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Table of Contents
CASE REPORT  
Year : 2013  |  Volume : 16  |  Issue : 4  |  Page : 283-285
Coronary artery bypass surgery in the presence of cerebrospinal fluid rhinorrhea


1 Medanta Institute of Critical Care and Anesthesiology, Medanta- The Medicity, Gurgaon, Haryana, India
2 Medanta Heart Institute, Medanta- The Medicity, Gurgaon, Haryana, India
3 Functional Neurosurgery, Medanta Institute of Neurosciences, Gurgaon, Haryana, India

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Date of Submission11-Jan-2013
Date of Acceptance03-Jul-2013
Date of Web Publication1-Oct-2013
 

   Abstract 

A seventy eight year old male patient was admitted in our hospital with headache, vomiting, irritability and confusion. Initially he was diagnosed as a case of pyogenic encephalitis. Further investigations revealed that patient had cerebrospinal fluid rhinorrhea and coronary artery disease. He successfully underwent coronary artery bypass grafting and cerebrospinal fluid leak repair.

Keywords: Cerebrospinal fluid; Coronary artery disease; Rhinorrhea

How to cite this article:
Rawat RS, Mehta Y, Trehan N, Gupta A. Coronary artery bypass surgery in the presence of cerebrospinal fluid rhinorrhea. Ann Card Anaesth 2013;16:283-5

How to cite this URL:
Rawat RS, Mehta Y, Trehan N, Gupta A. Coronary artery bypass surgery in the presence of cerebrospinal fluid rhinorrhea. Ann Card Anaesth [serial online] 2013 [cited 2020 Aug 5];16:283-5. Available from: http://www.annals.in/text.asp?2013/16/4/283/119181



   Introduction Top


Cerebrospinal fluid (CSF) rhinorrhea is a pathological communication between the subarachnoid space and nasal cavity. While managing the patient for the CSF leak coronary artery disease was detected in the patient. Timely interventions helped to manage the case and saved the life.


   Case Report Top


A 78-year-old hypertensive, non-diabetic, male patient was admitted with the complaints of sudden onset headache, vomiting and irritability. At admission, he developed tonic clonic seizures. A careful history revealed history of road traffic accident 5 years ago, but he had no neurological deficit. On examination, he was restless, confused and was not following verbal commands, but he was moving all four limbs. Pupils were 3 mm in size and reacting to light. Elicitation of planter reflexes showed extensor response. The magnetic resonance imaging (MRI) brain showed hemosiderin staining in left frontal region suggesting old venous hemorrhagic infarct with recanalized superior sagittal sinus and partial filling defect at the origin of left transverse sinus suggesting residual organized thrombus. The lumbar puncture showed normal pressure clear cerebrospinal fluid (CSF). Analysis of CSF showed protein 873 mg/dl, glucose 20 mg/dl, chloride 114 mmol/l; total and differential-white blood cells count was 266/HPF with neutrophils 95% and lymphocytes 5%. The CSF was sterile and culture growth was negative for acid fast bacillus (AFB; mycobacterium tuberculosis) and fungus. Blood and urine culture showed no growth. Widal test was negative. Polymerase chain reaction for mycobacterium tuberculosis was negative. A diagnosis of pyogenic encephalitis was made. He was treated with ceftriaxone, mannitol, phenytoin, dexamethasone, esomeprazole and promethazine. Patient showed some improvement and started following verbal commands. After 4 days, he again developed headache and this time there was no neurological abnormality. Typically, headache worsened with sitting up position. This time, he had clear fluid dribbling through the nose in the sitting position. MRI showed a focal defect in the cribriform plate with herniation of dura into the anterior ethmoid sinuses and presence of fluid within the ethmoid air cells [Figure 1]. Examination of this fluid showed 225 cell count/HPF, 2 g/l protein, 49 mg/dl glucose. A beta-2-transferrin test of the fluid confirmed it to be CSF; its culture showed no growth. Conservative treatment continued with bed rest in 30° propped up position, intravenous fluids and same broad spectrum antibiotics. He was advised not to strain to avoid rise in intracranial pressure (ICP). An oral laxative (cremaffin 30 ml at bed time) was also started. Gradually, CSF leak decreased and his general condition improved. On day 7, he was noted to be uncomfortable and he complained of chest pain and breathlessness. Echocardiography showed normal function of heart and valves with an ejection fraction of 60%. Coronary angiography revealed a long lesion with 80% stenosis in left anterior descending (LAD) artery with first and second diagonal arising from the diseased segments. In view of long lesion, coronary artery bypass grafting (CABG) and for CSF rhinorrhea CSF leak repair was planned.
Figure 1: Magnetic resonance image showing the defect in cribriform plate, herniation of dura into anterior ethmoid sinuses and presence of fluid within anterior ethmoid air cells. (a) Defect in cribriform plate. (b) Outpouching of cerebrospinal fluid in the nasal cavity

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Lorazepam 2 mg was administered as premedication at night before surgery and on the day of surgery. In the operating room, care was taken during his transfer from trolley to the operation table to avoid any strain. Anesthesia was induced with midazolam, fentanyl and sleep dose of thiopentone taking care to avoid sudden rise of blood pressure and ICP. Vecuronium was used to facilitate endotracheal intubation. Anesthesia was maintained with the supplemental doses of midazolam, fentanyl and vecuronium. Off-pump coronary artery bypass surgery (OPCAB) was performed with left internal mammary artery to LAD artery and reversed saphenous vein grafts to first and second diagonal branches. At sternal closure, propofol infusion was started to keep patient sedated in the post-operative period and intensive care unit to avoid straining. There was no CSF leak through the nose. Next day, patient was taken to neurosurgery operating room and bifrontal craniotomy was performed and CSF leak was traced to the defect in the cribriform area. It was closed with fascia and fibrin glue. Patient was ventilated overnight and trachea was extubated next day. Rest of the period was uneventful and the patient was discharged home 2 weeks after admission to hospital.


   Discussion Top


CSF rhinorrhea is a pathological communication between the subarachnoid space and the nasal cavity or tympano-mastoid space. It involves a breach of the dura that separates the subarachnoid space from the nasal cavity; most common site is sinuses and base of the skull. The etiology of CSF rhinorrhea includes head injury involving skull base fracture, blunt trauma head, surgery for tumor or paranasal sinuses, inflammatory diseases and the conditions that lead to increase in ventricular pressure (such as intracranial tumors, hydrocephalus. Arachnoid granulations present along the cribriform plate may also lead to spontaneous CSF rhinorrhea. [1] The presence of glucose content > 0.4 g/l and protein content < 1 g/l up to a maximum of 2 g/l in the rhinorrhea fluid is definitive of CSF; however, contamination of blood or wound secretions can confound the results. The presence of beta-2 transferrin in the fluid can distinguish between secretions and CSF. The beta-2 transferrin presence is highly sensitive and specific for the CSF. It makes a highly reliable assay for detecting CSF rhinorrhea in samples. [2] Imaging is performed to anatomically localize the site. Computed tomography (CT) scan may show small defects or fracture in the region of anterior skull base or sphenoid sinuses. The two most common areas for defects producing CSF rhinorrhea are the cribriform niche adjacent to the vertical attachments of the middle turbinate (fovea ethmoidalis) and the superior and lateral walls of the sphenoid sinus. Administration of intrathecal contrast prior to high resolution coronal CT scan can identify the true site of the leak. [1] Flow sensitive MRI has been also used to evaluate CSF flow in the head and spine and to evaluate the presence of communication between CSF spaces.

Most cases of CSF leak occurring after blunt trauma or base surgery resolve with conservative measure alone. Bed rest, elevation of the head, stool softener, avoidance of straining and decreasing CSF pressure with lumbar-drain or spinal taps have been used as effective options. Once the diagnosis of CSF rhinorrhea was made, patient was given complete bed rest. Propped up position helped to reduce ICP and thus to decrease the leak. Laxative also helped to avoid strain. All possible care was taken to avoid strain in perioperative period. Nasal packing was avoided to prevent any ascending bacterial infection. We gave sterile gauze pieces only to wipe the dribbling fluid. The leaks provide a favorable site for microbes to enter the subarachnoid space leading to meningitis. The risk of meningitis in patients with CSF leak range from 10% to 21% with or without antibiotic prophylaxis. [3] Apparently, patients of watery rhinorrhea particularly if the rhinorrhea increases with posture requires immediate attention. However, many patients have shown improvement with conservative management in the previous case reports; therefore, initially, we managed the patient conservatively, but in view of recent convulsions and coronary artery disease (CAD), CABG and repair for CSF leak were decided. Both these procedures are major; therefore, it was decided to proceed for these operations in two stages. Keeping in mind recent neurological event, we planned for OPCAB. The idea was to prevent further neurological complications, which are associated with CABG. OPCAB have been reported in the presence of raised ICP with a successful outcome. [4] OPCAB was considered a greater priority than repair of CSF rhinorrhea. Performing OPCAB in a patient with CSF rhinorrhea was not a major risk as antibiotics were already being administered and CSF leak was to be repaired the next day. Reversing the order of surgeries would have subjected this patient with CAD to the risk of acute cardiac event (myocardial infarction) during or after surgical repair for CSF leak. Endoscopic intranasal repair is preferred method of surgical repairs. Fibrin glue enhances adhesion of the graft.


   Conclusion Top


Patients with clear watery discharge through nose should be taken seriously. It could be CSF leak, which is a potential source of encephalitis. With adequate timely care, propped up position, avoiding strain and antibiotic cover helped us to perform major surgical procedures with successful result.

 
   References Top

1.Abuabara A. Cerebrospinal fluid rhinorrhoea: Diagnosis and management. Med Oral Patol Oral Cir Bucal 2007;12:E397-400.  Back to cited text no. 1
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2.Arrer E, Meco C, Oberascher G, Piotrowski W, Albegger K, Patsch W. Beta-trace protein as a marker for cerebrospinal fluid rhinorrhea. Clin Chem 2002;48:939-41.  Back to cited text no. 2
[PUBMED]    
3.Kuo CP, Wong CS, Borel CO, Yang CP, Yeh CC, Lu CH, et al. Cerebrospinal fluid rhinorrhea after thermometer insertion through the nose. Anesth Analg 2004;99:617-9.  Back to cited text no. 3
[PUBMED]    
4.Capdeville M, Lee JH, Abdel-Hady K. Off-pump coronary artery bypass surgery in a patient with a symptomatic intracranial mass. J Cardiothorac Vasc Anesth 2001;15:352-5.  Back to cited text no. 4
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Correspondence Address:
Yatin Mehta
Medanta Institute of Critical Care and Anesthesiology, Medanta. The Medicity, Sector 38, Gurgaon, Haryana - 122 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.119181

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