Evidence-based approaches to cranial cerebrospinal fluid leaks in low- and middle-income countries: a systematic review of the literature

Cerebrospinal fluid (CSF) leaks commonly occur due to trauma or surgical procedures. Here we review CSF leak diagnosis and management in Low- and Middle-Income Countries (LMICs). A systematic review of the CSF leak management in LMICs was conducted using PubMed, Google Scholar, Embase and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Eighteen articles with 3,596 patients (mean age = 39.58 years) were analyzed. Of these patients, 31.37% (1,128/3,596) were reported to have developed cranial CSF leaks. The predominant presentation of CSF leak included symptoms of rhinorrhea, headache, meningitis, and visual impairment. The primary etiology of CSF leak was complications from endoscopic surgery (482 patients), followed by spontaneous origin (46 patients), craniotomy (44 cases), and trauma from motor vehicle accidents (43 cases). Computed tomography (CT) scans (10 retrospective, 15 case, and 1 comparative study) and magnetic resonance imaging (MRI) (6 retrospective, 11 case, and 2 comparative studies) were identified as the most utilized diagnostic modalities. The endoscopic endonasal technique emerged as the predominant surgical approach for managing CSF leak (5 retrospective, 13 case, and 1 comparative study). Moreover, both acellular dermal matrix and turbinate flaps demonstrated comparable repair rates in the management of CSF rhinorrhea (95.23% and 96.00%, respectively). Additionally, porcine-derived fibrin sealant exhibited enhanced success rates for repairs in craniotomies, increasing from 49.21% to 97.81%. This study demonstrates progress in the diagnosis, treatment, and management of cerebrospinal fluid (CSF) leaks within LMICs, including the noteworthy advancement from traditional microscope utilization to the endoscopic endonasal technique.