A Case of late post-traumatic paradoxical nasal cerebrospinal fluid leak: a multidisciplinary approach to diagnosis and treatment

Abstract

Nasal cerebrospinal fluid (CSF) leakage occurs in 12–30% of patients with skull base fractures, whereas its late paradoxical form is observed in only 2% of traumatic brain injury (TBI) cases and represents an extremely rare and insufficiently studied phenomenon.

A retrospective analysis of this clinical case was performed, illustrating the complexity of differential diagnosis and emphasizing the priority of clinical reasoning in the management of complex patients with TBI.

Ten years after sustaining severe TBI with a fracture of the petrous part of the right temporal bone, the patient developed paradoxical nasal CSF leakage that had not been verified at the outpatient stage. Following comprehensive evaluation at the Romodanov Neurosurgery Institute of the National Academy of Medical Sciences of Ukraine, the patient underwent surgical treatment, which resulted in complete resolution of the CSF leak. The patient was discharged in satisfactory condition without signs of recurrence.

The presented case demonstrates an exceptionally rare combination in adults (0.05–1.0%) of meningoencephalocele and a porencephalic cyst associated with a growing skull base fracture, which led to the development of late post-traumatic paradoxical nasal CSF leakage. In the absence of access to β2-transferrin testing, the key diagnostic marker was identified as the combination of nasal CSF leakage with a specific audiometric pattern (mixed hearing loss with an intact tympanic membrane), which required mandatory verification using combined neuroimaging modalities (computed tomography and magnetic resonance imaging). A surgical strategy focused on watertight duraplasty proved effective, ensuring cessation of CSF leakage and partial regression of the conductive component of hearing loss despite the high recurrence risk reported in the literature.

Conclusions: Timely diagnosis of late post-traumatic paradoxical nasal CSF leakage is critically important for preventing intracranial complications; however, it remains a challenging task in patients with a history of TBI. The presented clinical case highlights the necessity of a multidisciplinary approach for accurate verification of the pathology and selection of effective treatment strategies in the remote post-traumatic period.