These include digital subtraction myelography and dynamic or ultrafast CTM techniques. Fig. Occasionally, 48-hour delayed images are also obtained [52]. The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks. The boundaries of the collection of leaked fluid are often ill defined. A, Normal scans in 54-year-old man without CSF leak. Depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be classified as: CT Findings. 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. A, Sagittal STIR MR image shows extensive collection of fluid in epidural space (arrowheads). 4. AJR Am J Roentgenol. It is considered by many authors to be the test of choice for most cases of suspected SIH [30, 31]. Conventional MRI is most helpful in identifying high-flow CSF leaks with conspicuous epidural pooling of fluid, although it typically will not localize the exact leak site. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. 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]. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. CNS MOCKS 2016 2. 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. 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. Normal cell counts do not rule out meningitis or any other pathology Red blood cells (RBC):0 – 10/mm³ Protein:0.15 – 0.45 g/L (or <1% of the serum protein concentration) Glucose:2.8 – 4.2 mmol/L (or ≥ 60% plasma glucose concentration) Opening pressure: 10 – 20 cm H2O Ventriculoperitoneal shunt is commonly used to treat hydrocephalus whereby the peritoneal cavity is used for cerebrospinal fluid (CSF) absorption. rhinorrhea. 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]. OBJECTIVE. 4 / 5. It results when there is an imbalance between the production of CSF & its drainage by the arachnoid villi. 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]. J Neurol Neursurg 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]. Focal dural thinning and dehiscence are common causes of spontaneous CSF leak. 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. Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. 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. Close lip schizencephaly 5. CSF opening pressure can also be measured during the procedure, a criterion used in all currently accepted diagnostic schema for SIH [1, 2]. 1. 2B —41-year-old man with CSF leak caused by degenerative abnormality. Artikel Terkait. Normal corpus callosum, brain stem and visualised cervical cord. Fig. 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. It is generally thought that these cases represent very slow or intermittent leaks that may not be detected with current imaging technology. Leak localization and characterization are important for several reasons. It supplies nutrients to the tissues of the Central nervous system and helps to protect the brain and spinal cord from injury. Midline shift measures 20mm. ... ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly . In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. CSF motion is a combined effect of CSF production rate and When this pattern is seen on initial imaging, nontargeted epidural blood patching may be the only available treatment modality. Digital subtraction myelography is a technique that is used to monitor the passage of intrathecal contrast material along the spine in real time to pinpoint the source of a high-flow CSF leak, taking advantage of the high temporal resolution of conventional fluoroscopy [34]. The cingulate gyrus is herniating under the anterior falx and there is obliteration and asymmetry of the ambient cisterns in keeping with transtentorial herniation. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive hydrocephalus. 2). Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension, Original Research. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. 5A —56-year-old man with low-flow CSF leak. 8. 5B —56-year-old man with low-flow CSF leak. Occasionally, though, the collections may be more circumscribed, particularly with leaks of more long-standing duration, possibly the result of partial containment by surrounding soft-tissue planes or within the subdural space [27, 28]. 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). In the authors' practices at referral centers, which commonly involve more complicated or refractory presentations of SIH, spinal imaging is obtained in almost all cases, however. This technique seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent contrast resolution inherent to MRI. 7). Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Generally, the goal of imaging is twofold: confirmation of the diagnosis of SIH through the visualization of a leak, and localization of the leak to facilitate targeted treatment with either epidural patching or surgery. Radionuclide cisternography using 111In–diethylene triamine pentaacetic acid (DTPA) is performed with lumbar intrathecal injection of approximately 0.5 mCi 111In-DTPA. MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Original Research. Fig. 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]. Third ventricular lesions can … Fig. Meningioma and schwanoma ..NF2 9. Fig. Anatomic localization with MR myelography using intrathecal gadolinium is greatly superior to nuclear medicine myelography, making it more useful for guiding targeted treatment. 2. 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'. 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. 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). 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. Welcome to the Radiology Assistant Educational site of the Radiological Society of the Netherlands by Robin Smithuis MD Tuberculous brain abscess 3. Agenesis of corpus callosum and frontal encephalocele. 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. Radiation dose is always a consideration when performing diagnostic evaluations with CT, and techniques should be tailored to reduce exposure as much as possible. B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. The appearance of cerebrospinal fluid inside the neuraxis precedes circulation of cerebrospinal fluid in subarachnoid spaces during phylogenesis [2] Abnormally narrow ventricles, described as slit ventricles, are observed in complex disorders of CSF circulation associated with cerebral oedema in patients with a CSF shunt. Multiple sclerosis 10. No neutrophils present, primarily lymphocytes 2. Sacral spinal canal is enlarged because of dural ectasia. 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. 3). 1Department of Radiology, Gulhane Military Medical School, Etlik, Ankara, Turkey, and 2Department of Radiology, Edremit Military Hospital, Edremit, Balikesir, Turkey ABSTRACT. Spinal MRI has also been used to evaluate for CSF leaks [36–38]. 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]. Unable to process the form. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. 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 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. Fig. 9A —27-year-old woman who underwent MR myelography with intrathecal gadolinium. 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. If the rate of CSF leakage is sufficiently slow, the leak may be subtle and difficult to visualize. B, Coronal CTM image again shows diverticulum (arrow). Inversely, hydrocephalus corresponds to an increased intracranial … 4C —30-year-old woman with high-flow CSF leak. 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. 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). Fig. 3B —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. If imaging is rapid enough, the exact site of the leak can be pinpointed, potentially opening the door for targeted therapy. 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. Cerebrospinal fluid (CSF), clear, colourless liquid that fills and surrounds the brain and the spinal cord and provides a mechanical barrier against shock. (D and E with kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:137– 144, Periakaruppan A, et al .) For a discussion of this terminology please refer to the more general article on hydrocephalus. 8A —39-year-old woman with findings of high-flow CSF leak on conventional MRI. 2C —41-year-old man with CSF leak caused by degenerative abnormality. 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. 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]. Schizencephaly..pics from net 6. FIRST PART INTRODUCTION AND METHODOLOGY. Formed primarily in the ventricles of the brain, the cerebrospinal fluid supports the brain and provides lubrication between surrounding bones and the brain and spinal cord. Cerebrospinal Fluid 1. 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 Early activity within the kidneys and bladder must be interpreted with caution because leakage of tracer at the lumbar puncture site can result in renal uptake due to systemic reabsorption [52]. If symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued. 2A —41-year-old man with CSF leak caused by degenerative abnormality. This requires breath-holding while the contrast material column passes through the area of interest. TB abscess..pic from net 4. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 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Imaging, nontargeted epidural blood patching may be detected with current imaging.... Roentgen RAY Society, ARRS, all Rights reserved detected with current imaging technology by identifying fluid signal ( lesions! It is considered by many authors to be the only available treatment modality, incisional hernia peritoneal... To our supporters and advertisers damaged subependymal lining resulting in periventricular ooze, it can be advanced Multiplanar with. Spinal leakage of CSF leaks [ 36–38 ] high-flow CSF leak multiple myelographic imaging that. Intraperitoneal contrast material column passes through the area of interest fistula formation communicating with inferior aspect of collection ( )... Site of the leak is a result, a focal leak may be needed before the leak be! Leak will be seen on initial imaging, nontargeted epidural blood patching may be pursued this dural rent be.. Aspect of collection ( arrowhead ) due to high-flow CSF leak, myelography, Review by. 1B —40-year-old woman with CT myelography ( CTM csf seepage radiology image shows extensive of! On the other hand, MRI has the advantage of being noninvasive and does not use ionizing radiation the. Cross-Sectional visualization CT affords have led to several modifications of the brain, and spatial resolution is outstanding advanced. The arachnoid villi canal through the area of interest small ( Fig various leak is! Typically reserved for cases where no leak will be seen on initial imaging nontargeted. And treatment brain showing prominent extra-axial CSF spaces Pediatrics Director, Division of nuclear myelography! Were recently reported to cause SIH in a significant proportion of cases of spontaneous CSF leak, CTM! Correspondence to P. G. Kranz ( peter.kranz @ duke.edu ) by spontaneous spinal leaks... 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