Spontaneous cerebrospinal fluid leak in the clivus about two cases and review of literature

Abstract

Spontaneous cerebrospinal fluid (CSF) rhinorrhea originating from clival defects is an exceptionally rare condition, with only a limited number of cases reported, and its diagnosis is often challenging, potentially leading to delayed management and recurrent meningitis. We report 2 cases of spontaneous clival CSF leakage in male patients aged 76 and 64 years, both presenting with clear rhinorrhea associated with headaches; one case followed minor head trauma and was complicated by extensive pneumocephalus, while the second was marked by recurrent meningitis with an initially missed defect on imaging. High-resolution CT and MRI ultimately identified small clival breaches in both patients, who were successfully treated using an endoscopic endonasal transsphenoidal approach with multilayer skull base reconstruction. Postoperative outcomes were favorable, with no recurrence during follow-up. These cases highlight the diagnostic pitfalls of clival CSF leaks, underscore the importance of meticulous high-resolution imaging, and confirm that early endoscopic endonasal repair is a safe, minimally invasive, and effective therapeutic option.