Magnetic Resonance Cisternography and Thin Coronal Computerized Tomography in the Evaluation of Cerebrospinal Fluid Rhinorrhea

1997 ◽  
Vol 11 (5) ◽  
pp. 387-392 ◽  
Author(s):  
Michael J. Sillers ◽  
C. Elliott Morgan ◽  
Taher El Gammal
Keyword(s):  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Lumbar Puncture ◽  
Computerized Tomography ◽  
Contrast Study ◽  
Precise Localization ◽  
Csf Rhinorrhea ◽  
Spin Echo Sequence ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

In recent years cerebrospinal fluid (CSF) rhinorrhea has been managed successfully with transnasal endoscopic techniques. The most important and often most difficult step is the precise localization of the fistula. Computerized tomographic and radionuclide cisternography are two commonly used techniques for preoperative identification of the CSF fistula when it cannot be seen clearly with nasal endoscopy. Each of these requires a lumbar puncture, and the intrathecal placement of contrast material has been associated with transient neurotoxicities. Magnetic resonance cisternography (MRC) is a non-contrast study that does not require a lumbar puncture and has been used recently in the diagnosis of spontaneous and traumatic CSF leaks. Magnetic resonance cisternography utilizes a fast spin-echo sequence with fat suppression and video image reversal that highlights CSF. This allows precise localization of the fistula in both coronal and sagittal planes. Thin section coronal computed tomography (TCCT) is another noninvasive technique that can be helpful in localizing CSF leaks. The technique of MRC and TCCT and the results of 16 CSF leaks in 15 patients are reported. There was good correlation between MRC, TCCT, and intraoperative findings. Magnetic resonance cisternography and thin coronal computerized tomography appear to be accurate and complementary, noninvasive radiographic studies that should be considered in the evaluation CSF rhinorrhea.

LOCALIZATION OF CEREBROSPINAL FLUID LEAKS BY GADOLINIUM-ENHANCED MAGNETIC RESONANCE CISTERNOGRAPHY

Neurosurgery ◽  
2008 ◽  
Vol 62 (3) ◽  
pp. 584-589 ◽  
Author(s):  
Kubilay Aydin ◽  
Ege Terzibasioglu ◽  
Serra Sencer ◽  
Altay Sencer ◽  
Yusufhan Suoglu ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Vital Signs ◽  
Imaging Method ◽  
Csf Rhinorrhea ◽  
Mr Cisternography ◽  
Csf Leakage ◽  
Dural Tears ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

Abstract OBJECTIVE Intrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application. METHODS Fifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patient's neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations. RESULTS Gd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years. CONCLUSION Gd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

Diagnosis and Localization of Cerebrospinal Fluid Rhinorrhea: A Systematic Review

2021 ◽  
pp. 194589242110609
Author(s):  
Michael Xie ◽  
Kelvin Zhou ◽  
Shamez Kachra ◽  
Tobial McHugh ◽  
Doron D. Sommer
Keyword(s):  
Computed Tomography ◽  
Systematic Review ◽  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
High Resolution ◽  
Case Series ◽  
Csf Rhinorrhea ◽  
Radionuclide Cisternography ◽  
Contrast Enhanced ◽  
Magnetic Resonance Cisternography

Background Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communications between the subarachnoid and sinonasal spaces. Accurate preoperative diagnosis and localization are vital for positive clinical outcomes. However, the diagnosis and localization of CSF rhinorrhea remain suboptimal due to a lack of accurate understanding of test characteristics. Objective This systematic review aims to assess the diagnostic accuracy of various tests and imaging modalities for diagnosing and localizing CSF rhinorrhea. Methods A systematic review of the MEDLINE and EMBASE databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Our search identified 4039 articles—53 cohort studies and 24 case series describing 1622 patients were included. The studies were heterogeneous and had a wide range of sensitivities and specificities. Many specificities were incalculable due to a lack of true negative and false positive results, thus precluding a meta-analysis. Median sensitivities and specificities were calculated for cohort studies of the following investigations: high-resolution computed tomography (HRCT) 0.93/0.50 (sensitivity/specificity), magnetic resonance cisternography (MRC) 0.94/0.77, computed tomography cisternography (CTC) 0.95/1.00, radionuclide cisternography (RNC) 0.90/0.50, and contrast-enhanced magnetic resonance cisternography (CEMRC) 0.99/1.00, endoscopy 0.58/1.00, topical intranasal fluorescein (TIF) 1.00/incalculable, intrathecal fluorescein (ITF) 0.96/1.00. Case series were reviewed separately. Etiology and site-specific data were also analyzed. Conclusion MR cisternography is more accurate than high-resolution CT at diagnosing and localizing CSF rhinorrhea. CT cisternography, contrast-enhanced MR cisternography, and radionuclide cisternography have good diagnostic characteristics but are invasive. Intrathecal fluorescein shows promising data but has not been widely adopted for purely diagnostic use. Office endoscopy has limited data but does not sufficiently diagnose CSF rhinorrhea independently. These findings confirm with current guidelines and evidence.

Evaluation of CSF Rhinorrhea by Computerized Tomography with Metrizamide

1989 ◽  
Vol 100 (2) ◽  
pp. 99-105 ◽  
Author(s):  
James M. Chow ◽  
David Goodman ◽  
Mahmood F. Mafee
Keyword(s):  
Cerebrospinal Fluid ◽  
Success Rate ◽  
Computerized Tomography ◽  
The Other ◽  
High Success Rate ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Csf Leaks

This study evaluates the ability of metrizamide computerized tomographic cisternography (MCTC) to delineate the site of leakage in patients with cerebrospinal fluid (CSF) rhinorrhea. From 1981 to 1986, thirteen patients were examined by MCTC to localize the site of CSF leakage. A total of 17 studies were performed. Thirteen scans (76%) identified the site of CSF leakage. Nine of these scans were confirmed surgically. The other four scans were performed on patients who refused surgery. Of the 15 scans in patients with active CSF leaks, 13 (87%) were positive. Of the two patients with inactive CSF leaks, neither was positive. One patient is presented in whom MCTC was both diagnostic and therapeutic. In conclusion, MCTC has a high success rate in localizing the site of active CSF leaks.

scholarly journals Surgical Outcomes and Postoperative Management in Spontaneous Cerebrospinal Fluid Rhinorrhea

2017 ◽  
Vol 79 (02) ◽  
pp. 193-199 ◽  
Author(s):  
Zi Yang Jiang ◽  
Caitlin McLean ◽  
Carlos Perez ◽  
Samuel Barnett ◽  
Deborah Friedman ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Visual Field ◽  
Lumbar Puncture ◽  
Treatment Algorithm ◽  
Postoperative Management ◽  
Empty Sella ◽  
Success Rates ◽  
Csf Rhinorrhea ◽  
Visual Field Deficits ◽  
Csf Leaks

Background The etiology of spontaneous cerebrospinal fluid (CSF) rhinorrhea remains unknown, though emerging evidence suggests that this likely represents a variant of idiopathic intracranial hypertension. Long-term success rates for repair and postoperative management strategies remain variable. Methods Retrospective review of patients undergoing surgical management of spontaneous CSF rhinorrhea was conducted over a 5-year period. Analysis was performed to correlate recurrence with demographics and perioperative variables. Lumbar puncture usage and neuro-ophthalmological examinations in clinical management were also assessed. Results Forty-eight patients were included in the study. The mean age was 51.4 years with 94% females. Leaks were most commonly located in the sphenoid (43.8%) and cribriform region (33.3%). The most common findings on magnetic resonance imaging were empty sella (48%) and Meckel's cave diverticula (24%). Nine patients (18.8%) had recurrent CSF leaks. Six occurred >1 month postoperatively. Three had repeat endoscopic repairs, two received ventriculoperitoneal shunts, and one was managed with a lumbar drain, with overall success rate of 93.8%. Acetazolamide was utilized in 19 cases (39.6%) postoperatively. Overall, 59% of patients had elevated opening pressures on postoperative lumbar puncture (n = 32). Neuro-ophthalmology evaluated 28 patients; 25% had visual field deficits, and 7.1% had papilledema. Conclusions Management of spontaneous CSF leaks remains a significant challenge. Endoscopic repair is successful in most patients with little morbidity; however, postoperative management remains inconsistent, and further studies are warranted to establish consensus on post-surgical care. The association with elevated intracranial pressure and visual field deficits/papilledema suggests opening pressures, and neuro-ophthalmologic evaluation should be considered in the treatment algorithm.

scholarly journals SPONTANEOUS CEREBROSPINAL FLUID LEAK AFTER INITIATION OF DOPAMINE AGONIST THERAPY IN MACROPROLACTINOMAS: TWO CASE REPORTS AND A LITERATURE REVIEW

2020 ◽  
Vol 6 (2) ◽  
pp. e90-e93
Author(s):  
Jonea Lim ◽  
Mitali Talsania ◽  
Madona Azar
Keyword(s):  
Magnetic Resonance Imaging ◽  
Cerebrospinal Fluid ◽  
Magnetic Resonance ◽  
Dopamine Agonist ◽  
Csf Leak ◽  
Resonance Imaging ◽  
Csf Rhinorrhea ◽  
History Of ◽  
Beta 2 ◽  
Csf Leaks

Objective: To describe 2 spontaneous cerebrospinal fluid (CSF) leaks complicating treatment of macroprolactinoma (MPRL) with dopamine agonist (DA) therapy. Methods: We present the 2 cases of spontaneous, DA-related CSF leaks. Prolactin levels were used to assess hyperprolactinemia. Beta-2 transferrin was tested in rhinorrhea fluid, and magnetic resonance imaging was used to assess the sella. Results: Case 1 was a 45-year-old woman with a history of MPRL, recently started on bromocriptine at 15 mg/day, presented with clear rhinorrhea, headache, and nuchal rigidity. Magnetic resonance imaging showed a large sellar lesion extending into the cavernous sinuses, posterior sphenoid sinuses, and suprasellar cistern. Computed tomography revealed areas concerning for bony erosion, likely representing leak sites, and the rhinorrhea fluid was positive for beta-2 transferrin, confirming the CSF source. Empiric antibiotics for meningitis were given and she underwent urgent neuroendoscopic, transsphenoidal CSF leak repair and debulking of the pituitary mass. Case 2 was a 55-year-old man with a 10-year history of untreated MPRL who was started on bromocriptine at 5 mg/day 2 weeks prior to admission. He presented with clear rhinorrhea and a metallic taste in his mouth, worse with the Valsalva maneuver. Imaging confirmed clinical suspicion and he was taken for surgery. A high-flow CSF leak was encountered once the tumor was debulked. This was repaired with an abdominal fat pad graft. Both patients developed diabetes insipidus and required postoperative adjuvant DA therapy. Conclusion: Spontaneous CSF leaks can complicate medical therapy of large MPRL with underlying skull defects, typically within weeks of initiation of DA. This should prompt clinicians to educate patients about the symptoms of potential CSF rhinorrhea and encourage them to promptly report them.

scholarly journals Identification and repair of intraoperative cerebrospinal fluid leaks in endonasal transsphenoidal pituitary surgery: surgical experience in a series of 1002 patients

2018 ◽  
Vol 129 (2) ◽  
pp. 425-429 ◽  
Author(s):  
Ben A. Strickland ◽  
Joshua Lucas ◽  
Brianna Harris ◽  
Edwin Kulubya ◽  
Joshua Bakhsheshian ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Pituitary Adenomas ◽  
Transsphenoidal Approach ◽  
Csf Leak ◽  
Sellar Region ◽  
Inclusion Criteria ◽  
Csf Rhinorrhea ◽  
Sellar Lesions ◽  
Sellar Reconstruction ◽  
Csf Leaks

OBJECTIVECerebrospinal fluid (CSF) rhinorrhea is among the most common complications following transsphenoidal surgery for sellar region lesions. The aim of this study was to review the authors’ institutional experience in identifying, repairing, and treating CSF leaks associated with direct endonasal transsphenoidal operations.METHODSThe authors performed a retrospective review of cases involving surgical treatment of pituitary adenomas and other sellar lesions at the University of Southern California between December 1995 and March 2016. Inclusion criteria included all pathology of the sellar region approached via a direct microscopic or endoscopic endonasal transsphenoidal approach. Demographics, pathology, intraoperative and postoperative CSF leak rates, and other complications were recorded and analyzed. A literature review of the incidence of CSF leaks associated with the direct endonasal transsphenoidal approach to pituitary lesions was conducted.RESULTSA total of 1002 patients met the inclusion criteria and their cases were subsequently analyzed. Preoperative diagnoses included pituitary adenomas in 855 cases (85.4%), Rathke’s cleft cyst in 94 (9.4%), and other sellar lesions in 53 (5.2%). Lesions with a diameter ≥ 1 cm made up 49% of the series. Intraoperative repair of an identified CSF leak was performed in 375 cases (37.4%) using autologous fat, fascia, or both. An additional 92 patients (9.2%) underwent empirical sellar reconstruction without evidence of an intraoperative CSF leak. Postoperative CSF leaks developed in 26 patients (2.6%), including 13 (1.3% of the overall group) in whom no intraoperative leak was identified. Among the 26 patients who developed a postoperative CSF leak, 13 were noted to have intraoperative leak and underwent sellar repair while the remaining 13 did not have an intraoperative leak or sellar repair. No patients who underwent empirical sellar repair without an intraoperative leak developed a postoperative leak. Eight patients underwent additional surgery (0.8% reoperation rate) for CSF leak repair, and 18 were successfully treated with lumbar drainage or lumbar puncture alone. The incidence of postoperative CSF rhinorrhea in this series was compared with that in 11 other reported series that met inclusion criteria, with incidence rates ranging between 0.6% and 12.1%.CONCLUSIONSIn this large series, half of the patients who developed postoperative CSF rhinorrhea had no evidence of intraoperative CSF leakage. Unidentified intraoperative CSF leaks and/or delayed development of CSF fistulas are equally important sources of postoperative CSF rhinorrhea as the lack of employing effective CSF leak repair methods. Empirical sellar reconstruction in the absence of an intraoperative CSF leak may be of benefit following resection of large tumors, especially if the arachnoid is thinned out and herniates into the sella.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Post-Operative Period Following Pituitary and Ventral Skull Base Surgery

2021 ◽  
Author(s):  
Peter A. Benedict ◽  
Joseph R. Connors ◽  
Micah R. Timen ◽  
Nupur Bhatt ◽  
Richard Lebowitz ◽  
...  
Keyword(s):  
Cerebrospinal Fluid ◽  
Skull Base ◽  
Postoperative Period ◽  
Skull Base Surgery ◽  
Tertiary Care ◽  
Csf Leak ◽  
Csf Rhinorrhea ◽  
Predictive Values ◽  
Ventral Skull Base ◽  
Csf Leaks

Objective: Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design: Retrospective chart review Setting: Tertiary care center Methods and Participants: All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017–March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intra-operative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures: Specificity and safety of ITF Results: Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50±11.89. There were 6 patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100% and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions: Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. Intrathecal fluorescein represents a specific and safe test with potential utility in the postoperative setting.

scholarly journals Surgical management of cerebrospinal fluid rhinorrhea under endoscopic control

2004 ◽  
Vol 62 (3b) ◽  
pp. 827-831 ◽  
Author(s):  
José Alberto Landeiro ◽  
Marlo S. Flores ◽  
Bruno C.R. Lázaro ◽  
Maria Helena Melo
Keyword(s):  
Cerebrospinal Fluid ◽  
Surgical Management ◽  
Inferior Turbinate ◽  
Saline Injection ◽  
Csf Rhinorrhea ◽  
Cerebrospinal Fluid Rhinorrhea ◽  
Endoscopic Control ◽  
Free Grafts ◽  
Cranial Approach ◽  
Csf Leaks

The surgical management of cerebrospinal fluid (CSF) rhinorrhea has changed after the introduction of functional endoscopic sinus surgery.The following three cases illustrate the repair of CSF leaks with the use of rigid endoscope. Two patients had the diagnosis and the site confirmed after intrathecal fluoresceine saline injection. The obliteration of the CSF was achieved with fat free, mucoperichondrial or mucoperiostal free grafts taken from middle or inferior turbinate and kept in place by fibrin glue. Primary closure was achieved in all patients. The repair of the CSF rhinorrhea by endonasal endoscopic surgery is safe, effective and is a valid alternative to the cranial approach.

Traumatic Anterior Cranial Fossa CSF Leaks

Neurotrauma ◽  
2019 ◽  
pp. 93-102
Author(s):  
Omaditya Khanna ◽  
Tomas Garzon-Muvdi ◽  
Hermes Garcia ◽  
Richard F. Schmidt ◽  
James J. Evans ◽  
...  
Keyword(s):  
Skull Base ◽  
Anterior Cranial Fossa ◽  
Confirmatory Test ◽  
Ct Cisternography ◽  
Csf Rhinorrhea ◽  
Csf Leakage ◽  
Cranial Fossa ◽  
Csf Diversion ◽  
Magnetic Resonance Cisternography ◽  
Csf Leaks

Traumatic CSF leaks are reported to complicate 10–30% of skull base fractures. CSF rhinorrhea or otorrhea may be clinically apparent but in patients with less obvious leaks, β‎2-transferrin evaluation is the most sensitive and specific confirmatory test to establish the diagnosis of CSF leakage. High-resolution CT effectively identifies the majority of skull base fractures and sites of CSF leakage. Adjunctive imaging modalities such as CT cisternography and magnetic resonance cisternography may be used for further evaluation. Most traumatic CSF leaks of the anterior cranial fossa resolve spontaneously with conservative management including bedrest, head elevation, and avoidance of activities that increase intracranial pressure. The risk of meningitis increases significantly with persistent CSF leakage beyond 1 week, and intervention in the form of CSF diversion or surgical closure of the leak should be pursued. Prophylactic antibiotics have not been shown to decrease the risk of meningitis in patients with traumatic CSF leaks.

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