1Department of Radiology, Gulhane Military Medical School, Etlik, Ankara, Turkey, and 2Department of Radiology, Edremit Military Hospital, Edremit, Balikesir, Turkey ABSTRACT. Methods One hundred forty-nine patients with newly diagnosed CIS and MS were included in the retrospective study. A spinal fluid leak occurs when CSF escapes from the dura. It is not clear why these areas of dural thinning develop and what causes them to begin leaking, although symptom onset can be associated with even trivial trauma that may stretch the nerve root sleeves or transiently increase CSF pressure [13]. Most of the lesions are asymptomatic and incidentally found. In most cases of SIH, CSF leakage originates from a single spinal level. 5B —56-year-old man with low-flow CSF leak. In these cases, imaging techniques that result in higher spatial and contrast resolution between CSF and background tissues are preferable. Link, Google Scholar; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER. More delayed imaging produces a gradient of contrast material that is often greatest close to the leak site and decreases further away [18] (Fig. In addition, the biomechanics of the thoracic spine during flexion and extension and the apposition of the dura to the normal kyphotic curvature of the posterior vertebral bodies may also play a role. Compared with CTM, MRI has the advantage of being noninvasive and does not involve ionizing radiation. C, Image from myelogram performed in right lateral decubitus position shows diverticulum (arrow) and leaked contrast material spreading in epidural space (arrowhead), originating from this site. Cerebral edema. TB abscess..pic from net 4. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. CNS MOCKS 2016 2. AJNR Am J Neuroradiol 1987;8:155–156. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. Sze G, De armond SJ, Brant-zawadzki M et-al. Fig. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. A leak on MRI is shown by identifying fluid signal (marked T2 hyperintensity) in the epidural space (Fig. Vanopdenbosch LJ, et al. To produce images with greater contrast between CSF and background tissues, heavy T2 weighting has been explored. The leak location is identified by the appearance of a fork or split in the column of flowing myelographic contrast material, with extraarachnoid contrast material continuing to flow downhill in a cranial direction. The investigation should be targeted toward the lower cervical and thoracic spine in most cases because most high-flow CSF leaks occur in these areas [17]. 7. net pics. Depending on the leak site and whether the patient is imaged in the prone or supine position, the collection may preferentially be located ventrally or dorsally in the spinal canal. Fig. 4B —30-year-old woman with high-flow CSF leak. 2012;199 (3): W258-73. B, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). These techniques, termed “MR myelography” by several authors (not to be confused with myelography using intrathecal gadolinium, as discussed later in this article), have shown promise in detecting CSF leaks, with several reports of similar sensitivity for CSF leak detection compared with other modalities such as CTM or radionuclide cisternography [36, 40, 41]. A, Normal scans in 54-year-old man without CSF leak. Evidence of typical changes associated with SIH, including dural enhancement, brain sagging, the venous distention sign, and other signs associated with low pressure, should be sought, recognizing that they may not be present in all patients [7, 55–57]. Radiology 1985;154:795–799. Neither technique possesses the temporal resolution needed for accurately localizing high-flow leaks, making them less useful in this setting. 5A —56-year-old man with low-flow CSF leak. Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. Close attention should be paid to the presence of thoracic disk protrusions or osteophytes in patients with this leak type, because degenerative lesions often cause fast CSF leaks [18]. 1 x. T2WI MRI brain showing prominent extra-axial CSF spaces. These types of tears are often associated with very rapid CSF leakage and are most commonly found along the ventral surface of the thecal sac in the thoracic or lower cervical spine [17, 19, 20]. Of note, a retrospinal fluid collection may be seen at the C1–C2 level in patients with CSF leak and is best seen on T2-weighted images. These lowflow leaks are often associated with nerve root sleeves (Fig. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive hydrocephalus. The recent murders of Black people at the hands of police officers and white vigilantes illustrate how, especially during a worldwide pandemic, systemic injustice and racism remain deeply ingrained in our society. Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. Although nontargeted epidural blood patching is often used to treat SIH, it may not provide durable relief in a substantial number of patients [3–5]. Fig. Leaked contrast material is seen in dorsal epidural space. In cases where fat suppression has not be used, decreased T1 signal caused by fluid in the epidural space may be seen, a sign that can easily be overlooked if not actively sought. C, Intraoperative photograph of spinal canal (viewed from posterior with spinal cord seen on left of image) shows calcified disk (arrow) protruding through tear in dura. Artikel Terkait. Cerebrospinal fluid is contained within the cerebral ventricles, the spinal canal and the subarachnoid space (space between arachnoid externally and pia mater internally) surrounding the brain and spinal cord (Figure 1182.1).Cerebrospinal fluid (CSF) is reabsorbed into the blood through the arachnoid villi of dural venous sinuses. 10). Unable to process the form. The subsequently described ultrafast technique positions the patient on the CT table in a prone Trendelenburg position, using a large wedge-shaped foam pad, and is intended primarily to detect ventral leaks associated with osteophytes and calcified disks [17]. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. In cases of fast or high-flow CSF leaks, a large pool of contrast material is seen in the epidural space surrounding the thecal sac. Anatomic localization with MR myelography using intrathecal gadolinium is greatly superior to nuclear medicine myelography, making it more useful for guiding targeted treatment. Inversely, hydrocephalus corresponds to an increased intracranial … 8. It results when there is an imbalance between the production of CSF & its drainage by the arachnoid villi. OBJECTIVE. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. It is quite useful in the evaluation of high-flow leaks, but because digital subtraction myelography is not generally used to evaluate the entire spine, it is not generally used as the initial myelographic test for SIH. A, Axial CT myelography (CTM) image shows focal contrast material leak (arrowhead) ventral to nerve root. 1). Sacral spinal canal is enlarged because of dural ectasia. Terminology. Leak detection and localization are important for both diagnosis and treatment. Cns mocks radiology fcps 1. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. A, Sagittal CT myelography (CTM) image shows dorsal collection of CSF (arrowheads), with gradient of myelographic contrast indicating CSF leak at inferior aspect of collection. AJR Am J Roentgenol. Fig. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. Fig. With dynamic CTM, the entire spinal canal can be examined, and spatial resolution is outstanding. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks. Furthermore, single or multiple nerve root sleeve diverticula of various sizes and configurations are seen commonly as an incidental finding in healthy patients and, therefore, should not be assumed to be pathologic when observed in isolation [10, 15]. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. Cerebrospinal fluid (CSF) is a clear, colorless plasma-like fluid that bathes the central nervous system (CNS).Cerebrospinal fluid circulates through a system of cavities found within the brain and spinal cord; ventricles, subarachnoid space of the brain and spinal cord and the central canal of the spinal cord. Agenesis of corpus callosum and frontal encephalocele. A, Sagittal CT myelography image shows calcified thoracic disk protrusion (arrow). Even faster dynamic or ultrafast CTM techniques, in which imaging begins while contrast material is still being actively injected, have also been described elsewhere [17, 32]. However, MRI typically does not localize the exact leak site, generally suffers from more artifacts, has lower spatial resolution than CTM, and requires very homogeneous suppression of fat signal to detect more subtle leaks. A, Sagittal STIR MR image shows extensive collection of fluid in epidural space (arrowheads). small vessel periventricular ischemic disease, low attenuation periventricular changes around the lateral ventricles, effacement of adjacent cerebral sulci may be seen, which is helpful to distinguish the condition from age related cerebral atrophy with, halo of high T2 or FLAIR signal around the lateral ventricles. Intracranial Hypotension: Improved MRI Detection With Diagnostic Intracranial Angles, Original Research. MS..pics from net 11. Fig. Although the site of CSF leakage can be generally assumed to be located somewhere along the length of the epidural collection, leaked CSF spreads away from the site of the original leak, and thus the precise site of leakage is often not able to be predicted by imaging the epidural collection itself. Choroid plexus xanthogranulomas are benign lesions, usually located in lateral and third ventricles. Fig. Idiopathic Intracranial Hypertension: MRI. Morphometric study of the midsagittal MR imaging plane in cases of hydrocephalus and atrophy and in normal brains. 1 Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Calcified disk protrusions or spiculated endplate osteophytes are often found to be the offending lesion, although they may be quite small (Fig. Transependymal edema, also known as interstitial cerebral edema or periventricular lucency (PVL), is a type of cerebral edema that occurs with increased pressure within the cerebral ventricles. In some cases, large diverticula may result in erosion of adjacent pedicles or vertebral elements. CSF opening pressure can also be measured during the procedure, a criterion used in all currently accepted diagnostic schema for SIH [1, 2]. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. In conclusion: CSF pseudocyst formation is a rare cause of a gradually enlarging breast lump, and should be borne in mind in patients with an The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. Fig. Follow-up Clinical Information: Given the patient’s obesity, the size of the pseudomeningocele and partial dehiscence of the deep layers of the wound, operative management was elected rather than more conservative treatment. Objective To identify CSF parameters at diagnosis of clinically isolated syndrome (CIS) and MS that are associated with early inflammatory disease activity as measured by standardized cerebral MRI (cMRI). Next, selection of any myelographic imaging test should be based on the information desired and its intended effect on the management of the individual patient. There is also indirect evidence of CSF leak indicated by activity in bladder (arrowheads) and kidneys at 1, 2, and 4 hours, as well as rapid loss of spinal activity and absence of activity over cerebral convexities at 24 hours. Communicating hydrocephalus is commonly used as the opposite of obstructive hydrocephalus which leads to much unnecessary confusion, as most causes of communicating hydrocephalus do have an element of obstruction to normal CSF flow / absorption. Third ventricular lesions can … If imaging is rapid enough, the exact site of the leak can be pinpointed, potentially opening the door for targeted therapy. Leakage of CSF into the epidural space through a defect in the thecal sac has been found to be the underlying cause of almost all cases of SIH [8, 9]. It is considered by many authors to be the test of choice for most cases of suspected SIH [30, 31]. Advantages of CTM include wide availability, familiarity among radiologists, good spatial resolution, good detail of degenerative changes that may contribute to CSF leaks, and infrequent technical artifacts. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. Medline, Google Scholar Cerebrospinal fluid within the cavities of the brain. The purpose of this article is to review the pathogenesis and imaging appearances of spinal CSF leaks specifically due to SIH (excluding other causes of spinal CSF leaks, such as trauma and postsurgical leaks), and to discuss the various imaging modalities used in their detection, to assist the reader in the selection and interpretation of imaging in this condition. 8A —39-year-old woman with findings of high-flow CSF leak on conventional MRI. 2 Department of Radiology, Mayo Clinic, Rochester, MN. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. Spontaneous intracranial hypotension (SIH) is an increasingly recognized disease caused in nearly all cases by spontaneous spinal CSF leaks. Most radiology departments can perform these procedures, however, in cases where a leak cannot be localized, neuroradiology departments that see larger volumes of spinal CSF leak patients may offer the additional expertise with interpretation as well as with optimization of imaging sensitivity. Fig. Fig. Thecal sac is partially collapsed because of loss of CSF. This technique seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent contrast resolution inherent to MRI. Fig. CSF comprises all intracerebral ventricles, spinal and brain subarachnoid spaces, such as cisterns and sulci, and the central canal of the spinal cord. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. AJNR 2008;29:536-41. Summary. 4 / 5. For example, the use of CT fluoroscopy to perform the lumbar puncture followed by an immediate myelogram can be used, eliminating the delay involved in transporting the patient between a fluoroscopy suite and CT, and allowing scanning within only a minute or two after intrathecal contrast material injection [27]. Regions of dehiscence, usually found on or adjacent to the spinal nerve roots, allow the protrusion of the inner arachnoid layer through the defect in the overlying dura, producing fragile meningeal diverticula that may be prone to tears [7, 10] (Fig. In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. 7C —51-year-old woman who underwent digital subtraction myelography to localize fast leak. B, Axial T2-weighted image again shows extradural fluid (arrowhead). In some cases of lowflow leaks, MRI may be sufficient to localize the leak site by revealing a focal area of extrathecal fluid around a nerve root or adjacent to an osteophyte [39]. 10B —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. 7A —51-year-old woman who underwent digital subtraction myelography to localize fast leak. 6C —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. Such techniques are optimally performed with some pretest probability based on prior imaging as to what spinal region the leak is coming from (e.g., cervical, thoracic, or lumbar), and what surface of the thecal sac is involved (e.g., ventral, dorsal, or lateral), and are therefore less commonly used as an initial screening tool. If confirmed by other investigators, such fistulas could be important because they may occur without concurrent epidural CSF leakage, making them difficult to detect with standard myelographic techniques. In addition to cross-sectional images, maximum-intensity-projection images can be used to create a 3D representation of the thecal sac [40]. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. Focal dural thinning and dehiscence are common causes of spontaneous CSF leak. CT myelography (CTM) is probably the most commonly used modality in investigating CSF leaks. The two major limitations are the associated radiation dose and patient discomfort associated with prolonged prone Trendelenburg positioning. rhinorrhea. Meningioma and schwanoma ..NF2 9. 4), although increased contrast concentration also can be seen in dependent portions of the epidural collection. 9B —27-year-old woman who underwent MR myelography with intrathecal gadolinium. The myelographic appearance of the leaks may vary, however, depending on the cause of the leak, rate of leakage, and imaging modality used. 4D —30-year-old woman with high-flow CSF leak. Trapped ventricle, also known as isolated ventricle, is a condition in which there is an obstruction to the entry and exit path of CSF through the ventricle. Images of patient in prone position obtained at 0.2, 1, 2, 4, and 24 hours show direct evidence of left lumbar CSF leak with focal increased activity within left lumbar paraspinal tissues (arrows). Fig. Digital subtraction myelography offers unparalleled temporal resolution but suffers from a limited area of coverage, uses planar rather than cross-sectional images, and requires either good patient cooperation or general anesthesia. Nevertheless, MRI has been shown to be sensitive for predicting the presence of a high-flow leak, thereby avoiding the need for multiple forms of invasive myelography (e.g., CTM followed by an additional study to further localize the leak) in patients with this leak type [29, 37]. When the patient is positioned on a tilting fluoroscopy table such that the dural defect is on the dependent aspect of the thecal sac, the CSF leak will be visualized on fluoroscopy as the patient is slowly tilted head down and the column of contrast material passes over the defect. C, Coronal CTM image shows close relationship of diverticulum (arrow) to exiting nerve root sleeve. A, Axial CTM image shows epidural pooling of contrast material (arrowhead) due to high-flow CSF leak. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. British Journal of Radiology 2010;83:225-232. Ventriculoperitoneal shunt is commonly used to treat hydrocephalus whereby the peritoneal cavity is used for cerebrospinal fluid (CSF) absorption. LaFata V, et al. Fig. Segev Y, Metser U, Beni-adani L et-al. Radionuclide cisternography using 111In–diethylene triamine pentaacetic acid (DTPA) is performed with lumbar intrathecal injection of approximately 0.5 mCi 111In-DTPA. Leak localization and characterization are important for several reasons. CONCLUSION. Image acquisition is stopped once a leak is seen. For fast CSF leaks, then, selection of an imaging modality with high temporal resolution and rapid imaging after introduction of the myelographic agent are key to localizing the actual leak site. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. Spinal MRI has also been used to evaluate for CSF leaks [36–38]. FLAIR is the most sensitive MRI sequence for detection. 1C —40-year-old woman with CSF leak caused by meningeal diverticulum. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. B, Image from digital subtraction myelography with patient in prone position shows leakage of contrast material (arrowhead) originating at level of disk space seen in A. In appropriate dilution, it has been found by multiple investigators to be well tolerated [30, 44, 45, 47, 48]. Because they are more easily localized than fast leaks, represent slower rates of CSF leakage, and are more anatomically accessible than ventrally located leaks, these leaks are often easier to treat percutaneously than their high-flow counterparts. Cerebrospinal fluid (CSF) leak may occur from the nose (rhinorrhea), from the external auditory canal (otorrhea), or from a traumatic or operative defect in the skull or spine. 3). Some authors strongly advocate for initial screening with MRI [29, 39], whereas others consider CTM to be the reference standard and the initial test of choice [31, 58, 59]. There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-labe cohort study. 4A —30-year-old woman with high-flow CSF leak. No evidence of periventricular CSF seepage. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. First, because contrast-enhanced brain MRI is critical to establishing the diagnosis of SIH, this should be part of the routine imaging assessment. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Original Research. It is generally thought that these cases represent very slow or intermittent leaks that may not be detected with current imaging technology. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. Typically, the leak is caused by one of two main categories of pathologic process: spontaneous dural dehiscence and dural tears caused by degenerative causes. One series of surgically confirmed cases described a variety of configurations of these dural defects, including defects located at the axilla of the nerve root, others along the length of the nerve root sleeve, and circumferential absence of the dura surrounding the base of the nerve root [10]. Some authors favor the use of general anesthesia to more effectively suspend respirations [24], whereas others have not found this necessary [19]. Figure 1182.1: Cranial meninges Leakage rates from the diverticula observed during surgical exploration have also been found to be variable, ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly [7]. 124 (2): 334. Transependymal edema, also known as interstitial cerebral edema or periventricular lucency (PVL), is a type of cerebral edema that occurs with increased pressure within the cerebral ventricles. The brain and spinal cord are surrounded by three protective membranes, the outermost of which is called the dura.One function of the dura is to contain the cerebrospinal fluid (CSF)–the liquid that bathes and cushions the brain and spinal cord. Schizencephaly..pics from net 6. Several investigators have reported that MR myelography using intrathecal gadolinium is more sensitive for slow-flow or intermittent leaks than CTM, with CSF leaks identified in approximately 20% of patients for whom no leak was identified on prior CTM [30, 45] (Fig. The brain is surrounded by cerebrospinal fluid (CSF) within the sulci, fissures and basal cisterns.CSF is also found centrally within the ventricles.The sulci, fissures, basal cisterns and ventricles together form the 'CSF spaces', also known as the 'extra-axial spaces'. 6B —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. There may be a mechanism in common with the dural tears associated with idiopathic spinal cord herniation, which occur in the same spinal region and are often associated with calcified disk protrusions and osteophytes as well [23]. Tuberculous brain abscess 3. Furthermore, if there is concern, the lumbar puncture site can be preemptively blood patched at the conclusion of the procedure. Leakage of CSF into spaces other than the epidural space, such as the pleural space or peritoneum, can also cause SIH and usually is found in patients with connective tissue disorders [26] (Fig. The contrast material leak ( Fig two major limitations are the associated radiation dose and patient discomfort associated with prone... And 24 hours spiculated endplate osteophytes are often associated with nerve root sleeve: CT findings show evidence lumbar. C, Coronal CTM image shows extensive collection of leaked fluid are found. Examined, and extends over cerebral convexities by 24 hours are displayed detected without a large associated of... Club: Incidence of complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution MR! Schievink w, Cedars-Sinai Medical Center, Los Angeles, CA ) gadolinium should be part the! Tissues of the spine, including disk protrusions and osteophytes, may also result in higher spatial contrast. Extravasation or transependymal CSF absorption and transependymal seepage of CSF formation in humans about! Differential diagnosis, Original Research the exact site of the Central nervous system and helps to protect the brain and! This should be used to establish the diagnosis [ 1, 2, T1-Weighted Imaging-Based diagnosis. [ 16–18 ] images with greater contrast between CSF and background tissues are preferable may in. Roots ) has also been observed [ 11 ] will be seen on initial imaging nontargeted! To establish the diagnosis of SIH, however, the leak can be into... Diagnosis [ 1, 2, T1-Weighted Imaging-Based Differential diagnosis, Original Research and MS were included the... 3B —27-year-old woman who underwent digital subtraction myelography and dynamic or ultrafast CTM techniques also obtained 52! Been refined to Detect these leaks, some general principles can be associated with small thoracic disk.. Beni-Adani L et-al Marek Czosnyka, Dong-Joo Kim as shunt migration, blockage retraction... Extensive leakage of CSF leaks can, however, will not have any identifiable connective tissue disorder general principles be... Technique seeks to combine the benefits of CSF-specific contrast obtained with CTM, the entire spinal canal be! X. T2WI MRI brain showing prominent extra-axial CSF spaces flair is the most sensitive MRI sequence detection... 1 Department of Radiology, Duke University Medical Center, Box 3808, Durham, 27710! That these cases, imaging techniques have been unrevealing Rothfus WE, Deeb ZL, Daffner RH, ER. Less useful in this setting the dura around nerve root sleeves ( Fig detected without a large pool... Blood cells ( WBC ):0 – 5 cells/µL 1 lining resulting in periventricular ooze, can! Of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic csf seepage radiology be quite (... Diagnosed CIS and MS were included in the setting of an acute obstructive hydrocephalus Kranz ( peter.kranz @ duke.edu.! Csf volume is 90–150 ml in adults and 10–60 ml in neonates with fistula formation over. Occurs when CSF escapes from the dura and indirect evidence of lumbar spinal CSF leaks Brant-zawadzki. Limitations are csf seepage radiology associated radiation dose and patient discomfort associated with abdominal complications such shunt. Seen outlining bowel loops ( arrowhead ) due to high-flow CSF leak caused by meningeal diverticulum obtained! Or shunting etc these include digital subtraction myelography to localize fast leak between production... Efforts to improve temporal resolution while maintaining the excellent contrast resolution inherent to.! Cis and MS were included in the retrospective study > 2: Improved MRI with... Recognized cases of SIH, CSF leakage originates from a single spinal level lucency in hydrocephalus: or... Migration of cerebrospinal fluid into the csf seepage radiology and spinal cord from injury man! Large diverticula may result in tears of the epidural collection keeping with transtentorial herniation Fig... [ 39 ]: extravasation or transependymal CSF absorption and transependymal seepage the!, MR myelography using intrathecal gadolinium should be used judiciously, and spatial and. Man without CSF leak caused by degenerative abnormality dura around nerve root (. The Central nervous system and helps to protect the brain and spinal cord injury! Low-Flow leaks may be extensive, spanning over multiple vertebral segments and, occasionally 48-hour... And spatial resolution is outstanding, csf seepage radiology Angeles, CA ) these leaks, each with its own strengths weaknesses. Hypotension, Original Research underwent MR myelography using intrathecal gadolinium that reaches basal cisterns at 5 hours, and hours. Increased intracranial … Summary initially thought to show definite CSF leak caused by abnormality... The midsagittal MR imaging plane in cases where first-line myelographic techniques have been unrevealing that offer greater sensitivity subtle! Leaks can, however, the exact csf seepage radiology of the CSF visualized only during Valsalva to. ( SIH ) is an increasingly recognized disease caused in nearly all cases of SIH however! Result, a number of imaging tests have been refined to Detect leaks!, Eun-Jin Jeong, Dae-Hyeon Park, Zofia Czosnyka, Dong-Joo Kim and therefore appears darker on CT images disk... Other hand, MRI has also been used to create a 3D representation of the midsagittal MR imaging in. There may be more conspicuous when digital subtraction is used probably the commonly! Csf may pour rapidly, 29 ] of meningeal dural and arachnoid laceration fistula. All Rights reserved setting of an acute obstructive hydrocephalus affords have led several. Disk protrusions or spiculated endplate osteophytes are often associated with nerve root sleeves Fig. ) to exiting nerve root sleeves ( Fig may uncommonly be encountered [ 12 ] occurs when CSF from... Alternative method for evaluating traumatic CSF rhinorrhea authors to be the test choice!, will not have any identifiable connective tissue disorder the boundaries of the utility each! Slow, the entire spine heavy T2 weighting has been increasing experience in recent years with MR myelography using gadolinium... Intermittent leaks that may not be detected without a large associated pool of epidural contrast material ( )! ):0 – 5 cells/µL 1 which CSF may pour rapidly note normal ascent of radioactivity reaches. Hydrocephalus: extravasation or transependymal CSF absorption? in keeping with transtentorial herniation to... Needed for accurately localizing high-flow leaks, each with its own strengths and weaknesses are... Contrast-Enhanced brain MRI is shown by identifying fluid signal ( marked T2 hyperintensity ) in retrospective... In higher spatial and contrast resolution between CSF and background tissues are preferable MRI sequence for detection 7b woman... White matter of the utility of each modality in various leak types is presented Table! Sensitivity and specificity [ 53 ] there is an increasingly recognized disease caused in nearly all of... Blood cells ( WBC ):0 – 5 cells/µL 1 to improve temporal while... May result in erosion of adjacent pedicles or vertebral elements area of interest Axial CT myelography ( CTM ) shows... Through C7–T1 level was not initially thought to show definite CSF leak by! Of CSF-specific contrast obtained with CTM with the excellent cross-sectional visualization CT affords have led to several modifications of utility. The CTM technique and arachnoid laceration with fistula formation each modality in various leak types is presented in 1. Include digital subtraction myelography to localize fast leak periventricular ooze, it can be examined, and over! First, because contrast-enhanced brain MRI is critical to establishing the diagnosis of SIH, however, the provides! Leaks can, however, the leak may be useful 31 ] due to high-flow CSF leak it supplies to... Be pinpointed, potentially opening the door for targeted therapy ) spaces include ventricles and and! Lateral to thecal sac ( arrow ) result of meningeal dural and arachnoid laceration with fistula.... To improve temporal resolution while maintaining the excellent contrast resolution inherent to MRI normal ascent of radioactivity that reaches cisterns...: an alternative method for evaluating traumatic CSF rhinorrhea: detection and localization are important treatment! Monitoring capability may aid in the detection of slow or intermittent leaks that may not detected. This was repaired using 4 inte… UCSF Department of Radiology and Pediatrics,. ( marked T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [ 39 ] Improved detection... The production of CSF into epidural space the entire spinal canal is enlarged because of ectasia! Using 4 inte… UCSF Department of Radiology and Pediatrics Director, Division of nuclear medicine October 2009 CSF. And contrast resolution between CSF and background tissues are preferable other hand, MRI has the advantage of cisternography... Paraspinal soft tissues CLUB: Incidence of complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution MR! Endoscopic findings direct CSF-venous fistulas were recently reported to cause SIH in small... From multiple adjacent spinal nerve roots ) has also been used to create a 3D representation of the collection fluid. Of high-flow CSF leak RAY Society, ARRS, all Rights reserved &... Leaks [ 36–38 ] detected without a large associated pool of epidural contrast material may be the offending,! Leaks are often associated with abdominal complications such as shunt migration, blockage, retraction, infection, hernia! University Medical Center, Box 3808, Durham, NC 27710, this should be used to a! Consequently csf seepage radiology intrathecal gadolinium should be part of the thecal sac ( arrow ), they... As: CT findings focal leak may be useful and specificity [ 53 ] SIH! A small series of three patients [ 24 ], Duke University Medical Center, Los Angeles CA... A Summary of the epidural collection calcified thoracic disk protrusion foramina at multiple levels and may track the! Or localization are important for several reasons url '': '' /signup-modal-props.json? lang=us\u0026email= '' } scans., csf seepage radiology can be important for several reasons other hand, MRI has the advantage of noninvasive! Diagnosis, Original Research in humans is about 0.3–0.4 ml min −1 ( about 500 ml day −1.! Of high-flow CSF leak, leak localization can be advanced inferior aspect of (! Were recently reported to cause SIH in a significant proportion of cases SIH...