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Liquorrhea

Liquorrhea is the outflow of cerebrospinal fluid (CSF). Cerebrospinal fluid may leak from the nose, ear with simultaneous damage to the bones of the skull base and dura mater, as well as after neurosurgical operations as a result of a loose closure of the edges of the skin suture or the formation of secondary CSF fistula.

Liquorrhea (from Lat. Liquor - liquid and Greek. Rhoia - outflow) is the outflow of cerebrospinal fluid to the outside with skull injuries, spinal wounds, after cranial and spinal surgeries, sometimes as a complication of a brain tumor, cerebral hernia, hydrocephalus, etc. Liquorrhea from the subarachnoid spaces or ventricles of the brain is possible through the wound, between the sutures after operations, from the nose or the external auditory canal with fractures of the skull base or through the uzura of the integuments, for example, with meningocele.

Liquorrhea is manifested by soaking the dressing and pillow under the patient’s head with a clear or bloody liquid (clear liquorrhea). If the base of the skull is damaged, the cerebrospinal fluid may enter the nasal passages and from there it is aspirated or swallowed by patients (hidden liquorrhea). It is also necessary to distinguish liquorrhea: 1) primary, or early (occurs immediately after an injury or operation); 2) secondary, or late (cerebrospinal fluid fistula, occurs after infectious complications at a later date). Prolonged primary liquorrhea can turn into a cerebrospinal fluid fistula if meningitis, encephalitis, or chorioependimitis develops.

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According to the source, liquorrhea and cerebrospinal fluid fistulas are divided into subarachnoid (including cisternal) and ventricular. A special place is occupied by spinal liquorrhea with penetrating injuries of the spine, after surgeries on it or with congenital deformities, for example, with ulceration of cerebral hernias. Liquorrhea after injuries of the skull is extremely unfavorable; it leads to massive loss of fluid, creates the threat of microflora penetration into the cerebrospinal fluid spaces and their severe infection.

The kind of wound with liquor is characteristic. The wound is quickly cleared of brain debris and blood, it becomes clean and moist. The brain substance does not tarnish (from drying out), but on the contrary, under the influence of constant moisture, it acquires a characteristic mirror shine. After 1-2 minutes you can see the accumulation of cerebrospinal fluid in any deepening of the wound ("lake"). Samples Pussep, Kvekkenshtedt, Stukkey strengthen liquorrhea.

The general condition of the wounded is usually severe. In addition to general and focal symptoms, brain dehydration and desolation (“collapse”) of the ventricles, contributing to cerebral hypotension, develop. The latter in the initial stages is manifested by severe headaches, aggravated by raising the head, dry mouth, thirst, decreased urine, general weakness, and later - symptoms of meningitis, hyperthermia, the development of cachexia and coma, which often happens with ventricular damage. The lumbar puncture is often “dry”.

Cisternale liquorrhea is observed in injuries of the fronto-temporal-orbital, temporal-mastoid regions or posterior cranial fossa and with closed fractures of the skull base, when the frontal sinuses, the ethmoid bone, the pyramid of the temporal bone, etc. are damaged. nose or expire from the ear canal. Such liquorrhea is dangerous in the development of rhinogenic or otogenic meningitis.

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Primary ventricular liquorrhea usually accompanies severe injuries with damage to the deep parts of the brain. At the same time on the first day of the outflow of fluid is very abundant; then, as the loss of liquor, it decreases. The wound channel begins to gap, the brain sinks. The exhaustion of the wounded quickly grows.

Primary liquorrhea treatment consists primarily of early radical treatment of a craniocerebral wound with the imposition of a deaf suture and chemotherapy (see. Traumatic brain injury). Dehydration - according to indications (more often with cistern liquor). In early cases of nasal liquorrhea with fractures of the base of the skull, malnutrition, the administration of adrenaline, laxatives, and diuretics, give a good effect. Sometimes lumbar puncture is effective with abundant fluid extraction and the introduction of air or oxygen into the subarachnoid spaces. In case of persistent liquorrhea, it is necessary to install a permanent vinyl chloride lumbar drainage according to V. I. Grebenyuk or operate (revision of the fracture site on the base of the skull, closing the defect of the dura mater and the bone). In case of postoperative liquorrhea, lumbar punctures are made, medical dehydration and (after shaving the hair around the outflow of the fluid), an additional suture is applied through the entire thickness of the integument or the pinhole is sealed with a colloidal bandage.

Liquor fistula (fig.) - This is a common consequence of encephalitis, meningitis, abscess, causing the breakdown of brain tissue and ventricular perforation. There are often no hypotension phenomena; liquor is abundant.

liquor fistula
Ventricular liquor fistula (schematically)

Usually there is a protrusion of the brain that supports encephalitis, ventricular infection and the development of basilar meningitis. Treatment of cerebrospinal fluid fistula is aimed at eliminating the infectious complication that led to the formation of a fistula, and the use of general strengthening means to combat cachexia and dehydration. Antibiotics (taking into account the flora isolated from the wound and cerebrospinal fluid), blood transfusion, parenteral administration of large amounts of fluid before the closure of the fistula and vigorous dehydration when it is closed, careful care are integral parts of the treatment of this terrible complication. Locally, long-term dressings are used (for subarachnoid fistulas) or dressings with hypertonic solution (for ventricular fistulas and protrusion of the brain), irradiation of the wound with ultraviolet rays, protection of the swelling brain with a cotton-gauze bagel, etc.

Spinal liquorrhea and cerebrospinal fluid fistula require prompt surgical treatment - excision of the walls of the fistula and the imposition of blind sutures on the wound. Mandatory use of antibiotics and dehydrating therapy.

In some cases, lumbar punctures have to be performed 1–2 times a day (until the wound has healed), or permanent lumbar drainage is set to periodically release the CSF.

Liquorrhea is especially dangerous in case of ulceration of cerebral hernia. In these cases, urgent radical surgery (see Brain, hernia, Spina bifida) is shown “under the protection” of antibiotics.