eMedicine Specialties > Radiology > Brain/Spine
Cerebrospinal Fluid, Leak: Imaging
Updated: Oct 26, 2009
Radiography
Findings
Skull radiographs are of limited diagnostic use in cerebrospinal fluid (CSF) leaks, but they may show a skull fracture or suggest the presence of empty sella.
Computed Tomography
Findings
This patient presented with a spontaneous onset of cerebrospinal fluid rhinorrhea 10 years after a head injury. This coronal CT cisternogram was obtained after an intrathecal injection of contrast material (Omnipaque 300, 8 mL) into the lumbar thecal sac and subsequent positioning of the contrast agent in the head. The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow).
Axial CT image was obtained with the patient (same patient as in Image 4) in the supine position. Contrast medium has drained out of the meningocele, but a small amount remains in the sphenoid sinus around the meningocele.
Axial CT image of the same patient as in Image 9 demonstrates pneumocephalus in association with the spontaneous cerebrospinal fluid rhinorrhea and a septal bone defect in the left posterior ethmoid air cell.
Coronal CT image of the temporal bone demonstrates a bone defect (small arrows) in the tegmen tympani with a protruding soft-tissue meningoencephalocele (large arrows). This patient had cerebrospinal fluid otorrhea after mastoidectomy.
CT findings associated with cerebrospinal fluid (CSF) leaks include fractures or other bone defects; meningocele; focal fluid accumulation in the ethmoid air cells or in the frontal, sphenoid, or maxillary sinuses or mastoid air cells; and, sometimes, pneumocephalus.
CT cisternography is performed with injection of 5-7 mL of nonionic myelographic contrast medium into the lumbar subarachnoid space. The patient is maintained in the prone position until a CT scan is performed. Ideally, the contrast medium is concentrated in the intracranial anterior and posterior skull base regions under fluoroscopic guidance by tilting the prone patient head downward on a fluoroscopic tilt table. Alternatively, with the patient lying prone on a stretcher, the patient's hips can be raised above the level of the head for 1-2 minutes to concentrate the contrast medium over the anterior and posterior regions of the skull base. Coronal CT images of 2-3 mm thickness are then obtained through the face and cranium, including all of the paranasal sinuses and the mastoid air cells.
CT cisternographic findings in CSF leak include the concentration of contrast medium in portions of a sinus or within ethmoid or mastoid air cells. Occasionally, a stream of contrast medium is demonstrated at the fistula site.
Digital subtraction radiographic cisternography can be similarly performed with a spinal subarachnoid injection of nonionic iodinated contrast medium. The images may demonstrate a CSF fistula, but this technique is used less frequently than the other cisternographic methods.
Degree of Confidence
The incidence of cerebrospinal fluid (CSF) fistula detection varies from 22-100% in clinical studies. The fistula detection rate is lowest for intermittent CSF leaks. The accuracy of active fistula detection with CT cisternography is 65-85%. 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.28 Computer-reconstructed coronal images are less accurate and acceptable only until direct CT coronal images can be obtained.
Magnetic Resonance Imaging
Findings
MRI of the brain and spine
Fast spin-echo T2-weighted coronal image of a patient with a spontaneous onset of cerebrospinal fluid rhinorrhea demonstrates an empty-sella configuration.
Spontaneous intracranial hypotension syndrome in a patient with chronic headaches, which began after lumbar puncture. Axial fast spin-echo T2-weighted MRI demonstrates widened extra-axial fluid spaces but no focal extra-axial fluid collection.
Coronal fast spin-echo T2-weighted MRI in the same patient as in Image 17.
Gadolinium-enhanced T1-weighted axial MRI in the same patient as in Image 17 shows diffuse moderate dural thickening with contrast enhancement.
Gadolinium-enhanced, coronal, T1-weighted MRI in the same patient as in Image 17 shows dural and tentorial thickening with contrast enhancement.
Gadolinium-enhanced, T1-weighted axial MRI in the same patient as in Image 17 obtained 2 weeks after a 7-mL extradural blood patch was applied to the midlumbar region. This image shows complete resolution of the previous dural thickening and contrast enhancement. The patient's severe postural headaches were markedly decreased in intensity.
Gadolinium-enhanced, coronal, T1-weighted MRI in the same patient as in Image 17.
Brain tissue herniation is best seen on MRI. Herniation of the inferior frontal gyrus may occur in frontal head injuries or in ethmoid developmental defects of the cribriform plate.
In spontaneous intracranial hypotension syndrome (SIHS), brain MRI shows thickening and contrast enhancement in the cranial pachymeninges. Subdural hygroma or hematoma on the cerebral convexities is common. The brain is noted to sink downward in the cranium with development of a pseudo-Chiari I malformation. The cerebral dural venous sinuses may be engorged. The cerebral ventricles may be reduced in size, and the pituitary gland may appear enlarged. The upper cervical epidural veins are congested. All of these changes are reversible with ablation of the cause of CSF leak.
Spinal MRI in patients with SIHS may show some irregularity of the thecal sac due to partial dural collapse. Extradural fluid collections are common in spinal cerebrospinal fluid (CSF) leak. Intense extradural contrast enhancement is noted in congested epidural veins. One or more CSF fistulas may originate from spinal nerve root sleeves in the case of spontaneous spinal CSF leak.
A variety of cisternographic studies may be necessary to localize some spinal CSF fistulas. Spinal MRI findings are potentially reversible after successful ablation of a CSF fistula.
MR cisternography and myelography
Acute posttraumatic cerebrospinal fluid rhinorrhea. This coronal magnetic resonance cisternogram demonstrates a left-sided cerebrospinal fluid leak through the cribriform plate (small arrows), which was clinically suspected. The image also shows a right-sided meningocele (large arrow) protruding through the cribriform plate, which was not suspected but was surgically repaired at the same time as the left cribriform cerebrospinal fluid leak site.
Magnetic resonance cisternogram in the same patient as in Image 4 with cerebrospinal fluid rhinorrhea demonstrates a meningocele extending into the left lateral recess of the sphenoid sinus (arrows).
Axial magnetic resonance cisternogram of the same patient as in Image 4 demonstrates the connection of the meningocele to the middle cranial fossa (arrows). Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane.
Sagittal magnetic resonance cisternogram in the same patient as in Image 4 demonstrates the connection of the meningocele to the middle cranial fossa; this finding facilitated surgical planning.
MR cisternography and myelography can accurately localize CSF leaks in the cranium and spine.29,30,31,32 This technique is based on the intrinsic T2 contrast between CSF and adjacent structures. A positive diagnosis of CSF fistula is made by finding direct continuity of the CSF fistula with the subarachnoid space. Coronal and sagittal imaging is necessary.
The high T2 signal from CSF fistula may be difficult to differentiate from that of sinusitis on axial images. A high rate of fistula detection may be possible with imaging in the prone position, but this may be uncomfortable for the patient. Therefore, imaging is usually done with the patient in the supine position. Rapid echo-planar imaging with the patient in the prone position and performing a Valsalva maneuver may allow for limited coronal imaging and increase the accuracy of MR cisternography.
MR cisternography is performed with heavily T2-weighted, fast spin-echo, fat-saturated sequences with thin sections and minimal or no gap. Typical imaging parameters include a repetition time of 10,000 ms, an effective echo time of 200 ms, 4 signals acquired, an echo train length of 16, a matrix of 512 X 192, no phase-wrap option, 3-mm sections interleaved contiguously (0-mm gap), and a 16-cm field of view.
A short repetition time can be used to achieve a result similar to that of the technique above, with slightly faster imaging times. The gray scale is reversed for optimal viewing. Two to three scans of 8 minutes each are needed to cover the required area in each projection. With one method, the average total time for coronal and sagittal imaging is 48 minutes.33 Most MRI machines offer fat suppression and image gray-scale reversal. Additional hardware or software is not required to perform MR myelography or cisternography.
MR cisternography may demonstrate inactive CSF fistulas. MR T2 myelography may demonstrate spinal CSF fistulas (see Images below and Images 14-16 in Multimedia). 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 small series of patients had no apparent side effect from the contrast medium.31,34 Gadolinium-based contrast media have not been approved for intrathecal use in humans by the Food and Drug Administration (FDA), and this is strictly an experimental animal study in the United States.Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow).
Magnetic resonance myelogram in a patient with a brachial plexus injury and pseudomeningoceles (arrows).
Magnetic resonance myelogram demonstrates pseudomeningoceles secondary to a stretch injury of the lumbosacral nerve roots.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], and gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy.
NSF/NFD has occurred in patients with moderate to end-stage renal disease who have been given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the sclera of the eyes; joint stiffness with difficulty moving or straightening the arms, hands, legs, or feet; pain deep in the hips or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory or Medscape.
Degree of Confidence
In one study, the detection of cerebrospinal fluid (CSF) fistula by MR cisternography had an accuracy of 89%, a sensitivity of 87%, and a specificity of 100%.
False Positives/Negatives
A study of 50 patients without a cerebrospinal fluid (CSF) leak who had an MRI brain scan had a 42% false-positive rate for cribriform plate fistula, which was likely related to a high T2 signal in ethmoid air cells from associated sinusitis and apparent defects in dura or bone from irregular superior ethmoid bone surfaces.
Ultrasonography
Findings
Diagnostic ultrasound has not been useful in cranial cerebrospinal fluid (CSF) leak. Paraspinal fluid collections can be localized for needle aspiration with ultrasound guidance.
Nuclear Imaging
Findings
Lateral 24-hour cranial scintigraphic image from a nuclear medicine cisternographic study in a patient with clinically evident right-sided cerebrospinal fluid rhinorrhea. Image demonstrates increased tracer accumulation in the nasal region (arrow).
Anterior 48-hour scintigraphic image in the same patient as in Image 1 demonstrates tracer accumulation in the right nasal region. Imaging findings were correlated with both the clinical findings and nasal pledget counts obtained as part of this study.
Nuclear cisternogram obtained at 24 hours in the same patient as in Image 17 demonstrates diffuse epidural accumulation of the tracer in the midlumbar region. This finding is suggestive of a site of cerebrospinal fluid leak.
Radionuclide cisternography is currently performed by administering a lumbar subarachnoid intrathecal injection of indium, Indium-111 (111 In) diethylenetriamine pentaacetic acid (DTPA), in a 500 µCi dose.111 In has minimal background activity and does not accumulate in the brain. Technetium as 99m Tc DTPA is a less frequently used isotope.35
Head images are acquired 2, 6, 12, and 24 hours after injection of the isotope. Follow-up 48- or 72-hour scans are possible with111 In and are useful in the detection of intermittent cerebrospinal fluid (CSF) fluid leaks.
The entire spine is scanned up to 24 hours in cases of spontaneous intracranial hypotension, spinal trauma, or postoperative CSF leaks.36 Cotton pledgets labeled for the placement site are positioned in the nose before the lumbar subarachnoid space injection of the isotope. Pledgets are placed closest to the cribriform plate, in the middle meatus, and in the sphenoethmoidal recess of the right and left nasal cavities. A control pledget for lacrimal secretions is placed under one inferior nasal turbinate.
Pledgets are scanned in a glass tube at intervals of 2-24 hours with the highest count rate indicating a possible leak site. Alternatively, radioactivity of the nasal pledgets is compared with that of known plasma radioactivity.
For otorrhea, 1 cotton pledget is placed in each external auditory canal.
Degree of Confidence
The sensitivity for cerebrospinal fluid (CSF) leaks is in the range of 50-100%. The specificity is almost 100% for contemporary radionuclide cisternography.
Angiography
Findings
Cerebral arteriography is not used in the diagnostic imaging workup to localize the site of a cerebrospinal fluid (CSF) leak. Arterial injury may occur with skull trauma that causes CSF leakage. In this case, diagnostic cerebral and cervical arteriography is necessary.
More on Cerebrospinal Fluid, Leak |
| Overview: Cerebrospinal Fluid, Leak |
 Imaging: Cerebrospinal Fluid, Leak |
| Follow-up: Cerebrospinal Fluid, Leak |
| Multimedia: Cerebrospinal Fluid, Leak |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics
CSF Rhinorrhea
Skull Base, CSF Otorrhea
Head Injury
Closed Head Trauma
Penetrating Head Trauma
Upper Cervical Spine, Trauma
Thoracic Spine, Trauma
Keywords
cerebrospinal fluid leak, CSF leak, dural tear, dural leak, CSF rhinorrhea, CSF otorrhea, pneumocephalus, spinal CSF leak, intracranial hypotension, spontaneous intracranial hypotension syndrome, SIHS, traumatic CSF fistula, double-ring sign, lumbar extradural blood patch
