# Indirect Fistula: A New Terminology for Cerebrospinal Fluid Fistula With Different ‘Apparent Origin’ and ‘Real Origin’

## TL;DR

This paper proposes a new term, 'Indirect Fistula,' to describe cerebrospinal fluid leaks where the visible origin does not match the actual source.

## Contribution

The paper introduces the novel terminology 'Indirect Fistula' to address a previously unnamed clinical condition.

## Key findings

- A systematic review found 29 relevant publications, none of which named the condition where apparent and real origins differ.
- Eleven studies described cases where the CSF leak site did not match its origin, highlighting the need for a new term.
- The proposed term 'Indirect Fistula' is suggested to improve classification and understanding of these cases.

## Abstract

Fistulas are abnormal communications between body cavities. They can occur between the CNS and the extracranial space, presenting clinically as CSF leaks. Due to the variety of features, multiple classifications have been implemented to better study this pathology.

A systematic review was conducted using the Scopus, Medline, and Web of Science databases. Observational studies such as cohort studies, case reports, case series, cross-sectional studies, systematic reviews, and publications that assess the classification of CSF leaks were included.

The systematic review identified 29 publications that met the required criteria for inclusion. Although the primary focus of most of these publications was not on classification, they briefly mentioned it. The included publications describe classifications according to etiology, exiting flow pressure, anatomic site, and some new classification proposals. Of the 29 included studies, 11 referred to the appearance of CSF rhinorrhea or otorrhea with no relationship between the cause or site of origin and the site of the CSF leak. However, none of these publications names this situation. These results clearly indicate that a term for this circumstance needs to be established; none of the previously listed publications provide a name for this condition.

This systematic review aims to demonstrate the necessity of implementing a new term to describe CSF leaks where the 'apparent origin' does not correspond to the 'real origin.' The results show no existing term that considers such cases; therefore, we propose the term 'Indirect Fistula' to designate these cases.