Conservative and Medical Therapy for Cerebrospinal Fluid Leaks

Abstract

Cerebrospinal fluid (CSF) leaks and associated management are largely dependent on the volume, location, and etiology of the skull base defect. CSF leaks can broadly be separated into traumatic, spontaneous, and iatrogenic categories, which inform and guide the treatment pathways. Conservative medical treatment—focused on bed rest, treatment of comorbid intracranial hypertension, minimizing straining, and meningitis prophylaxis—and surgical repair of the skull base are the predominant treatment modalities. Conservative therapy relies on healing by secondary intention to close a skull base dehiscence and seal off the intracranial space, although permanent epithelialized tracts (fistulas) are unlikely to close with non-surgical therapy (Georgalas et al. Int Forum Allergy Rhinol. 11:794–803, 2021). Of note, CSF diversion—either by lumbar drain, external ventricular device, or ventriculoperitoneal shunt—plays a prominent role for many physicians in the role of CSF leak therapy. CSF diversion will be discussed in detail in other chapters. In this chapter we highlight the indications for conservative medical management outside of CSF diversion and describe the current treatment paradigm.