Which signs indicate postoperative CSF leakage after craniotomy and what is the management?

• A. Clear drainage from wound or nasal/ear sites; test for beta-2 transferrin; manage with airtight dressings and surgical assessment; avoid nasal suction.
• B. Purulent drainage; start broad-spectrum antibiotics and suction.
• C. No drainage changes; monitor vitals only.
• D. Bloody drainage; start anticoagulation.

Answer: (A)

A postoperative CSF leak shows up as clear, watery drainage from the craniotomy wound or from the nose or ears. This clarity helps distinguish it from typical wound drainage, and the presence of CSF in these areas can lead to meningitis if not addressed. A key confirmatory step is testing the drainage for beta-2 transferrin, a protein that is essentially unique to CSF, which makes the diagnosis fairly specific when positive.

Management focuses on containment and preventing infection while arranging definitive repair if needed. Apply an airtight dressing over the wound to seal the leak and reduce further escape of CSF, and keep the head elevated to lower CSF pressure. Avoid activities that increase intranasal or intracranial pressure, such as nasal suction, nose blowing, coughing, or straining. The patient should be evaluated promptly by a neurosurgeon for potential surgical repair if the leak persists or is significant, since many leaks require operative closure.

Purulent drainage would point to infection rather than CSF leakage; no drainage changes would not indicate a leak; Bloody drainage would suggest a different postoperative issue and anticoagulation would be inappropriate in this context.