Roentgen Visualization of Cerebrospinal Fluid Fistula with Contrast Medium

Abstract

Cerebrospinal rhinorrhea and otorrhea with or without pneumocephalus (2) are not unusual complications of head injuries. In the majority of cases loss of cerebrospinal fluid subsides spontaneously by closure (9) of the meningeal tear, and air within the meninges is absorbed. In those cases, however, in which the discharge of fluid following trauma does not cease, it is mandatory (6) to close the fistula by operative means, mainly in order to prevent meningitis, but also to stop fluid loss and intracranial hypotension with their inherent dangers. X-ray visualization of the bone defect of the skull which accompanies the fistula usually presents serious technical problems, which cannot always be overcome even with the help of special projections, stereoscopic views, or laminagraphy (7). Special difficulties may be encountered in cases of so-called frontobasal fistulas in the region of the ethmoidal cells. It may be impossible to recognize fractures in their thin bony septa (4), or even to decide clinically on which side the fistula is located, and whether it is solitary. Multiple fistulous openings, especially in the cribriform plate, may occur on both sides (5) of the septum and are not uncommon. The advantages of accurate preoperative localization of bone defects are, therefore, obvious. A number of films may be taken in order to visualize a small fissure, but such an attempt is generally unsuccessful. In addition to the routine views, seven different diagnostic x-ray methods to achieve this purpose are listed by Brandt (3). Nevertheless, the desired result is rarely obtained. To our knowledge, no account has so far been published of the use of a contrast medium to visualize a cerebrospinal fistula. In the case to be reported here such a procedure was performed successfully and made possible precise preoperative localization of a fistula without complicated radiological measures. Case Report J. E., a 24-year-old army officer, sustained a severe head injury on Aug. 11, 1960, by accidental explosion of a hand grenade, causing a comminuted fracture of the frontal bone, mainly on the right (Figs. 1 and 2). The roof of the right orbit was completely destroyed. The right eye was lost. The frontal dura and the right frontal lobe were lacerated, and there was a perforating wound of the left globe. There were superficial injuries of the chest and abdominal wall. First Operation: The edges of the wound in the right frontal region were débrided and a great many small bone fragments were removed. An intracerebral hematoma in the right frontal pole was evacuated, including destroyed brain substance. Repair of the dura was made difficult owing to the loss of tissue covering the floor of the right anterior cranial fossa. With free pericranial graft, however, what appeared to be a satisfactory closure of the dura was accomplished.