences of craniocerebral trauma, in particular, fractures of the bones of the cranial vault (frontal) or its base (latticed, temporal, wedge, occipital bones).

Localization of leakage of the cerebrospinal fluid at CCT is divided into such species as nasal liquorrhea, that is, cerebrospinal fluid from the nose (rinolikvoreya or nasal liquorrhea), and an otlikvoreya - liquorrhea from the ear or an earworm.

Often, outflow of liquor to the outside has a iatrogenic etiology when postoperative cerebrospinal fluid develops as a result of the formation of cerebrospinal fistulas (fistulas) during surgical interventions on the brain, on any of the paranasal sinuses (with the removal of cysts, polyps, tumors), rhinoplasty, etc.

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

Because of the violation of the integrity of the cerebral ventricles or subarachnoidal cisterns (cisternae subarachnoidales) entering the cerebrospinal fluid system, inflammation of the brain (encephalitis) and its membranes (meningitis), symptomatic liquorrhea is observed. This type of leakage of cerebrospinal fluid is characteristic for congenital anomalies in the form of cerebral hernias -  meningocele, and for birth defects of the labyrinth of the ear, and for tumors of the spinal cord and brain (especially in the pituitary gland).

The reasons why nontraumatic spontaneous liquorrhea may arise from time to time may be associated with both an ideopathic increase in intracranial pressure and defects in bones of the sphenoid sinus or a latticed maze, in particular of the latticed bone, in cases of a relatively high location the maxillary sinus.

[9], [10],

Risk factors

According to the research, in addition to neurosurgical or otolaryngological surgery and the above manipulations, the risk factors can be intracranially expanding (deep into the subarachnoid space) brain tumors and congenital cysts filled with cerebrospinal fluid.

Also, in the development of spontaneously occurring nasal liquorrhea, the role of the presence of  hydrocephalus  and associated with the development of pituitary adenoma acromegaly; genetically determined anatomical abnormalities of bone structures of the skull or brain membranes; syndrome of an empty Turkish saddle, as well as hereditary collagenosis, known as  the Marfan syndrome.

[11], [12], [13], [14],

Pathogenesis

With fractures of bones or operations on the brain and spinal cord, the pathogenesis of liquorrhea is caused by the fact that disturbances in their hard shell can lead to the formation of a fistula or a hernial sac in the fracture zone (or the surgical suture that has a defect closure). In both cases, the cerebrospinal fluid system ceases to be airtight.

Through the fistula, the cerebrospinal fluid freely seeps from the spinal subarachnoid space, and this spinal liquorrhea.

Under the influence of intracranial pressure, the hernia is perforated, and then the cerebrospinal fluid flows into the epidural space of the vertebral canal or leaves the cerebral space filled with cerebrospinal fluid (located under the arachnoid membrane). Whence through the nasal spike of the brain the liquor enters the sinuses of the nose and flows through the nasal passages, and with the cerebrospinal fluid from the external auditory canal.

In addition, for various reasons, the integrity of the cerebrospinal canals of the soft shell of the brain may be compromised, which increases the risk of nasal liquorrhea of a spontaneous nature.

A higher rate of cerebrospinal fluid with fractures of the skull base bones is explained by localization in the subarachnoid space of this area filled with liquor of cisterns.

[15], [16], [17]

Symptoms of the liquorrhea

The first signs of nasal liquorrhea are manifested by the release of an almost colorless transparent liquid through one of the nasal passages. The outflow, as a rule, intensifies if the head is tilted forward. With an otlichvoree cerebrospinal fluid flows more intensively their ear passages with lateral inclinations of the head, the hearing on this ear can decrease.

The pinkish tinge of the marked CSF indicates that it contains an admixture of blood.

Symptoms of liquorrhea from the nose can also manifest in the form of a night cough, which is explained by the flow of CSF into the respiratory tract in the prone position.

Since intracranial pressure may decrease, headaches are not excluded. And intensive spinal liquorrhea is accompanied by a general dehydration of the body and an increase in the dryness of the skin.

Complications and consequences

What is dangerous for liquorrhea? With the expiration and uncompensated reduction of the volume of the cerebrospinal fluid, its resorption, intracranial pressure and cerebral blood supply decrease, which is fraught with tissue atrophy and damage to the brain structures that lead to functional disorders of the central and autonomic nervous system - up to the development of the terminal state.

In addition, for various types of liquorrhea, the consequences and complications associated with infection are characteristic. So, in the absence of proper treatment, nasal liquorrhea can lead to meningitis, encephalitis, inflammation of the cerebral ventricles (ependymitis), intracranial air accumulation (pneumocephaly), as well as inflammation of the bronchi and stomach (if the patient is swallowing the spinal fluid).

[18], [19], [20]

Diagnostics of the liquorrhea

Complex diagnostics of liquorrhea includes analyzes of leaky cerebrospinal fluid, as well as a test for the oil stain, which remains when the napkin dries with a sample of a liquid emerging from the nose or ear.

Instrumental diagnostics using rhinoscopy, otoscopy, radiography, CT and MRI of the brain (spinal cord) is used.

[21], [22], [23]

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 diagnosis is performed.

Treatment of the liquorrhea

Conservative treatment of liquorrhea - in a hospital environment, with the observance of bed rest (with a raised head of the bed with a rhino or otlikvoree) - presupposes the use of drugs that help reduce intracranial pressure, and for this purpose diuretics (osmotic or loop), as well as delayed production of cerebrospinal fluid acetazolamide - Diacarb or Diumerid (0.25 g per day).

In addition, edema and inflammatory drugs are used in the group of corticosteroids (parenterally), antibiotics of the cephalosporin group (depending on the patient's condition, parenterally or inward), as well as analgesic and anti-inflammatory drugs of the NSAID group (in tablets or intramuscularly).

With insufficient diuretic and diacarb effectiveness and increased CSF pressure, a spinal puncture with lumbar (drainage) drainage is used.

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

Prevention

There are no specific prophylaxis for liquorrhea by patients, and medical recommendations concern neurosurgical treatment of craniocerebral trauma and techniques for performing operations on the spinal column, brain, accessory nasal sinuses and procedures such as spinal puncture.

[24], [25], [26], [27]

Forecast

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