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Spontaneous and idiopathic CSF leak in the infrasellar, clival region. Problem: Although rarely developing spontaneously, cerebrospinal fluid (CSF) rhinorrhea may have devastating consequences such as meningitis, intracranial hypotension, (meningo)encephalocele formation, or intracranial abscesses.
Case Description: A 66-year old man presented with fulminant pneumococcal meningitis. After putting the patient upright, clear CSF was observed leaking through the left nostril and was clinically confirmed. Computed tomography and magnetic resonance imaging showed CSF in the extensively pneumatized left sphenoidal sinus. An endoscopic, endonasal, transsphenoidal exploration revealed an infra- to retrosellar, clival breach and linear dural tear. Inlay plugging with autologous fat and fascia and an overlay covering with a free mucosal flap efficiently closed the defect.
Conclusions: Spontaneous CSF leakage without predisposing factors is rare and its exact pathophysiology is incompletely understood, but a consensus exists that a triad of dura disruption, bony defect, and pressure gradient promote these types of CSF leaks.