At any given time, approximately 90-150 mL of CSF is circulating throughout the CNS. Enrique Palacios, MD, FACR Professor of Radiology, Tulane University Medical Center How . Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. [QxMD MEDLINE Link]. (See images below.). 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 Kim DH, Kim SW, Han JS, Kim GJ, Basurrah MA, Hwang SH. FOIA Share cases and questions with Physicians on Medscape consult. A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. 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. This site needs JavaScript to work properly. [24] Most MRI machines offer fat suppression and image gray-scale reversal. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. A doctor can use a number of tests to diagnose a CSF leak. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. [QxMD MEDLINE Link]. FOIA Epub 2015 Sep 15. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. [QxMD MEDLINE Link]. 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. 2016 Nov 1. Defects in the posterior table of the frontal sinus may be approached externally via a coronal incision and osteoplastic flap. Gosal JS, Gurmey T, Kursa GK, Salunke P, Gupta SK. Clin Radiol. 1969 Apr. Blunt trauma is the most common cause. Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. Another Na+/K+ ATPase lining the ventricular side of the epithelium extrudes Na+ into the ventricle, with water following across this ionic gradient. Marshall AH, Jones NS, Robertson IJ. doi: 10.1371/journal.pntd.0004516. HHS Vulnerability Disclosure, Help [QxMD MEDLINE Link]. to maintaining your privacy and will not share your personal information without Most of the patients (95%) with a delayed CSF leak present within 3 months after the injury. Anterior 48-hour scintigraphic image demonstrates tracer accumulation in the right nasal region. Kranz PG, Gray L, Taylor JN. 34(7):410-6. Epub 2012 Aug 13. Clipboard, Search History, and several other advanced features are temporarily unavailable. Clinical images are chosen because they are particularly intriguing, classic or dramatic. The leak almost never recurs. The intrathecal injection of gadolinium-based contrast media has been shown in several off-label studies to be effective and safe in selected patients in whom other cisternographic or myelographic studies have failed to demonstrate the CSF leak site. Laryngoscope. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Li L, Gao FQ, Zhang B, Luo BN, Yang ZY, Zhao J. Overdosage of intrathecal gadolinium and neurological response. CT cranial cisternography is performed with injection of 5-7 mL of nonionic myelographic contrast medium into the lumbar subarachnoid space. National Library of Medicine 1994 Nov. 111(5):600-5. 2015 May. Laryngoscope. 1993 Apr. [QxMD MEDLINE Link]. Am J Rhinol. [5]. CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. 2017 Jan. 55 (1):167-187. Am J Rhinol Allergy. 2008 Jan. 29(1):116-21. Int Forum Allergy Rhinol. [11, 12, 5, 7, 13], Methods for detecting CSF fistulas with intrathecal injections of dye pose a risk of chemical meningitis. Contrast medium has drained out of the meningocele, but a small amount remains in the sphenoid sinus around the meningocele. Kevin C Welch, MD Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology and Skull Base Surgery, Northwestern University, The Feinberg School of Medicine Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. 63 (2):197-201. Triplanar images of a patient with a left lateral recess meningoencephalocele. MR cisternography is performed with heavily T2-weighted, fast spin-echo, fat-saturated sequences with thin sections and minimal or no gap. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa. Axial fast spin-echo T2-weighted MRI demonstrates widened extra-axial fluid spaces but no focal extra-axial fluid collection. AJNR Am J Neuroradiol. Normal CSF pressure is approximately 10-15 mm Hg, and elevated pressure constitutes an intracranial pressure (ICP) greater than 20 mm Hg. Serum glucose, chloride, and total protein tests of the fluid are not specific or conclusive for CSF. [QxMD MEDLINE Link]. Background: A control pledget for lacrimal secretions is placed under one inferior nasal turbinate. double ring sign: two concentric rings around the optic nerve characteristic of optic nerve hypoplasia. Liu HS, Chen YT, Wang D, et al. For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis. The fluid from his ear dripped onto the bedsheet, showing a halo pattern (Figure 1). Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management. 2nd edition. Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. Byrne JV, Ingram CE, MacVicar D, et al. eCollection 2016 Mar. Lippincott Williams and Wilkins, Philadelphia 2000; Otolaryngol Clin North Am. 2009 Jul. The fistula detection rate is lowest for intermittent CSF leaks. CT cisternographic findings in CSF leak include the concentration of contrast medium in portions of a paranasal sinus or within ethmoid or mastoid air cells. J Neurotrauma. [QxMD MEDLINE Link]. The test for CSF fluid involves placing a sample of what the doctor suspects to be CSF discharge on a piece of filter paper. An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. The typical history of a cerebropsinal fluid (CSF) leak is that of clear, watery discharge, usually unilateral. Pledgets are scanned in a glass tube at intervals of 2-24 hours, with the highest count rate indicating a possible leak site. All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries. Shetty PG, Shroff MM, Sahani DV, Kirtane MV. [5], Perform magnetic resonance (MR) cisternography. J Neurosurg. Gadolinium-enhanced, T1-weighted axial MRI obtained 2 weeks after a 7-mL extradural blood patch was applied to the midlumbar region. Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane. 2nd edition. Lawrence SK, Delbeke D, Partain CL. Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. Otolaryngology procedures, including FESS and septoplasty, can lead to a skull base defect and CSF rhinorrhea. Clin Nucl Med. [QxMD MEDLINE Link]. nSAIDs and aspirin . However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Lucien M Levy, MD, PhD This dislocation allows CSF to flow to the opposite side and manifest at the contralateral naris. The site is secure. Other stresses include Valsalva-like maneuvers during nose blowing or straining. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. For more information, please refer to our Privacy Policy. This can lead to dural tears in areas of abnormalities of the bony floor. [QxMD MEDLINE Link]. Get new journal Tables of Contents sent right to your email inbox, Letter to the Editor: Double Ring Sign Does Not Exclude CSF Leak. This finding is suggestive of a site of cerebrospinal fluid leak. [QxMD MEDLINE Link]. Epub 2018 Sep 24. 8600 Rockville Pike Clin Neurol Neurosurg. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the sclera of the eyes; joint stiffness with difficulty moving or straightening the arms, hands, legs, or feet; pain deep in the hips or ribs; and muscle weakness. Lopatin AS, Kapitanov DN, Potapov AA. Dr. Kaplan responds: Thank you so much for your thoughtful reply to my article. [QxMD MEDLINE Link]. Br J Radiol. Intermittent leakage over several years is characteristic. In one study of 45 patients, CT of the skull and facial bones with high-resolution, thin-section axial and coronal images had an accuracy of 92%, a sensitivity of 92%, and a specificity of 100% in depicting the presence or absence of CSF fistula. Pledgets are placed close to the cribriform plate, in the middle meatus, and in the sphenoethmoidal recess of the right and left nasal cavities. CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. 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. Preoperative Medical Treatment for Patients With Acromegaly: Yes or No? Free shipping for many products! Emily Ann King of Clear Lake, Texas and Craig Anthony Przyborski of Conroe, Texas were united in marriage on June 14, 2003 at 7:30 in the evening at St. Paul the Apostle . However, if CSF rhinorrhea persists beyond this point, or if a large skull base defect is observed at the time of injury, surgical repair is warranted. All methods of cisternographyradionuclide, CT, and MRprovide improved or optimal CSF fistula detection when the fistula is active and when a Valsalva maneuver or jugular venous compression is added to the imaging protocol. Iatrogenic CSF rhinorrhea results from surgical disruption of the skull base and dura as previously discussed. Nuclear cisternogram obtained at 24 hours demonstrates diffuse epidural accumulation of the tracer in the midlumbar region. 835-9. Cappabianca P, Cavallo LM, Esposito F, et al. The images may demonstrate a CSF fistula, but this technique is used less frequently than other cisternographic methods. All rights reserved. A large defect is noted, and the meningocele has been resected. [QxMD MEDLINE Link]. If an iatrogenic leak is detected intraoperatively, it should be repaired at the time of the original surgery. 2008 Sep. 63(9):1063-8. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl 2015 Sep. 123 (3):732-6. Curr Opin Otolaryngol Head Neck Surg. (Ann Emerg Med. A 27-year-old male driver in a single-vehicle rollover collision was transferred to a trauma centre after stabilization and endotracheal intubation at a community hospital. J Neurosurg. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. At this point, the dura herniates through the defect (meningocele). High-resolution CT (HRCT) is then recommended as the first-line study for localization. Alternatively, with the patient lying prone on a stretcher, the patient's hips can be raised above the level of the head for 1-2 minutes to concentrate the contrast medium over the anterior and posterior regions of the skull base. 2015 Mar-Apr. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. Conclusion: Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA. Oh JW, Kim SH, Whang K. Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. 2011 Apr. Case report. Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension. A basal layer Na+/K+ ATPase is responsible for actively transporting Na+ into epithelial cells, after which water follows across this gradient. Would you like email updates of new search results? In most cases of iatrogenic injury presenting in a delayed fashion, surgical repair is necessary. Slow CSF leaks may be detected by postmyelogram CT scan in which there is a time delay between the contrast medium intrathecal injection in the fluoroscopic room and subsequent transfer to the CT scan room. Korean J Neurotrauma. 2017 Oct. 2 (5):215-24. PMC CSF rhinorrhoea: the place of endoscopic sinus surgery. MRI cisternography, and the localization of CSF fistulae. This patient presented with a spontaneous onset of cerebrospinal fluid rhinorrhea 10 years after a head injury. The image also shows a right-sided meningocele (large arrow) protruding through the cribriform plate, which was not suspected but was surgically repaired at the same time as the left cribriform cerebrospinal fluid leak site. Neurosurgery. The leakage stops within 1 week in 70% of patients, within 3 months in 20-30%, and within 6 months in most patients. 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. These are infrequently associated with CSF rhinorrhea. Traumatic CSF leak is reported in approximately 10-30% of skull base fractures in adults. Laryngoscope. Once in contact with the paper, any CSF will separate from any. Gadolinium-enhanced T1-weighted axial MRI shows diffuse moderate dural thickening with contrast enhancement. Each patient subsequently underwent a procedure for an epidural blood patch, and all patients experienced symptomatic relief. 2006; [1]:CD004884.) Patients with recurrent meningitis, especially pneumococcal meningitis, should be evaluated for a defect that exposes the intracranial space to the upper airway, regardless of the presence or absence of CSF rhinorrhea. [2] Small series of patients had no apparent adverse effect from the gadolinium contrast medium. 2017 Oct. 13 (2):63-67. [15]. 1993:22[4]:718.) 1998 Apr. Fortschr Med. 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 . [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. This sign appears when CSF mixes with blood on an absorbent surface, such as paper or bed sheets, and creates a double ring pattern. An absorptive sponge pad placed at or near the presumed site of fluid leak can facilitate the collection of the fluid. Delayed fistulas are difficult to diagnose and can occur years after the trauma or operation. If you log out, you will be required to enter your username and password the next time you visit. Drainage of CSF in some cases may often be elicited on endoscopy by having the patient perform a Valsalva maneuver or by compressing both jugular veins (Queckenstedt-Stookey test). After circulating through the subarachnoid space, CSF is reabsorbed via the arachnoid villi. 2014 Jul;15(4):363. doi: 10.5811/westjem.2014.4.21346. [QxMD MEDLINE Link]. AJNR Am J Neuroradiol. [QxMD MEDLINE Link]. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. However, the presence of a ring sign is not exclusive to CSF and can lead to false-positive results. National Library of Medicine J Neurosurg. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. 2016 Nov. 6 (11):1126-30. What's the Most Likely Cause of This Man's Severe Headaches? [Full Text]. Also, it serves as nutrient delivery and waste removal system for the brain. [QxMD MEDLINE Link]. J Neurol Neurosurg Psychiatry. Intrathecal gadolinium-enhanced magnetic resonance cisternography in cerebrospinal fluid rhinorrhea: road ahead?. From the first intracranial repair in the 1900s to the use of endoscopes and image-guidance systems, the management of cerebrospinal fluid (CSF) rhinorrhea has greatly evolved. Gubbels SP, Selden NR, Delashaw JB Jr, McMenomey SO. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. Optic nerve deficits suggest a lesion in the region of tuberculum sellae, sphenoid sinus, or posterior ethmoid cells. CT showed decreased thickening of the arterial wall and was negative for the double-ring sign (Figure 1B). Clin Nucl Med. Cerebrospinal fluid rhinorrhoea in closed head injuries. CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. Alternatively, radioactivity of the nasal pledgets is compared with that of known plasma radioactivity. [QxMD MEDLINE Link]. If persistent fluid drainage occurs after a fracture, the fluid may be evaluated to test for the presence of CSF. FREE shipping Etsy's Pick Add to Favorites Two-finger Ring Stainless Steel Glasses, Unisex stainless Ring, Double . From the Department of Emergency Medicine (Sunder), Royal Inland Hospital, Kamloops, BC; and the Department of Radiology (Tyler), Queens University, Kingston, Ont. Coronal and sagittal imaging is necessary. Otol Neurotol. 1997. When CSF rhinorrhea is suspected, fluorescein may be injected into the lumbar subarachnoid space. (Defect measured approximately 7mm.). Int J Pediatr Otorhinolaryngol. A positive diagnosis of CSF fistula is made by finding direct continuity of the CSF fistula with the subarachnoid space. Goel G, Ravishankar S, Jayakumar PN, et al. 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. 2001 Aug. 22(7):1239-50. Spinal MRI in patients with SIHS may show some irregularity of the thecal sac due to partial dural collapse. Certain neurosurgical procedures such as craniotomy and transsphenoidal pituitary resections are most commonly associated with an increased risk of CSF rhinorrhea. The sella turcica and sphenoid sinus are involved in 15% of the cases as well. These patients typically present with aural fullness due to a serous middle ear effusion. Technetium as 99mTc DTPA is a less frequently used isotope. Diagnostic ultrasound has not been useful in cranial CSF leak. The .gov means its official. This article discusses current concepts in the etiology, diagnosis, and treatment of CSF rhinorrhea, as well as long-term management of patients following successful treatment. 2008 Mar-Apr. [QxMD MEDLINE Link]. Br J Surg. The management of CSF rhinorrhea depends on the cause, location, and severity of the leak. CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Meningoencephaloceles usually present in childhood as an intranasal/extranasal mass that transilluminates and expands with crying (Furstenberg sign). Adv Med Sci. Apr 2012. 2001 Jul. Obstructive sleep apnea (OSA) has also been linked to elevated ICP. In patients undergoing endoscopic sinus surgery, the site of injury is most frequently the lateral lamella of the cribriform plate, where the bone of the anterior skull base is thinnest. Endoscopic endonasal CSF rhinorrhea repair in children: Systematic review with meta-analysis. Gadolinium-enhanced, coronal, T1-weighted MRI shows dural and tentorial thickening with contrast enhancement. [QxMD MEDLINE Link]. Double ring sign. CSF leak; CSF rhinorrhea; cerebrospinal fluid; diagnosis; diagnostic algorithm; localization. Results: 2013 Mar 19;185(5):416. doi: 10.1503/cmaj.120055. Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North AmericaDisclosure: Nothing to disclose. West J Emerg Med. This feature is the basis for a specific test for CSF based on immunoelectrophoresis. CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo. [Full Text]. All rights reserved. CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. If you log out, you will be required to enter your username and password the next time you visit. MRI in the Localization of CSF Fistulae: Is It of Any Value?. Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Postoperative Period following Pituitary and Ventral Skull Base Surgery. Disclaimer. Serum glucose, chloride,. [10]. Other proposed mechanisms for nontraumatic CSF leaks include focal atrophy, rupture of arachnoid projections that accompany the fibers of the olfactory nerve, and persistence of an embryonic olfactory lumen. Accessibility Cerebrospinal fluid imaging. [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. 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. Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports.
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