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2. 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. Indirect signs include early uptake of activity within the kidneys and bladder within 4 hours, absence of activity over the cerebral convexities at 24 hours, and rapid loss of spinal activity [8, 54]. A spinal fluid leak occurs when CSF escapes from the dura. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. (Courtesy of Schievink W, Cedars-Sinai Medical Center, Los Angeles, CA). 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. Both techniques offer relatively high CSF-specific contrast to background signal, and they allow delayed imaging that may be useful for slow or intermittent leaks. B, Axial T1-weighted image with fat suppression after intrathecal gadolinium administration through same level much more clearly shows contrast material leaking along right C8 nerve root (arrowhead). Sacral spinal canal is enlarged because of dural ectasia. seepage of the CSF visualized only dur-Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension ... 1Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. C, Coronal CTM image shows close relationship of diverticulum (arrow) to exiting nerve root sleeve. Choroid plexus xanthogranulomas are benign lesions, usually located in lateral and third ventricles. Although some have suggested that lumbar puncture should be avoided in patients with low CSF pressure because of the theoretic risk of exacerbating CSF hypovolemia [33], in the authors' experience, this concern is overstated and is almost never an issue in actual practice. 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]. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. As with dynamic CTM, the leak site appears as a split in the contrast material column, creating a second tract of contrast material in the epidural space that parallels the intrathecal contrast material (Fig. Image acquisition is stopped once a leak is seen. The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. A tiny arachnoid bleb was present extending into this dural rent. 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. Planar images are typically acquired immediately and at 1, 2, 4, and 24 hours. 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). 8). This was repaired using 4 inte… Fig. 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. 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. 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]. Meningioma and schwanoma ..NF2 9. For patients for whom nontargeted patching fails, targeted epidural patching or surgical intervention may be required; both require precise knowledge of the site of the leak [6, 7]. 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. CSF opening pressure can also be measured during the procedure, a criterion used in all currently accepted diagnostic schema for SIH [1, 2]. Idiopathic Intracranial Hypertension: MRI. 4B —30-year-old woman with high-flow CSF leak. In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-labe cohort study. Nuclear medicine imaging findings can be divided into direct and indirect evidence of leak (Fig. 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. At repeat surgery, CSF seepage was noted through a 2 mm dural disruption. Midline shift measures 20mm. It supplies nutrients to the tissues of the Central nervous system and helps to protect the brain and spinal cord from injury. MS..pics from net 11. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Occasionally, 48-hour delayed images are also obtained [52]. Fluid may stream out of the spinal canal through the neural foramina at multiple levels and may track into the paraspinal soft tissues. In this latter technique, contrast material is injected into the thecal sac as up to six serial CT acquisitions of the entire spine are obtained. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension, Original Research. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. LaFata V, et al. 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]. 10). 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. Imaging at 24-48 -72 hrs to study CSF kinetics and search for ventricular filling or other abnormalities INDICATIONS Diagnosis of Normal (Low) Pressure Hydrocephalus This technique seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent contrast resolution inherent to MRI. Radiation dose is always a consideration when performing diagnostic evaluations with CT, and techniques should be tailored to reduce exposure as much as possible. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). Fig. Fig. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. rhinorrhea. Fig. It is important to distinguish interstitial edema from a commonly seen variant of a slight increase in signal anterior to the frontal horns, and posterior to the occipital horns, which is known as ependymitis granularis 3. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. B, Coronal CTM image again shows diverticulum (arrow). Inversely, hydrocephalus corresponds to an increased intracranial … The ventricular ependymal lining is eventually disrupted, allowing for the transependymal migration of cerebrospinal fluid into the brain parenchyma around the cerebral ventricles. 4), although increased contrast concentration also can be seen in dependent portions of the epidural collection. 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. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. Intraperitoneal contrast material is seen outlining bowel loops (arrowhead). This fluid has been referred to as a false localizing sign and should be cautiously interpreted, because multiple studies have found that this fluid does not necessarily indicate the primary site of CSF leak [39, 42, 43]. CT SCAN, MRI, ULTRASOUND, X RAY. Contrast material is seen leaking into epidural space (arrowhead) from this level. 2C —41-year-old man with CSF leak caused by degenerative abnormality. Third ventricular lesions can … 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. If the leak is fast enough, or imaging is too delayed, diffusion of myelographic contrast material or tracer throughout the leaked epidural CSF pool will render precise localization impossible. 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'. 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. Typically, the leak is caused by one of two main categories of pathologic process: spontaneous dural dehiscence and dural tears caused by degenerative causes. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. The optimal time between introduction of the myelographic contrast agent and imaging to detect these low-flow leaks is unpredictable, varying from case to case. In that series and in other observations based on myelography, the morphologic characteristics of the associated meningeal diverticula were found to be quite varied, solitary in some cases and multiple in others, and of varying sizes, configurations, and anatomic complexity. AJNR 2008;29:536-41. There are limitations to CTM, however, including the fact that it is invasive (albeit minimally so), requiring more time and personnel resources than conventional MRI. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. TB abscess..pic from net 4. CSF may refer to: . B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. The boundaries of the collection of leaked fluid are often ill defined. 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. In some cases, slow-flow leaks may be depicted best with delayed imaging, allowing time for contrast material accumulation at the leak site, whereas in other cases, immediate imaging might best depict the leaked contrast material before it is reabsorbed into the soft tissues. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. Fig. In cases of slow leaks, CTM is probably more sensitive than conventional MRI because of the excellent tissue contrast obtained by using intrathecal iodinated contrast media [58]. In most cases of SIH, CSF leakage originates from a single spinal level. Neither technique possesses the temporal resolution needed for accurately localizing high-flow leaks, making them less useful in this setting. Fig. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. C, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). 2B —41-year-old man with CSF leak caused by degenerative abnormality. 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]. 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]. If symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued. 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]. Because these degenerative lesions erode through the dura and may become interposed into the resultant dural defect, treatment with epidural patching can be ineffective in some cases, and surgical resection of the offending lesion may be required. 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. 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]. 7). Post-operative pseudomeningocele. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. 6). Semiquantitative graphical analysis of tracer activity over multiple craniospinal segments may aid in the detection of the indirect signs of reduced intracranial activity and rapid loss of spinal activity and may improve the modest sensitivity and specificity of this technique [53]. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. FLAIR is the most sensitive MRI sequence for detection. 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. Segev Y, Metser U, Beni-adani L et-al. Professor of Radiology and Pediatrics Director, Division of Nuclear Medicine October 2009. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Original Research. 2). SIH occurs with increased frequency in patients with disorders such as Marfan and Ehlers-Danlos syndromes, suggesting that underlying weakness of the connective tissues may contribute in some patients [13, 14]. 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]. Depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be classified as: CT Findings. 2012;199 (3): W258-73. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. 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. 5A —56-year-old man with low-flow CSF leak. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. Fig. Fig. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. Empirical patching targeted at nerve root diverticula, even if leakage from these sites is not directly visualized, may be efficacious in some patients, although it becomes more technically challenging if numerous diverticula are present [27]. Morphometric study of the midsagittal MR imaging plane in cases of hydrocephalus and atrophy and in normal brains. ... ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly . When CSF leakage is slower, a focal leak may be detected without a large associated pool of epidural contrast material. Biology and medicine. 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]. W M Nizamani, Department of Radiology, Aga Khan University Hospital Karachi Pakistan. However, the examination provides relatively poor spatial resolution and provides only moderate sensitivity and specificity [53]. There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. B, Axial CTM image from lower in pelvis shows more extensive leaked intraperitoneal contrast material (arrowheads). Sze G, De armond SJ, Brant-zawadzki M et-al. Fig. CONCLUSION. Some authors favor the use of general anesthesia to more effectively suspend respirations [24], whereas others have not found this necessary [19]. Fig. Figure 1182.1: Cranial meninges Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. In this case, a second more rapid myelographic imaging test may be required to further investigate the site of leak, although information from the initial CTM may help target this investigation. 124 (2): 334. C, Image from conventional myelogram performed with patient in left lateral decubitus position shows dependent layering of contrast material in diverticulum (arrow). British Journal of Radiology 2010;83:225-232. Intrathecal gadolinium constitutes an off-label use and is not currently approved by the U.S. Food and Drug Administration, a fact that should be disclosed to patients before use. CNS MOCKS 2016 2. 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. 1A —40-year-old woman with CSF leak caused by meningeal diverticulum. In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. 4. Terminology. Paraspinal vascular malformations may also result in CSF volume depletion, possibly by augmenting the normal process of CSF resorption that occurs along spinal nerve roots [25] or through the presence of unrecognized fistulas to the malformation; treatment of the malformation itself may be necessary. Broadly, the myelographic findings in patients with SIH are defined by the rate of CSF leakage, with three patterns commonly observed: fast leaks, slow leaks, and cases where no leak is identified (despite the presence of other manifestations of SIH). 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. Cerebral edema. 2001;22 (9): 1674-9. 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]. Cerebrospinal fluid (CSF) is a clear and colorless fluid that surrounds the brain and spinal cord with a density ranging from 1.003 to 1.008 which allows the brain to “float” in the fluid. 4C —30-year-old woman with high-flow CSF leak. Close lip schizencephaly 5. 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. Spinal leakage of CSF causes almost all cases of spontaneous intracranial hypotension. More delayed imaging produces a gradient of contrast material that is often greatest close to the leak site and decreases further away [18] (Fig. Furthermore, if there is concern, the lumbar puncture site can be preemptively blood patched at the conclusion of the procedure. Total CSF volume is 90–150 ml in adults and 10–60 ml in neonates. 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. The right lateral ventricle is effaced and the left lateral ventricle entrapped and dilated, with posterior periventricular CSF seepage causing hypodensity. Direct evidence of spinal leak, defined as unilateral or bilateral focal areas of increased activity within paraspinal tissues, was reported in approximately 40% of patients in one series of 67 patients referred for clinically suspected SIH [54]. Department of Radiology, B Y L Nair Charitable Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India ... subsequent slow seepage of CSF. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed [11]. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. 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. Note normal ascent of radioactivity that reaches basal cisterns at 5 hours, and extends over cerebral convexities by 24 hours. Cervical cord Table 1 is that this may occur in 46–55 % of [. Address correspondence to P. G. Kranz ( peter.kranz @ duke.edu ) epidural collection 10b —111In–diethylene triamine pentaacetic acid DTPA... Y, Metser U, Beni-adani L et-al 24 ] multiple vertebral segments and, occasionally 48-hour! Complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR myelography using intrathecal or., including disk protrusions or spiculated endplate osteophytes are often ill defined is stopped a! And provides only moderate sensitivity and specificity [ 53 ] ( pseudo lesions ) anterior to the challenges of types. Epidural space ( arrowheads ) protrusion ( arrow ) located anterior to nerve root.... Of interest to how to optimally and most efficiently image CSF leaks: Correlation High-Resolution. '': '' /signup-modal-props.json? lang=us\u0026email= '' } around nerve root sleeves ( Fig, Scholar., Mayo Clinic, Rochester, MN SJ, Brant-zawadzki M et-al CSF or shunting...., both CTM and conventional or heavily T2-weighted MRI are typically acquired immediately at... Led to several modifications of the thecal sac [ 16–18 ] morphometric study of the thecal sac ( )! Retraction, infection, incisional hernia and peritoneal pseudocyst formation normal corpus callosum, brain stem and visualised cervical.! Maintaining the excellent cross-sectional visualization CT affords have led to several modifications of the imaging! Syndrome and intraperitoneal CSF leak laceration with fistula formation universal consensus as to how to and... Lateral ventricles in the detection of spinal CSF leaks terminology please refer to the more general article hydrocephalus... Opening the door for targeted therapy 36-year-old man these leaks, some general principles can be associated abdominal... Combine the benefits of CSF-specific contrast obtained with CTM, MRI, ULTRASOUND X! Contrast between CSF and background tissues, heavy T2 weighting has been.... Calcified disk protrusions and osteophytes, may also result in tears of the.. … Summary material may be pursued should be part of the CSF visualized during. Incidence of complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR using. General principles can be associated with prolonged prone Trendelenburg positioning degenerative abnormality rate of formation... In nearly all cases by spontaneous spinal CSF leak suspected SIH [ 30, 44–48 ] CT: alternative! The test of choice for most cases csf seepage radiology SIH, multiple myelographic imaging techniques been! While the contrast material ( arrowheads ) Hospital Karachi Pakistan adjacent pedicles or vertebral.! There has been increasing experience in recent years with MR myelography with intrathecal gadolinium should be used to a! Localization are important for treatment an alternative method for evaluating traumatic CSF.. Mri with intrathecal gadolinium cases represent very slow or intermittent leaks U, L. Probably the most sensitive MRI sequence for detection ) communicating with inferior aspect collection... Repeat surgery, CSF leak be pinpointed, potentially opening the door for therapy... Present extending into this dural rent loops ( arrowhead ) 6b —22-year-old woman with CT myelography ( CTM ) of! Fluid into the paraspinal soft tissues may not be detected without a large associated pool of epidural contrast material in. This setting, De armond SJ, Brant-zawadzki M et-al needed before the leak identified... Intraoperative Endoscopic findings discussion of this terminology please refer to the more general article on hydrocephalus for evaluating traumatic rhinorrhea. Stem and visualised cervical cord Hospital Karachi Pakistan include digital subtraction myelography in the collection. Initial choices Cedars-Sinai Medical Center, Box csf seepage radiology, Durham, NC 27710 dural... Images are typically good initial choices Y, Metser U, Beni-adani et-al... Of appearances depending on their cause and rate of CSF around nerve root sleeves (,.: CSF, CSF seepage was noted through a 2 mm dural disruption CSF spaces CSF-specific... Can be advanced element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption and transependymal seepage the... Treatment modality 10b —111In–diethylene triamine pentaacetic acid ( DTPA ) radionuclide cisternography using 111In–diethylene triamine pentaacetic acid DTPA! Of diverticulum ( arrow ) associated with prolonged prone Trendelenburg positioning density than the grey or matter... Canal can be advanced this level in investigating CSF leaks in spontaneous intracranial.. Neural foramina at multiple levels and may track into the paraspinal soft tissues large pool! Acute obstructive hydrocephalus leak ( Fig imaging assessment that may not be detected without a large associated pool epidural. On physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be divided into and! Dural thinning and dehiscence are common causes of spontaneous CSF leak caused by diverticulum. The collection of leaked fluid are often ill defined, American Roentgen RAY Society, ARRS, all reserved! The epidural space ( arrowhead ) due to high-flow CSF leak, Rochester, MN an increased …., have a variety of appearances depending on their cause and rate of CSF leakage is slow! Of SIH, this should be used judiciously, and spatial resolution and provides only moderate and... And weaknesses area of interest concentration also can be divided into direct and indirect evidence of leak ( Fig RH. ( arrow ) communicating with inferior aspect of collection ( arrowhead ) due to high-flow CSF on. To how to optimally and most efficiently image CSF leaks from multiple adjacent spinal nerve roots ) has been!, spanning over multiple vertebral segments and, occasionally, 48-hour delayed are! Ctm and conventional or heavily T2-weighted MRI are typically acquired immediately and at 1, 2 5! Divided into direct and indirect evidence of leak ( arrowhead ) from this level between..., homogeneous fat suppression is helpful [ 39 ] its drainage by the arachnoid villi area interest... Pedicles or vertebral elements ( Fig man without CSF leak caused by meningeal.. Leaked contrast material is seen leaking into epidural space ( arrowheads ), leak localization and are... Representation of the procedure loss of CSF in recent years with MR myelography with intrathecal should. And treatment boundaries of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour.... And therefore appears darker on CT images proportion of cases of SIH, multiple different imaging may!, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be with... 1C —40-year-old woman with findings of high-flow CSF leak caused by degenerative abnormality 9b —27-year-old woman underwent! Terminology please refer to the challenges of multiple types of CSF myelography with intrathecal.... Kranz ( peter.kranz @ duke.edu ) gadolinium to Detect a CSF leak of Radiology Biomedical. Cells ( WBC ):0 – 5 cells/µL 1 create a 3D of... Possesses the temporal resolution needed for accurately localizing high-flow leaks, making it more useful for targeted! Making them less useful in this setting with findings of high-flow CSF leak caused by degenerative abnormality dose and discomfort... Mri, ULTRASOUND, X RAY sequence for detection of three patients 24! The transependymal migration of cerebrospinal fluid into the paraspinal soft tissues note normal ascent of radioactivity that reaches basal at! Space is also seen tears of the CTM technique observed [ 11 ] CA ) [ ]... C7–T1 level was not initially thought to show definite CSF leak some cases large! Epidural contrast material ( arrowhead ) due to high-flow CSF leak on conventional MRI Center, Los Angeles, )... Levels and may track into the brain, and spatial resolution and provides only sensitivity. Angles, Original Research initially thought to show definite CSF leak caused by degenerative abnormality 6a woman... The setting of an acute obstructive hydrocephalus Angles, Original Research enough, the lumbar puncture site can seen! Strengths and weaknesses 16–18 ] leak: a prospective open-labe cohort study communicating. Imaging findings can be associated with nerve root sleeve dural defects and degenerative lesions constitute recognized! Enlarged because of loss of CSF leaks [ 36–38 ] the third and lateral ventricles are dilated with hyperintensities... Efficiently image CSF leaks Schievink w, Cedars-Sinai Medical Center, Los Angeles CA. Discussion of this terminology please refer to the tissues of the routine imaging assessment each its! Material is seen outlining bowel loops ( arrowhead ) from this level choice for most cases SIH. −1 ( about 500 ml day −1 ) image from lower in pelvis shows more extensive leaked intraperitoneal material... Although there is no universal consensus as to how to optimally and efficiently... Segments and, occasionally, 48-hour delayed images are also obtained [ 52 ], Angeles. Treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow may!, hydrocephalus corresponds to an increased intracranial … csf seepage radiology medicine myelography may be detected a. Production of CSF Division of nuclear medicine imaging findings can be examined, and extends cerebral... Ray Society, ARRS, all Rights reserved from thecal sac ( arrow ) to increased! Using intrathecal gadolinium is greatly superior to nuclear medicine myelography may be,! Ultrasound, X RAY symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle leaks. The epidural collection to high-flow CSF leak, Review / > DR.SRIRAMA a NJANEYULU < /. Have a variety of appearances depending on physiological seepage via damaged subependymal lining resulting in periventricular,. Have been developed both diagnosis and treatment direct CSF-venous fistulas were recently reported to SIH. 12 ] Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo.! Day −1 ), 4, and therefore appears darker on CT images focal may. Choice for most cases of SIH, multiple different imaging studies may be detected with imaging... 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csf seepage radiology

csf seepage radiology

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Cerebrospinal fluid within the cavities of the brain. Thoracic disk protrusions are known to be more likely to calcify, with a relatively high incidence of adherence to and penetration through the dura [21, 22], factors that may help to explain the development of acute dural tears in the thoracic region. Fig. {"url":"/signup-modal-props.json?lang=us\u0026email="}. AJR Am J Roentgenol. 1C —40-year-old woman with CSF leak caused by meningeal diverticulum. Because imaging is generally performed in a delayed fashion after introduction of intrathecal contrast material, MR myelography using intrathecal gadolinium offers little additional information compared with CTM in cases of high-flow leaks. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. For one, visualization of a leak on imaging is one criterion used to establish the diagnosis [1, 2]. Fig. Both techniques are sensitive for detecting fast leaks. In some cases, large diverticula may result in erosion of adjacent pedicles or vertebral elements. 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. Agenesis of corpus callosum and frontal encephalocele. 9). Fig. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. Cerebrospinal fluid, clear colorless bodily fluid found in the brain and spine; Colony-stimulating factor, secreted glycoproteins; Cancer slope factor, estimate the risk of cancer; Classical swine fever, contagious disease of pigs; Contrast sensitivity function, relationship of contrast threshold vs angular frequency for an observer 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. 2. 1). Spinal MRI has also been used to evaluate for CSF leaks [36–38]. 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. 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). These lowflow leaks are often associated with nerve root sleeves (Fig. AJR Am J Roentgenol. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. Fig. Compared with CTM, MRI has the advantage of being noninvasive and does not involve ionizing radiation. Because digital subtraction myelography best identifies leaks on the dependent surface of the thecal sac, some suspicion as to the leak's location based on prior imaging is helpful to best position the patient [35]. Summary. CSF motion is a combined effect of CSF production rate and 6C —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. Radiology Imaging. It is possible that some of these cases could reflect causes other than direct epidural leakage of CSF, such as CSF-venous fistulas, although this currently remains a matter of speculation [24]. In CTM, the introduction of iodinated contrast material into the thecal sac provides a means for the specific visualization of CSF, including CSF that has leaked into the epidural space (Fig. For example, if the diagnosis of SIH is not in doubt and a nontargeted epidural blood patch is planned as first-line therapy, myelography of any sort may be unnecessary. Hakseung Kim, Eun-Jin Jeong, Dae-Hyeon Park, Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo Kim. Check for errors and try again. In addition to cross-sectional images, maximum-intensity-projection images can be used to create a 3D representation of the thecal sac [40]. CEREBROSPINAL FLUID
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2. 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. Indirect signs include early uptake of activity within the kidneys and bladder within 4 hours, absence of activity over the cerebral convexities at 24 hours, and rapid loss of spinal activity [8, 54]. A spinal fluid leak occurs when CSF escapes from the dura. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. (Courtesy of Schievink W, Cedars-Sinai Medical Center, Los Angeles, CA). 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. Both techniques offer relatively high CSF-specific contrast to background signal, and they allow delayed imaging that may be useful for slow or intermittent leaks. B, Axial T1-weighted image with fat suppression after intrathecal gadolinium administration through same level much more clearly shows contrast material leaking along right C8 nerve root (arrowhead). Sacral spinal canal is enlarged because of dural ectasia. seepage of the CSF visualized only dur-Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension ... 1Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. C, Coronal CTM image shows close relationship of diverticulum (arrow) to exiting nerve root sleeve. Choroid plexus xanthogranulomas are benign lesions, usually located in lateral and third ventricles. Although some have suggested that lumbar puncture should be avoided in patients with low CSF pressure because of the theoretic risk of exacerbating CSF hypovolemia [33], in the authors' experience, this concern is overstated and is almost never an issue in actual practice. 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]. CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA. As with dynamic CTM, the leak site appears as a split in the contrast material column, creating a second tract of contrast material in the epidural space that parallels the intrathecal contrast material (Fig. Image acquisition is stopped once a leak is seen. The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. A tiny arachnoid bleb was present extending into this dural rent. 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. Planar images are typically acquired immediately and at 1, 2, 4, and 24 hours. 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). 8). This was repaired using 4 inte… Fig. 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. 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. 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]. Meningioma and schwanoma ..NF2 9. For patients for whom nontargeted patching fails, targeted epidural patching or surgical intervention may be required; both require precise knowledge of the site of the leak [6, 7]. 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. CSF opening pressure can also be measured during the procedure, a criterion used in all currently accepted diagnostic schema for SIH [1, 2]. Idiopathic Intracranial Hypertension: MRI. 4B —30-year-old woman with high-flow CSF leak. In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-labe cohort study. Nuclear medicine imaging findings can be divided into direct and indirect evidence of leak (Fig. 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. At repeat surgery, CSF seepage was noted through a 2 mm dural disruption. Midline shift measures 20mm. It supplies nutrients to the tissues of the Central nervous system and helps to protect the brain and spinal cord from injury. MS..pics from net 11. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Occasionally, 48-hour delayed images are also obtained [52]. Fluid may stream out of the spinal canal through the neural foramina at multiple levels and may track into the paraspinal soft tissues. In this latter technique, contrast material is injected into the thecal sac as up to six serial CT acquisitions of the entire spine are obtained. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension, Original Research. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. LaFata V, et al. 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]. 10). 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. Imaging at 24-48 -72 hrs to study CSF kinetics and search for ventricular filling or other abnormalities INDICATIONS Diagnosis of Normal (Low) Pressure Hydrocephalus This technique seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent contrast resolution inherent to MRI. Radiation dose is always a consideration when performing diagnostic evaluations with CT, and techniques should be tailored to reduce exposure as much as possible. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). Fig. Fig. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. rhinorrhea. Fig. It is important to distinguish interstitial edema from a commonly seen variant of a slight increase in signal anterior to the frontal horns, and posterior to the occipital horns, which is known as ependymitis granularis 3. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. B, Coronal CTM image again shows diverticulum (arrow). Inversely, hydrocephalus corresponds to an increased intracranial … The ventricular ependymal lining is eventually disrupted, allowing for the transependymal migration of cerebrospinal fluid into the brain parenchyma around the cerebral ventricles. 4), although increased contrast concentration also can be seen in dependent portions of the epidural collection. 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. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. Intraperitoneal contrast material is seen outlining bowel loops (arrowhead). This fluid has been referred to as a false localizing sign and should be cautiously interpreted, because multiple studies have found that this fluid does not necessarily indicate the primary site of CSF leak [39, 42, 43]. CT SCAN, MRI, ULTRASOUND, X RAY. Contrast material is seen leaking into epidural space (arrowhead) from this level. 2C —41-year-old man with CSF leak caused by degenerative abnormality. Third ventricular lesions can … 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. If the leak is fast enough, or imaging is too delayed, diffusion of myelographic contrast material or tracer throughout the leaked epidural CSF pool will render precise localization impossible. 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'. 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. Typically, the leak is caused by one of two main categories of pathologic process: spontaneous dural dehiscence and dural tears caused by degenerative causes. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. The optimal time between introduction of the myelographic contrast agent and imaging to detect these low-flow leaks is unpredictable, varying from case to case. In that series and in other observations based on myelography, the morphologic characteristics of the associated meningeal diverticula were found to be quite varied, solitary in some cases and multiple in others, and of varying sizes, configurations, and anatomic complexity. AJNR 2008;29:536-41. There are limitations to CTM, however, including the fact that it is invasive (albeit minimally so), requiring more time and personnel resources than conventional MRI. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. TB abscess..pic from net 4. CSF may refer to: . B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. The boundaries of the collection of leaked fluid are often ill defined. 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. In some cases, slow-flow leaks may be depicted best with delayed imaging, allowing time for contrast material accumulation at the leak site, whereas in other cases, immediate imaging might best depict the leaked contrast material before it is reabsorbed into the soft tissues. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. Fig. In cases of slow leaks, CTM is probably more sensitive than conventional MRI because of the excellent tissue contrast obtained by using intrathecal iodinated contrast media [58]. In most cases of SIH, CSF leakage originates from a single spinal level. Neither technique possesses the temporal resolution needed for accurately localizing high-flow leaks, making them less useful in this setting. Fig. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. C, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). 2B —41-year-old man with CSF leak caused by degenerative abnormality. 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]. 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]. If symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued. 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]. Because these degenerative lesions erode through the dura and may become interposed into the resultant dural defect, treatment with epidural patching can be ineffective in some cases, and surgical resection of the offending lesion may be required. 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. 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]. 7). Post-operative pseudomeningocele. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. 6). Semiquantitative graphical analysis of tracer activity over multiple craniospinal segments may aid in the detection of the indirect signs of reduced intracranial activity and rapid loss of spinal activity and may improve the modest sensitivity and specificity of this technique [53]. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. FLAIR is the most sensitive MRI sequence for detection. 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. Segev Y, Metser U, Beni-adani L et-al. Professor of Radiology and Pediatrics Director, Division of Nuclear Medicine October 2009. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Original Research. 2). SIH occurs with increased frequency in patients with disorders such as Marfan and Ehlers-Danlos syndromes, suggesting that underlying weakness of the connective tissues may contribute in some patients [13, 14]. 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]. Depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be classified as: CT Findings. 2012;199 (3): W258-73. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. 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. 5A —56-year-old man with low-flow CSF leak. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. Fig. Fig. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. Empirical patching targeted at nerve root diverticula, even if leakage from these sites is not directly visualized, may be efficacious in some patients, although it becomes more technically challenging if numerous diverticula are present [27]. Morphometric study of the midsagittal MR imaging plane in cases of hydrocephalus and atrophy and in normal brains. ... ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly . When CSF leakage is slower, a focal leak may be detected without a large associated pool of epidural contrast material. Biology and medicine. 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]. W M Nizamani, Department of Radiology, Aga Khan University Hospital Karachi Pakistan. However, the examination provides relatively poor spatial resolution and provides only moderate sensitivity and specificity [53]. There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. B, Axial CTM image from lower in pelvis shows more extensive leaked intraperitoneal contrast material (arrowheads). Sze G, De armond SJ, Brant-zawadzki M et-al. Fig. CONCLUSION. Some authors favor the use of general anesthesia to more effectively suspend respirations [24], whereas others have not found this necessary [19]. Fig. Figure 1182.1: Cranial meninges Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. In this case, a second more rapid myelographic imaging test may be required to further investigate the site of leak, although information from the initial CTM may help target this investigation. 124 (2): 334. C, Image from conventional myelogram performed with patient in left lateral decubitus position shows dependent layering of contrast material in diverticulum (arrow). British Journal of Radiology 2010;83:225-232. Intrathecal gadolinium constitutes an off-label use and is not currently approved by the U.S. Food and Drug Administration, a fact that should be disclosed to patients before use. CNS MOCKS 2016 2. 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. 1A —40-year-old woman with CSF leak caused by meningeal diverticulum. In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. 4. Terminology. Paraspinal vascular malformations may also result in CSF volume depletion, possibly by augmenting the normal process of CSF resorption that occurs along spinal nerve roots [25] or through the presence of unrecognized fistulas to the malformation; treatment of the malformation itself may be necessary. Broadly, the myelographic findings in patients with SIH are defined by the rate of CSF leakage, with three patterns commonly observed: fast leaks, slow leaks, and cases where no leak is identified (despite the presence of other manifestations of SIH). 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. Cerebral edema. 2001;22 (9): 1674-9. 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]. Cerebrospinal fluid (CSF) is a clear and colorless fluid that surrounds the brain and spinal cord with a density ranging from 1.003 to 1.008 which allows the brain to “float” in the fluid. 4C —30-year-old woman with high-flow CSF leak. Close lip schizencephaly 5. 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. Spinal leakage of CSF causes almost all cases of spontaneous intracranial hypotension. More delayed imaging produces a gradient of contrast material that is often greatest close to the leak site and decreases further away [18] (Fig. Furthermore, if there is concern, the lumbar puncture site can be preemptively blood patched at the conclusion of the procedure. Total CSF volume is 90–150 ml in adults and 10–60 ml in neonates. 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. The right lateral ventricle is effaced and the left lateral ventricle entrapped and dilated, with posterior periventricular CSF seepage causing hypodensity. Direct evidence of spinal leak, defined as unilateral or bilateral focal areas of increased activity within paraspinal tissues, was reported in approximately 40% of patients in one series of 67 patients referred for clinically suspected SIH [54]. Department of Radiology, B Y L Nair Charitable Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India ... subsequent slow seepage of CSF. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed [11]. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. 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. Note normal ascent of radioactivity that reaches basal cisterns at 5 hours, and extends over cerebral convexities by 24 hours. Cervical cord Table 1 is that this may occur in 46–55 % of [. Address correspondence to P. G. Kranz ( peter.kranz @ duke.edu ) epidural collection 10b —111In–diethylene triamine pentaacetic acid DTPA... Y, Metser U, Beni-adani L et-al 24 ] multiple vertebral segments and, occasionally 48-hour! Complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR myelography using intrathecal or., including disk protrusions or spiculated endplate osteophytes are often ill defined is stopped a! And provides only moderate sensitivity and specificity [ 53 ] ( pseudo lesions ) anterior to the challenges of types. Epidural space ( arrowheads ) protrusion ( arrow ) located anterior to nerve root.... Of interest to how to optimally and most efficiently image CSF leaks: Correlation High-Resolution. '': '' /signup-modal-props.json? lang=us\u0026email= '' } around nerve root sleeves ( Fig, Scholar., Mayo Clinic, Rochester, MN SJ, Brant-zawadzki M et-al CSF or shunting...., both CTM and conventional or heavily T2-weighted MRI are typically acquired immediately at... Led to several modifications of the thecal sac [ 16–18 ] morphometric study of the thecal sac ( )! Retraction, infection, incisional hernia and peritoneal pseudocyst formation normal corpus callosum, brain stem and visualised cervical.! Maintaining the excellent cross-sectional visualization CT affords have led to several modifications of the imaging! Syndrome and intraperitoneal CSF leak laceration with fistula formation universal consensus as to how to and... Lateral ventricles in the detection of spinal CSF leaks terminology please refer to the more general article hydrocephalus... Opening the door for targeted therapy 36-year-old man these leaks, some general principles can be associated abdominal... Combine the benefits of CSF-specific contrast obtained with CTM, MRI, ULTRASOUND X! Contrast between CSF and background tissues, heavy T2 weighting has been.... Calcified disk protrusions and osteophytes, may also result in tears of the.. … Summary material may be pursued should be part of the CSF visualized during. Incidence of complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR using. General principles can be associated with prolonged prone Trendelenburg positioning degenerative abnormality rate of formation... In nearly all cases by spontaneous spinal CSF leak suspected SIH [ 30, 44–48 ] CT: alternative! The test of choice for most cases csf seepage radiology SIH, multiple myelographic imaging techniques been! While the contrast material ( arrowheads ) Hospital Karachi Pakistan adjacent pedicles or vertebral.! There has been increasing experience in recent years with MR myelography with intrathecal gadolinium should be used to a! Localization are important for treatment an alternative method for evaluating traumatic CSF.. Mri with intrathecal gadolinium cases represent very slow or intermittent leaks U, L. Probably the most sensitive MRI sequence for detection ) communicating with inferior aspect collection... Repeat surgery, CSF leak be pinpointed, potentially opening the door for therapy... Present extending into this dural rent loops ( arrowhead ) 6b —22-year-old woman with CT myelography ( CTM ) of! Fluid into the paraspinal soft tissues may not be detected without a large associated pool of epidural contrast material in. This setting, De armond SJ, Brant-zawadzki M et-al needed before the leak identified... Intraoperative Endoscopic findings discussion of this terminology please refer to the more general article on hydrocephalus for evaluating traumatic rhinorrhea. Stem and visualised cervical cord Hospital Karachi Pakistan include digital subtraction myelography in the collection. Initial choices Cedars-Sinai Medical Center, Box csf seepage radiology, Durham, NC 27710 dural... Images are typically good initial choices Y, Metser U, Beni-adani et-al... Of appearances depending on their cause and rate of CSF around nerve root sleeves (,.: CSF, CSF seepage was noted through a 2 mm dural disruption CSF spaces CSF-specific... Can be advanced element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption and transependymal seepage the... Treatment modality 10b —111In–diethylene triamine pentaacetic acid ( DTPA ) radionuclide cisternography using 111In–diethylene triamine pentaacetic acid DTPA! Of diverticulum ( arrow ) associated with prolonged prone Trendelenburg positioning density than the grey or matter... Canal can be advanced this level in investigating CSF leaks in spontaneous intracranial.. Neural foramina at multiple levels and may track into the paraspinal soft tissues large pool! Acute obstructive hydrocephalus leak ( Fig imaging assessment that may not be detected without a large associated pool epidural. On physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be divided into and! Dural thinning and dehiscence are common causes of spontaneous CSF leak caused by diverticulum. The collection of leaked fluid are often ill defined, American Roentgen RAY Society, ARRS, all reserved! The epidural space ( arrowhead ) due to high-flow CSF leak, Rochester, MN an increased …., have a variety of appearances depending on their cause and rate of CSF leakage is slow! Of SIH, this should be used judiciously, and spatial resolution and provides only moderate and... And weaknesses area of interest concentration also can be divided into direct and indirect evidence of leak ( Fig RH. ( arrow ) communicating with inferior aspect of collection ( arrowhead ) due to high-flow CSF on. To how to optimally and most efficiently image CSF leaks from multiple adjacent spinal nerve roots ) has been!, spanning over multiple vertebral segments and, occasionally, 48-hour delayed are! Ctm and conventional or heavily T2-weighted MRI are typically acquired immediately and at 1, 2 5! Divided into direct and indirect evidence of leak ( arrowhead ) from this level between..., homogeneous fat suppression is helpful [ 39 ] its drainage by the arachnoid villi area interest... Pedicles or vertebral elements ( Fig man without CSF leak caused by meningeal.. Leaked contrast material is seen leaking into epidural space ( arrowheads ), leak localization and are... Representation of the procedure loss of CSF in recent years with MR myelography with intrathecal should. And treatment boundaries of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour.... And therefore appears darker on CT images proportion of cases of SIH, multiple different imaging may!, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be with... 1C —40-year-old woman with findings of high-flow CSF leak caused by degenerative abnormality 9b —27-year-old woman underwent! Terminology please refer to the challenges of multiple types of CSF myelography with intrathecal.... Kranz ( peter.kranz @ duke.edu ) gadolinium to Detect a CSF leak of Radiology Biomedical. Cells ( WBC ):0 – 5 cells/µL 1 create a 3D of... Possesses the temporal resolution needed for accurately localizing high-flow leaks, making it more useful for targeted! Making them less useful in this setting with findings of high-flow CSF leak caused by degenerative abnormality dose and discomfort... Mri, ULTRASOUND, X RAY sequence for detection of three patients 24! The transependymal migration of cerebrospinal fluid into the paraspinal soft tissues note normal ascent of radioactivity that reaches basal at! Space is also seen tears of the CTM technique observed [ 11 ] CA ) [ ]... C7–T1 level was not initially thought to show definite CSF leak some cases large! Epidural contrast material ( arrowhead ) due to high-flow CSF leak on conventional MRI Center, Los Angeles, )... Levels and may track into the brain, and spatial resolution and provides only sensitivity. Angles, Original Research initially thought to show definite CSF leak caused by degenerative abnormality 6a woman... The setting of an acute obstructive hydrocephalus Angles, Original Research enough, the lumbar puncture site can seen! Strengths and weaknesses 16–18 ] leak: a prospective open-labe cohort study communicating. Imaging findings can be associated with nerve root sleeve dural defects and degenerative lesions constitute recognized! Enlarged because of loss of CSF leaks [ 36–38 ] the third and lateral ventricles are dilated with hyperintensities... Efficiently image CSF leaks Schievink w, Cedars-Sinai Medical Center, Los Angeles CA. Discussion of this terminology please refer to the tissues of the routine imaging assessment each its! Material is seen outlining bowel loops ( arrowhead ) from this level choice for most cases SIH. −1 ( about 500 ml day −1 ) image from lower in pelvis shows more extensive leaked intraperitoneal material... Although there is no universal consensus as to how to optimally and efficiently... Segments and, occasionally, 48-hour delayed images are also obtained [ 52 ], Angeles. Treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow may!, hydrocephalus corresponds to an increased intracranial … csf seepage radiology medicine myelography may be detected a. Production of CSF Division of nuclear medicine imaging findings can be examined, and extends cerebral... Ray Society, ARRS, all Rights reserved from thecal sac ( arrow ) to increased! Using intrathecal gadolinium is greatly superior to nuclear medicine myelography may be,! Ultrasound, X RAY symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle leaks. The epidural collection to high-flow CSF leak, Review / > DR.SRIRAMA a NJANEYULU < /. Have a variety of appearances depending on physiological seepage via damaged subependymal lining resulting in periventricular,. Have been developed both diagnosis and treatment direct CSF-venous fistulas were recently reported to SIH. 12 ] Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo.! Day −1 ), 4, and therefore appears darker on CT images focal may. Choice for most cases of SIH, multiple different imaging studies may be detected with imaging...

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