2012;199 (3): W258-73. 7C —51-year-old woman who underwent digital subtraction myelography to localize fast leak. B, Axial CTM image shows focal diverticulum lateral to thecal sac (arrow) communicating with inferior aspect of collection (arrowhead). When this pattern is seen on initial imaging, nontargeted epidural blood patching may be the only available treatment modality. 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]. 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). Figure 1182.1: Cranial meninges Multiple sclerosis 10. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. A, Sagittal STIR MR image shows extensive collection of fluid in epidural space (arrowheads). 5B —56-year-old man with low-flow CSF leak. 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. This is usually seen surrounding the lateral ventricles in the setting of an acute obstructive hydrocephalus. Calcified disk protrusions or spiculated endplate osteophytes are often found to be the offending lesion, although they may be quite small (Fig. 7. net pics. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. 2B —41-year-old man with CSF leak caused by degenerative abnormality. 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. This requires breath-holding while the contrast material column passes through the area of interest. No evidence of periventricular CSF seepage. 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]. 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. Radiology Imaging. 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. Such techniques are optimally performed with some pretest probability based on prior imaging as to what spinal region the leak is coming from (e.g., cervical, thoracic, or lumbar), and what surface of the thecal sac is involved (e.g., ventral, dorsal, or lateral), and are therefore less commonly used as an initial screening tool. Fig. A, Normal scans in 54-year-old man without CSF leak. 1A —40-year-old woman with CSF leak caused by meningeal diverticulum. CSF comprises all intracerebral ventricles, spinal and brain subarachnoid spaces, such as cisterns and sulci, and the central canal of the spinal 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. Nuclear medicine imaging findings can be divided into direct and indirect evidence of leak (Fig. It results when there is an imbalance between the production of CSF & its drainage by the arachnoid villi. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. CONCLUSION. 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. No neutrophils present, primarily lymphocytes 2. Hakseung Kim, Eun-Jin Jeong, Dae-Hyeon Park, Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo Kim. The two major limitations are the associated radiation dose and patient discomfort associated with prolonged prone Trendelenburg positioning. FIRST PART INTRODUCTION AND METHODOLOGY. 9). 9B —27-year-old woman who underwent MR myelography with intrathecal gadolinium. Occasionally, 48-hour delayed images are also obtained . The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. A summary of the utility of each modality in various leak types is presented in Table 1. B, Axial T1-weighted image with fat suppression after intrathecal gadolinium administration through same level much more clearly shows contrast material leaking along right C8 nerve root (arrowhead). In retrospect, there may be very subtle extradural contrast material seen in right neural foramen. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. The myelographic appearance of the leaks may vary, however, depending on the cause of the leak, rate of leakage, and imaging modality used. 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  or through the presence of unrecognized fistulas to the malformation; treatment of the malformation itself may be necessary. 8B —39-year-old woman with findings of high-flow CSF leak on conventional MRI. Images of patient in prone position obtained at 0.1, 1, 2, 5, and 24 hours are displayed. Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. Radionuclide cisternography using 111In–diethylene triamine pentaacetic acid (DTPA) is performed with lumbar intrathecal injection of approximately 0.5 mCi 111In-DTPA. Fig. 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. 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. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. 4A —30-year-old woman with high-flow CSF leak. Midline shift measures 20mm. CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. Spinal leakage of CSF causes almost all cases of spontaneous intracranial hypotension. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. In addition, leak localization can be important for treatment. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. 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]. 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. AJR Am J Roentgenol. C, Coronal CTM image shows close relationship of diverticulum (arrow) to exiting nerve root sleeve. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. LaFata V, et al. This was repaired using 4 inte… Link, Google Scholar; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER. ... 6.Associatd whitemater lesions could be explained by defective CSF absorption and transependymal seepage of CSF . 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. Fig. Unable to process the form. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. Fig. 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 , in the authors' experience, this concern is overstated and is almost never an issue in actual practice. Because imaging is generally performed in a delayed fashion after introduction of intrathecal contrast material, MR myelography using intrathecal gadolinium offers little additional information compared with CTM in cases of high-flow leaks. A, Axial CTM image shows epidural pooling of contrast material (arrowhead) due to high-flow CSF leak. Fig. Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. Focal dural thinning and dehiscence are common causes of spontaneous CSF leak. J Neurol Neursurg Fig. 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 . Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. 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. (2016) Journal of Neurosurgery. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. CSF motion is a combined effect of CSF production rate and Most patients with SIH, however, will not have any identifiable connective tissue disorder. 1986;147 (2): 331-7. Choroid plexus xanthogranulomas are benign lesions, usually located in lateral and third ventricles. Efforts to improve temporal resolution while maintaining the excellent cross-sectional visualization CT affords have led to several modifications of the CTM technique. However, simultaneous CSF leaks from multiple adjacent spinal nerve roots may uncommonly be encountered . 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'. 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. Image acquisition is stopped once a leak is seen. The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. Fig. The leak location is identified by the appearance of a fork or split in the column of flowing myelographic contrast material, with extraarachnoid contrast material continuing to flow downhill in a cranial direction. Department of Radiology, B Y L Nair Charitable Hospital and Topiwala National Medical College, Mumbai, Maharashtra, India ... subsequent slow seepage of CSF. 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). 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). Fig. A, Axial CT myelography image through C7–T1 level was not initially thought to show definite CSF leak. In most cases of SIH, CSF leakage originates from a single spinal level. 6B —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. For one, visualization of a leak on imaging is one criterion used to establish the diagnosis [1, 2]. Spontaneous intracranial hypotension (SIH) is an increasingly recognized disease caused in nearly all cases by spontaneous spinal CSF leaks. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. 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. CT myelography (CTM) is probably the most commonly used modality in investigating CSF leaks. Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man . Extensive leakage of CSF into epidural space is also seen. For example, if the diagnosis of SIH is not in doubt and a nontargeted epidural blood patch is planned as first-line therapy, myelography of any sort may be unnecessary. 3B —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. B, Coronal CTM image again shows diverticulum (arrow). AJNR Am J Neuroradiol 1987;8:155–156. 4B —30-year-old woman with high-flow CSF leak. Follow-up Clinical Information: Given the patient’s obesity, the size of the pseudomeningocele and partial dehiscence of the deep layers of the wound, operative management was elected rather than more conservative treatment. 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. Total CSF volume is 90–150 ml in adults and 10–60 ml in neonates. Most of the lesions are asymptomatic and incidentally found. A tiny arachnoid bleb was present extending into this dural rent. Fig. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. AJNR Am J Neuroradiol. Transependymal edema, also known as interstitial cerebral edema or periventricular lucency (PVL), is a type of cerebral edema that occurs with increased pressure within the cerebral ventricles. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed . 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. 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  (Fig. 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 . Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful . 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. 5). Fig. 2. 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. 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 . Biology and medicine. 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). Methods One hundred forty-nine patients with newly diagnosed CIS and MS were included in the retrospective study. Professor of Radiology and Pediatrics Director, Division of Nuclear Medicine October 2009. Fig. In this latter technique, contrast material is injected into the thecal sac as up to six serial CT acquisitions of the entire spine are obtained. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. 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 CSF leakage is slower, a focal leak may be detected without a large associated pool of epidural contrast material. 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. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. 7.Treatment include Diamox or repeated letting out CSF or shunting etc . 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