Complications From Sleep Apnea Can Cause Leaking of Cerebrospinal Fluids
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Complications From Sleep Apnea Can Cause Leaking of Cerebrospinal Fluids
By Admin
Recent studies have found that leakage of cerebrospinal fluids may be closely linked to sleep apnea. Build-up and leakage of these fluids from the brain or spinal column may even be caused by long-term sleep apnea conditions, as the increased pressure of apnea events, hypertension, and resulting hypercapnia can lead to fluid loss in these vital regions, causing severe headaches, disorientation, or mood problems. While seemingly a rare condition, some researchers believe that cerebrospinal fluid leaks are commonly misdiagnosed as migraine headaches, while untreated conditions can lead to serious health problems over time. Since cerebrospinal fluids tend to drain from the nose or ears, the condition often goes unnoticed as the brain and spine lose vital fluids needed to protect the central nervous system from physical damage or infection. Sleep apnea is commonly associated with a number of potentially life-threatening comorbid conditions, and anyone diagnosed with the disorder should be extremely wary of this far-too-often-overlooked health problem.
What is Cerebrospinal Fluid?
Cerebrospinal fluid (CSF) is a watery fluid that circulates through the brain's ventricles (inner cavities) and around the surface of the brain and spinal cord. The ventricles are like sacs within the brain that pulsate with CSF fluid, similar to the way the heart pulsates with blood. In addition to the ventricles, CSF also fills areas such as cisterns and sulci (the folds you see in brain matter), as well as the central canal of the spinal cord. The fluid protects the brain by buffering it from the skull and providing cushioning for movement and immunological protection. Like other bodily fluids, CSF is produced continuously and absorbed by the body (within the blood stream), which allows it to deliver nutrients and remove waste materials as it circulates the brain and spine.
What is a Cerebrospinal Fluid Leak?
A cerebrospinal fluid leak is a condition that occurs when the fluid leaks through a defect in the dura, which is the connective tissue, or membrane, between the brain and the skull, though it can also leak from the spine. In most cases, this is caused by a tear in the membrane, often associated with inflammatory conditions such as sinusitis and rhinitis or rhinorrhea. Other causes for CSF leak include head or spinal injuries (trauma), some surgical procedures (when it disrupts the spine or skull alignment), and fluid build-up, which leads to pressure in the brain called intracranial hypertension, a condition now linked to the effects of sleep apnea. Sleep apnea, particularly obstructive sleep apnea (OSA), is also associated with CSF leakage caused by hypercapnia from prolonged or repeated apnea events.
During CSF leaks, fluid usually exits the body through the nose or ears. The fluid is clear and colorless, and it resembles other bodily fluids such as mucus or post-nasal drip. When the brain loses a significant amount of CSF, intracranial hypotension can develop, which is the opposite of hypertension. With enough leakage, the pressure is relieved but the brain loses too much fluid, leading to physical symptoms such as headache or disorientation. Headaches from intracranial hypotension can be positional, occurring when sitting upright and often relieved when lying down. While this condition is considered rare, studies show that it is often misdiagnosed, leading to further complications over time without proper treatment. In fact, some researchers believe that intracranial hypotension from loss of fluid may be an underdiagnosed cause of common headaches or migraines.
When too much fluid is leaked from the brain, the loss of cushioning can cause the brain to sag or move within the skull, which results in a headache, a severe migraine, or a loss of balance. Loss of fluid can also cause meningitis, which is, statistically, the most significant risk associated with cranial CSF leaks (though not for spinal leaks). Meningitis is the inflammation or swelling of the membranes that cover the brain and spine, and anything that damages or infects the membrane can cause it to swell. Whether caused by an infection in the fluid or damage due to other factors, a CSF leak tells you that the membrane is vulnerable and may become inflamed.
In addition to headaches and disorientation or loss of balance, other common symptoms of CSF leaks include neck pain and stiffness, pain in the arm or between the shoulders, nausea, sensitivity to light or sound, and changes in hearing, vision, or smell (including loss of senses). The most common sign that you have a CSF leak is the drainage from nose or ears. Drainage is clear and watery, and sometimes occurs at night or when lying down or turning the head. Drainage can also lead to the back of the throat, causing complications similar to the airway blockage of obstructive sleep apnea. When combined, the two conditions can cause serious sleep complications as the symptoms lead to awakenings throughout the night.
Cerebrospinal Fluid and Sleep Apnea
Recent studies have found that patients with CSF leak-related headaches are nearly five times more likely to have a sleep apnea diagnosis than those of the general population. According to the research, this could be related to increases in fluid pressure from apnea symptoms, primarily obstructive sleep apnea symptoms. Other studies have found that nearly half of patients sampled from populations with CSF related conditions had OSA as well, linked not only to CSF leaks but also to intracranial pressure (ICP), which appears to spike during apnea events, further suggesting that episodic rises in ICP may also contribute to skull base erosion over time. While further research is needed to determine the effects of CPAP on CSF leaks more specifically, study authors recommend that more, if not all, patients with CSF leaks undergo a polysomnogram to check for the presence of OSA.
This connection between sleep apnea and fluid pressure can also cause problems when there are no signs of a CSF leak, as the pressure may be a symptom of hypertension in the brain. A study linking these two conditions, published by Rowe Neurology Institute, uses the term “pseudotumor” to describe the areas of swelling that sometimes develop. This condition occurs when the brain becomes swollen without signs of other causes such as infection, stroke, or tumor. In most cases, a headache or migraine is the first sign of swelling, though In severe cases, the swelling of the optic nerves, or papilledema, can lead to loss of vision if left untreated. As the authors note, improvements in sleep study data have helped to identify a strong link between pseudotumor and OSA, though the precise cause is more difficult to establish. An article by Deborah Wardly, Ph.D.,, titled “Intracranial hypertension associated with obstructive sleep apnea,” suggests that weight issues may play a significant role in the development of these two conditions, as the return of venous blood to the brain can be impaired by excess fatty tissue in the necks of overweight individuals. The article also explains how excess glutamate in people with OSA can cause over-stimulation, or “neuro-excitability,” in the memory structures of the brain, leading both to swelling and to the death of cells used in memory processes. In addition, people with OSA can have, according to the article, “hypercoagulability,” which leads to slower, thicker blood and easier clotting, a condition that CPAP therapy can reverse with regular use. But hypercoagulability, when left untreated, can increase the chance of clots in veins and arteries that can later cause strokes or heart attacks if they loosen up and travel through the bloodstream. Further difficulties can arise when the “blood-brain barrier” is weakened by apnea symptoms and fails to protect the brain from unwanted chemicals and other substances. According to the Wardly, treatment of OSA with PAP therapy has been shown to restore the barrier, another factor in the support of treatment adherence. Using CPAP, the author stresses, can also reduce some of the swelling, though careful, adequate titration is crucial for the healing process. Even if the effects of CPAP on CSF leaks is uncertain, these studies show that relief of pressure, improved circulation, and the strengthening of membranes and barriers between the brain, the spine, and the rest of the body can have a considerable effect on cerebrospinal health.
Diagnosis and Treatment of CSF-Related Conditions
According to Cleveland Clinic, craniospinal fluid leaks are regularly misdiagnosed as migraines or sinusitis, and are much more common among women, people with high blood pressure, and those who are overweight or obese. Like other conditions that cause headaches or balance problems, diagnosis of a CSF leak usually begins with a physical exam. If there is noticeable discharge, the fluids can be collected and sent to a laboratory to determine if it is indeed cerebrospinal fluid. This test, known as a pledget test, however, cannot be used to determine the location of the leak. Often, a doctor will also examine the condition of the brain and spinal cord using imaging tests to determine the exact location of the leak. A CT scan, an MRI, or in the case of the lower spine, a myelogram or a cisternogram can be used to pinpoint the exact location of the leak and determine if a tear has occurred in the membrane. While some CSF leaks heal on their own and require only a period of increased rest, it is never a good idea to ignore symptoms, especially with so many possible complications involved in brain and spinal conditions. In some cases, especially when the brain if effected, surgery may be necessary to repair the leak. For some spinal CSF leaks, an epidural patch may be used to clot the leaking area with the patient’s own blood. Other treatments involve medications such as diuretics to release more water from the body. And for those with sleep apnea, continued CPAP therapy is recommended for both the sleep apnea symptoms and the cerebrospinal fluid issues that may or may not be related to apnea events. Further studies are needed to more closely evaluate the relationship between sleep apnea and cerebrospinal fluid, but it is clear that a connection does exist, and the best course of action for any symptoms resembling a CSF issue is to meet with a primary care provider as soon as possible.
Sources
Cedars-sinai.org - https://www.cedars-sinai.org/health-library/diseases-and-conditions/i/intracranial-hypotension.html
Chest - https://pubmed.ncbi.nlm.nih.gov/2914475/
Chinese Journal of Traumatology - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5392710/
Cleveland Clinic - https://my.clevelandclinic.org/health/diseases/16854-cerebrospinal-fluid-csf-leak
CSF Leak Association - https://www.csfleak.info/what-is-a-cerebrospinal-fluid-csf-leak/diagnosis/
Elsevier - Medical Hypoptheses - https://www.neurokc.com/wp-content/uploads/2017/10/Wardly-Medicalhypoth-2014-Intracranial-Hypertension-and-OSA.pdf
Investigative Otolaryngology - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5655559/
Journal of Neurology, Neurosurgery, and Psychiatry - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1032509/
Otolaryngology Head and Neck Surgery - https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2341263
JAMA Network - Neurology - https://jamanetwork.com/journals/jamaneurology/fullarticle/785098
Rowe Neurology Institute - CSF Leak Headache - https://www.neurokc.com/headache-article/obstructive-sleep-apnea-csf-leak-headache/
Rowe Neurology Institute - Hypertension - https://www.neurokc.com/sleep-article/obstructive-sleep-apnea-intracranial-hypertension-pseudotumor/
Science Direct - https://www.sciencedirect.com/topics/medicine-and-dentistry/intracranial-pressure
StatPearl Publishing - https://www.ncbi.nlm.nih.gov/books/NBK538157/
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