eMedicine Specialties > Radiology > Brain/Spine
Cerebrospinal Fluid, Leak: Multimedia
Updated: Oct 26, 2009
Multimedia
 | Media file 1: 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). |
 | Media file 2: 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. |
 | Media file 3: 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. |
 | Media file 4: 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). |
 | Media file 5: 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. |
 | Media file 6: 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). |
 | Media file 7: 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. |
 | Media file 8: 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. |
 | Media file 9: Fast spin-echo T2-weighted coronal image of a patient with a spontaneous onset of cerebrospinal fluid rhinorrhea demonstrates an empty-sella configuration. |
 | Media file 10: 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. |
 | Media file 11: 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. |
 | Media file 12: Coronal fast spin-echo T2-weighted image in the same patient as in Image 11 demonstrates herniation of meninges and brain tissue (arrows) with adjacent cerebrospinal fluid into the postmastoidectomy tegmen tympani defect. This finding is consistent with a meningoencephalocele of the temporal bone. |
 | Media file 13: Artist's rendering of a tegmen tympani bone defect with a herniated meningoencephalocele. |
 | Media file 14: Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow). |
 | Media file 15: Magnetic resonance myelogram in a patient with a brachial plexus injury and pseudomeningoceles (arrows). |
 | Media file 16: Magnetic resonance myelogram demonstrates pseudomeningoceles secondary to a stretch injury of the lumbosacral nerve roots. |
 | Media file 17: 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. |
 | Media file 18: Coronal fast spin-echo T2-weighted MRI in the same patient as in Image 17. |
 | Media file 19: Gadolinium-enhanced T1-weighted axial MRI in the same patient as in Image 17 shows diffuse moderate dural thickening with contrast enhancement. |
 | Media file 20: Gadolinium-enhanced, coronal, T1-weighted MRI in the same patient as in Image 17 shows dural and tentorial thickening with contrast enhancement. |
 | Media file 21: 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. |
 | Media file 22: 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. |
 | Media file 23: Gadolinium-enhanced, coronal, T1-weighted MRI in the same patient as in Image 17. |
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 |
| « Previous Page |
References
Thomas DL, Menda Y, Graham MM. Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports. Clin Nucl Med. Jul 2009;34(7):410-6. [Medline].
Banks CA, Palmer JN, Chiu AG, O'Malley BW Jr, Woodworth BA, Kennedy DW. Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg. Jun 2009;140(6):826-33. [Medline].
Warnecke A, Averbeck T, Wurster U, Harmening M, Lenarz T and Stover T. Diagnostic Relevance of Beta-2 Transferrin for the Detection of Cerebrospinal Fluid Fistulas. Arch Otolarygol Head and Neck Surg. Oct 2004;130:1178-1194.
Arrer E, Meco C, Oberascher G, Piotrowski W, Albegger K and Patsch W. B-Trace Protein as a Marker for Cerebrospinal Fluid Rhinorrhea. Clinical Chemistry. 2002;48:939-941.
Bachmann G, Nekic M and Michel O. Clinical Experience with Beta Trace Protein as a Marker for Cerebrospinal Fluid. Ann Otol Rhinol Laryngol. 2000;109:1099-1102.
Snow JB Jr, Ballenger JJ. Complications of skull base surgery. In: Ballenger's Otorhinolaryngology. 16th ed. Hamilton, Ontario: Decker;. 2003: 508-36; 684-7; 799.
Pearson BW. Cerebrospinal fluid rhinorrhea. In: Otolaryngology. 3rd ed. Philadelphia: W. B. Saunders Co;. 1991: 1899-909.
Sautter NB, Batra PS, Citardi MJ. Endoscopic management of sphenoid sinus cerebrospinal fluid leaks. Ann Otol Rhinol Laryngol. Jan 2008;117(1):32-9. [Medline].
May JS, Mikus JL, Matthews BL, et al. Spontaneous cerebrospinal fluid otorrhea from defects of the temporal bone: a rare entity?. Am J Otol. Nov 1995;16(6):765-71. [Medline].
Burton EM, Keith JW, Linden BE, Lazar RH. CSF fistula in a patient with Mondini deformity: demonstration by CT cisternography. AJNR Am J Neuroradiol. Jan-Feb 1990;11(1):205-7. [Medline].
Rajkumar KT, Orabi AA, Timms MS. Spontaneous cerebrospinal fluid leak presenting as unilateral (left-sided) middle ear effusion. Ear Nose Throat J. Feb 2008;87(2):79-80. [Medline].
Ommaya AK. Cerebrospinal fluid fistula and pneumocephalus. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. 2nd ed. New York: McGraw-Hill;. 1996: 2773-82.
Buchanan RJ, Brant A, Marshall LF. Traumatic cerebrospinal fluid fistulas. In: Winn HR, ed. Youmans Neurological Surgery. 5th ed. Philadelphia: W. B. Saunders Co;. 2004: 5265-72.
Clarot F, Callonnec F, Douvrin F, et al. Giant cervical epidural veins after lumbar puncture in a case of intracranial hypotension. AJNR Am J Neuroradiol. Apr 2000;21(4):787-9. [Medline].
Hannallah D, Lee J, Khan M, Donaldson WF, Kang JD. Cerebrospinal fluid leaks following cervical spine surgery. J Bone Joint Surg Am. May 2008;90(5):1101-5. [Medline].
Zaatreh M, Finkel A. Spontaneous intracranial hypotension. South Med J. Nov 2002;95(11):1342-6. [Medline].
Mokri B. Spontaneous intracranial hypotension. Curr Neurol Neurosci Rep. Mar 2001;1(2):109-17. [Medline].
Mokri B. Spontaneous intracranial hypotension. Curr Pain Headache Rep. Jun 2001;5(3):284-91. [Medline].
Shiley SG, Limonadi F, Delashaw JB, et al. Incidence, etiology, and management of cerebrospinal fluid leaks following trans-sphenoidal surgery. Laryngoscope. Aug 2003;113(8):1283-8. [Medline].
Falcioni M, Romano G, Aggarwal N, Sanna M. Cerebrospinal fluid leak after retrosigmoid excision of vestibular schwannomas. Otol Neurotol. Apr 2008;29(3):384-6. [Medline].
Schlosser RJ, Bolger WE. Spontaneous nasal cerebrospinal fluid leaks and empty sella syndrome: a clinical association. Am J Rhinol. Mar-Apr 2003;17(2):91-6. [Medline].
Burns BJ. Images in emergency medicine. Traumatic cerebrospinal fluid leak. Ann Emerg Med. Jun 2008;51(6):704, 706. [Medline].
Limawararut V, Valenzuela AA, Sullivan TJ, McNab AA, Malhotra R, Davis G, et al. Cerebrospinal fluid leaks in orbital and lacrimal surgery. Surv Ophthalmol. May-Jun 2008;53(3):274-84. [Medline].
Daudia A, Biswas D, Jones NS. Risk of meningitis with cerebrospinal fluid rhinorrhea. Ann Otol Rhinol Laryngol. Dec 2007;116(12):902-5. [Medline].
Zuckerman JD, DelGaudio JM. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair. Am J Rhinol. Mar-Apr 2008;22(2):151-4. [Medline].
Gubbels SP, Selden NR, Delashaw JB Jr, McMenomey SO. Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management. Otol Neurotol. Dec 2007;28(8):1131-9. [Medline].
Hai-Sheng L, Ye-Tao C, Dong W, Hui L, Yunpeng W, Shi-Jie W, et al. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. Surg Neurol. Oct 2009;72(4):341-5. [Medline].
Shetty PG, Shroff MM, Sahani DV, Kirtane MV. Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula. AJNR Am J Neuroradiol. Apr 1998;19(4):633-9. [Medline].
Matsumura A, Anno I, Kimura H, et al. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. Case report. J Neurosurg. May 2000;92(5):873-6. [Medline].
Jinkins JR, Rudwan M, Krumina G, Tali ET. Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience. Radiology. Feb 2002;222(2):555-9. [Medline].
Goel G, Ravishankar S, Jayakumar PN, Vasudev MK, Shivshankar JJ, Rose D. Intrathecal gadolinium-enhanced magnetic resonance cisternography in cerebrospinal fluid rhinorrhea: road ahead?. J Neurotrauma. Oct 2007;24(10):1570-5. [Medline].
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. Br J Radiol. Sep 1 2009;[Medline].
El Gammal T, Sobol W, Wadlington VR, et al. Cerebrospinal fluid fistula: detection with MR cisternography. AJNR Am J Neuroradiol. Apr 1998;19(4):627-31. [Medline].
Albayram S, Kilic F, Ozer H, Baghaki S, Kocer N, Islak C. Gadolinium-enhanced MR cisternography to evaluate dural leaks in intracranial hypotension syndrome. AJNR Am J Neuroradiol. Jan 2008;29(1):116-21. [Medline].
Okizaki A, Shuke N, Aburano T, et al. Detection of cerebrospinal fluid leak by dual-isotope spect with In-111 DTPA and Tc-99m HMDP. Clin Nucl Med. Jul 2001;26(7):628-9. [Medline].
Lawrence SK, Delbeke D, Partain CL. Cerebrospinal fluid imaging. In: Diagnostic Nuclear Medicine. 4th ed. Baltimore: Lippincott, Williams & Wilkins. 2003: 835-9.
Fishman G, Fliss DM, Benjamin S, Margalit N, Gil Z, Derowe A, et al. Multidisciplinary surgical approach for cerebrospinal fluid leak in children with complex head trauma. Childs Nerv Syst. Aug 2009;25(8):915-23. [Medline].
Abuabara A. Cerebrospinal fluid rhinorrhoea: diagnosis and management. Med Oral Patol Oral Cir Bucal. Sep 1 2007;12(5):E397-400. [Medline].
Duffy PJ, Crosby ET. The epidural blood patch. Resolving the controversies. Can J Anaesth. Sep 1999;46(9):878-86. [Medline].
Franzini A, Messina G, Nazzi V, Mea E, Leone M, Chiapparini L, et al. Spontaneous intracranial hypotension syndrome: a novel speculative physiopathological hypothesis and a novel patch method in a series of 28 consecutive patients. J Neurosurg. Jul 10 2009;[Medline].
Sencakova D, Mokri B, McClelland RL. The efficacy of epidural blood patch in spontaneous CSF leaks. Neurology. Nov 27 2001;57(10):1921-3. [Medline].
Bluestone CD, Strol SE, Alper LM. Otorrhea. Pediatric Otolaryngology. 4th ed. Philadelphia, Pa: WB Saunders Co;. 2003: 297-9, 839-42.
Chiapparini L, Farina L, D'Incerti L, et al. Spinal radiological findings in nine patients with spontaneous intracranial hypotension. Neuroradiology. Feb 2002;44(2):143-50; discussion 151-2. [Medline].
Chung SJ, Kim JS, Lee MC. Syndrome of cerebral spinal fluid hypovolemia: clinical and imaging features and outcome. Neurology. Nov 14 2000;55(9):1321-7. [Medline].
Dillon WP. Spinal manifestations of intracranial hypotension. AJNR Am J Neuroradiol. Aug 2001;22(7):1233-4. [Medline].
Hegarty SE and Millar JS. MRI in the Localization of CSF Fistulae: Is It of Any Value?. Clinical Radiology. 1997;52:768-770.
Schlosser RJ, Bolger WE. Nasal cerebrospinal fluid leaks: critical review and surgical considerations. Laryngoscope. Feb 2004;114(2):255-65. [Medline].
Schnabel C, Di Martino E, Gilsbach JM, Riediger D, Gressner AM and Kunz D. Comparison of B2-Transferrin and B-Trace Protein for Detection of Cerebrospinal Fluid in Nasal and Ear Fluids. Clinical Chemistry. 2004;50:661-663.
Spelle L, Boulin A, Tainturier C, et al. Neuroimaging features of spontaneous intracranial hypotension. Neuroradiology. Aug 2001;43(8):622-7. [Medline].
Taivainen T, Pitkanen M, Tuominen M, Rosenberg PH. Efficacy of epidural blood patch for postdural puncture headache. Acta Anaesthesiol Scand. Oct 1993;37(7):702-5. [Medline].
Wax MK, Ramadan HH, Ortiz O, Wetmore SJ. Contemporary management of cerebrospinal fluid rhinorrhea. Otolaryngol Head Neck Surg. Apr 1997;116(4):442-9. [Medline].
Yousry I, Forderreuther S, Moriggl B, et al. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. AJNR Am J Neuroradiol. Aug 2001;22(7):1239-50. [Medline].
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
