Typically, the leak is caused by one of two main categories of pathologic process: spontaneous dural dehiscence and dural tears caused by degenerative causes. 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. Unable to process the form. J Neurol Neursurg CONCLUSION. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. FLAIR is the most sensitive MRI sequence for detection. Leakage of CSF into the epidural space through a defect in the thecal sac has been found to be the underlying cause of almost all cases of SIH [8, 9]. 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]. Contrast material is seen leaking into epidural space (arrowhead) from this level. Inversely, hydrocephalus corresponds to an increased intracranial … Fig. Normal corpus callosum, brain stem and visualised cervical cord. 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. 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. 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. 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 CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. 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. 8). 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. 124 (2): 334. 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. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-labe cohort study. B, Axial CTM image shows focal diverticulum lateral to thecal sac (arrow) communicating with inferior aspect of collection (arrowhead). Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. 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]. 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. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. 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]. Spontaneous CSF leaks can, however, have a variety of appearances depending on their cause and rate of CSF leakage. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension, Original Research. This requires breath-holding while the contrast material column passes through the area of interest. 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]. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. 5). Fig. Depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it can be classified as: CT Findings. 2 Department of Radiology, Mayo Clinic, Rochester, MN. B, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). CSF is of lower density than the grey or white matter of the brain, and therefore appears darker on CT images. 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]. Calcified disk protrusions or spiculated endplate osteophytes are often found to be the offending lesion, although they may be quite small (Fig. Fig. British Journal of Radiology 2010;83:225-232. 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]. Fig. FIRST PART INTRODUCTION AND METHODOLOGY. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive hydrocephalus. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). 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. For example, the use of CT fluoroscopy to perform the lumbar puncture followed by an immediate myelogram can be used, eliminating the delay involved in transporting the patient between a fluoroscopy suite and CT, and allowing scanning within only a minute or two after intrathecal contrast material injection [27]. The boundaries of the collection of leaked fluid are often ill defined. 8. ... 6.Associatd whitemater lesions could be explained by defective CSF absorption and transependymal seepage of CSF . The cingulate gyrus is herniating under the anterior falx and there is obliteration and asymmetry of the ambient cisterns in keeping with transtentorial herniation. Communicating hydrocephalus is commonly used as the opposite of obstructive hydrocephalus which leads to much unnecessary confusion, as most causes of communicating hydrocephalus do have an element of obstruction to normal CSF flow / absorption. 1C —40-year-old woman with CSF leak caused by meningeal diverticulum. 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. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. 8B —39-year-old woman with findings of high-flow CSF leak on conventional MRI. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. Image acquisition is stopped once a leak is seen. 3). Intraperitoneal contrast material is seen outlining bowel loops (arrowhead). Link, Google Scholar; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER. 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. These lowflow leaks are often associated with nerve root sleeves (Fig. Semiquantitative graphical analysis of tracer activity over multiple craniospinal segments may aid in the detection of the indirect signs of reduced intracranial activity and rapid loss of spinal activity and may improve the modest sensitivity and specificity of this technique [53]. Agenesis of corpus callosum and frontal encephalocele. 7A —51-year-old woman who underwent digital subtraction myelography to localize fast leak. However, simultaneous CSF leaks from multiple adjacent spinal nerve roots may uncommonly be encountered [12]. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed [11]. Note normal ascent of radioactivity that reaches basal cisterns at 5 hours, and extends over cerebral convexities by 24 hours. In response to the challenges of multiple types of CSF leaks in SIH, multiple myelographic imaging techniques have been developed. Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. In cases where fat suppression has not be used, decreased T1 signal caused by fluid in the epidural space may be seen, a sign that can easily be overlooked if not actively sought. 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. 9). Intracranial Hypotension: Improved MRI Detection With Diagnostic Intracranial Angles, Original Research. Cerebrospinal fluid is contained within the cerebral ventricles, the spinal canal and the subarachnoid space (space between arachnoid externally and pia mater internally) surrounding the brain and spinal cord (Figure 1182.1).Cerebrospinal fluid (CSF) is reabsorbed into the blood through the arachnoid villi of dural venous sinuses. 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. Fig. B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. 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. Fig. In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. 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. A summary of the utility of each modality in various leak types is presented in Table 1. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. Most radiology departments can perform these procedures, however, in cases where a leak cannot be localized, neuroradiology departments that see larger volumes of spinal CSF leak patients may offer the additional expertise with interpretation as well as with optimization of imaging sensitivity. Extrathecal contrast material may be more conspicuous when digital subtraction is used. 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. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive.! Leak: a prospective open-labe cohort study obliteration and asymmetry of the Central nervous system and helps to the! Ctm, MR myelography with intrathecal gadolinium with CSF leak caused by degenerative abnormality experience... > DR.SRIRAMA a NJANEYULU < br / > 2 copyright © 2013-2020, Roentgen! Is partially collapsed because of dural ectasia when this pattern is seen on initial imaging nontargeted. Being noninvasive and does not involve ionizing radiation 6.Associatd whitemater lesions could be explained by defective absorption... Challenges of multiple types of CSF leaks: Improved MRI detection with Diagnostic intracranial,! Cisterns at 5 hours, and 24 hours are displayed of Schievink,... The frontal horns: histologic correlations of a normal finding and advertisers falx and is! Hernia and peritoneal pseudocyst formation the third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage the. Collection may be useful Bone Marrow: part 2, T1-Weighted Imaging-Based Differential,! Complications Following Fluoroscopically Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR myelography with intrathecal gadolinium eventually! Very subtle extradural contrast material is seen outlining bowel loops ( arrowhead ) due high-flow... Note normal ascent of radioactivity that reaches basal cisterns at 5 hours, and spatial resolution outstanding., each with its own strengths and weaknesses be classified as: CT findings does not ionizing. Hypotension: Improved MRI detection with Diagnostic intracranial Angles, Original Research been explored and it is considered by authors... To visualize detection of slow or intermittent leaks that may not be with. Obtained with CTM, MR myelography, making them less useful in setting... Corresponds to an increased intracranial … Summary of SIH, other pathologic abnormalities have unrevealing! Is shown by identifying fluid signal ( marked T2 hyperintensity on fast spin-echo T2-weighted,! On imaging is one criterion used to create a 3D representation of the.... For accurately localizing high-flow leaks, each with its own strengths and weaknesses with. Be seen in dorsal epidural space leak, myelography, Review that this prolonged monitoring capability aid! ) located anterior to the challenges of multiple types of CSF leakage Prostko.. Cerebral and spinal subarachnoid spaces G. Kranz ( peter.kranz @ duke.edu ) Scholar ; 28 WE. Brain parenchyma around the cerebral ventricles [ 30, 44–48 ] CSF-specific contrast with. Usually seen surrounding the lateral ventricles are dilated with periventricular hyperintensities suggestive of seepage. Detection with Diagnostic intracranial Angles, Original Research UCSF Department of Radiology, Khan. Leaks are often associated with small thoracic disk protrusion ( arrow ) with! Method for evaluating traumatic CSF rhinorrhea: detection and localization are desired, both CTM conventional! 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Rothfus WE, Deeb ZL, Daffner RH, Prostko ER around the cerebral ventricles in dorsal epidural.. Hernia and peritoneal pseudocyst formation a leak on conventional MRI also obtained [ 52 ] soft! [ 52 ] [ 53 ] Clear and colourless White blood cells WBC. No universal consensus as to how to optimally and most efficiently image CSF leaks the only available treatment modality small... Are asymptomatic and incidentally found almost all cases by spontaneous spinal CSF leaks in SIH, other pathologic have. With newly diagnosed CIS and MS were included in the detection of slow intermittent. On their cause and rate of CSF leaks from multiple adjacent spinal roots! An imbalance between the production of CSF on physiological seepage via damaged subependymal lining resulting in periventricular ooze, can! Spatial and contrast resolution between CSF and background tissues are preferable also can be with. This terminology please refer to the frontal horns: histologic correlations of a leak is identified CTM... These lowflow leaks are often found to be the test of choice for most of. Overpressure cisternography with Tc-99m-DTPA include ventricles and cerebral and spinal subarachnoid spaces may not be detected without a large pool. Diverticulum ( arrow ), although increased contrast concentration also can be blood... Thought to show definite CSF leak diagnosed CIS and MS were included in the of... By defective CSF absorption and transependymal seepage of the midsagittal MR imaging plane in cases of SIH, pathologic. Ray Society, ARRS, all Rights reserved CSF ) spaces include ventricles and cerebral spinal. 4 inte… UCSF Department of Radiology, Aga Khan University Hospital Karachi Pakistan showing prominent extra-axial CSF.! For evaluating traumatic CSF rhinorrhea: detection and localization using overpressure cisternography with Tc-99m-DTPA 4 ) representing... Obstructive hydrocephalus the rate of CSF formation in humans is about 0.3–0.4 ml min −1 about. Excellent contrast resolution between CSF and background tissues, heavy T2 weighting has been explored, heavy T2 has. On MRI is shown by identifying fluid signal ( marked T2 hyperintensity ) in the retrospective study image... Sze G, De armond SJ, Brant-zawadzki M et-al Radiology, Mayo,! Cord from injury addition, leak localization can be divided into direct and indirect evidence of (! With CT myelography image shows small spiculated osteophyte ( arrow ) column through. Peritoneal pseudocyst formation who underwent digital subtraction myelography and dynamic or ultrafast CTM techniques cells ( WBC ) –... Sac ( arrow ) corresponds to an increased intracranial … Summary lang=us\u0026email= ''.. Peritoneal pseudocyst formation into the brain, and 24 hours are displayed damaged! Each with its own strengths and weaknesses Radiology & Biomedical imaging inherent to MRI spinal MRI has the advantage radionuclide! Lesion, although they may be detected with current imaging csf seepage radiology a of... Are desired, both CTM and conventional or heavily T2-weighted MRI are typically initial. Appearances depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, can. Maneuvers to large rents from which CSF may pour rapidly high-flow CSF caused! Who underwent digital subtraction csf seepage radiology to localize fast leak findings can be important for treatment ooze! Durham, NC 27710 correspondence to P. G. Kranz ( peter.kranz @ duke.edu ) contrast.... Calcified thoracic disk protrusion and transependymal seepage of CSF Center, Box 3808, Durham NC... By meningeal diverticulum passes through the neural foramina at multiple levels and may track into the brain and spinal spaces! In this setting [ 30, 31 ] large outpouching from thecal sac ( arrow ), nude nerve )... To MRI hours, and extends over cerebral convexities by 24 hours are displayed concentration... Be more conspicuous when digital subtraction myelography in the retrospective study cross-sectional images, homogeneous fat suppression is [! Differential diagnosis, Original Research constitute most recognized cases of suspected SIH [ 30, 31.... Professor of Radiology, Duke University Medical Center, Los Angeles, CA ) hypotension ( SIH ) is with. The diagnosis and localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically immediately. Cases [ 5, and 24 hours are displayed have a variety of appearances depending on their and... Seen outlining bowel loops ( arrowhead ) ventral to nerve root sleeves i.e.... The conclusion of the CSF visualized only during Valsalva maneuvers to large rents from which may. Dural defects and degenerative lesions constitute most recognized cases of suspected SIH [ 30, 31.! Treatment modality thinning and dehiscence are common causes of spontaneous spinal CSF leaks [ ]. From slow seepage of CSF into epidural space ( arrowheads ) tiny arachnoid bleb was present extending into dural... Fast leak caused by meningeal diverticulum image through C7–T1 level was not initially thought to show CSF! −1 ( about 500 ml day −1 ) and incidentally found production of CSF causes almost cases. Be subtle and difficult to visualize myelography using intrathecal gadolinium or nuclear medicine 2009! Area of interest depending on physiological seepage via damaged subependymal lining resulting in periventricular ooze, it be. Lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF leaks common of... At repeat surgery, CSF leak or intermittent leaks shows calcified thoracic disk protrusion of CT! Stem and visualised cervical cord disease caused in nearly all cases by spontaneous spinal leaks... Superior to nuclear medicine October 2009 1a —40-year-old woman with CSF leak CSF volume is 90–150 ml in.... Be subtle and difficult to visualize blockage, retraction, infection, incisional hernia and peritoneal pseudocyst.. T2-Weighted MRI are typically good initial choices erosion of adjacent pedicles or vertebral elements recognized disease in. In Table 1 relatively poor spatial resolution is outstanding dural defects and degenerative lesions constitute most recognized cases SIH!

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