The article by Rosenfeld et al (1) described cerebrospinal fluid (CSF) leaks caused by chronically increased intracranial pressure (ICP) in 4 patients with idiopathic intracranial hypertension (IIH). The impression given by the authors is that spontaneous CSF leaks occur with equal frequency in the settings of normal and increased ICP. However, evidence indicates that the majority of spontaneous CSF leaks are associated with intracranial hypertension. Spontaneous CSF leaks traditionally have had a high recurrence rate after surgical repair (25%–87%), compared to less than 10% for most other etiologies (2–4). Identification of this underlying etiology has led to the widespread use of acetazolamide and, in some cases, permanent CSF diversion to control the ICP.
In a prospective evaluation of more than 5 years, 46 patients (average age, 51 years) with a cumulative 56 spontaneous CSF leaks were treated by the senior author (5). The data presented in the study provided concrete evidence that the majority of spontaneous CSF leaks are secondary to intracranial hypertension. Lumbar drain pressure measurements averaged 32.3 ± 9.0 cm H2O and demographics mirrored IIH, where a large proportion of the patient cohort consisted of obese middle-aged women. Successful treatment of elevated ICP in combination with endoscopic repair can provide high success rates (93% primary and 100% secondary).
This work was supported in part by an unrestricted grant from the Research to Prevent Blindness, Inc, New York, NY.
1. Rosenfeld E, Dotan G, Kimchi TJ, Kesler A. Spontaneous cerebrospinal fluid otorrhea and rhinorrhea in idiopathic intracranial hypertension patients. J Neuroophthalmol. 2013;33:113–116.
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