Risk Reduction of Recurrent Cerebrospinal Fluid Leaks With Postoperative Intracranial Pressure Management: A Systematic Review.

Abstract

To evaluate whether postoperative intracranial pressure-lowering interventions reduce recurrence of lateral skull base spontaneous cerebrospinal fluid leaks after surgical repair. Ovid MEDLINE, Embase, Cochrane CENTRAL, Web of Science Core Collection, and Scopus were searched from inception through April 7, 2025. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and included studies of adults with lateral skull base spontaneous cerebrospinal fluid leaks undergoing primary repair where postoperative intracranial pressure-lowering interventions were specified. Pooled recurrence rates were calculated by intervention type and compared with cohorts that did not receive intracranial pressure-lowering therapy. Thirty-six studies including 687 patients (737 cases) met inclusion criteria. Six comparative cohorts (34 treated, 155 untreated) showed no significant difference in recurrence (risk ratio 1.16, 95% confidence interval [CI]: 0.14-9.76; I² = 0%). Across 82 intervention-only cases, recurrence occurred in three (pooled proportion 0.10, 95% CI: 0.04-0.26; I² = 0%). Among 650 control-only cases, 45 recurred (pooled proportion 0.09, 95% CI: 0.07-0.12; I² = 0%). No heterogeneity was observed across pooled analyses. Available evidence does not support universal postoperative intracranial pressure-lowering therapy after lateral skull base spontaneous cerebrospinal fluid leak repair. Limited observational data suggest acetazolamide may be associated with lower recurrence, whereas lumbar drainage has not demonstrated sustained benefit. Given the heterogeneity in patient selection and intervention practices, postoperative management should be individualized. Future prospective studies are needed to better define the role of targeted therapy in high-risk patients.