Spontaneous Middle Cranial Fossa Cerebrospinal Fluid Leaks and Intracranial Hypertension: Systematic Review With Meta-Analysis.

Introduction: The perioperative management of spontaneous cerebrospinal fluid leaks (sCSFL) of lateral skull base remains under debate. We systematically synthesized and evaluated the current literature, to investigate the perioperative cranial-pressure assessment protocols and relief methods. The assessment corresponded to fulfillment of criteria for idiopathic intracranial hypertension (IIH) or otherwise defined in the study. Relief methods included either medical, that is, acetazolamide, or invasive, that is, lumbar puncture (LP) or drain (LD) or ventriculoperitoneal shunt (VPS). Methods: Selected studies concerned surgical treatment of lateral sCSFL. Data extracted included the following: study characteristics, patient characteristics, primary outcomes, and secondary outcomes. Data sources: MEDLINE, EMBASE, and Cochrane Library. Results: Baseline data were calculated from 2039 operations, out of which 423 had perioperative LP or LD. When only studies which mentioned recurrence or persistence rates were considered, 262 of them were used routinely or in selected patients and 117 occasionally. In those two cohorts, recurrence or persistence rates were similar (10.1% vs. 8.9%). Intracranial pressure was assessed in 335 patients from 10 studies and 48 among them were diagnosed with IIH (14.3%). Acetazolamide was inconsistently used in 17.7% of cases. From 18 studies that reported the use of VPS, this was used in 11.2% of the cases. Discussion: Systematic perioperative LP or LD use does not affect the recurrence or persistence rates. However, decision making with respect to the use of LP or LD is inconsistently reported in the literature. The same issue holds for the use of acetazolamide or VPS. Assessment of intracranial hypertension is usually neglected, and when used, not standardized. Level of Evidence: 2.