Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. It is produced in epithelial cells of the choroid plexus and meninges and is found in CSF, perilymph, seminal fluid, and urine. Diagnostic Nuclear Medicine. and transmitted securely. Axial CT image was obtained with the patient in the supine position. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair. [QxMD MEDLINE Link]. Kim DH, Kim SW, Han JS, Kim GJ, Basurrah MA, Hwang SH. CSF consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). Coronal fast spin-echo T2-weighted image demonstrates herniation of meninges and brain tissue (arrows) with adjacent cerebrospinal fluid into the postmastoidectomy tegmen tympani defect. Clinical Radiology. 34(7):410-6. Spinal radiological findings in nine patients with spontaneous intracranial hypotension. This sign appears when CSF mixes with blood on an absorbent surface, such as paper or bed sheets, and creates a double ring pattern. Various other authors, including Dohlman (1948), Hirsch (1952), and Hallberg (1964), subsequently reported successful repair of CSF rhinorrhea through different external approaches. The leak almost never recurs. Magnetic resonance myelogram in a patient with a brachial plexus injury and pseudomeningoceles (arrows). Ideally, the contrast medium is concentrated in the intracranial anterior and posterior skull base regions under fluoroscopic guidance by tilting the prone patient head downward on a fluoroscopic tilt table. [QxMD MEDLINE Link]. Computed tomography (CT) of the patients head showed, among other injuries, a transverse fracture of the petrous segment of his right temporal bone (Appendix 1, available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.120055/-/DC1). How . All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. Oakley GM, Alt JA, Schlosser RJ, Harvey RJ, Orlandi RR. [QxMD MEDLINE Link]. The classical ring signatures [37] for a set of npublic keys pk are constructed by computing n 1 \pseudo-signatures" (the outputs computed from the veri cation function) sequentially in a ring structure rst and then using one signer secret key to create a real signature. Drops of fluid from a CSF leak placed on absorbent filter paper may result in the double-ring sign, a central circle of blood and an outer clear ring of CSF. 2022 Jan 18;84(1):17-23. doi: 10.1055/a-1722-4433. The enzyme B2Tr is produced in the brain by neuraminidase activity and is present in CSF, perilymph, and ocular aqueous humor but not in sinonasal mucous secretions and tears. Careers. 2 transferrin is specific for CSF (absent in nasal discharge) Olfactory slit - cribriform plate of Ethmoid Bone (most common site)In traumatic CSF leak, CSF and blood are mixed - double ring sign or target sign; Immediate Management - Antibiotics and Observation Persistent Case Treated surgically by nasal endoscopy or intracranial route Occasionally, a stream of contrast medium is demonstrated at the fistula site. 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). 2016 Jan. 206 (1):8-19. Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons Cochrane Database Syst Rev. Dr. Kaplan responds: Thank you so much for your thoughtful reply to my article. A 58-year-Old non-smoking woman with intractable cough and rhinorrhea. An official website of the United States government. Eljamel MS, Pidgeon CN, Toland J, et al. J Neurol Neurosurg Psychiatry. ( Cochrane Database Syst Rev. The ring sign: Is it a reliable indicator for cerebral spinal fluid? In spontaneous intracranial hypotension syndrome (SIHS), brain MRI shows thickening and contrast enhancement in the cranial pachymeninges. Neurosurgery. From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. Other proposed mechanisms for nontraumatic CSF leaks include focal atrophy, rupture of arachnoid projections that accompany the fibers of the olfactory nerve, and persistence of an embryonic olfactory lumen. 2002 Dec. 51(6):1365-71; discussion 1371-2. Perform high-resolution, thin-section axial and coronal cranial and facial computed tomography (CT) scanning. The cerebral ventricles may be reduced in size, and the pituitary gland may appear enlarged. [QxMD MEDLINE Link]. This site needs JavaScript to work properly. The localization of one or multiple leaks can make possible and facilitate therapeutic CT-guided epidural blood patching. Results: The type of filter paper did not affect the development of a ring. 2020 Feb 28. Drainage may be intermittent as the fluid accumulates in one of the paranasal sinuses and drains externally with changes in head position (ie, reservoir sign). Share cases and questions with Physicians on Medscape consult. The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%). Clinical images are chosen because they are particularly intriguing, classic or dramatic. Lippincott Williams and Wilkins, Philadelphia 2000; Otolaryngol Clin North Am. doi: 10.1371/journal.pntd.0004516. Radionuclide cisternography is performed by administering a lumbar subarachnoid intrathecal injection of Indium-111 (111In) diethylenetriamine pentaacetic acid (DTPA) in a 500 Ci dose. Blood alone does not produce a ring. [7], Brain and spinal MRI is useful in demonstrating meningocele and meningoencephalocele when associated with CSF leak, as well as for examining patients with spontaneous intracranial hypotension syndrome. This patient had cerebrospinal fluid otorrhea after mastoidectomy. The leakage stops within 1 week in 70% of patients, within 3 months in 20-30%, and within 6 months in most patients. 4th ed. MR cisternography may demonstrate inactive CSF fistulas. Am J Rhinol Allergy. This can lead to dural tears in areas of abnormalities of the bony floor. Blood-tinged fluid can be placed on filter paper to look for a double ring sign of CSF around blood, but this is not a reliable test. These nsignatures together form a ring signature on behalf of pk. [QxMD MEDLINE Link]. Unable to load your collection due to an error, Unable to load your delegates due to an error. You may be trying to access this site from a secured browser on the server. Rarely, the leak can originate in the middle or posterior cranial fossa and can reach the nasal cavity by way of the middle ear and eustachian tube. [QxMD MEDLINE Link]. Other stresses include Valsalva-like maneuvers during nose blowing or straining. Cerebrospinal fluid (CSF) leaks are generally classified as traumatic, iatrogenic, and spontaneous/idiopathic. The underlying defect responsible for cerebrospinal fluid (CSF) leaks, regardless of the etiology, is the same: disruption in the arachnoid and dura mater coupled with an osseous defect and a CSF pressure gradient that is continuously or intermittently greater than the tensile strength of the disrupted tissue. Marshall AH, Jones NS, Robertson IJ. Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. [Full Text]. 1969 Apr. Disclaimer. A large defect is noted, and the meningocele has been resected. CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. CSF is colorless, clear, and typically devoid of cells such as polymorphonuclear cells and mononuclear cells (< 5/L). ), She stated that the cerebrospinal fluid (CSF) double ring sign raises concern about a CSF leak. Please enable it to take advantage of the complete set of features! Radiol Clin North Am. 2011 May. The investigators suggested that intracranial hypertension may put patients at risk for developing these defects. 1993:22[4]:718.) [1] The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. This article discusses current concepts in the etiology, diagnosis, and treatment of CSF rhinorrhea, as well as long-term management of patients following successful treatment. If persistent fluid drainage occurs after a fracture, the fluid may be evaluated to test for the presence of CSF. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New ZealandDisclosure: Nothing to disclose. ISSN 1488-2329 (e) 0820-3946 (p). 2017 Oct. 2 (5):215-24. Clin Neurol Neurosurg. At any given time, approximately 90-150 mL of CSF is circulating throughout the CNS. PMC 2007 Oct. 24(10):1570-5. Specialties: When you call one of our electricians, you can rest assured that we will provide professional, honest, and effective electrical services and repair for your home or property. double-ring sign (Figure 1B). This occurred on bed linen, filter paper, absorbent paper, and coffee filters. Minimalist Double Finger Ring Double Band Ring 9K Gold Two Finger Band Ring Diamond Dainty Ring Abstract Geometric Knuckle Ring Gift for Her 5 out of 5 stars (17) $ 139.21. Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management. MR cisternography and myelography can accurately localize CSF leaks in the cranium and spine. J Neurotrauma. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzM4OTg5LW92ZXJ2aWV3. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. The fluid can be placed on filter paper and a "halo" or double ring may be seen. Paradoxical rhinorrhea occurs when midline structures that act as separating barriers (eg, crista galli, vomer) are dislocated. Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow). Royal College of Physicians and Surgeons of Canada, American Society of Functional Neuroradiology, American Society of Head and Neck Radiology. 2012 Mar. Clipboard, Search History, and several other advanced features are temporarily unavailable. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. HHS Vulnerability Disclosure, Help There may be apparent downward displacement of the optic chiasm. Ray BS, Bergland RM. [5]. Adv Med Sci. In most cases, the patient will have been discharged when the leak presents itself. Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience. C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North AmericaDisclosure: Nothing to disclose. If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). Herniation of the inferior frontal gyrus may occur in frontal head injuries or in ethmoid developmental defects of the cribriform plate. CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. Nadieska Caballero, MD Fellow in Rhinology and Skull Base Surgery, Sinus and Nasal Institute of Florida Although the value of this sign has been debated, an experiment showed that the sign was consistently visible when CSF concentrations were 30%-90% when mixed with blood. This coronal magnetic resonance cisternogram demonstrates a left-sided cerebrospinal fluid leak through the cribriform plate (small arrows), which was clinically suspected. Beta2-transferrin assay is currently single best laboratory test for identifying the presence of CSF in sinonasal fluid. 33(3):535-40. In most cases of iatrogenic injury presenting in a delayed fashion, surgical repair is necessary. When trauma is the cause, the interval between trauma and the onset of the leak is important. Wolters Kluwer Health, Inc. and/or its subsidiaries. Multiple studies demonstrate a 90-95% success rate with closure of skull base defects using the endoscopic approach. ), 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 ofspontaneous intracranial hypotension (SIH). to maintaining your privacy and will not share your personal information without [5], Perform magnetic resonance (MR) cisternography. (See images below.). [QxMD MEDLINE Link]. A brief explanation (250 words maximum) of the educational significance of the images with minimal references is required. Dandy is credited with the first surgical repair of a CSF leak via a frontal craniotomy approach in 1926. This finding is consistent with a meningoencephalocele of the temporal bone. Also, it serves as nutrient delivery and waste removal system for the brain. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. I absolutely agree that not having a double ring sign does not exclude a CSF leak. Obstructive sleep apnea in patients undergoing endoscopic surgical repair of cerebrospinal fluid rhinorrhea. [QxMD MEDLINE Link]. Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. DeConde AS, Suh JD, Ramakrishnan VR. Each patient subsequently underwent a procedure for an epidural blood patch, and all patients experienced symptomatic relief. Unauthorized use of these marks is strictly prohibited. This patient presented with a spontaneous onset of cerebrospinal fluid rhinorrhea 10 years after a head injury. J Neurol Surg B Skull Base. doi: 10.1136/bcr-2016-218995. After transfer, a bloody discharge was noted from his right external auditory canal, and the right tympanic membrane was perforated. In radiology, the halo sign is a finding of a dark halo around the arterial lumen on ultrasound that suggests the diagnosis of temporal arteritis. AJNR Am J Neuroradiol. This finding is suggestive of a site of cerebrospinal fluid leak. On occasion, the patient has a history of headache relieved by drainage of CSF. Laryngoscope. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. [QxMD MEDLINE Link]. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. G-CSF-induced vasculitis has been reported to occur in 0.47% of patients. 2011 Apr. Br J Surg. [QxMD MEDLINE Link]. Kranz PG, Gray L, Taylor JN. A 27-year-old male driver in a single-vehicle rollover collision was transferred to a trauma centre after stabilization and endotracheal intubation at a community hospital. The fluid from his ear dripped onto the bedsheet, showing a halo pattern (Figure 1). High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. Would you like email updates of new search results? FOIA The fistula detection rate is lowest for intermittent CSF leaks. Axial magnetic resonance cisternogram demonstrates the connection of the meningocele to the middle cranial fossa (arrows). [11] In contrast to unilateral rhinorrhea, bilateral rhinorrhea gives no clue of the laterality of the defect. [QxMD MEDLINE Link]. 2006; [1]:CD004884.) Traumatic cerebrospinal fluid leak. 2017 Oct. 13 (2):63-67. and transmitted securely. L Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. -2 transferrin is a protein found in CSF, but not in serum, nasal secretions, or adjacent tissue. (Ann Emerg Med. The brain is noted to sink downward in the cranium with development of a pseudo-Chiari I malformation. Cerebrospinal fluid (CSF) rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality for the patient. 28.10). Despite the multifactorial causes of elevated ICP, once this problem ensues, the pressure exerted on areas of the anterior skull base such as the lateral lamella of the cribriform or lateral recess of the sphenoid sinus results in bone remodeling and thinning. 2022 Dec 8;12(12):1685. doi: 10.3390/brainsci12121685. Jinkins JR, Rudwan M, Krumina G, Tali ET. Unable to load your collection due to an error, Unable to load your delegates due to an error. BMJ Case Rep. 2017 Apr 22;2017:bcr2016218995. In patients with nonsurgical trauma, waiting a period of 5-7 days to allow conservative measures (bed rest, stool softeners, and lumbar drainage) to assist with secondary closure of the traumatic defect is reasonable. [31] Cotton pledgets labeled for the placement site are positioned in the nose before the lumbar subarachnoid space injection of the isotope. [QxMD MEDLINE Link]. Physical examination should include complete rhinologic (including endoscopic), otologic, head and neck, and neurologic evaluations. The entire spine is scanned up to 24 hours in cases of spontaneous intracranial hypotension, spinal trauma, or postoperative CSF leaks. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. Thomas DL, Menda Y, Graham MM. Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. 93(6):E14-9. The patient had no Battle sign (i.e., bruising over the mastoid process). CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. Gubbels SP, Selden NR, Delashaw JB Jr, McMenomey SO. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. There are several causes of elevated ICP; however, the proposed mechanism underlying spontaneous CSF rhinorrhea is idiopathic intracranial hypertension (IIH). Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea. All of these changes are reversible with ablation of the cause of CSF leak, which is usually in the spine. The resulting communication with the central nervous system (CNS) can result in a multitude of infectious complications that impart significant morbidity and potentially disastrous long-term deficits for the patient.