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The efficacy and safety of intrathecal fluorescein in endoscopic cerebrospinal fluid leak repair –a systematic review

Published:April 04, 2022DOI:https://doi.org/10.1016/j.anl.2022.03.014

      Abstract

      Background

      Effective management of cerebrospinal fluid (CSF) leaks can reduce significant associated morbidity. Intrathecal fluorescein (IF) may be a valuable intra-operative adjunct to localise leak sites. Recent reports have demonstrated low doses of IF to be safe, however, no internationally accepted dose of IF has been agreed.

      Objective

      To assess the efficacy and safety of IF used in the endoscopic management of anterior skull base CSF fistulae.

      Methods

      A systematic review and descriptive analysis were performed of all published data in accordance to PRISMA guidelines.

      Results

      There were 18 included articles giving a total of 335 procedures where IF was used. Doses of IF ranged from 10mg - 150mg. IF positively identified the site of CSF fistula in 88.7% of cases (n = 297). There was a total of 25 reported peri-operative complications in all included studies (7.5%) with 5.1% (n = 17) potentially related to IF use. Of these, the complication rate was 3.9% at low IF doses (<50mg) and 80.0% at higher doses ( 50mg).

      Conclusion

      Our review demonstrates that IF is effective at localising CSF fistulae with most significant complications being related to doses 50mg. We therefore propose that there is a potential for the licensing of IF in this field. Doses <50mg have consistently been shown to be safe while still maintaining effective localisation rates. Based on the most common doses used in this group, we recommend utilisation of a dosing below 50mg, with the most frequent range being between 10-30mg.

      Keywords

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      References

        • Bernal-Sprekelsen M
        • Alobid I
        • Mullol J
        • Trobat F
        • Tomas-Barberan M.
        Closure of cerebrospinal fluid leaks prevents ascending bacterial meningitis.
        Rhinology. 2005 Dec 1; 43: 277
        • Zhu ZJ
        • Cheng L
        • Yang J.
        Transnasal endoscopic repair of adult spontaneous cerebrospinal fluid rhinorrhea with assistance of computer-assisted navigation system: an analysis of 21 cases.
        Eur Arch Oto-Rhino-Laryngol. 2019 Oct 1; 276: 2835-2841
        • Kreatsoulas DC
        • Shah VS
        • Otto BA
        • Carray RL
        • Prevedello DM
        • Hardesty DA.
        Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea.
        J Neurosurg. 2020 Feb 28; 1: 1-7
        • Zweig JL
        • Carrau RL
        • Celin SE
        • Snyderman CH
        • Kassam A
        • Hegazy H.
        Endoscopic repair of acquired encephaloceles, meningoceles, and meningo-encephaloceles: predictors of success.
        Skull Base. 2002; 12: 133-140
        • Hegazy HM
        • Carrau RL
        • Snyderman CH
        • Kassam A
        • Zweig J.
        Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis.
        Laryngoscope. 2000; 110: 1166-1172
        • Gonen L
        • Monteiro E
        • Klironomos G
        • Alghonaim Y
        • Vescan A
        • Gelareh Z
        • et al.
        Endoscopic endonasal repair of spontaneous and traumatic cerebrospinal fluid rhinorrhea: a review and local experience.
        Neurosurg Clin N Am. 2015 Jul 1; 26: 333-348
        • Keshri A
        • Jain R
        • Manogaran RS
        • Behari S
        • Khatri D
        • Mathialagan A.
        Management of Spontaneous CSF Rhinorrhea: An Institutional Experience.
        J Neurol Surg B Skull Base. Oct 2019; 80: 493-499
        • Keerl R
        • Weber RK
        • Draf W
        • Wienke A
        • Schaefer SD.
        Use of sodium fluorescein solution for detection of cerebrospinal fluid fistulas: an analysis of 420 administrations and reported complications in Europe and the United States.
        Laryngoscope. 2004; 114: 266-272
        • Kirchner FR
        • Proud GO.
        Method for the identification and localization of cerebrospinal fluid, rhinorrhea and otorrhea.
        Laryngoscope. 1960; 70: 921-931
        • Moseley JI
        • Carton CA
        • Stern WE
        Spectrum of complications in the use of intrathecal fluorescein.
        J Neurosurg. 1978; 48: 765-767
        • Felisati G
        • Bianchi A
        • Lozza P
        • Portaleone S.
        Italian multicentre study on intrathecal fluorescein for craniosinusal fistulae.
        Acta Otorhinolaryngol Ital. 2008; 28: 159-163
        • Javadi SA
        • Samimi H
        • Naderi F
        • Shirani M.
        The use of low- dose intrathecal fluorescein in endoscopic repair of cerebrospinal fluid rhinorrhea.
        Arch Iran Med. 2013; 16: 264-266
        • Laufer I
        • Anand VK
        • Schwartz TH.
        Endoscopic, endonasal extended transsphenoidal, transplanum transtuberculum approach for resection of suprasellar lesions.
        J Neurosurg. 2007; 106: 400-406https://doi.org/10.3171/jns.2007.106.3.400
        • Lund VJ.
        Endoscopic management of cerebrospinal fluid leaks.
        Am J Rhinol. 2002; 16: 17-23
        • Page MJ
        • McKenzie JE
        • Bossuyt PM
        • Boutron I
        • Hoffmann TC
        • Murlow CD
        • et al.
        The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
        BMJ. 2021; 372: n71
      1. OCEBM Levels of Evidence Working Group. The Oxford Levels of Evidence 2 (Internet). Oxford Centre for Evidence-Based Medicine. https://www.cebm.net/index.aspx?o=5653.

        • Jolly K
        • Gupta KK
        • Banota A
        • Ahmed SK.
        The Effectiveness and Safety of Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leaks.
        Am J Rhinol Allergy. 2021; 35: 879-884https://doi.org/10.1177/19458924211020564
        • Flynn JP
        • Pavelonis A
        • Ledbetter L
        • Bhalla V
        • Alvi SA
        • Chiu AG
        • et al.
        The Utility of Computed Tomography and Intrathecal Fluorescein in the Management of Cerebrospinal Fluid Leak.
        Am J Rhinol Allergy. May 2020; 34: 342-347
        • Ramalingam N
        • Nair NP
        • Saxena SK
        • Hegde JS.
        Role of Blue-green-light Filter in Detecting a Spontaneous Cerebrospinal Fluid Rhinorrhea in an Unusual Site.
        Clin Rhinol An Int J. 2018; 11: 52-54
        • Englhard AS
        • Volgger V
        • Leunig A
        • Mesmer CS
        • Ledderose GJ.
        Spontaneous nasal cerebrospinal fluid leaks: management of 24 patients over 11 years.
        Eur Arch Oto-Rhino-Laryngol. 2018 Oct 1; 275: 2487-2494
        • Borsetto D
        • Ciorba A
        • Cazzador D
        • Volo T
        • Denaro L
        • D'Avellal ED
        • et al.
        Transnasal endoscopic management of anterior cerebrospinal fluid (CSF) leak: experience from a large case series.
        B-ENT. 2017 Jan 1; 13: 15-21
        • Rodríguez-Navarro MÁ
        • Díaz-Alejo C
        • Padilla-Del Rey ML
        • Alcaraz AB
        • Gonzalez-Perez P
        • Benitez M
        Safe intrathecal fluorescein use for identification of cerebrospinal fluid leaks: Case-report and perioperative algorithm description.
        Rev Esp Anestesiol Reanim. 2017; 64: 533-536https://doi.org/10.1016/j.redar.2017.03.003
        • Emanuelli E
        • Milanese L
        • Rossetto M
        • Cazzador D
        • d'Avella E
        • Volo T
        • et al.
        The endoscopic endonasal approach for cerebrospinal fluid leak repair in the elderly.
        Clin Neurol Neurosurg. 2015; 132: 21-25https://doi.org/10.1016/j.clineuro.2015.02.013
        • Banu MA
        • Kim JH
        • Shin BJ
        • Woodworth GF
        • Anand VK
        • Schwartz TH.
        Low-dose intrathecal fluorescein and etiology-based graft choice in endoscopic endonasal closure of CSF leaks.
        Clin Neurol Neurosurg. 2014 Jan 1; 116: 28-34
        • Jacob AK
        • Dilger JA
        • Hebl JR.
        Status epilepticus and intrathecal fluorescein: anesthesia providers beware.
        Anesth Analg. Jul 2008; 107: 229-231https://doi.org/10.1213/ane.0b013e318174dfbe
        • Anari S
        • Waldron M
        • Carrie S
        Delayed absence seizure: A complication of intrathecal fluorescein injection: A case report and literature review.
        Auris Nasus Larynx. 2007 Dec 1; 34: 515-518
        • Park KY
        • Kim YB.
        A case of myelopathy after intrathecal injection of fluorescein.
        J Korean Neurosurg Soc. Dec 2007; 42 (Epub 2007 Dec 20): 492-494https://doi.org/10.3340/jkns.2007.42.6.492
        • Silva LR
        • Santos RP
        • Zymberg ST
        Endoscopic endonasal approach for cerebrospinal fluid fistulae.
        Minim Invasive Neurosurg. Apr 2006; 49: 88-92
        • Landeiro JA
        • Lazaro B
        • Melo MH
        Endonasal endoscopic repair of cerebrospinal fluid rhinorrhea.
        Minim Invasive Neurosurg. Jun 2004; 47: 173-177
        • White DR
        • Dubin MG
        • Senior BA
        Endoscopic repair of cerebrospinal fluid leaks after neurosurgical procedures.
        Am J Otolaryngol. 2003 Jul 1; 24: 213-216
        • Gendeh BS
        • Wormald PJ
        • Forer M
        • Goh BS
        • Misiran K.
        Endoscopic repair of spontaneous cerebrospinal fluid rhinorrhoea: a report of 3 cases.
        Med J Malaysia. Dec 2002; 57: 503-508
        • Wallace JD
        • Weintraub MI
        • Mattson RH
        • Rosnagle R.
        Status epilepticus as a complication of intrathecal fluorescein.
        J Neurosurg. May 1972; 36: 659-660https://doi.org/10.3171/jns.1972.36.5.0659