METHODS: A retrospective study was performed over 4 years involving three surgeons from Malaysia, Singapore, and Thailand. Hospital records were reviewed to determine the patients' characteristics, the causes and sites of leaks, methods of investigation, skull base configurations, choices of treatment, and outcomes.
RESULTS: A total of 15 cases (7 traumatic and 8 non-traumatic) were included. Imaging was performed in all cases. The most common site of leakage was the cribriform plate (9/15 cases). The mean ± SD of the Keros heights were 4.43 ± 1.66 (right) and 4.21 ± 1.76 mm (left). Type II Keros was the most common (60%). The mean ± SD angles of the cribriform plate slope were 51.91 ± 13.43 degrees (right) and 63.54 ± 12.64 degrees (left). A class II Gera configuration was the most common (80%). All except two patients were treated with endonasal endoscopic surgical repair, with a success rate of 92.3%. A multilayered repair technique was used in all patients except one. The mean ± SD postoperative hospital stay was 9.07 ± 6.17 days.
CONCLUSIONS: Non-traumatic CSF rhinorrhea outnumbered traumatic CSF rhinorrhea, with the most common site of leak at the cribriform plate. Imaging plays an important role in investigation, and Gera classification appears to be better than Keros classification for evaluating risk. Both conservative and surgical repairs are practiced with successful outcomes. Endonasal endoscopic CSF leak repair is the mainstay treatment.
METHODS: Albuminocytologic dissociation (ACD) was defined as an increased protein level (>0.45 g/L) in the absence of elevated white cell count (<50 cells/μL). We excluded 124 (8%) patients because of other diagnoses, protocol violation, or insufficient data. The CSF was examined in 1,231 patients (89%).
RESULTS: In 846 (70%) patients, CSF examination showed ACD, which increased with time from weakness onset: ≤4 days 57%, >4 days 84%. High CSF protein levels were associated with a demyelinating subtype, proximal or global muscle weakness, and a reduced likelihood of being able to run at week 2 (odds ratio [OR] 0.42, 95% CI 0.25-0.70; p = 0.001) and week 4 (OR 0.44, 95% CI 0.27-0.72; p = 0.001). Patients with the Miller Fisher syndrome, distal predominant weakness, and normal or equivocal nerve conduction studies were more likely to have lower CSF protein levels. CSF cell count was <5 cells/μL in 1,005 patients (83%), 5-49 cells/μL in 200 patients (16%), and ≥50 cells/μL in 13 patients (1%).
DISCUSSION: ACD is a common finding in GBS, but normal protein levels do not exclude this diagnosis. High CSF protein level is associated with an early severe disease course and a demyelinating subtype. Elevated CSF cell count, rarely ≥50 cells/μL, is compatible with GBS after a thorough exclusion of alternative diagnoses.
CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that CSF ACD (defined by the Brighton Collaboration) is common in patients with GBS.