Potential role of standardized orbital ultrasound in the management of spontaneous CSF leaks

Spontaneous Cerebrospinal Fluid (sCSF) leak is a rare condition commonly associated with Idiopathic Intracranial Hypertension (IIH). Orbital ultrasound is an effective and non-invasive method for monitoring intracranial pressure (ICP) variations in sCSF leak patients undergoing surgical repair. This study aims to consolidate existing data by sharing our single-center, long-lasting clinical experience with Standardized Orbital Ultrasound (SOUS) evaluation in this patient cohort. Data from sCSF leak patients who underwent endoscopic surgical repair from 2003 to 2023 at Fondazione Policlinico Universitario Agostino Gemelli IRCCS (Rome, Italy) were retrospectively collected. As part of our diagnostic, therapeutic flow chart, all patients underwent a comprehensive preoperative assessment, including a head CT scan and/or brain MRI. Postoperatively, all patients were prescribed Acetazolamide. Patients with radiological findings suggestive of IIH were further evaluated with SOUS preoperatively (T0). Ultrasonographic measurements were also recorded at 3 (T1), 6 (T2), and 12 (T3) months after surgical treatment and the initiation of medical therapy. 23 out of 56 patients underwent SOUS examination preoperatively and postoperatively. The mean preoperative optic nerve sheath diameter (ONSD) was 4.8 mm ± 0.1. Postoperatively, the mean ONSD was 5.1 mm ± 0.1 at T1, 4.9 mm ± 0.2 at T2, and 4.8 mm ± 0.2 at T3. None of those patients experienced CSF leak recurrence within the first year. SOUS has shown a promising role in evaluating the quality of the surgical repair and monitoring the ICP response to Acetazolamide, thereby reducing the risk of CSF leak recurrence after surgical treatment.