What to know about a CSF leak

Nuclear cisternography in the detection of CSF leak - Siemens ...

Cerebrospinal fluid (CSF) is a
clear liquid that surrounds the brain and spinal cord. Its role is to supply
nutrients to these areas and to cushion the brain inside the skull.
The brain is covered in thin
layers of tissue collectively called the dura mater, and CSF can escape through
a tear in this tissue. The fluid may then leak from the nose or ears or into
other parts of the body.
Also, CFS in the spine can
leak into muscles and connective tissue surrounding the spinal column.
A CSF leak is a serious issue
that can cause complications such as headaches, meningitis, and seizures.
This article describes the
causes and symptoms of a CSF leak. It also looks into how doctors diagnose and
treat the issue and what to expect during recovery.
According to the Spinal CSF
Leak Foundation, the most common symptom of a CSF leak is an upright headache —
a headache that worsens when the head is in an upright position, as when a
person is sitting or standing. These headaches usually improve when the person
lies down.
Sometimes, the position of the
head does not directly affect the severity of the headache. Instead, a person
may experience a headache that worsens throughout the day.
An individual with a CSF leak
may also notice clear, watery fluid draining from their nose or ears when they
move their head, especially when bending forward. CSF may also drain down the
back of the throat. People describe the taste as salty and metallic.
Other symptoms of a CSF leak

  • tinnitus, or ringing in the
  • hearing loss
  • changes in vision

In adults, up to 90% of all
CSF leaks result from head injuries.
Blunt force head injuries can
fracture bones in the face or the temporal bones on either side of the skull.
These fractures can also tear the dura mater, causing a CSF leak.
Other causes of a CSF leak —
in the skull or spine — include:

  • infection
  • an epidural injection
  • an anesthetic injection
  • a lumbar puncture
  • brain tumors
  • surgery on or around the base
    of the skull or spine
  • structural abnormalities of
    the skull that have been present from birth

A doctor can use a number of
tests to diagnose a CSF leak.
One test involves placing a
sample of what the doctor suspects to be CSF discharge on a piece of filter
paper. Once in contact with the paper, any CSF will separate from any blood or
mucus. The result will form two distinct rings, called a “target” or “double
ring” sign.
A healthcare professional can
often identify CSF just by looking at a sample on a handkerchief or piece of
gauze. Unlike mucus, which is thick and sticky, CSF is clear and watery.
Compared with mucus, CSF also
has a high concentration of glucose. Checking the glucose levels in nasal
discharge can help determine whether it contains CSF. Any sample of discharge
that contains CSF can indicate a leak.
If a doctor suspects a CSF
leak, they may order a CT or MRI scan to help confirm the diagnosis and locate
the leak.
Treatment options

Treatment for a CSF leak
depends on its severity and the cause. Some leaks respond to conservative
treatment, while others require more invasive approaches.
Conservative treatments

Conservative treatments mainly
focus on managing symptoms. These treatments may include:

  • bed rest
  • staying hydrated
  • taking over-the-counter or
    prescription pain relief medication
  • receiving intravenous caffeine
Invasive treatments

A CSF leak that does not
respond to conservative treatment may require more invasive approaches, such as
those below.
An epidural blood patch
An epidural blood patch is a
surgical procedure that involves using a person’s own blood to patch tears in
the dura mater.
During the procedure, the
surgeon draws 5–25 milliliters of the person’s blood, then injects it into a
space just outside of the tear in the dura mater.
Epidural blood patches have
high success rates but may not cure all types of CSF leaks.
In one 2016 study, researchers
compared the success rates of epidural blood patches in 133 people with CSF
The researchers divided the
participants into two groups based on the type of CSF leak. In one group,
medical procedures had been responsible for the leaks. In the other group,
there was no identified cause.
In 90.9% of the CSF leaks
resulting from medical procedures, a single blood patch successfully treated
each leak. In the other group, however, only 44.1% of the participants
experienced full recovery after each having received a single patch. The rest
of the group required additional treatment.
A doctor may recommend surgery
if a person has:

  • a CSF leak that does not
    improve with conservative treatment
  • a severe CSF leak that is
    unlikely to heal on its own
  • blood clotting in the brain or
    spinal cord
  • herniated brain tissue that
    pushes into the ears or nose
  • meningitis
Surgery involves suturing — or
stitching— any tear to prevent further CSF leakage.
The specific approach depends
on the location of the tear. For example, if a tear is in dura mater at the
front of the head and causes the fluid to leak through the nose, the
neurosurgeon may perform an endoscopic repair.
This is minimally invasive and
involves inserting a thin, flexible tube called an endoscope through the nose,
then passing tiny surgical tools through the tube to repair the tear.
If a tear causes CSF to drain
from the ears, a neurosurgeon will need to perform open surgery. This involves
making an incision in the scalp.
While an endoscopic approach
presents less risk than traditional open surgery, the two methods have similar
success rates.
A 2013 review compared the
success rates of endoscopic and traditional surgical treatments of CSF leaks in
the front of the skull. The review evaluated 71 studies, involving a total of
1,178 participants. The researchers found that each method successfully treated
around 90% of CSF leaks.
When to see a doctor

A person should consider
seeing a doctor if they experience any of the following symptoms of a CSF leak:

  • a persistent runny nose
  • drainage from the ears
  • a headache that worsens when
    the head is upright
Also, anyone who experiences
symptoms of a CSF leak following any of the following should seek medical

  • a head injury
  • a recent epidural
  • brain surgery
  • spinal cord surgery

Recovery depends largely on
the severity of the leak and the type of treatment.
People who receive
conservative treatment can expect to stay in bed for at least 3 days. The
doctor may recommend keeping the head elevated to encourage CSF drainage.
However, if the fluid drains
too quickly, it can cause pockets of gas — called cranial aeroceles — to form
inside the skull.
Other potential complications
of a CSF leak include:

  • brain herniation, which
    involves the dislocation of brain tissue within the skull
  • a stroke
  • a coma
When a person has undergone
surgical repair, they can expect to stay in the hospital for a few days or
weeks. During this time, healthcare professionals will closely monitor their
recovery and check for signs of complications, such as:

  • abscesses
  • infections
  • meningitis

Early and accurate diagnosis
of a CSF leak can lead to better treatment outcomes. It can also help prevent
If symptoms do not improve
within 10 days of conservative treatment, or if they return, a more invasive
intervention may be necessary.
Both epidural blood patch and
surgical procedures have relatively high success rates. However, they may not
work. Even after surgery, some people continue to experience symptoms or
disability resulting from CSF leakage.
A doctor or another healthcare
professional who specializes in neurological conditions can discuss the options
and recommend a course of treatment.


A CSF leak is a serious health
issue. It involves this type of fluid escaping through a tear in the dura
The symptoms of a CSF leak
include fluid drainage from the ears or nose and a headache that worsens when
the head is upright.
These leaks can result from
head injuries, infections, and certain medical procedures. Although this issue
may not cause alarming symptoms, it can lead to complications if the person
does not receive appropriate treatment.
The right treatment varies,
depending on factors specific to each person. Early conservative treatment
usually involves bed rest and hydration. If symptoms do not improve within 10
days, the person may require a more invasive procedure, such as an epidural
blood patch or surgery.
Medically reviewed by Nancy
Hammond, MD

Written by Jamie Eske

Kayode Ojo
Kayode Emmanuel Ojo is the Co-Founder and Managing Director at SHEFFA Limited. He is presently studying Computer Science at the National Open University, Victoria Island, Lagos.