Idiopathic intracranial hypertension presenting as recurrent cerebrospinal fluid rhinorrhea

Karthika1*, Girija2, Arputha Mary3, Esther Rani4

1 Nursing Incharge, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2 Senior Staff Nurse, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3 Assistant Nursing Superintend, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

4 Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

*Correspondence

Abstract

Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri, is a condition characterized by raised intracranial pressure without an identifiable intracranial pathology. The increased pressure is due to impaired cerebrospinal fluid (CSF) dynamics and can lead to symptoms such as headache, visual disturbances and CSF leakage.

Key words: Idiopathic intracranial hypertension (IIH); Cerebrospinal fluid rhinorrhea

Case presentation

We report a case of a 32-year-old female who presented with recurrent CSF rhinorrhea and fever. She had a known history of CSF rhinorrhea for which she underwent endoscopic repair at an outside hospital and remained asymptomatic for two months. She later developed recurrent nasal CSF leakage associated with fever and blurring of vision for one week. On examination, the patient was conscious, oriented, afebrile, and hemodynamically stable. CSF rhinorrhea was noted on bending forward. Laboratory investigations revealed mild anemia and leukocytosis. Clinical findings were suggestive of raised intracranial pressure, and a diagnosis of idiopathic intracranial hypertension was considered.

Investigations

Laboratory investigations revealed hemoglobin of 11.9 g/dL, total leukocyte count of 15,000 cells/mm³, platelet count of 2.31 lakhs/mm³, and an international normalized ratio (INR) of 1.10. Serum electrolytes, liver function tests, and renal function tests were within normal limits. Serological tests were negative. CT cisternography demonstrated a bony defect measuring 3–4 mm in the anterolateral wall of the left sphenoid sinus with minimal contrast leakage. An additional small bony defect measuring approximately 1 mm was noted at the root of the ethmoid sinus, also showing minimal contrast leak. MRI brain revealed features suggestive of raised intracranial pressure, including thickened bilateral optic nerve sheath complexes with widened perioptic cerebrospinal fluid spaces and empty sella. Postoperative changes were noted in the floor of the left anterior cranial fossa, nasal septum, and turbinates’. Air–fluid levels were observed in the left sphenoid and anterior ethmoid sinuses.

Course of Illness

This patient is a well-known case of cerebrospinal fluid rhinorrhea; status post endoscopic repair performed at an outside hospital. She remained asymptomatic initially but subsequently developed recurrent CSF rhinorrhea. She presented with complaints of CSF nasal discharge associated with headache and visual disturbances. There was no history of trauma. MRI brain findings were suggestive of idiopathic intracranial hypertension, including thickened bilateral optic nerve sheaths, widened perioptic CSF spaces, and empty sella. Based on the clinical presentation and radiological findings, a diagnosis of idiopathic intracranial hypertension with recurrent CSF rhinorrhea following endoscopic repair was made.

Treatment and outcome

Initially she planned for conservative management with close observation for first few days. Later she continued to have CSF rhinorrhea. Then we plan to post the patient for lumbar drainage on 24.11 2025. CSF analysis and culture were sent during the procedure. All the investigation was normal and culture was sterile. After procedure there was reduction in CSF leakage then planned to remove lumbar drain. And the lumbar drain was removed on 30.11.2025. Then she improved and managed with analgesics, antibiotics, antiemetic and other supportive treatments. The patient improved clinically with complete resolution of symptoms. She was stable at the time of discharge and advised regular follow-up for monitoring of intracranial pressure and visual status.

Other Management

Acute management included strict head elevation, avoidance of straining, coughing, and nose blowing, use of stool softeners and maintenance of adequate hydration. CSF pressure control was achieved with temporary lumbar CSF drainage. CSF output and neurological status were closely monitored, and periodic CSF analysis was performed to rule out infection. Medical management included acetazolamide as first-line therapy for idiopathic intracranial hypertension, along with analgesics for headache, antiemetic’s for nausea, and antibiotics when indicated. Surgical options, including repeat endoscopic skull base repair, ventriculoperitoneal or lumbo-peritoneal shunting, and optic nerve sheath fenestration, were discussed as potential interventions in case of recurrence or vision-threatening complications. Long-Term Management Weight Reduction (if applicable) Regular ophthalmological evaluation (visual fields, fundus exam) Neuroimaging follow-up Patient education regarding warning symptoms.

Nursing management

  • Positioning Maintain strict head elevation (30–45°) to reduce intracranial pressure. Avoid head-down positions and excessive neck flexion.
  • Neurological Monitoring Regular assessment of level of consciousness, headache severity, and visual symptoms. Monitor for signs of raised intracranial pressure such as vomiting or altered sensorium.
  • Lumbar drain care if presents Maintain strict aseptic precautions. Monitor CSF output, color, and consistency. Observe for complications such as infection, headache, or neurological changes.
  • Medication Administration Prescribed medications such as acetazolamide, analgesics, antibiotics, and antiemetics. Monitor for side effects (electrolyte imbalance, dehydration).
  • Infection prevention Monitor temperature and signs of meningitis. Maintain hygiene and aseptic technique during procedures.
  • Nutrition and elimination Encourage adequate oral intake. Provide stool softeners to prevent straining. Monitor intake–output and ensure proper hydration.

Health education

  • Disease awareness Educate the patient about IIH, its symptoms, and the importance of controlling intracranial pressure.
  • Lifestyle modification Encourage weight reduction if overweight. Advise avoiding heavy lifting, bending forward, and strenuous activities .
  • Warning signs Instruct the patient to report immediately if there is: Recurrence of nasal discharge Severe headache Visual disturbances Fever or neck stiffness.
  • Follow up care Emphasize regular follow-up with neurology, ENT, and ophthalmology. Importance of periodic visual field and fundus examinations.
  • Post discharge care Maintain head elevation during sleep. Avoid nose blowing and forceful sneezing. Follow proper nasal hygiene as advised.

Conclusion

Idiopathic intracranial hypertension is an important and often under-recognized cause of recurrent cerebrospinal fluid rhinorrhea, particularly in patients with a history of skull base repair. Persistent elevation of intracranial pressure can lead to failure of surgical repair and recurrence of CSF leakage. Radiological features such as empty sella and optic nerve sheath distension play a crucial role in establishing the diagnosis. In the present case, recurrent CSF rhinorrhea following endoscopic repair was successfully managed with conservative measures and lumbar CSF drainage, resulting in significant clinical improvement. This case underscores the importance of identifying and treating the underlying intracranial hypertension rather than addressing the CSF leak alone. Early diagnosis, appropriate CSF diversion, and close clinical and ophthalmological follow-up are essential to prevent recurrence, reduce morbidity, and preserve visual function in patients with idiopathic intracranial hypertension.

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