The efficacy and safety of intrathecal fluorescein in endoscopic cerebrospinal fluid leak repair –a systematic review

Background: Effective management of cerebrospinal fluid (CSF) leaks can reduce significant associated morbidity. Intrathecal fluorescein (IF) may be a valuable intra-operative adjunct to localise leak sites. Recent reports have demonstrated low doses of IF to be safe, however, no internationally accepted dose of IF has been agreed. Objective: To assess the efficacy and safety of IF used in the endoscopic management of anterior skull base CSF fistulae. Methods: A systematic review and descriptive analysis were performed of all published data in accordance to PRISMA guidelines. Results: There were 18 included articles giving a total of 335 procedures where IF was used. Doses of IF ranged from 10mg -150mg. IF positively identified the site of CSF fistula in 88.7% of cases (n = 297). There was a total of 25 reported peri-operative complications in all included studies (7.5%) with 5.1% (n = 17) potentially related to IF use. Of these, the complication rate was 3.9% at low IF doses ( < 50mg) and 80.0% at higher doses ( > 50mg). Conclusion: Our review demonstrates that IF is effective at localising CSF fistulae with most significant complications being related to doses > 50mg. We therefore propose that there is a potential for the licensing of IF in this field. Doses < 50mg have consistently been shown to be safe while still maintaining effective localisation rates. Based on the most common doses used in this group, we recommend utilisation of a dosing below 50mg, with the most frequent range being between 10-30mg. (C) 2022 Japanese Society of Otorhinolaryngology-Head and Neck Surgery, Inc. Published by Elsevier B.V. All rights reserved.