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OBJECTIVE: Currently, diagnosis of cerebrospinal fluid (CSF) rhinorrhea relies on a multimodal approach, increasing costs and ultimately delaying diagnosis. In the United States and internationally, the crux of such a diagnosis relies on confirmation testing (via biomarkers) and localization (e.g., imaging). Biomarker testing may require analysis at an outside facility, resulting in delays diagnosis and treatment. In addition, specialized imaging may be nonspecific and often requires an active leak for diagnosis. There remains a clear need for innovative new technology. METHODS: A comprehensive review was conducted on both foundational and innovative scholarly articles regarding current and emerging diagnosis modalities for CSF. RESULTS: Current modalities in CSF rhinorrhea diagnosis and localization include laboratory tests (namely, B2T immunofixation), imaging (CT and/or MRI) with or without intrathecal administration, and surgical exploration. Each of these modalities carry flaws, risks, and benefits, ultimately contributing to delays in diagnosis and morbidity. Promising emerging technologies include lateral flow immunoassays (LFI) and biologically functionalized field-effect transistors (BioFET). Nevertheless, these carry some drawbacks of their own, and require further validation. CONCLUSION: CSF rhinorrhea remains a challenging diagnosis, requiring a multimodal approach to differentiate from nonpathologic causes of rhinorrhea. Current methods in diagnosis are imperfect, as the ideal test would be a readily accessible, inexpensive, rapid, highly accurate point-of-care test without the need for excess fluid or specialized processing. Critical work is being done to develop promising, new, improved tests, though a clear successor has not yet emerged. LEVEL OF EVIDENCE: N/A.

Purpose: Peri-operative management of nasal cerebrospinal fluid (CSF) leaks is not consensual due to limited evidence. The main aim of this study was to identify key factors in peri-operative management of endoscopic endonasal CSF leak repair among international experts. Methods: A 60-item survey questionnaire collected opinions of members of international learned societies of ENT surgeons and neurosurgeons on nasal packing, post-operative instructions, antibiotic prophylaxis, and CSF volume depletion. Results: The survey had 153 respondents (124 otorhinolaryngologists and 29 neurosurgeons). A resting position was recommended by 85% (130/151) of respondents for extended CSF leak of the anterior skull base, mainly in Fowler's position (72% (110/153)). Nasal packing was used by 85% (130/153) of respondents; 33.3% (51/153) used it to stabilize the reconstruction, and 22.2% (34/153) to prevent bleeding. It was usually removed after 48 h in 44.4% of cases (68/153). CSF depletion was considered by 47.1% (72/153) of respondents in case of CSF leak recurrence and by 34.6% (53/153) in cases of increased intracranial pressure. All respondents gave specific postoperative instructions to patients including driving, running, swimming, diving restrictions and flighting restrictions. In subgroup analysis, ENT surgeons more often recommended a resting position than neurosurgeons (71% vs. 37.9% ; p = 0.0008) and prescribed more antibiotics (82.3% vs. 21.4% ; p < 0.0001). Conclusion: Although postoperative management after CSF closure remains challenging and not codified, this international survey revealed some points of consensus concerning resting position and restriction of post-operative activities. Prospective clinical studies must be undertaken to evaluate their efficiency. [ABSTRACT FROM AUTHOR]

Introduction Pedicled nasoseptal flap (NSF) placement is a critical component of skull base reconstruction after endoscopic endonasal approaches (EEAs). The effectiveness of NSF reuse has not been thoroughly studied. Prior reports using flaps harvested at one center and reused at another may have technical variability bias. Methods We identified patients who underwent both their initial and NSF-reused surgeries at Weill Cornell Medical College from 2004 to 2022 using a prospective database of all EEAs. Surgical pathology, intraoperative leak grade, use of cerebrospinal fluid (CSF) diversion and skull base coverage were examined. The primary outcome measure was occurrence of CSF leak. Results Fourteen patients (six women, eight men) underwent 14 first time and 14 revision operations with median age of 36.6 years (interquartile range [IQR]: 23.9–61.3) at the time of the NSF reuse. The median interval between the first NSF use and reuse was 70.6 months (IQR: 16.6–87). Eight patients were operated on for pituitary adenoma. Nonadenomas included three craniopharyngiomas and one case each of epidermoid, ependymoma, and chordoma. There were 16 high-flow, 8 low-flow intraoperative leaks, and 4 with no leak. CSF diversion was used in 24 operations. There were three postoperative leaks, one after a first operation and two after NSF reuse. All postoperative CSF leaks, whether first or second operations, occurred in cases with both high-flow intraoperative CSF leak and incomplete NSF coverage (p = 0.006). Conclusion NSF reuse is effective at preventing postoperative CSF leak. The primary predictors of leak are high-flow intraoperative leak and inadequate defect coverage with NSF, regardless of the operation number. [ABSTRACT FROM AUTHOR]

Introduction Endoscopic endonasal surgery has globally improved postoperative results in pituitary adenomas. Material and Methods We retrospectively analyzed 101 patients who underwent endonasal endoscopic surgery for pituitary adenomas in the period from 2016 to 2021. Data on epidemiological variables, preoperative radiological factors including tumor volume, tumor appearance, cavernous sinus invasion (modified Knosp scale), degree of extension according to the SIPAP (stands for the five directions in which a pituitary adenoma can extend: suprasellar, infrasellar, parasellar, anterior, and posterior) classification, and preoperative visualization of the healthy gland on magnetic resonance imaging (MRI) were collected as well as intra- and postoperative cerebrospinal fluid (CSF) leak. As variables of interest, data on the degree of tumoral resection and preservation of hormonal function were collected. Results Among the preoperative factors related to greater tumoral resection, we found a lesser tumoral extension according to the SIPAP scale, and the absence of a postoperative CSF leak had a statistically significant relation with greater hormonal preservation. Conclusion The SIPAP classification is a simple-to-measure preoperative radiological variable that could predict the extent of resection, and, conversely, the occurrence of a postoperative CSF leak has been associated with an inferior endocrinological outcome in this type of surgery. [ABSTRACT FROM AUTHOR]

Rhinorrhea is a common complication after endoscopic endonasal transsphenoidal pituitary surgery (EETPS). This study evaluates the effectiveness of our sellar reconstruction technique in preventing rhinorrhea. From June 2020 to March 2024, a surgical team performed 490 EETPS procedures on 458 pituitary adenoma patients. Demographic data, surgery status, and radiological and histopathological classifications were retrospectively analyzed. 4 grades for sellar reconstruction were defined based on intraoperative cerebrospinal fluid (CSF) leakage and diaphragm sella defect size. Grade 0: no CSF leakage; cavity filled with absorbable material. Grade 1: small defect; covered with fat and fascia lata grafts. Grade 2: large defect; added lumbar drainage. Grade 3: extended approach; added nasoseptal flap. Of the 490 operations, 433 were primary and 57 recurrent. Patients were 50.2% male, mean age 49.01 years. Follow-up averaged 20.5 months. Postoperative rhinorrhea occurred in 8 cases (1.6%). In 404 surgeries (82.5%) without intraoperative CSF leakage, 3 cases (0.7%) developed postoperative rhinorrhea. CSF leakage was detected in 86 cases (17.5%), with postoperative rhinorrhea in 5 cases (5.8%). The risk of rhinorrhea was 8.3 times higher with intraoperative CSF leakage (P = 0.005). Rhinorrhea rates: 0.7% in Grade 0, 3% in Grade 1, 8.7% in Grade 2, and 0% in Grade 3 (P = 0.017). Meningitis occurred in 8 patients (1.7%) and pneumocephalus in 4 (0.9%), with one death (0.2%). The average hospital stay was 17.4 days with rhinorrhea and 5.2 without (P = 0.024). Intraoperative CSF leakage is highly correlated with rhinorrhea. Multilayered and graded closure strategies significantly reduce postoperative rhinorrhea rates in EETPS. [ABSTRACT FROM AUTHOR]

Achieving watertight dural closure without grafts via the retrosigmoid approach can be challenging, contributing to a significant rate of postoperative cerebrospinal fluid (CSF) leaks. This study describes a dural incision technique for achieving primary dural closure without grafts following the retrosigmoid approach and presents clinical data from the authors' experience. Clinical and surgical data of 227 patients who underwent the dural incision technique following the retrosigmoid approach for various pathologies were retrospectively reviewed. To achieve no-graft watertight dural closure, the dural incision involves 2 critical steps: a 1 cm transverse incision of the dura parallel to the foramen magnum to drain CSF from the cisterna magna, and a vertical linear opening of the retrosigmoid dura. Dural incisions were closed watertight with vicryl 4/0 running sutures, without the use of grafts, fibrin glue, hemostatic overlays, or dural substitutes. Pre- or postoperative lumbar drainage was not employed. Primary watertight dural closure was successfully achieved in all patients without the use of grafts or duraplasty. The average duration of dura closure was 17.7 minutes. During an average follow-up period of 49.3 months, there were no instances of CSF leaks or meningitis. In the authors' preliminary experience, the linear dural incision described herein was effective for achieving a no-graft, watertight primary dural closure in the retrosigmoid approach, with no CSF leaks or meningitis in our series. Validation of these preliminary data in a larger patient cohort is necessary. [ABSTRACT FROM AUTHOR]

Introduction: Identifying spontaneous CSF leaks can be difficult on CT myelography (CTM) in patients with suspected spontaneous intracranial hypotension (SIH). The current study compared renal collecting system (RCS) density during CTM in patients with suspected SIH relative to non-SIH controls and evaluated the overall utility as an indirect sign of spontaneous CSF leak in patients with SIH. Methods: All CTM performed over an 8-year period (n = 392) were retrospectively reviewed and included cases (n = 295) were divided into groups consisting of SIH patients with (n = 35) or without (n = 77) confirmed CSF leak on CTM and non-SIH controls (n = 183). Average and relative average (relative to systemic contrast density) RCS densities were compared with multivariate analysis adjusting for patient characteristics and CTM technical differences. Results: Average RCS densities were greater for confirmed versus non-confirmed SIH groups and greater for both SIH groups relative to non-SIH controls. Correlations between RCS density and time from injection to CTM were higher within SIH patient groups compared to controls. Measured RCS density had a higher negative predictive value for excluding CSF leak both within the SIH patient groups as well as the overall cohort (84% and 96%, respectively), with optimized thresholds yielding 80% sensitivity and 70% specificity for the presence of leak in the overall cohort. Conclusion: Accounting for RCS density may provide reliable additional indirect diagnostic value about the suspicion of a CSF leak in patients undergoing CTM for evaluation of SIH symptoms. [ABSTRACT FROM AUTHOR]

Study Design: Technical Report Objective: Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. Methods: In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. Results: The patient had complete resolution of his preoperative symptoms after primary repair. Conclusions: In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks. [ABSTRACT FROM AUTHOR]

Aims: Post-operative CSF leak is the major source of morbidity following transsphenoidal approaches (TSA) and expanded endonasal approaches (EEA) to lesions of the sella turcica and the ventral skull base. There are conflicting reports in the literature as to whether obesity (BMI ≥30) is a risk factor for this complication. We aimed to evaluate data collected as part of prospective multicentre cohort study to address this question. Methods: The CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) study database was reviewed and patients were divided into obese and non-obese cohorts. Data on patient demographics, underlying pathology, intra-operative findings and skull base repair techniques were analysed. Results: TSA were performed on 726 patients, of whom 210 were obese and 516 were non-obese. The rate of post-operative CSF leak in the obese cohort was 11/210 (5%), compared to 17/516 (3%) in the non-obese cohort, which was not statistically significant (χ² = 1.520, p=0.217). EEA were performed on 140 patients, of whom 28 were obese and 112 were non-obese. The rate of post-operative CSF leak in the obese cohort was 2/28 (7%), which was identical to the rate observed in the non-obese cohort 8/112 (7%) Fisher's Exact Test, p=1.000). These results persisted following adjustment for inter-institutional variation and baseline risk of post-operative CSF leak. Conclusion: CSF leak rates following TSA and EEA, in association with modern skull base repair techniques, were found to be low in both obese and non-obese patients. However, due to the low rate of post-operative CSF leak, we were unable to fully exclude a small contributory effect of obesity to the risk of this complication. [ABSTRACT FROM AUTHOR]

Background Large pituitary adenoma often pushes the diaphragma sella and extends to the suprasellar compartment. The thinned out diaphragma may get opened during endonasal endoscopic surgery and pose high risk for cerebrospinal fluid (CSF) leak. Such larger defects are difficult to plug with fat graft that tends to slip in to the subarachnoid space. Here, we describe a unique technique of closure of diaphragma sella that augment repair of the skull base in such cases. Materials and Method The free edge of diaphragma sella was sutured with the anterior tuberculum sella dura in five cases of large pituitary adenoma that needed extra arachnoidal resection. Suturing was done with 6-0 prolene using endoscopic needle holder that converted a large diaphragm defect in to a smaller arachnoid rent and was easily plugged with fat graft. Result None of these patients had postoperative CSF leak. Conclusion Though technically difficult, direct repair of the diaphragma sella is possible. This augments the skull base reconstruct and effectively reduces the chances of postoperative CSF leak. [ABSTRACT FROM AUTHOR]

Background: Aspiration pneumonitis (AP) secondary to cerebrospinal fluid (CSF) leak is underestimated and rarely discussed. This study aimed to evaluate the association between AP and CSF leaks. Methods: Clinical and surgical characteristics of CSF leak patients with and without AP between January 2010 and December 2022 were included and compared. Results: This study included 159 patients, 16 with CSF otorrhea and 143 with CSF rhinorrhea. Among them, 40 (25.2%) had AP. Bilateral pneumonitis was identified in 32 cases, of which 11 showed severe pneumonitis in the right upper lung lobe. Twenty-one (52.5%) asymptomatic and 19 (47.5%) symptomatic cases were documented. The major clinical manifestations included cough (n = 19, 47.5%) and expectoration (n = 9, 22.5%). The prevalence of pneumonitis was significantly higher in the spontaneous group than in the traumatic group. High-flow CSF leak was associated with AP (42.5% vs. 16.8%, p = 0.001). No significant differences were identified in defect locations between patients with and without AP. Patients with pneumonitis had a higher prevalence of meningitis (32.5% vs. 12.6%, p = 0.003). Multiple logistic regression results revealed that meningitis, spontaneous and high-flowCSF leaks are independent factors forAP occurrence. Both the CSF leak and pulmonary complications resolved following successful surgical repair. Conclusions: AP secondary to CSF leaks is frequently underdiagnosed, with a higher incidence identified in spontaneous cases. The occurrence of AP was associated with high-flow CSF leak. [ABSTRACT FROM AUTHOR]

Study Design: : Retrospective Chart Review. Objectives: Incidental durotomies (IDs) are common spine surgery complications. In this study, we present a review on the most commonly utilized management strategies, report our institutional experience with case examples, and describe a stepwise management algorithm. Methods: A retrospective review was performed of the electronic medical records of all patients who underwent a thoracolumbar or lumbar spine surgery between March 2017 and September 2019. Additionally, a literature review of the current management approaches to treat IDs and persistent postoperative CSF leaks following lumbar spine surgeries was performed. Results: We looked at 1133 patients that underwent posterior thoracolumbar spine surgery. There was intraoperative evidence of ID in 116 cases. Based on our cohort and the current literature, we developed a progressive treatment algorithm for IDs that begins with a primary repair, which can be bolstered by dural sealants or a muscle patch. If this fails, the primary repair can be followed by a paraspinal muscle flap, as well as a lumbar drain. If the patient cannot be weaned from temporary CSF diversion, the final step in controlling postoperative leak is longterm CSF diversion via a lumboperitoneal shunt. In our experience, these shunts can be weaned once the patient has no further clinical or radiographic signs of CSF leak. Conclusions: There is no standardized management approach of IDs and CSF leaks in the literature. This article intends to provide a progressive treatment algorithm and contribute to the development process of a treatment consensus. [ABSTRACT FROM AUTHOR]

Purpose of Review: Rebound intracranial hypertension (RIH) is a post-procedural treatment complication in patients with spontaneous intracranial hypotension (SIH) characterized by transient high-pressure headache symptoms. This article reviews the epidemiology, clinical features, risk factors, and treatment options for RIH. Recent Findings: This article discusses how changes in underlying venous pressure and craniospinal elastance can explain symptoms of RIH, idiopathic intracranial hypertension (IIH), and SIH. Summary: The pathophysiology of RIH provides a clue for how high and low intracranial pressure disorders, such as IIH and SIH, are connected on a shared spectrum. [ABSTRACT FROM AUTHOR]

Objective: We undertook a systematic review of the literature with meta‐analysis to identify the role of obesity (BMI ≥30) in the patient characteristics presenting with spontaneous cerebrospinal fluid (sCSF) leaks of the lateral skull base and the outcomes of their repair. Data Sources: A Systematic Review of English Articles using MEDLINE, EMBASE, and Cochrane Library. Review Methods: The research algorithm included the following keywords: "spontaneous CSF leak," "lateral skull base," "temporal bone," "meningocele," "encephalocele," and "otorrhea." We also manually searched the references of included studies, to identify possible studies missed during our literature search. Results: More than two‐thirds of the patients were female (69.2%) and often were obese (mean BMI 36.5 kg/m2) with a mean age of 57. Most common presenting symptoms were otorrhea and hearing loss. Most authors did not report a routine use of a post‐operative lumbar drain. Most patients had a single skull base defect and encephaloceles prolapsing through, across obese and non‐obese groups. Median length of stay in hospital was 3.2 days, and the majority of patients did not have any recurrence during their follow‐up (89.6%), which was not affected by obesity. Conclusion: Obesity does not affect length of hospital stay or recurrence rate following surgical repair of lateral skull base sCSF leaks. Surgical repair is a safe and viable approach in the management of obese patients with sCSF leaks in the temporal bone. Level of Evidence: NA Laryngoscope, 134:2012–2018, 2024 [ABSTRACT FROM AUTHOR]

We describe a unique case of a 38-year-old female who presented at the emergency room due to a minor sacral fracture and local pain complicated by an initially undiagnosed cerebrospinal fluid (CSF) leak. This case emphasizes the importance of radiologists being attentive to subtle imaging findings of CSF leaks on computed tomography (CT) examinations, even in cases of low-energy traumas, as well as the complementary role of a dedicated magnetic resonance (MR) imaging protocol for such diagnosis.

Durotomies, traditionally used during the midline suboccipital approach, involve sacrificing the occipital sinus (OS) with consequent shrinking of the dura, risk of venous complications, difficulty performing watertight closure, and a higher rate of postoperative cerebrospinal fluid (CSF) leaks. The present technical note describes the OS-sparing linear paramedian dural incision, which leads to a decrease in the risk of complications during the median suboccipital approach in our case series. The OS-sparing linear incision technique involves a dural incision placed 1 cm lateral to the OS. The angle of view of the microscope is frequently changed to overcome the narrowed exposure of the linear durotomy. Copious irrigation with saline prevents drying of the dura. A running watertight closure of the dura is performed. The overall results of 5 cases are reviewed. The cases were 3 tumors and 2 cavernomas. The OS was preserved in all 5, and no duraplasty was needed. The average dura closure time was 16.8 minutes. No CSF leak occurred, and no wound complications were observed. A gross total resection of the lesion was achieved in all the patients. The mean follow-up was 10.2 months, and there were no late complications related to the dura closure. In comparison to the types of durotomies conventionally used for the midline suboccipital approach, the OS-sparing linear paramedian dural incision entails lower risks of bleeding, venous complications, CSF leaks, and infections by avoiding duraplasty. Validation of this technical note on a larger patient cohort is needed. [ABSTRACT FROM AUTHOR]

The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks. [ABSTRACT FROM AUTHOR]

Spontaneous cerebrospinal fluid (CSF) leaks are an uncommon clinical entity, often challenging to diagnose accurately. We present a unique case of a patient with symptoms suggestive of an ethmoidal CSF leak, initially supported by radiological findings, but ultimately revealed to be a mid-clival CSF leak (from the posterior wall of the sphenoid sinus). This case underscores the complexities of diagnosing CSF leaks and highlights the importance of surgical exploration in cases where radiological evidence appears contradictory. The patient's Computed Tomography scan indicated a CSF leak in the cribriform plate, prompting a surgical approach to address this region. However, intraoperative findings surprisingly revealed no evidence of leak in the cribriform plate but instead a posterior wall of the sphenoid defect as the culprit. This report emphasizes the critical role of interdisciplinary collaboration, meticulous preoperative and intraoperative assessment, and adaptability in managing challenging cases of CSF leaks, ultimately leading to successful surgical repair and improved patient outcomes. It serves as a valuable reminder for clinicians to consider the possibility of a masquerading CSF leak when clinical and radiological findings do not align, thereby facilitating more precise diagnosis and targeted treatment. [ABSTRACT FROM AUTHOR]

The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks. [ABSTRACT FROM AUTHOR]

The outer layer of the meninges, known as duramater plays a critical role in protecting the brain. In cases where it is damaged due to head trauma or surgery there can be a risk of leakage that may have life threatening consequences. While suturing to repair the mater is not always feasible due to the potential for further leakage finding biomaterials capable of replacing the damaged dura becomes essential. During the 19th century initial attempts at using synthetic materials for dural replacement faced challenges as they were rejected by the immune system. However researchers have made progress by developing materials such as collagen based xenografts that undergo treatments to prevent adverse reactions. This review focuses on types of dural replacement materials, like autografts, allografts, xenografts and synthetics. It sheds light on efforts to find an ideal neurosurgical dural replacement material while also discussing associated challenges. [ABSTRACT FROM AUTHOR]

With the advancement of endoscopic endonasal surgery in the treatment of anterior skull base (ASB) pathologies, extended, watertight reconstructions are needed to prevent cerebrospinal fluid (CSF) leakage. This often involves the use of multilayers closure, with free fascia lata (FL) graft frequently used as an in- and/or outlay. However, positioning the FL properly can be challenging and time-consuming, particularly on wider defects. In this technical note, we present an easier and faster way to position FL using a silicone sheet. FL graft is harvested using a standard technique. The required dimensions are evaluated depending on the extent of the dural defect taking in consideration that FL graft should exceed the edges of the dural defect especially laterally. It is then wrapped around a semi rigid pattern (Silastic sheet) and secured with several monofilament 5/0 sutures. The "package" is transferred through the endonasal corridor to the defect. The sutures are divided and taken out; the fascia is unfolded, and its edges are inserted into the subdural space without any twisting or folding of the flap. Finally, the silicone sheet is withdrawn from the nasal cavity, leaving the FL well-stretched in perfect position. We illustrate this technique in the management of a large anterior skull base chondrosarcoma, which necessitated significant bone and dural resection. The "Gift wrap" technique offers an alternative approach for positioning the FL, which is less time-consuming compared to the traditional technique. Moreover, it enables improved placement of the FL, enhancing its efficacy. [ABSTRACT FROM AUTHOR]

Key Points: Nasal packing type was not associated with postoperative cerebrospinal fluid leaksNondissolvable packing conferred an increased risk for postoperative sinonasal infectionsNasal packing type did not influence short‐ and long‐term quality‐of‐life scores [ABSTRACT FROM AUTHOR]

Background and Objectives: Skull base reconstruction is a crucial step during transsphenoidal surgery. Sphenoid mucosa is a mucosal membrane located in the sphenoid sinus. Preservation and lateral shifting of sphenoid mucosa as sphenoid mucosal flap (SMF) during the transsphenoidal exposure of the sella may be important for later closure. This is the first systematic review to evaluate the utility of sphenoid mucosal flap for sellar reconstruction after transsphenoidal surgery. Materials and Methods: A systematic literature search was performed in January 2023: Cochrane, EMBASE, PubMed, Scopus, and Web of Science. The following keywords and their combinations were used: "sphenoid mucosa", "sphenoid sinus mucosa", "sphenoid mucosal flap", "sphenoid sinus mucosal flap". From a total number of 749 records, 10 articles involving 1671 patients were included in our systematic review. Results: Sphenoid sinus mucosa used to be applied for sellar reconstruction as either a vascularized pedicled flap or as a free flap. Three different types of mucosal flaps, an intersinus septal flap, a superiorly based flap and an inferiorly based flap, were described in the literature. Total SMF covering compared to partial or no SMF covering in sellar floor reconstruction resulted in fewer postoperative CSF leaks (p = 0.008) and a shorter duration of the postoperative lumbar drain (p = 0.003), if applied. Total or partial SMF resulted in fewer local complications (p = 0.012), such as fat graft necrosis, bone graft necrosis, sinusitis or fungal infection, in contrast to no SMF implementation. Conclusions: SMF seems to be an effective technique for skull base reconstruction after transsphenoidal surgery, as it can reduce the usage of avascular grafts such as fat along with the incidence of local complications, such as fat graft necrosis, bone graft necrosis, sinusitis and fungal infection, or it may improve the sinonasal quality of life by maintaining favorable wound healing through vascular flap and promote the normalization of the sphenoid sinus posterior wall. Further clinical studies evaluating sphenoid mucosal flap preservation and application in combination with other techniques, particularly for higher-grade CSF leaks, are required. [ABSTRACT FROM AUTHOR]

Abstract Objective Currently, diagnosis of cerebrospinal fluid (CSF) rhinorrhea relies on a multimodal approach, increasing costs and ultimately delaying diagnosis. In the United States and internationally, the crux of such a diagnosis relies on confirmation testing (via biomarkers) and localization (e.g., imaging). Biomarker testing may require analysis at an outside facility, resulting in delays diagnosis and treatment. In addition, specialized imaging may be nonspecific and often requires an active leak for diagnosis. There remains a clear need for innovative new technology. Methods A comprehensive review was conducted on both foundational and innovative scholarly articles regarding current and emerging diagnosis modalities for CSF. Results Current modalities in CSF rhinorrhea diagnosis and localization include laboratory tests (namely, B2T immunofixation), imaging (CT and/or MRI) with or without intrathecal administration, and surgical exploration. Each of these modalities carry flaws, risks, and benefits, ultimately contributing to delays in diagnosis and morbidity. Promising emerging technologies include lateral flow immunoassays (LFI) and biologically functionalized field‐effect transistors (BioFET). Nevertheless, these carry some drawbacks of their own, and require further validation. Conclusion CSF rhinorrhea remains a challenging diagnosis, requiring a multimodal approach to differentiate from nonpathologic causes of rhinorrhea. Current methods in diagnosis are imperfect, as the ideal test would be a readily accessible, inexpensive, rapid, highly accurate point‐of‐care test without the need for excess fluid or specialized processing. Critical work is being done to develop promising, new, improved tests, though a clear successor has not yet emerged. Level of Evidence N/A

AimsPost-operative CSF leak is the major source of morbidity following transsphenoidal approaches (TSA) and expanded endonasal approaches (EEA) to lesions of the sella turcica and the ventral skull base. There are conflicting reports in the literature as to whether obesity (BMI ≥30) is a risk factor for this complication. We aimed to evaluate data collected as part of prospective multi-centre cohort study to address this question.MethodsThe CRANIAL (CSF Rhinorrhoea After Endonasal Intervention to the Skull Base) study database was reviewed and patients were divided into obese and non-obese cohorts. Data on patient demographics, underlying pathology, intra-operative findings and skull base repair techniques were analysed.ResultsTSA were performed on 726 patients, of whom 210 were obese and 516 were non-obese. The rate of post-operative CSF leak in the obese cohort was 11/210 (5%), compared to 17/516 (3%) in the non-obese cohort, which was not statistically significant (χ2 = 1.520, p=0.217). EEA were performed on 140 patients, of whom 28 were obese and 112 were non-obese. The rate of post-operative CSF leak in the obese cohort was 2/28 (7%), which was identical to the rate observed in the non-obese cohort 8/112 (7%) Fisher’s Exact Test, p=1.000). These results persisted following adjustment for inter-institutional variation and baseline risk of post-operative CSF leak.ConclusionCSF leak rates following TSA and EEA, in association with modern skull base repair techniques, were found to be low in both obese and non-obese patients. However, due to the low rate of post-operative CSF leak, we were unable to fully exclude a small contributory effect of obesity to the risk of this complication.

Background: Anterior cervical discectomy with fusion is a commonly performed procedure for symptomatic cervical disc herniation. However, Cerebrospinal fluid (CSF) leak is a rare complication accounting for about 0.2–3% and there is no definitive management algorithm for the management of the same.Case description: We report, case of a 32 year old quadriplegic gentleman with C3–C4 level traumatic disc prolapse with cord contusion and edema following road traffic accident. He developed incidental durotomy with significant CSF leak during ACDF surgery. It was managed successfully using a small rolled piece of surgicel, acetazolamide and lumbar drain. He has been on regular follow up and at 10 months postoperatively, there is no CSF related complication with Karnofsky Performance score of 90. Conclusion: Our treatment approach provides a viable option of managing CSF leak in low to medium income countries or in situations where ready access to fibrin glue or tacho sealant is not possible. In case of traumatic disc prolapse with cord contusion, it reduces the chances of mass effect, infection, foreign body reaction and overall cost of surgery. In this case of traumatic disc prolapse, CSF leak had actually hastened recovery of neurological deficits.

Spontaneous intracranial hypotension (SIH), which generally presents as orthostatic headache, is increasingly being identified due to improved imaging technologies and heightened awareness. Many prior studies have reported the characteristic brain MRI findings of SIH. However, recently, focus has shifted to spinal MRI, as SIH is believed to be caused by leakage of cerebrospinal fluid from the spinal dural sac. Advanced techniques such as ultrafast CT myelography and digital subtraction myelography have emerged as useful technique to identify the site of cerebrospinal fluid leakage. In this review, we discuss the diagnosis, spinal MRI findings, imaging techniques, and treatment of SIH.

AbstractObjectiveMethodsResultsConclusionsSpinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach. [ABSTRACT FROM AUTHOR]

Case: A 61-year-old woman with recurrent left L5 radiculopathy underwent revision L4-5 decompression complicated by incidental durotomy requiring primary repair. Postoperative course was complicated by wound drainage and headache. Repeat magnetic resonance imaging demonstrated cerebrospinal fluid dissecting a plane deep to the dura mater but superficial to the arachnoid, with the collection compressing the cauda equina in an atypical horizontal and linear fashion. Nonoperative treatment was ineffective, and she required revision decompression and dural repair. Conclusion: Spine surgeons should recognize this finding on postoperative imaging as a potential sign of an incomplete dural repair necessitating return to the operating room. [ABSTRACT FROM AUTHOR]

Background: With a rising incidence of cerebrospinal fluid (CSF) leaks, endoscopic endonasal CSF leak repair is increasingly performed. Current approaches utilize a variety of materials including free mucosal grafts and vascularized flaps, but post-op leaks continue to be reported. Steroid-eluting bioabsorbable stents (SES) are used during functional endoscopic sinus surgery for chronic rhinosinusitis to reduce inflammation and scarring while maintaining patency of sinus ostia. Objective: The aim of this study is to assess the feasibility of SES as a graft/flap bolster for endoscopic endonasal CSF leak repair. Methods: This is a retrospective review of patients undergoing endoscopic endonasal CSF leak repair with SES placed as part of the bolster technique at a tertiary care center between January 2019 and May 2022. Age, sex, BMI, comorbid idiopathic intracranial hypertension, pathology, location of CSF leak, intraoperative CSF leak flow, reconstruction type, and presence of post-op CSF leak were recorded. Results: Twelve patients (mean age 52, median BMI 30.9, 58% female) had SES placement as part of the bolster technique. The most common pathology was meningoencephalocele (75%). Reconstruction was performed with either a free mucosal graft (6), or a flap (6). No post-op CSF leaks occurred at a reconstruction site with a stent, and no known complications were reported. All sinusotomies were patent at the last follow-up visit. Conclusions: SES placement as an adjunct to graft and/or flap bolster appears to be safe and feasible during anterior skull base reconstruction and CSF leak repair providing longer term structural support and preserving sinus drainage patency. [ABSTRACT FROM AUTHOR]

BACKGROUND: The precise treatment of iatrogenic cerebrospinal fluid (CSF) otorhinorrhea has been poorly studied. The purpose of the study was to investigate the clinical manifestation, surgical results, and management of CSF leak. METHODS: Electronic medical record database of iatrogenic CSF leaks after erebellopontine angle(CPA) surgery from 2019 to 2022 was retrospectively analyzed. Three patients returned to the hospital with the complication of CSF leak. After failed attempts of conservative strategies or reverse surgical repair, adipose tissue was applied to the mastoid cracks repair. RESULTS: With the techniques described above, the CSF leaks were successfully settled. The identified patients were observed for at least 10 months. and there was no recurrence or other complications. CONCLUSION: Conservative treatment and initial surgical methods for occult postoperative CSF leaks are prone to delay effective results, particularly in patients with well-evaporated temporal bone. This complication can be minimized with transmastoid closure utilizing autologous fat. [ABSTRACT FROM AUTHOR]

Purpose: Endoscopic endonasal approaches in the pediatric population pose specific challenges. Management of postoperative cerebrospinal fluid [CSF] leak is probably the major concern. The purpose of the present investigation is to describe and analyze the incidence of postoperative CSF leaks in our pediatric series of endoscopic endonasal approaches. Methods: This is a retrospective analysis, case review of our institutional series. Descriptive statistical parameters and bivariate correlations are analyzed. Results: Twenty-one patients have been operated through endoscopic approaches in our series. Four patients showed a postoperative CSF leak needing a revision surgery; these cases are described in further detail. Approaches expanded beyond the sellar area and non-sellar pneumatization of the sphenoid sinus were significantly associated with a higher risk of postoperative CSF leak. Conclusions: CSF leak incidence after endoscopic endonasal approaches is higher in pediatric patients than in adult series. Anatomic and pathologic factors add complexity to these approaches in children. Multilayer closure is advisable to prevent and treat this complication. [ABSTRACT FROM AUTHOR]

Collection of cerebrospinal fluid (CSF) in the subdural compartment is a major cause of postoperative morbidity, especially for posterior fossa surgeries. Arachnoid closure techniques, including suturing of the arachnoid and use of synthetic sealants, have been described in the literature. However, they are not always feasible or effective and have not been universally adopted. We describe the technique of arachnoid welding for a case of brainstem cavernoma. This is a simple, cost-effective, and easily reproducible technique using readily available bipolar cautery kept at a low-current setting. At the end of surgery, the arachnoid leaflets are closely approximated, and bipolar cautery is used to seal the edges together. An illustrative video shows the technical nuances of this procedure. This technique can also be applied for arachnoid closure at other cranial and spinal sites. Arachnoid closure can act as an effective natural barrier to keep CSF in its physiological subarachnoid compartment. It provides an additional barrier to prevent CSF leak. It also prevents morbidity associated with adhesions and arachnoiditis. Proper closure of arachnoid makes durotomy during repeat surgery much easier and avoids injury to the underlying pia. A brief review of related literature shows the benefits of closing the arachnoid before dural closure and the different techniques that have been described so far. The arachnoid welding technique has a wide application, is easy to learn, and can be used especially for posterior fossa surgeries in which rates of CSF leak are the highest. [ABSTRACT FROM AUTHOR]

Different materials and techniques have been proposed for surgical repair of spontaneous middle cranial fossa (MCF) defects. However, conclusive evidence supporting their selection and impact on clinical outcomes is lacking. The study aims to conduct a systematic review and meta-analysis on materials and techniques employed to repair MCF defects and evaluate complications and rates of recurrent cerebrospinal fluid (CSF) leaks. A PRISMA-guided systematic review and meta-analysis were performed using MESH terms and specific keywords including studies published before May 2022. Primary outcomes included recurrence of CSF leak and complication rates by type of reconstructive material and technique utilized. Meta-analyses of proportions were performed using random effects and confidence intervals for individual proportions were calculated using the Clopper-Pearson method. Twenty-nine studies were included (n = 471 cases). Materials employed for repair were categorized according to defect size: 65% of defects were of unknown size, 24% were small (< 1 cm), and 11% were large (≥ 1 cm). Rigid reconstruction (RR) was significantly favored over soft reconstruction (SR) for larger defects (94% of cases, p < 0.05). Complications and recurrent CSF leak rates of SR and RR techniques were comparable for defects of all sizes (p > 0.05). Complication rates reported for these procedures are low regardless of technique and material. RR was universally preferred for larger defects and analysis of complication and recurrence rates did not reveal differences regardless of defect size. While RR was more frequently reported in smaller defects, SR was used by several centers, particularly for smaller MCF floor defects. [ABSTRACT FROM AUTHOR]

Background & objectives: Spontaneous intracranial hypotension (SIH) is an underdiagnosed and debilitating condition caused by a spinal cerebrospinal fluid (CSF) leak. Although SIH can lead to substantial morbidity and disability, little data exists about patients' perspectives. Without hearing directly from patients, our understanding of the full experience of having SIH is limited, as is our ability to identify and use appropriate patient-reported outcome measures (PROMs) within clinical care and research. The purpose of this study was to conduct qualitative interviews with confirmed SIH patients to fully describe their experiences and identify relevant concepts to measure. Methods: Patients were recruited from an SIH specialty clinic at a large, U.S.-based healthcare center. Patients undergoing an initial consultation who were ≥ 18 years old, English-speaking, met the International Classification of Headache Disorders-3 criteria for SIH, and had a brain MRI with contrast that was positive for SIH were eligible to participate. During semi-structured qualitative interviews with a trained facilitator, participants were asked to describe their current SIH symptoms, how their experiences with SIH had changed over time, and the aspects of SIH that they found most bothersome. Analysts reviewed the data, created text summaries, and wrote analytic reports. Results: Fifteen participants completed interviews. Common symptoms reported by patients included headache, tinnitus, ear fullness/pressure/pain, and neck or interscapular pain. Patients reported that their symptoms worsened over the course of their day and with activity. The most bothersome aspect of SIH was disruption to daily activities and limits to physical activities/exercise, which were severe. With regard to symptoms, the most bothersome and impactful included physical pain and discomfort (including headache), as well as fatigue. Conclusions: Patients reported a diverse set of symptoms that were attributed to SIH, with devastating impacts on functioning and high levels of disability. Researchers considering use of PROMs for SIH should consider inclusion of both symptom scales and aspects of functioning, and future work should focus on evaluating the validity of existing measures for this patient population using rigorous qualitative and quantitative methods in diverse samples. Additionally, these data can be used to assist clinicians in understanding the impacts of SIH on patients. [ABSTRACT FROM AUTHOR]

Introduction: Germinal matrix / intraventricular haemorrhage (GMIVH) remains a significant complication of prematurity. The more severe grades are associated with parenchymal haemorrhagic infarction (PHI) and hydrocephalus. A temporising procedure is usually the first line in management of neonatal post-haemorrhagic hydrocephalus (nPHH) as the risk of failure of a permanent cerebrospinal fluid (CSF) diversion is higher in the early stage. Our choice of temporising procedure is a ventriculosubgaleal shunt (VSGS). In this technical note, we describe a modification in technique whereby the pocket of the VSGS is fashioned away from the surgical wound. This resulted in lower CSF leak and subsequent infection rates in our centre. Methods: We conducted a retrospective analysis of all patients who underwent insertion of a VSGS between September 2014 and February 2023. Results: Twenty children were included in our study with a mean gestational age of 31 weeks + 4 days. Post-operatively, 10% of patients did not need a tap, and 10%, 20%, 15%, 25% and 20% respectively had 1, 2, 3, 4 and 5 taps. Two patients experienced CSF leak from their wounds. In both these patients, the pocket was deemed too close to the wound. None of the patients without suspected pre-existing CNS infection at the time of insertion of VSGS had a subsequent VSGS-related infection. VSGS conversion to permanent ventriculoperitoneal shunts (VPS) was required in 15 (75%) of the patients with an average interval duration of 72 days. On reviewing the literature, the infection rate following VSGS is quoted up to 13.5%. In our own centre, 13 patients had undergone VSGS insertion between 2005 and 2013 with a 30.8% infection rate which seemed related to increased leak rates. Conclusion: Our modified surgical approach seems to be effective in reducing the risk of infection, which we postulate is a direct result of reduction in the risk of leak from the surgical wound. [ABSTRACT FROM AUTHOR]

Aim: Posterior cranial fossa (PCF) surgery is associated with complications, including cerebrospinal fluid (CSF) leakage. Dural sealants such as polyethylene glycol (PEG)-based hydrogels and fibrin glue can prevent CSF leaks, with evidence suggesting PEG hydrogels may outperform fibrin glue. However, the budget impact of using PEG hydrogels in PCF surgeries in Europe is unclear. Materials & methods: A decision tree was developed based on a previous US model, to assess the budget impact of switching from fibrin glue to PEG hydrogel in PCF surgery across five European countries. Input costs were derived from published sources for the financial year 2022/2023. Health outcomes, including CSF leaks, were considered. Results: The model predicted that using PEG hydrogel instead of fibrin glue in PCF surgery can lead to cost savings in five European countries. Cost savings per patient ranged from EUR 419 to EUR 1279, depending on the country. Sensitivity analysis showed that the incidence of CSF leaks and pseudomeningoceles had a substantial impact on the model’s results. Conclusion: PEG hydrogels may be a cost-effective alternative to fibrin glue in PCF surgery. The model predicted that cost savings would be mainly driven by a reduction in the incidence of postoperative CSF leaks, resulting in reduced reliance on lumbar drains, reparative surgery and shortened hospital stays.

Introduction  There are many reported modifications to the retrosigmoid approach including variations in skin incisions, soft tissue dissection, bone removal/replacement, and closure. Objective  The aim of this study was to report the technical nuances developed by two senior skull base surgeons for retrosigmoid craniectomy with reconstruction and provide anatomic dissections, surgical video, and outcomes. Methods  The regional soft tissue and bony anatomy as well as the steps for our retrosigmoid craniectomy were recorded with photographs, anatomic dissections, and video. Records from 2017 to 2019 were reviewed to determine the incidence of complications after the authors began using the described approach. Results  Dissections of the relevant soft tissue, vascular, and bony structures were performed. Key surgical steps are (1) a retroauricular C-shaped skin incision, (2) developing a skin and subgaleal tissue flap of equal thickness above the fascia over the temporalis and sub-occipital muscles, (3) creation of subperiosteal soft tissue planes over the top of the mastoid and along the superior nuchal line to expose the suboccipital region, (4) closure of the craniectomy defect with in-lay titanium mesh and overlay hydroxyapatite cranioplasty, and (5) reapproximation of the soft tissue edges during closure. Complications in 40 cases were pseudomeningocele requiring shunt ( n  = 3, 7.5%), wound infection ( n  = 1, 2.5%), and aseptic meningitis ( n  = 1, 2.5%). There were no incisional cerebrospinal fluid leaks. Conclusion  The relevant regional anatomy and a revised technique for retrosigmoid craniectomy with reconstruction have been presented with acceptable results. Readers can consider this technique when using the retrosigmoid approach for pathology in the cerebellopontine angle.

Abstract Background To identify and predict risk factors associated with recurrent spontaneous cerebrospinal fluid (CSF) rhinorrhea, a cohort study included a total of 37 adult patients with spontaneous CSF rhinorrhea were analyzed. Results Over a 2-year period, 37 patients of spontaneous CSF leak with exclusion of other etiologies (traumatic, congenital) were enrolled: primary (non-recurrent) (n = 20) and secondary (recurrent) (n = 17), where 83.8% were females with an average body mass index (BMI) of 36.4 kg/m2. Associated symptoms of high intracranial pressure (ICP) namely, blurred vision and unsteadiness (P-value = 0.006 and 0.01, respectively), multiparity (92.3%), and failure to localize the defect (17.6%) contributed to patients having more recurrence. Although the cribriform plate was detected frequently (n = 29.4%), they were associated with lower recurrence compared to lateral recess of sphenoid (66.6% vs 20%). Conclusion Direct endoscopic visualization and repair of skull base defects achieve a high success rate, but failure is still a possibility especially in spontaneous etiology of leaks. In a multiparous female, with high CSF pressure, lateral sphenoid recess, large size, or unidentified defect, the incidence of recurrence is much higher. Level of evidence 4

Abstract Background & objectives Spontaneous intracranial hypotension (SIH) is an underdiagnosed and debilitating condition caused by a spinal cerebrospinal fluid (CSF) leak. Although SIH can lead to substantial morbidity and disability, little data exists about patients’ perspectives. Without hearing directly from patients, our understanding of the full experience of having SIH is limited, as is our ability to identify and use appropriate patient-reported outcome measures (PROMs) within clinical care and research. The purpose of this study was to conduct qualitative interviews with confirmed SIH patients to fully describe their experiences and identify relevant concepts to measure. Methods Patients were recruited from an SIH specialty clinic at a large, U.S.-based healthcare center. Patients undergoing an initial consultation who were ≥ 18 years old, English-speaking, met the International Classification of Headache Disorders-3 criteria for SIH, and had a brain MRI with contrast that was positive for SIH were eligible to participate. During semi-structured qualitative interviews with a trained facilitator, participants were asked to describe their current SIH symptoms, how their experiences with SIH had changed over time, and the aspects of SIH that they found most bothersome. Analysts reviewed the data, created text summaries, and wrote analytic reports. Results Fifteen participants completed interviews. Common symptoms reported by patients included headache, tinnitus, ear fullness/pressure/pain, and neck or interscapular pain. Patients reported that their symptoms worsened over the course of their day and with activity. The most bothersome aspect of SIH was disruption to daily activities and limits to physical activities/exercise, which were severe. With regard to symptoms, the most bothersome and impactful included physical pain and discomfort (including headache), as well as fatigue. Conclusions Patients reported a diverse set of symptoms that were attributed to SIH, with devastating impacts on functioning and high levels of disability. Researchers considering use of PROMs for SIH should consider inclusion of both symptom scales and aspects of functioning, and future work should focus on evaluating the validity of existing measures for this patient population using rigorous qualitative and quantitative methods in diverse samples. Additionally, these data can be used to assist clinicians in understanding the impacts of SIH on patients.