1998 Apr. Defects in the closure of the anterior neuropore can result in the herniation of central nervous tissue through anterior cranial fossa. Liu HS, Chen YT, Wang D, et al. Despite the multifactorial causes of elevated ICP, once this problem ensues, the pressure exerted on areas of the anterior skull base such as the lateral lamella of the cribriform or lateral recess of the sphenoid sinus results in bone remodeling and thinning. In 1981, Wigand reported on the use of the endoscope to assist with the repair of a skull base defect. After circulating through the subarachnoid space, CSF is reabsorbed via the arachnoid villi. Background: Sometimes, associated symptoms can assist in localizing the leak. CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. 1954 Jul;42(171):1-18. doi: 10.1002/bjs.18004217102. 2015 Jan-Feb. 29 (1):77-81. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New ZealandDisclosure: Nothing to disclose. 2014 Sep. 59 (2):196-9. Conclusion: The intrathecal injection of 0.5 mL of gadopentetate dimeglumine diluted in 3-5 mL of CSF for MR cisternography has been reported to have high sensitivity and specificity for detection of active CSF fistula, exceeding the rate of fistula demonstration by CT, nuclear medicine, or noncontrasted MR cisternography. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. With one method, the average total time for coronal and sagittal imaging is 48 minutes. 8600 Rockville Pike 4th ed. [22, 25] Gadolinium-based contrast media are approved for intravenous injection for MRI but have not been approved for intrathecal use in humans by the Food and Drug Administration (FDA). Careers. Cerebrospinal fluid (CSF) rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality for the patient. Double Ring Sign: CSF mixed with blood or nasal discharge forms two rings because CSF being a watery fluid invades linen more than blood called the double-ring sign, halo sign, or . Cerebral arteriography is not used in the diagnostic imaging workup to localize the site of a CSF leak. Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. All authors agreed on recommendations through an iterative process. AJNR Am J Neuroradiol. 5 Testing fluid from the ear or nose for -2 transferrin is the recommended method to assess patients for a cranial CSF leak because this approach is noninvasive as well as highly sensitive and specific. G-CSF-induced vasculitis has been reported to occur in 0.47% of patients. eCollection 2023 Feb. 2022 Dec 8;12(12):1685. doi: 10.3390/brainsci12121685. Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care. Bookshelf Gadolinium-enhanced, coronal, T1-weighted MRI shows dural and tentorial thickening with contrast enhancement. Dynamic CT myelography is recommended in these patients, with the injection of the iodinated contrast medium intrathecal on the CT scan table with immediate spine CT scan. Fast spin-echo T2-weighted coronal image of a patient with a spontaneous onset of cerebrospinal fluid rhinorrhea demonstrates an empty-sella configuration. An official website of the United States government. The sella turcica and sphenoid sinus are involved in 15% of the cases as well. It is produced in epithelial cells of the choroid plexus and meninges and is found in CSF, perilymph, seminal fluid, and urine. 2020;42[12]:31; http://bit.ly/2HVJcdt. Additionally, a mixture of at least 30 percent CSF to blood was required to produce a double ring sign reliably, so the absence of a double ring sign does not exclude a CSF leak. Once in contact with the paper, any CSF will separate from any blood or mucus. Subdural hygroma or hematoma on the cerebral convexities is common. More than half of these present within 48 hours. Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. Chazen JL, Talbott JF, Lantos JE, Dillon WP. 2013 Jul;7(7):1447-9. doi: 10.7860/JCDR/2013/5377.3170. for: Medscape. 2008 Jun. The high T2 signal from CSF fistula may be difficult to differentiate from that of sinusitis on axial images. A case of cerebrospinal fluid rhinorrhoea: a surgical challenge. Skull radiographs are of limited diagnostic use in CSF leaks, but they may show a relevant skull fracture or the presence of empty sella. CSF is colorless, clear, and typically devoid of cells such as polymorphonuclear cells and mononuclear cells (< 5/L). Treatment of cerebrospinal fluid rhinorrhea. For more information, see Medscape. 2002 Dec. 51(6):1365-71; discussion 1371-2. 28.10). [QxMD MEDLINE Link]. Diagnosis is made more easily in patients with recent trauma or surgery than in others. 33(3):535-40. [11, 12, 5, 7, 13], Methods for detecting CSF fistulas with intrathecal injections of dye pose a risk of chemical meningitis. The Canadian CT Head Rule for patients with minor head injury, Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, Sodiumglucose cotransporter-2 inhibitors in patients without diabetes, www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.120055/-/DC1. Also, it serves as nutrient delivery and waste removal system for the brain. [29]. The ring is a result of the different densities of blood and CSF, and is concerning for a basilar skull fracture." While the presence of a double ring sign (sometimes called a halo sign) is often cited as indicating the presence of CSF ( Sapira's Art and Science of Bedside Diagnosis. double-ring sign (Figure 1B). This patient had cerebrospinal fluid otorrhea after mastoidectomy. Please confirm that you would like to log out of Medscape. CSF leak; CSF rhinorrhea; cerebrospinal fluid; diagnosis; diagnostic algorithm; localization. Cochrane Database Syst Rev. Typically, the leak is caused by either spontaneous dural dehiscence or dural tears caused by degenerative causes. government site. By the same principles as those applied in planar chromatography, the drainage of bloody discharge onto the patient's pillow or a paper towel can be seen to . Would you like email updates of new search results? Am J Rhinol Allergy. 1993:22[4]:718.). Does a CSF leak heal itself? The typical history of a cerebropsinal fluid (CSF) leak is that of clear, watery discharge, usually unilateral. Cerebrospinal fluid fistula: detection with MR cisternography. However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. (Defect measured approximately 7mm.). 19(4):627-31. Please confirm that you would like to log out of Medscape. National Library of Medicine The https:// ensures that you are connecting to the This coronal magnetic resonance cisternogram demonstrates a left-sided cerebrospinal fluid leak through the cribriform plate (small arrows), which was clinically suspected. Fast CSF leaks have rapid contrast diffusion and may not be localized to a 2-vertebral segment of the spinal canal (suitable for local treatment by extradural blood patch or alternate therapy) by routine postmyelogram CT spine scan. Epub 2013 Jul 1. Methods: For example, anosmia (present in 60% of individuals with post-traumatic rhinorrhea), indicates an injury in the olfactory area and anterior fossa, especially when it is unilateral. [QxMD MEDLINE Link]. Neuroradiology. Ryall RG, Peacock MK, Simpson DA. CT findings associated with cerebrospinal fluid leaks include fractures or other bone defects; meningocele; focal fluid accumulation in the ethmoid air cells; frontal, sphenoid, or maxillary sinuses or mastoid air cells; and, sometimes, pneumocephalus. Spelle L, Boulin A, Tainturier C, Visot A, Graveleau P, Pierot L. Neuroimaging features of spontaneous intracranial hypotension. One or more CSF fistulas may originate from spinal nerve root sleeves in the case of spontaneous spinal CSF leak. Epub 2012 Aug 13. Unable to load your collection due to an error, Unable to load your delegates due to an error. A new approach for simple radioisotope cisternography examination in cerebrospinal fluid leakage detection. This website also contains material copyrighted by 3rd parties. To receive any of these resourcesin an accessible format, please contact us at CMAJ Group, 500-1410 Blair Towers Place, Ottawa ON, K1J 9B9; p: 1-888-855-2555;e:cmajgroup@cmaj.ca. Typically, 0.5 mL of a 10% fluorescein solution is injected into the lumbar subarachnoid space over more than 1 minute. Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. [QxMD MEDLINE Link]. Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR Professor Emeritus of Radiology, Louisiana State University Health Sciences Center, New Orleans; Clinical Professor of Radiology, Tulane University School of Medicine [QxMD MEDLINE Link]. I absolutely agree that not having a double ring sign does not exclude a CSF leak. These are infrequently associated with CSF rhinorrhea. MR cisternography and myelography can accurately localize CSF leaks in the cranium and spine. Unauthorized use of these marks is strictly prohibited. Cerebrospinal fluid rhinorrhoea in closed head injuries. To sign up for email alerts or to access your current email alerts, enter your email address below: Enter multiple addresses on separate lines or separate them with commas. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption and the patients written consent for publication. [QxMD MEDLINE Link]. Study objective: The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow). Br J Surg. CSF consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). 1-7. [7], A literature review by Lobo et al indicated that in addition to increased ICP, risk factors for spontaneous CSF leaks include obesity, female gender, and obstructive sleep apnea. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. Craig Anthony Przyborski. 52:768-770. A 58-year-Old non-smoking woman with intractable cough and rhinorrhea. CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. These cases often lead to a misdiagnosis of allergic and vasomotor rhinitis. Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons 2004 Aug. 114(8):1475-81. It should be kept in mind, however, that this test does not provide information regarding the site or laterality of the defect. The images may demonstrate a CSF fistula, but this technique is used less frequently than other cisternographic methods. Observe with a Wood lamp 30 minutes later for fluorescence of nasal discharge; if present, this confirms CSF . G-CSF-induced vasculitis has been reported to occur in 0.47% of patients.1 The double-ring sign, which reflects inflammatory changes in the adventitia and oedema of the intima, is thought to be characteristic of Takayasu arteritis (TA); however, herein, it was also observed for G-CSF-induced vasculitis.2 It is [QxMD MEDLINE Link]. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [QxMD MEDLINE Link]. Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists Kranz PG, Gray L, Taylor JN. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. 2015 Oct 14. However, most of the time physical examination is unrevealing, especially in patients with intermittent CSF rhinorrhea. Int Forum Allergy Rhinol. James Stankiewicz, MD Professor, Chair, Program Director, Department of Otolaryngology-Head and Neck Surgery, Loyola University Chicago School of Medicine (See images below.). Temporal lobe gyral herniation may occur through a petrous temporal bone tegmen tympani defect. Therefore, imaging is usually done with the patient in the supine position. In radiology, the halo sign is a finding of a dark halo around the arterial lumen on ultrasound that suggests the diagnosis of temporal arteritis. Skull base injuries can vary from simple cracks in the bony architecture to large (>1 cm) defects with disruption of the dura and potentially brain parenchyma. Share cases and questions with Physicians on Medscape consult. [QxMD MEDLINE Link]. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. Copyright 2023, CMA Impact Inc.or its licensors. 2010 Mar. 2000 May. Hence, educating the patient regarding the common symptoms associated with a CSF leak such as salty or metallic taste is of paramount importance. This site needs JavaScript to work properly. This finding is suggestive of a site of cerebrospinal fluid leak. J Clin Diagn Res. Epub 2018 Sep 24. [QxMD MEDLINE Link]. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. [Full Text]. Serum glucose, chloride, and total protein tests of the fluid are not specific or conclusive for CSF. In a study of 4 patients who underwent radionuclide cisternography, as well as MRI and/or CT, for suspected CSF leaks, Thomas et al found that radionuclide cisternography accurately detected and localized the leaks in all patients. Bethesda, MD 20894, Web Policies [QxMD MEDLINE Link]. Other stresses include Valsalva-like maneuvers during nose blowing or straining. Rapid echo-planar imaging with the patient in the prone position and performing a Valsalva maneuver may allow for limited coronal imaging and increase the accuracy of MR cisternography. 2011 May. 2022. Multiple studies demonstrate a 90-95% success rate with closure of skull base defects using the endoscopic approach. Nadieska Caballero, MD Fellow in Rhinology and Skull Base Surgery, Sinus and Nasal Institute of Florida A variety of cisternographic studies may be necessary to localize some spinal CSF fistulas. This image represents an endoscopic view with a 70-degree telescope through the left frontal recess. A defect in the skull base is measured with a sterile ruler. The https:// ensures that you are connecting to the Neurosurgery. Lee TJ, Huang CC, Chuang CC, et al. [QxMD MEDLINE Link]. Respir Med Case Rep. 2023 Feb 11;42:101814. doi: 10.1016/j.rmcr.2023.101814. Wolters Kluwer Health, Inc. and/or its subsidiaries. Joseph M Scianna, MD Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Sciannais a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society, Srinivas Mukkamala, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center.

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