2īasal encephaloceles are lesions consisting of herniation of intracranial contents – meninges alone (meningoceles) brain tissue (meningoencephalocele) or a ventricle (hydroencephalomeningocele) – through a defect in the skull base. 1 Most CSF-Ls encountered in the emergency department (ED) are in the setting of trauma or recent surgical procedures however, it is important to recognize that leaks can also occur secondary to nontraumatic causes, including radiation, tumors, infections, or from either congenital or spontaneous encephaloceles. Meningitis, which often occurs within a year from onset of the leak, has been found to complicate almost 20% of patients with persistent leak with 10% mortality. Most notably, the abnormal communication between the subarachnoid space and the extracranial space poses significant risk for meningitis. INTRODUCTIONĬerebrospinal fluid leaks (CSF-L) are rare but can occur in patients of all ages with potentially devastating consequences if not diagnosed and treated expeditiously. ![]() All front-line providers should be aware of the potential presence and rupture of congenital meningoceles in patients who have undergone recent nasopharyngeal swab when risk-stratifying for potential CSF leak and meningitis. Nasopharyngeal swabs are being performed much more frequently due to the COVID-19 pandemic. This patient’s meningitis developed due to prolonged occult CSF leak after her COVID-19 nasopharyngeal swab ruptured a pre-existing congenital meningocele. Lumbar puncture revealed acute streptococcal meningitis. On ED presentation, she was afebrile, but with mild tachycardia, leukocytosis, and meningismus. As part of her outpatient workup, an otolaryngology consultation with subsequent beta-2 transferrin testing and magnetic resonance imaging was performed and she was diagnosed with a CSF leak from ruptured congenital meningocele. Prior to this presentation, the patient had experienced two months of persistent headache and rhinorrhea since her coronavirus disease 2019 (COVID-19) nasopharyngeal swab. This report highlights a unique case of meningitis after CSF leak caused by ruptured congenital meningocele during a routine nasopharyngeal swab.Ī 54-year-old female with diagnosed CSF leak presented to the emergency department (ED) with acute onset of severe headache, and neck and back pain. Cerebrospinal fluid leaks from congenital and spontaneous encephaloceles can be clinically occult and have devastating consequences if undetected for prolonged periods of time. They note that the CSF leak may be located ventrally and may require conventional or digital subtraction myelography for exact localization and that transdural repair is safe and effective in eliminating the headaches.Cerebrospinal fluid (CSF) leaks are often the result of trauma or recent surgical procedures however, a subset can develop from non-traumatic etiologies. The authors conclude that persistent postdural puncture headache requiring surgical repair is rare in children. Postoperative recovery was uneventful, with complete resolution of orthostatic headache and of the ventral cerebrospinal fluid leak on MRI. Through a posterior transdural approach, the dural defect was repaired using 6-0 Prolene sutures and a dural substitute. Conventional myelography or digital subtraction myelography revealed a ventral dural defect at L2–3 requiring surgical repair. All 3 patients presented with new-onset orthostatic headaches, and in all 3 cases MRI demonstrated a large ventral lumbar or thoracolumbar CSF collection. The boy also had undergone a laminectomy and exploration of the posterior dural sac, but no CSF leak could be identified. ![]() ![]() The patients were 2 girls (ages 14 and 16 years) who had undergone lumbar puncture for evaluation of headache and fever and 1 boy (age 13 years) who had undergone placement of a lumboperitoneal shunt using a Tuohy needle for treatment of pseudotumor cerebri. A CSF leak could be demonstrated radiologically and treated surgically in 3 of these patients, and the authors report these 3 cases. The authors reviewed the medical records and imaging studies of all patients 19 years of age or younger who they evaluated between 20 for intracranial hypotension, and they identified 8 children who had persistent post–dural puncture headache despite maximal medical treatment and placement of epidural blood patches. Persistence of post–dural puncture headache in spite of bed rest, increased fluid intake, and epidural blood patch treatment, however, is rare. Headache occurs after dural puncture in about 1%–25% of children who undergo the procedure-a rate similar to that seen in adults.
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