From the Guidelines
Acetazolamide is used to ameliorate symptoms of rebound headache following treatment of a cerebrospinal fluid (CSF) leak, by lowering CSF production. This is typically considered in the postprocedural period, as rebound headaches can occur in about a quarter of patients following treatment of a CSF leak 1.
Key Points to Consider
- Rebound headaches are characterized by a postprocedural elevation in CSF pressure, usually occurring within the first 1 to 2 postprocedural days 1
- Acetazolamide may be prescribed to manage symptoms of rebound headache, which can include nausea, emesis, and blurry vision 1
- CSF drainage via lumbar puncture or lumbar drain can be used in more severe cases that are refractory to medical management 1
- It is essential to recognize the clinical features of rebound headache to avoid mistaking these symptoms as refractory SIH, which may lead to unnecessary imaging or repeat blood/fibrin patch procedures 1
Management Approach
- Conservative management, including monitoring and supportive care, remains the primary approach for managing rebound headaches and CSF leaks
- Acetazolamide should only be used under close medical supervision, with careful monitoring for potential side effects 1
From the Research
Relationship between Acetazolamide and CSF Leak
The relationship between Acetazolamide, a carbonic anhydrase inhibitor, and cerebrospinal fluid (CSF) leak is supported by several studies.
- Acetazolamide decreases the production of cerebrospinal fluid (CSF), reducing intracranial pressure (ICP) and allowing it to be used for treatment of idiopathic intracranial hypertension and elevated ICP due to CSF leaks 2.
- A systematic review evaluated the efficacy of acetazolamide in the event of CSF leaks of the anterior skull base, including iatrogenic, traumatic, and spontaneous CSF leaks, and found that acetazolamide should be considered as a treatment option in patients with CSF leak secondary to surgery of the anterior cranial fossa, trauma, and idiopathic causes 3.
Efficacy of Acetazolamide in CSF Leak Treatment
The efficacy of acetazolamide in treating CSF leaks is supported by several studies.
- A prospective evaluation found that administration of acetazolamide significantly decreased intracranial pressure in patients with high intracranial pressure CSF leaks 4.
- A retrospective review found that preoperative use of acetazolamide enabled surgery to be avoided in 31.3% of patients with spontaneous CSF rhinorrhea 5.
- A randomized clinical trial found that early acetazolamide administration can prevent CSF leakage in patients with a high risk of permanent CSF leak 6.
Potential Benefits and Uses of Acetazolamide
The potential benefits and uses of acetazolamide in CSF leak treatment include:
- Avoidance of invasive procedures in patients with a CSF leak or elevated ICP 2.
- Treatment of idiopathic intracranial hypertension and elevated ICP due to CSF leaks 2.
- Reduction of intracranial pressure in patients with high intracranial pressure CSF leaks 4.
- Prevention of CSF leakage in patients with a high risk of permanent CSF leak 6.