Traumatic and iatrogenic CSF leaks

Consideration for nonsurgical management within the first 7 days is feasible in traumatic skull base injuries (strong recommendation)

Lumbar drains may shorten the interval to traumatic CSF leak cessation during conservative management (conditional recommendation)

The evidence for acetazolamide in traumatic or iatrogenic CSF leaks is lacking (strong recommendation).

There is a lack of evidence to support prophylactic antibiotics administration in patients with a traumatic CSF leak (conditional recommendation).

For defects in the ethmoid roof and sphenoid, Non-iatrogenic (after conservative measures fail) and iatrogenic traumatic CSF (generally not treated conservatively) leaks can be repaired endoscopically with high success rates (strong recommendation)

For frontal sinus defects, the transnasal endoscopic approach to frontal sinus CSF leaks is safe and effective in select patients, but may have higher rates of failure than other locations (strong recommendation).

Spontaneous CSF rhinorrhea

There is a direct relationship between spontaneous CSF leaks and IIH; most spontaneous leaks represent a variant of IIH (strong recommendation).

After clinical examination, B2- transferrin and beta trace protein are the initial preferred methods of detection of CSF leaks (conditional recommendation).

For site of leak detection, High resolution CT (HRCT) and Magnetic   resonance    imaging (MRI) are the initial imaging modalities (non invasive). CT cysternography with intrathecal dye injection (Invasive) may be required if the previous measures failed to determine the site of leak (conditional recommendation).

Perioperative lumbar drains are not necessary for the successful repair of most spontaneous CSF leaks. Lumbar drains remain an option for adjunctive measures such as administration of intrathecal fluorescein or high-risk cases (strong recommendation) (Recommendation against except in high risk cases).

Postoperative ICP management should be considered in patients with spontaneous CSF leaks and elevated ICPs.  Acetazolamide can be used as an effective ICP-lowering   medication   with an option of CSF shunting procedures in patients unable to tolerate medical management or with recalcitrantly elevated ICPs or recurrent CSF leaks (conditional recommendation).

Reconstructive technique should be left to the discretion of the surgeon with consideration of defect location, size and etiology (strong recommendation).

Intrathecal   application   is   an off-label use of fluorescein for which informed consent must be obtained from the patient (conditional recommendation).