Headache and cerebrospinal fluid dynamics: spontaneous CSF rhinorrhea in a patient with history of idiopathic intracranial hypertension.

Spontaneous cerebrospinal fluid (CSF) rhinorrhea, characterized by the unexplained leakage of CSF from the nose, is a rare and clinically intriguing condition. Trauma accounts for 80-90% of cases, other causes are postoperative (10%), spontaneous (4%), neoplastic (2%), inflammatory (2%) [1]. When not associated with other factors, it is termed spontaneous, and it is at high risk of bacterial meningitis and cerebral abscesses [2]. Diagnosis involves clear unilateral rhinorrhea and confirmation through fluid analysis (Beta-2 transferrin, glucose) [2]. Radiological examination, preferably CT with potential MRI, is crucial. Treatment entails surgical closure of the osteomeningeal defect, but it’s insufficient for overall management, for the frequent underlying chronic idiopathic intracranial hypertension (IIH) [3]. Chronic IIH and spontaneous CSF leakage are suggested to be linked, sharing demographic similarities, increased intracranial pressure (ICP) after repair, elevated risk of recurrence, and heightened risk with tumor-associated IIH. Uncontrolled IIH increases the risk of repair failure or recurrence. IIH involves increased ICP without secondary causes, presenting symptoms like headache, papilledema, and visual disturbances. Its association with spontaneous CSF rhinorrhea is uncommon, providing sparse literature, necessitating further exploration for enhanced understanding and optimal management. Case Report: We report the case of a 51-year-old woman with a seven-year history of IIH, diagnosed by the presence of headaches and papilledema. She was treated pharmacologically with acetazolamide to manage her symptoms and stabilize intracranial pressure. The patient was admitted to the hospital due to the spontaneous onset of cerebrospinal fluid rhinorrhea following a sneeze, accompanied by severe headache and retro-orbital pain that worsened with an upright posture. A cranial CT scan and subsequent brain MRI revealed numerous invaginations of the meninges containing cerebrospinal fluid, some of which were associated with clear fistulous tracts involving bony structures. The fibrolaryngoscopic examination confirmed secretion at specific intranasal sites. Consequently, the patient was referred for surgery to close the fistula. Conclusions: This case raises questions about the IIH-CSF leakage association and calls for multidisciplinary management. The connection has gained recognition, but opinions on assessment and management vary. Scientific literature hints at a potential link between pathology and compromised CSF barrier stability, urging further exploration of the ICP-CSF barrier relationship. A multidisciplinary approach is recommended for accurate diagnosis, treatment, and follow-up. We aim to assess clinical implications of the case and conduct a literature review on the IIH-spontaneous CSF leakage association, emphasizing the need for a unified and comprehensive approach to patient care.