Multimodal Imaging and Endoscopic Reconstruction of Skull Base Cerebrospinal Fluid Leaks: A Multidisciplinary Approach

Abstract

Skull base cerebrospinal fluid fistulas represent a complex clinical condition in which precise anatomical localization, appropriate surgical planning, and durable reconstruction are essential to prevent persistent leakage, recurrent meningitis, pneumocephalus, and other intracranial complications. This study analyzed the diagnostic and therapeutic management of skull base cerebrospinal fluid leaks from an integrated radiological, otorhinolaryngological, and neurosurgical perspective. A structured integrative review guided by the Scientific Method was performed, incorporating evidence from systematic reviews, meta-analyses, consensus statements, diagnostic studies, and surgical series addressing high-resolution computed tomography, magnetic resonance imaging, cisternographic techniques, endoscopic repair, reconstructive strategies, recurrence, and intracranial pressure abnormalities. High-resolution computed tomography showed particular value for identifying osseous defects and defining skull base anatomy, whereas magnetic resonance imaging and MR cisternography provided complementary information regarding cerebrospinal fluid pathways, meningoceles, encephaloceles, and soft-tissue abnormalities. The combined use of both modalities provided the most comprehensive framework for preoperative localization. Endoscopic repair demonstrated high rates of successful closure, with primary success exceeding 90% in major evidence syntheses and overall success approaching 97–100% after revision procedures. Multilayer reconstruction showed higher pooled closure rates than single-layer techniques, although the difference was not statistically significant in the most recent meta-analysis. Vascularized and mucosal flap reconstruction was associated with lower postoperative leakage rates in large or high-flow defects. Spontaneous fistulas were frequently associated with obesity, obstructive sleep apnea, and elevated intracranial pressure, emphasizing the need to investigate underlying pressure-related disorders. Overall, the findings support a multidisciplinary and risk-adapted approach in which multimodal radiological localization, defect-specific endoscopic reconstruction, and postoperative evaluation of intracranial pressure are integrated into a continuous diagnostic–therapeutic pathway.