Dr. Kaplan responds: Thank you so much for your thoughtful reply to my article. 1979 Oct 25;97(40):1814-20. These are infrequently associated with CSF rhinorrhea. 4 5 7 Immunofixation electrophoresis is the Clipboard, Search History, and several other advanced features are temporarily unavailable. This patient presented with a spontaneous onset of cerebrospinal fluid rhinorrhea 10 years after a head injury. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. National Library of Medicine Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care. In one study of 45 patients, CT of the skull and facial bones with high-resolution, thin-section axial and coronal images had an accuracy of 92%, a sensitivity of 92%, and a specificity of 100% in depicting the presence or absence of CSF fistula. Emily Ann King of Clear Lake, Texas and Craig Anthony Przyborski of Conroe, Texas were united in marriage on June 14, 2003 at 7:30 in the evening at St. Paul the Apostle . Traumatic cerebrospinal fluid leak. Cerebrospinal fluid imaging. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. Epub 2015 Sep 15. Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Louisiana State Medical Society, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, Royal Society of Medicine, Orleans Parish Medical Society, American Society of Spine Radiology, American Society of Functional Neuroradiology, Southern Radiology ConferenceDisclosure: Nothing to disclose. Izumoto Y, Matsuyama T, Mizuhira M, Imaseki H, Hamano T, Sakai Y, Oguri Y, Yoshii H. J Radiol Prot. However, even in this situation, exceptions can occur. The fluid can be placed on filter paper and a "halo" or double ring may be seen. Lawrence SK, Delbeke D, Partain CL. 2014 Sep. 59 (2):196-9. If you log out, you will be required to enter your username and password the next time you visit. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. MR cisternography and myelography can accurately localize CSF leaks in the cranium and spine. After transfer, a bloody discharge was noted from his right external auditory canal, and the right tympanic membrane was perforated. [Diagnostic value of computed tomographic cisternography and magnetic resonance hydrography in cerebrospinal fluid rhinorrhea]. 2001 Jul. I absolutely agree that not having a double ring sign does not exclude a CSF leak. Burns BJ. He had been wearing a seat belt. The resulting communication with the central nervous system (CNS) can result in a multitude of infectious complications that impart significant morbidity and potentially disastrous long-term deficits for the patient. Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Head and Neck Society, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, New York Academy of MedicineDisclosure: Nothing to disclose. Griauzde J, Gemmete JJ, Pandey AS, Chaudhary N. Intrathecal preservative-free normal saline challenge magnetic resonance myelography for the identification of cerebrospinal fluid leaks in spontaneous intracranial hypotension. [QxMD MEDLINE Link]. Typically, the leak is caused by either spontaneous dural dehiscence or dural tears caused by degenerative causes. Drops of fluid from a CSF leak placed on absorbent filter paper may result in the double-ring sign, a central circle of blood and an outer clear ring of CSF. 2011 Apr. 2010 Mar. Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: a review of 31 cases. Small series of patients had no apparent adverse effect from the gadolinium contrast medium. An absorptive sponge pad placed at or near the presumed site of fluid leak can facilitate the collection of the fluid. CT cisternographic findings in CSF leak include the concentration of contrast medium in portions of a paranasal sinus or within ethmoid or mastoid air cells. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. AJNR Am J Neuroradiol. On occasion, the patient has a history of headache relieved by drainage of CSF. Our services include electrician services, electrical repair, and home electrical wiring. Intermittent leakage over several years is characteristic. A lumbar drain placed at the time of repair has not been shown to decrease recurrence of the CSF leak. Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. 2015 May. A high percentage of fast leaks have spinal extradural fluid collections on preliminary MRI spine scans. Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. A new approach for simple radioisotope cisternography examination in cerebrospinal fluid leakage detection. 134:110044. Paraspinal fluid collections can be localized for needle aspiration with ultrasound guidance. After intrathecal fluorescein is administered, an exposed frontal recess encephalocele is seen. Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). [QxMD MEDLINE Link]. Goel G, Ravishankar S, Jayakumar PN, et al. J Neurosurg. [10]. Congenital skull base defects and certain tumors can also lead to CSF rhinorrhea. Pre-cut Filter Paper for Detecting Anti-Japanese Encephalitis Virus IgM from Dried Cerebrospinal Fluid Spots. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. 1997. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. Other than notation of the patients fluctuating score on the Glasgow Coma Scale and movement of his four limbs, a neurologic examination was not documented before intubation. The double ring ceremony was officiated by Monsignor David W . Predicting Fast Spinal CSF Leaks in Patients with Spontaneous intracranial Hypotension. eCollection 2023. 2018 Dec;38(4):1384-1392. doi: 10.1088/1361-6498/aae39b. For more information, please refer to our Privacy Policy. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzM4OTg5LW92ZXJ2aWV3. Diagnostic Nuclear Medicine. A small cribriform plate encephalocele is observed only after removing the middle turbinate. All rights reserved. Management and Disposition Identify underlying brain injury, which is best accomplished by CT. CT is also the best diagnostic tool for identifying the fracture site, but fractures may not always be evident. The dura of the anterior cranial base is subject to wide variations in CSF pressure because of several factors, including normal arterial and respiratory fluctuations. Iatrogenic causes include neurosurgical and otolaryngologic approaches to neoplastic disease, as well as functional endoscopic sinus surgery (FESS). According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves. Distinguishing blood due to a basilar skull fracture from cutaneous bleeding using the "halo sign" (applying a drop of blood to a filter paper looking for more rapidly diffusing cerebrospinal fluid surrounding the blood), is often cited but unreliable (3-5). CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. sharing sensitive information, make sure youre on a federal Occasionally, a stream of contrast medium is demonstrated at the fistula site. [QxMD MEDLINE Link]. Otolaryngol Head Neck Surg. The leak almost never recurs. 2015 Sep 15. 19(4):627-31. (Ann Emerg Med. Epub 2012 Aug 13. West J Emerg Med. Additional hardware or software is not required to perform MR myelography or cisternography. Algin O, Hakyemez B, Gokalp G, Ozcan T, Korfali E, Parlak M. The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. 2014 Nov. 124 (11):2645-50. 142:43-7. 32(5):832-8. eCollection 2023 Feb. Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. 2002 Dec. 51(6):1365-71; discussion 1371-2. your express consent. Michael G D'Antonio, MD Associate Professor of Clinical Radiology, Department of Radiology, Section of Neuroradiology, Louisiana State University Health Sciences Center in New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associate, Inc, West Jefferson Medical CenterDisclosure: Nothing to disclose. [QxMD MEDLINE Link]. [1] The standard diagnostic test for temporal arteritis is biopsy; however, ultrasound and MRI show promise for replacing it. Share cases and questions with Physicians on Medscape consult. Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. Zuckerman JD, DelGaudio JM. 2014 Jul;15(4):363. doi: 10.5811/westjem.2014.4.21346. 2015 Mar-Apr. Surg Neurol. Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. These patients typically present with aural fullness due to a serous middle ear effusion. [6] Include all of the paranasal sinuses and petrous temporal bones in the scans. [Anatomical structures, physiology and pathophysiology of cerebrospinal fluid metabolism; a review for an understanding of cerebrospinal fluid findings]. Chazen JL, Talbott JF, Lantos JE, Dillon WP. [Full Text]. Lopatin AS, Kapitanov DN, Potapov AA. It should be kept in mind, however, that this test does not provide information regarding the site or laterality of the defect. Intracranial repair was frequently used (and is still used in select cases) for the routine repair of anterior cranial fossa CSF leaks. Temporal lobe gyral herniation may occur through a petrous temporal bone tegmen tympani defect. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons 33:690-94. In this experimental setting, the ring or halo sign is reliable for detecting cerebrospinal fluids but is not exclusive for cerebrospinal fluid. MR T2 myelography may demonstrate spinal CSF fistulas (see the images below). The lateral lamella of the cribriform plate appears to be involved in approximately 40% of the cases, whereas a defect in the region of the fontal sinus is detected 15% of the time. If you log out, you will be required to enter your username and password the next time you visit. Free shipping for many products! A study by Lieberman et al found evidence of a significant incidence of multiple simultaneous skull base defects in cases of spontaneous CSF rhinorrhea, reporting the existence of such defects in eight out of 44 patients (18.2%) in the study. [QxMD MEDLINE Link]. Brain Sci. These cases often lead to a misdiagnosis of allergic and vasomotor rhinitis. The type of filter paper did not affect the development of a ring. encoded search term (Cerebrospinal Fluid Leak Imaging) and Cerebrospinal Fluid Leak Imaging, Plastic Surgery for Frontal Sinus Fractures, Plasma Biomarkers and Genetics in the Diagnosis and Prediction of Alzheimer's Disease. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%). The majority of patients with a CSF leak due to accidental trauma (eg, motor vehicle accident) present immediately. In radiology, the halo sign is a finding of a dark halo around the arterial lumen on ultrasound that suggests the diagnosis of temporal arteritis. [Full Text]. Ann Emerg Med. Is acetazolamide really useful in the management of traumatic cerebrospinal fluid rhinorrhea?. Spinal MRI findings are also potentially reversible after successful ablation of a CSF fistula. [QxMD MEDLINE Link]. CSF consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). (EMN. Would you like email updates of new search results? Methods: The intrathecal injection of 0.5 mL of gadopentetate dimeglumine diluted in 3-5 mL of CSF for MR cisternography has been reported to have high sensitivity and specificity for detection of active CSF fistula, exceeding the rate of fistula demonstration by CT, nuclear medicine, or noncontrasted MR cisternography. The gray scale is reversed for optimal viewing. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension.
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