In response to the challenges of multiple types of CSF leaks in SIH, multiple myelographic imaging techniques have been developed. 10B —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. 10). Agenesis of corpus callosum and frontal encephalocele. 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]. 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. AJNR Am J Neuroradiol. CT SCAN, MRI, ULTRASOUND, X RAY. Calcified disk protrusions or spiculated endplate osteophytes are often found to be the offending lesion, although they may be quite small (Fig. 1. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. 2A —41-year-old man with CSF leak caused by degenerative abnormality. Cerebrospinal fluid (CSF) is a clear, colorless plasma-like fluid that bathes the central nervous system (CNS).Cerebrospinal fluid circulates through a system of cavities found within the brain and spinal cord; ventricles, subarachnoid space of the brain and spinal cord and the central canal of the spinal cord. MS..pics from net 11. 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]. Ho ML, Rojas R, Eisenberg RL. 2001;22 (9): 1674-9. Sze G, De armond SJ, Brant-zawadzki M et-al. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. Fig. B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. ... ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly . B, Coronal CTM image again shows diverticulum (arrow). Fig. First, because contrast-enhanced brain MRI is critical to establishing the diagnosis of SIH, this should be part of the routine imaging assessment. In some cases, large diverticula may result in erosion of adjacent pedicles or vertebral elements. Cerebrospinal fluid (CSF) is a clear and colorless fluid that surrounds the brain and spinal cord with a density ranging from 1.003 to 1.008 which allows the brain to “float” in the fluid. C, Image from myelogram performed in right lateral decubitus position shows diverticulum (arrow) and leaked contrast material spreading in epidural space (arrowhead), originating from this site. In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. rhinorrhea. 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. In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. Both techniques are sensitive for detecting fast leaks. Contrast material is seen leaking into epidural space (arrowhead) from this level. If there is evidence of a fast CSF leak on initial imaging, a test with high temporal resolution may be needed to further localize the leak. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. Fig. In most cases of SIH, CSF leakage originates from a single spinal level. 9A —27-year-old woman who underwent MR myelography with intrathecal gadolinium. Artikel Terkait. 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). 5B —56-year-old man with low-flow CSF leak. 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. For a discussion of this terminology please refer to the more general article on hydrocephalus. OBJECTIVE. 8). 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]. It is considered by many authors to be the test of choice for most cases of suspected SIH [30, 31]. MRI of Spinal Bone Marrow: Part 2, T1-Weighted Imaging-Based Differential Diagnosis, Original Research. 6C —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. It is quite useful in the evaluation of high-flow leaks, but because digital subtraction myelography is not generally used to evaluate the entire spine, it is not generally used as the initial myelographic test for SIH. 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. In conclusion: CSF pseudocyst formation is a rare cause of a gradually enlarging breast lump, and should be borne in mind in patients with an Intracranial Hypotension: Improved MRI Detection With Diagnostic Intracranial Angles, Original Research. Medline, Google Scholar 9). 6). Because digital subtraction myelography best identifies leaks on the dependent surface of the thecal sac, some suspicion as to the leak's location based on prior imaging is helpful to best position the patient [35]. The recent murders of Black people at the hands of police officers and white vigilantes illustrate how, especially during a worldwide pandemic, systemic injustice and racism remain deeply ingrained in our society. Close attention should be paid to the presence of thoracic disk protrusions or osteophytes in patients with this leak type, because degenerative lesions often cause fast CSF leaks [18]. CT myelography (CTM) is probably the most commonly used modality in investigating CSF leaks. Leak localization and characterization are important for several reasons. The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. Depending on the leak site and whether the patient is imaged in the prone or supine position, the collection may preferentially be located ventrally or dorsally in the spinal canal. CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Third ventricular lesions can … There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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]. Fig. This requires breath-holding while the contrast material column passes through the area of interest. 1 Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710. However, MRI typically does not localize the exact leak site, generally suffers from more artifacts, has lower spatial resolution than CTM, and requires very homogeneous suppression of fat signal to detect more subtle leaks. Both techniques offer relatively high CSF-specific contrast to background signal, and they allow delayed imaging that may be useful for slow or intermittent leaks. 4C —30-year-old woman with high-flow CSF leak. The two major limitations are the associated radiation dose and patient discomfort associated with prolonged prone Trendelenburg positioning. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). 7A —51-year-old woman who underwent digital subtraction myelography to localize fast leak. In cases of high-flow CSF leaks, contrast material may spill so quickly from the thecal sac that by the time the images are acquired, myelographic contrast material has spread widely in the epidural space, making precise leak localization impossible. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. Close lip schizencephaly 5. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. Summary. The cingulate gyrus is herniating under the anterior falx and there is obliteration and asymmetry of the ambient cisterns in keeping with transtentorial herniation. A, Sagittal CT myelography image shows calcified thoracic disk protrusion (arrow). Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. In addition to cross-sectional images, maximum-intensity-projection images can be used to create a 3D representation of the thecal sac [40]. 2012;199 (3): W258-73. In some cases, slow-flow leaks may be depicted best with delayed imaging, allowing time for contrast material accumulation at the leak site, whereas in other cases, immediate imaging might best depict the leaked contrast material before it is reabsorbed into the soft tissues. In cases of slow leaks, CTM is probably more sensitive than conventional MRI because of the excellent tissue contrast obtained by using intrathecal iodinated contrast media [58]. 2C —41-year-old man with CSF leak caused by degenerative abnormality. 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]. Oleh Habifa. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. 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. It can be associated with abdominal complications such as shunt migration, blockage, retraction, infection, incisional hernia and peritoneal pseudocyst formation. Extensive leakage of CSF into epidural space is also seen. Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. 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 Normal corpus callosum, brain stem and visualised cervical cord prolonged monitoring may. Foci of MRI signal ( pseudo lesions ) anterior to nerve root (... 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