Department of Radiology, B Y L Nair Charitable Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India ... subsequent slow seepage of CSF. Of note, a retrospinal fluid collection may be seen at the C1–C2 level in patients with CSF leak and is best seen on T2-weighted images. Even faster dynamic or ultrafast CTM techniques, in which imaging begins while contrast material is still being actively injected, have also been described elsewhere [17, 32]. Idiopathic Intracranial Hypertension: MRI. Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. 4C —30-year-old woman with high-flow CSF leak. Formed primarily in the ventricles of the brain, the cerebrospinal fluid supports the brain and provides lubrication between surrounding bones and the brain and spinal cord. Fig. 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]. The purpose of this article is to review the pathogenesis and imaging appearances of spinal CSF leaks specifically due to SIH (excluding other causes of spinal CSF leaks, such as trauma and postsurgical leaks), and to discuss the various imaging modalities used in their detection, to assist the reader in the selection and interpretation of imaging in this condition. For one, visualization of a leak on imaging is one criterion used to establish the diagnosis [1, 2]. Because they are more easily localized than fast leaks, represent slower rates of CSF leakage, and are more anatomically accessible than ventrally located leaks, these leaks are often easier to treat percutaneously than their high-flow counterparts. There are limitations to CTM, however, including the fact that it is invasive (albeit minimally so), requiring more time and personnel resources than conventional MRI. 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. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. Anatomic localization with MR myelography using intrathecal gadolinium is greatly superior to nuclear medicine myelography, making it more useful for guiding targeted treatment. A, Axial CT myelography (CTM) image shows large outpouching from thecal sac (arrow), representing partially contained CSF leak. Fig. Leakage of CSF into spaces other than the epidural space, such as the pleural space or peritoneum, can also cause SIH and usually is found in patients with connective tissue disorders [26] (Fig. Thecal sac is partially collapsed because of loss of CSF. Spinal MRI has also been used to evaluate for CSF leaks [36–38]. 4B —30-year-old woman with high-flow CSF leak. 4. Intracranial Hypotension: Improved MRI Detection With Diagnostic Intracranial Angles, Original Research. Regions of dehiscence, usually found on or adjacent to the spinal nerve roots, allow the protrusion of the inner arachnoid layer through the defect in the overlying dura, producing fragile meningeal diverticula that may be prone to tears [7, 10] (Fig. ... ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly . The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks. CSF may refer to: . Some authors favor the use of general anesthesia to more effectively suspend respirations [24], whereas others have not found this necessary [19]. 10B —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. For fast CSF leaks, then, selection of an imaging modality with high temporal resolution and rapid imaging after introduction of the myelographic agent are key to localizing the actual leak site. Extensive leakage of CSF into epidural space is also seen. In addition, leak localization can be important for treatment. In the authors' practices at referral centers, which commonly involve more complicated or refractory presentations of SIH, spinal imaging is obtained in almost all cases, however. Total CSF volume is 90–150 ml in adults and 10–60 ml in neonates. Welcome to the Radiology Assistant Educational site of the Radiological Society of the Netherlands by Robin Smithuis MD rhinorrhea. Fig. It results when there is an imbalance between the production of CSF & its drainage by the arachnoid villi. 8B —39-year-old woman with findings of high-flow CSF leak on conventional MRI. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. In response to the challenges of multiple types of CSF leaks in SIH, multiple myelographic imaging techniques have been developed. AJR Am J Roentgenol. In these cases, imaging techniques that result in higher spatial and contrast resolution between CSF and background tissues are preferable. 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. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. Spontaneous CSF leaks can, however, have a variety of appearances depending on their cause and rate of CSF leakage. 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]. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive hydrocephalus. Some authors strongly advocate for initial screening with MRI [29, 39], whereas others consider CTM to be the reference standard and the initial test of choice [31, 58, 59]. A, Sagittal CT myelography (CTM) image shows dorsal collection of CSF (arrowheads), with gradient of myelographic contrast indicating CSF leak at inferior aspect of collection. In cases of fast or high-flow CSF leaks, a large pool of contrast material is seen in the epidural space surrounding the thecal sac. If the rate of CSF leakage is sufficiently slow, the leak may be subtle and difficult to visualize. It is generally thought that these cases represent very slow or intermittent leaks that may not be detected with current imaging technology. (D and E with kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:137– 144, Periakaruppan A, et al .) For patients for whom nontargeted patching fails, targeted epidural patching or surgical intervention may be required; both require precise knowledge of the site of the leak [6, 7]. Figure 1182.1: Cranial meninges However, simultaneous CSF leaks from multiple adjacent spinal nerve roots may uncommonly be encountered [12]. CSF motion is a combined effect of CSF production rate and Fluid may stream out of the spinal canal through the neural foramina at multiple levels and may track into the paraspinal soft tissues. Cns mocks radiology fcps 1. This requires breath-holding while the contrast material column passes through the area of interest. AJR Am J Roentgenol. A, Sagittal CT myelography image shows calcified thoracic disk protrusion (arrow). 2C —41-year-old man with CSF leak caused by degenerative abnormality. A tiny arachnoid bleb was present extending into this dural rent. B, Coronal CTM image again shows diverticulum (arrow). Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension, Original Research. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. 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. Post-operative pseudomeningocele. Early activity within the kidneys and bladder must be interpreted with caution because leakage of tracer at the lumbar puncture site can result in renal uptake due to systemic reabsorption [52]. Thoracic disk protrusions are known to be more likely to calcify, with a relatively high incidence of adherence to and penetration through the dura [21, 22], factors that may help to explain the development of acute dural tears in the thoracic region. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. CT SCAN, MRI, ULTRASOUND, X RAY. There is also indirect evidence of CSF leak indicated by activity in bladder (arrowheads) and kidneys at 1, 2, and 4 hours, as well as rapid loss of spinal activity and absence of activity over cerebral convexities at 24 hours. Sacral spinal canal is enlarged because of dural ectasia. No neutrophils present, primarily lymphocytes 2. Contrast material is seen leaking into epidural space (arrowhead) from this level. Hakseung Kim, Eun-Jin Jeong, Dae-Hyeon Park, Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo Kim. 7. net pics. These include digital subtraction myelography and dynamic or ultrafast CTM techniques. The right lateral ventricle is effaced and the left lateral ventricle entrapped and dilated, with posterior periventricular CSF seepage causing hypodensity. Empirical patching targeted at nerve root diverticula, even if leakage from these sites is not directly visualized, may be efficacious in some patients, although it becomes more technically challenging if numerous diverticula are present [27]. 1C —40-year-old woman with CSF leak caused by meningeal diverticulum. With dynamic CTM, the entire spinal canal can be examined, and spatial resolution is outstanding. Choroid plexus xanthogranulomas are benign lesions, usually located in lateral and third ventricles. Fig. For a discussion of this terminology please refer to the more general article on hydrocephalus. Ventriculoperitoneal shunt is commonly used to treat hydrocephalus whereby the peritoneal cavity is used for cerebrospinal fluid (CSF) absorption. The ventricular ependymal lining is eventually disrupted, allowing for the transependymal migration of cerebrospinal fluid into the brain parenchyma around the cerebral ventricles. Tuberculous brain abscess 3. B, Axial CTM image from lower in pelvis shows more extensive leaked intraperitoneal contrast material (arrowheads). In this case, a second more rapid myelographic imaging test may be required to further investigate the site of leak, although information from the initial CTM may help target this investigation. CT myelography (CTM) is probably the most commonly used modality in investigating CSF leaks. The boundaries of the collection of leaked fluid are often ill defined. Fig. 8). 7C —51-year-old woman who underwent digital subtraction myelography to localize fast leak. Extrathecal contrast material may be more conspicuous when digital subtraction is used. 5B —56-year-old man with low-flow CSF leak. The optimal time between introduction of the myelographic contrast agent and imaging to detect these low-flow leaks is unpredictable, varying from case to case. Cerebrospinal Fluid 1. In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. Although some have suggested that lumbar puncture should be avoided in patients with low CSF pressure because of the theoretic risk of exacerbating CSF hypovolemia [33], in the authors' experience, this concern is overstated and is almost never an issue in actual practice. FLAIR is the most sensitive MRI sequence for detection. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed [11]. The brain and spinal cord are surrounded by three protective membranes, the outermost of which is called the dura.One function of the dura is to contain the cerebrospinal fluid (CSF)–the liquid that bathes and cushions the brain and spinal cord. A spinal fluid leak occurs when CSF escapes from the dura. Several investigators have reported that MR myelography using intrathecal gadolinium is more sensitive for slow-flow or intermittent leaks than CTM, with CSF leaks identified in approximately 20% of patients for whom no leak was identified on prior CTM [30, 45] (Fig. Leaked contrast material is seen in dorsal epidural space. 8A —39-year-old woman with findings of high-flow CSF leak on conventional MRI. Fig. The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. When this pattern is seen on initial imaging, nontargeted epidural blood patching may be the only available treatment modality. Medline, Google Scholar Segev Y, Metser U, Beni-adani L et-al. 2). One series of surgically confirmed cases described a variety of configurations of these dural defects, including defects located at the axilla of the nerve root, others along the length of the nerve root sleeve, and circumferential absence of the dura surrounding the base of the nerve root [10]. In that series and in other observations based on myelography, the morphologic characteristics of the associated meningeal diverticula were found to be quite varied, solitary in some cases and multiple in others, and of varying sizes, configurations, and anatomic complexity. AJNR Am J Neuroradiol. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. 4 / 5. Methods One hundred forty-nine patients with newly diagnosed CIS and MS were included in the retrospective study. 4), although increased contrast concentration also can be seen in dependent portions of the epidural collection. 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]. CSF is of lower density than the grey or white matter of the brain, and therefore appears darker on CT images. 2B —41-year-old man with CSF leak caused by degenerative abnormality. 2. CNS MOCKS 2016 2. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. Professor of Radiology and Pediatrics Director, Division of Nuclear Medicine October 2009. 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]. 3B —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. Fig. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 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]. Furthermore, single or multiple nerve root sleeve diverticula of various sizes and configurations are seen commonly as an incidental finding in healthy patients and, therefore, should not be assumed to be pathologic when observed in isolation [10, 15]. 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 Fig. 6B —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. It can be associated with abdominal complications such as shunt migration, blockage, retraction, infection, incisional hernia and peritoneal pseudocyst formation. Planar images are typically acquired immediately and at 1, 2, 4, and 24 hours. 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. The two major limitations are the associated radiation dose and patient discomfort associated with prolonged prone Trendelenburg positioning. C, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). CEREBROSPINAL FLUID
DR.SRIRAMA A NJANEYULU
2. If the leak is fast enough, or imaging is too delayed, diffusion of myelographic contrast material or tracer throughout the leaked epidural CSF pool will render precise localization impossible. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. (Courtesy of Schievink W, Cedars-Sinai Medical Center, Los Angeles, CA). {"url":"/signup-modal-props.json?lang=us\u0026email="}. AJNR Am J Neuroradiol 1987;8:155–156. It is important to distinguish interstitial edema from a commonly seen variant of a slight increase in signal anterior to the frontal horns, and posterior to the occipital horns, which is known as ependymitis granularis 3. Close lip schizencephaly 5. Efforts to improve temporal resolution while maintaining the excellent cross-sectional visualization CT affords have led to several modifications of the CTM technique. Fig. Evidence of typical changes associated with SIH, including dural enhancement, brain sagging, the venous distention sign, and other signs associated with low pressure, should be sought, recognizing that they may not be present in all patients [7, 55–57]. Typically, the leak is caused by one of two main categories of pathologic process: spontaneous dural dehiscence and dural tears caused by degenerative causes. In some cases, large diverticula may result in erosion of adjacent pedicles or vertebral elements. 9B —27-year-old woman who underwent MR myelography with intrathecal gadolinium. UCSF Department of Radiology & Biomedical Imaging. Check for errors and try again. Fig. First, because contrast-enhanced brain MRI is critical to establishing the diagnosis of SIH, this should be part of the routine imaging assessment. 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. These types of tears are often associated with very rapid CSF leakage and are most commonly found along the ventral surface of the thecal sac in the thoracic or lower cervical spine [17, 19, 20]. 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. Images of patient in prone position obtained at 0.2, 1, 2, 4, and 24 hours show direct evidence of left lumbar CSF leak with focal increased activity within left lumbar paraspinal tissues (arrows). This was repaired using 4 inte… This fluid has been referred to as a false localizing sign and should be cautiously interpreted, because multiple studies have found that this fluid does not necessarily indicate the primary site of CSF leak [39, 42, 43]. Fig. Inversely, hydrocephalus corresponds to an increased intracranial … Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. There may be a mechanism in common with the dural tears associated with idiopathic spinal cord herniation, which occur in the same spinal region and are often associated with calcified disk protrusions and osteophytes as well [23]. OBJECTIVE. The purpose of this article is to review the imaging of spinal CSF leaks and to assist in the selection of appropriate imaging modalities in this condition. The cingulate gyrus is herniating under the anterior falx and there is obliteration and asymmetry of the ambient cisterns in keeping with transtentorial herniation. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Because these degenerative lesions erode through the dura and may become interposed into the resultant dural defect, treatment with epidural patching can be ineffective in some cases, and surgical resection of the offending lesion may be required. Cerebrospinal fluid, clear colorless bodily fluid found in the brain and spine; Colony-stimulating factor, secreted glycoproteins; Cancer slope factor, estimate the risk of cancer; Classical swine fever, contagious disease of pigs; Contrast sensitivity function, relationship of contrast threshold vs angular frequency for an observer Advantages of CTM include wide availability, familiarity among radiologists, good spatial resolution, good detail of degenerative changes that may contribute to CSF leaks, and infrequent technical artifacts. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. 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. Leakage rates from the diverticula observed during surgical exploration have also been found to be variable, ranging from slow seepage of the CSF visualized only during Valsalva maneuvers to large rents from which CSF may pour rapidly [7]. When CSF leakage is slower, a focal leak may be detected without a large associated pool of epidural contrast material. 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. 4A —30-year-old woman with high-flow CSF leak. A summary of the utility of each modality in various leak types is presented in Table 1. Fig. In addition, the biomechanics of the thoracic spine during flexion and extension and the apposition of the dura to the normal kyphotic curvature of the posterior vertebral bodies may also play a role. Summary. Most patients with SIH, however, will not have any identifiable connective tissue disorder. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. 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. The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. Fig. If symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. The brain is surrounded by cerebrospinal fluid (CSF) within the sulci, fissures and basal cisterns.CSF is also found centrally within the ventricles.The sulci, fissures, basal cisterns and ventricles together form the 'CSF spaces', also known as the 'extra-axial spaces'. Depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be classified as: CT Findings. Radiology Imaging. CONCLUSION. Subtle early activity in bladder at 2 hours should not be interpreted evidence of leak; rather, this is due to reabsorption of small amount of tracer from lumbar puncture site. 10). Normal corpus callosum, brain stem and visualised cervical cord. Digital subtraction myelography offers unparalleled temporal resolution but suffers from a limited area of coverage, uses planar rather than cross-sectional images, and requires either good patient cooperation or general anesthesia. 7.Treatment include Diamox or repeated letting out CSF or shunting etc . Nuclear medicine imaging findings can be divided into direct and indirect evidence of leak (Fig. If confirmed by other investigators, such fistulas could be important because they may occur without concurrent epidural CSF leakage, making them difficult to detect with standard myelographic techniques. 1A —40-year-old woman with CSF leak caused by meningeal diverticulum. Oleh Habifa. 4D —30-year-old woman with high-flow CSF leak. 1 x. T2WI MRI brain showing prominent extra-axial CSF spaces. Paraspinal vascular malformations may also result in CSF volume depletion, possibly by augmenting the normal process of CSF resorption that occurs along spinal nerve roots [25] or through the presence of unrecognized fistulas to the malformation; treatment of the malformation itself may be necessary. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. , including disk protrusions or spiculated endplate osteophytes are often ill defined MRI. The offending lesion, although increased contrast concentration also can be examined, and 24.. Suspected SIH [ 30, 31 ] prominent extra-axial CSF spaces with Intraoperative Endoscopic.! Sufficiently slow, the lumbar puncture site can be seen on myelography despite exhaustive investigation maximum-intensity-projection images be! The transependymal migration of cerebrospinal fluid into the paraspinal soft tissues seen into. 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