Cranial Cerebrospinal Fluid (CSF) Leaks

CSF Leaks in the Skull

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Duke specialists work together to diagnose, locate, and treat cerebrospinal fluid (CSF) leaks in the skull, also called the cranium. Because leaks can be difficult to find and dangerous when left untreated, it’s important to see an expert. Duke’s team of sinus specialists, neurotologists, and neurosurgeons work to treat the problem quickly and use the least-invasive options available.

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About Cranial CSF Leaks

Cerebrospinal fluid (CSF) is a watery fluid that protects, nourishes, and removes waste from the brain and spinal cord. When an area of the skull is damaged, becomes thin, or cracks, the dura (the tissue that holds cerebrospinal fluid and surrounds the brain and spine) is exposed and can easily tear. This can be caused by a traumatic injury, tumor, infection, surgery, or intracranial hypertension.

Intracranial hypertension is similar to high blood pressure, but in the brain. Too much CSF can wear down the skull, making it weak and prone to crack. Intracranial hypertension can be primary, meaning there is no certain cause, or secondary to another problem, such as a brain bleed.

Cranial CSF Leak Signs
The most common signs for cranial CSF leaks include chronic headaches and watery discharge from the nose or ear, especially on one side. Without treatment, CSF leaks can lead to loss of vision or other senses, hydrocephalus (a buildup of fluid in the cavities inside the brain), dangerous infections like meningitis, or death.

Our Locations

Duke Health offers locations throughout the Triangle. Find one near you.

Tests for Cranial CSF Leaks

Following a comprehensive physical exam and medical history, your doctor may order one or more of the following tests to confirm a CSF leak diagnosis or locate the leak site.

Beta-2 Transferrin Testing

Beta-2 transferrin is a protein that is only found in cerebrospinal fluid. In this test, a small amount of watery discharge from the nose or ear is collected and tested in a lab. A positive result indicates a CSF leak.

MRI Scan

A specific type of MRI called a CISS (constructive interference in steady state) sequence MRI may be performed. This high-resolution imaging option can differentiate cerebrospinal fluid from surrounding soft tissues.


For this test, a radioactive tracer dye is injected into the spinal canal during a lumbar puncture, and the dye is tracked over time to find the location of a CSF leak. After the injection, you’ll lie down for about an hour, and then you may have blood drawn or have an X-ray, CT scan, or MRI imaging. The blood draws or imaging scans may be repeated six and 24 hours after the initial lumbar puncture.

Intrathecal Fluorescein

A fluorescent dye is injected into the spinal fluid during a lumbar puncture. The dye circulates with CSF through the spinal cord and to the brain. Then surgeons open and explore an area of the skull where the leak might be, looking for the fluorescent dye. When it is found, the surgeons often can repair the hole during this procedure.

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Cranial CSF Leak Repair Surgery

Surgery is often the best treatment option for cranial CSF leaks. Surgical approaches are tailored to the exact location of the leak. Once surgeons reach the leak site, they repair the hole by plugging it with tissue or fat. 

Anterior Approach
For leaks on the front of the skull (anterior), surgeons may access and repair the leak through the nostrils using a minimally invasive, endoscopic approach. This technique speeds recovery, leaves no visible scars, and requires only a couple of nights’ stay in the hospital.

Lateral Approach
For leaks on the side of the skull (lateral), surgeons may access and repair the leak through incisions behind the ear, which leave less visible scarring. You’ll need to stay in the hospital for three or four nights.

Posterior and Other Approaches
For leaks on the back of the skull (posterior) or that are difficult to access through the nose or behind the ear, surgeons may perform a traditional craniotomy, which requires a larger opening in the skull. This requires a longer hospital stay, usually three to seven days.

After Surgery
You’ll be asked to return for follow-up visits one week after surgery and several more times at increasing intervals. You should begin to find relief from pain and other symptoms after seven to ten days.

Other Cranial CSF Leak Treatments


Intracranial hypertension can be treated by placing a shunt -- a device that helps divert excess fluid away from the brain. A shunt consists of two long, flexible tubes (catheters) that are joined by a valve. One end of the shunt is placed into the part of the brain where there is too much fluid. The other end drains the fluid to another area in the body.


Certain medications can treat intracranial hypertension by reducing the production of spinal fluid. 

Consistently Ranked Among the Nation’s Best Hospitals

Duke University Hospital is proud of our team and the exceptional care they provide. They are why we are once again recognized as the best hospital in North Carolina, and nationally ranked in 11 adult and 9 pediatric specialties by U.S. News & World Report for 2023–2024.

Why Choose Duke

CT/MRI Fusion Technique
CT/MRI fusion is a navigation system, similar to a GPS, used during CSF leak surgery. The technique combines CT scans (which are ideal for displaying bony anatomy) and MRI scans (which are ideal for displaying softer tissues and fluids) and uses reference points to identify important neurological structures. This can optimize your surgeon's accuracy and help them avoid damage to surrounding tissue.

Vast Experience with CSF Leaks
Duke is one of the few centers in the country with the expertise to diagnose and treat CSF leaks that cause chronic headaches and other symptoms. Our advanced training, experience, and large number of cases contribute to our excellent results.  

A Team of Specialists
Our team of sinus specialists, otologists, neurotologists, neuroradiologists, neurosurgeons, neurologists, neuro-ophthalmologists, and others work together to coordinate your treatment. Their combined expertise ensures you experience a better outcome.  

Patient Navigators for Coordination of Care
Our patient navigators become your one-stop shop for scheduling appointments, coordinating your visits, communicating your test results, and planning surgery. They make your treatment journey easier by guiding you through it step by step. They are more than willing to answer all of your questions along the way.

This page was medically reviewed on 04/26/2023 by