[QxMD MEDLINE Link]. Fortschr Med. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. [4], CT cisternography or radionuclide cisternography may be useful if CT and MR cisternography do not show the CSF fistula. Akbar JJ, Luetmer PH, Schwartz KM, Hunt CH, Diehn FE, Eckel LJ. An Analysis of Patients Treated for Cerebrospinal Fluid Rhinorrhea in the United States from 2002 to 2010. Distinguishing blood due to a basilar skull fracture from cutaneous bleeding using the "halo sign" (applying a drop of blood to a filter paper looking for more rapidly diffusing cerebrospinal fluid surrounding the blood), is often cited but unreliable (3-5). (See images below.). Basal skull fracture should be considered in all patients with head injuries, especially those with physical signs such as otorrhea, Battle sign or periorbital ecchymoses.1 The halo or double-ring sign is a classic image in medicine and was taught as a method for determining whether bloody discharge from the ears or nose contained cerebrospinal fluid (CSF). 2016 Jan. 206 (1):8-19. All rights reserved. Spinal MRI findings are also potentially reversible after successful ablation of a CSF fistula. Adams AS, Francis DO, Russell PT. Radiol Clin North Am. MR cisternography is performed with heavily T2-weighted, fast spin-echo, fat-saturated sequences with thin sections and minimal or no gap. Bethesda, MD 20894, Web Policies Facial Fracture Management in the Emergency Department - Medscape From the Department of Emergency Medicine (Sunder), Royal Inland Hospital, Kamloops, BC; and the Department of Radiology (Tyler), Queens University, Kingston, Ont. Fast CSF leaks have rapid contrast diffusion and may not be localized to a 2-vertebral segment of the spinal canal (suitable for local treatment by extradural blood patch or alternate therapy) by routine postmyelogram CT spine scan. Lu X, Zhai X, Li H, Yang X, Hang W, Liu G. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. NSF/NFD is a debilitating and sometimes fatal disease. High-Resolution Computed Tomography as an Initial Diagnostic and Localization Tool in Patients with Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis. Radiology. The cerebral dural venous sinuses may be engorged. double ring sign: two concentric rings around the optic nerve characteristic of optic nerve hypoplasia. Li L, Gao FQ, Zhang B, Luo BN, Yang ZY, Zhao J. Overdosage of intrathecal gadolinium and neurological response. 28.10). Double ring sign (CSF leak) If ring sign test is positive, which drugs are restricted? C Douglas Phillips, MD, FACR Director of Head and Neck Imaging, Division of Neuroradiology, New York-Presbyterian Hospital; Professor of Radiology, Weill Cornell Medical College CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. 110(7):1166-72. Other local services are: Electrical . CSF rhinorrhoea: the place of endoscopic sinus surgery. However, most of the time physical examination is unrevealing, especially in patients with intermittent CSF rhinorrhea. Neurol India. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvODYxMTI2LW92ZXJ2aWV3. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). CSF Rhinorrhea: Practice Essentials, History Of The Procedure, Problem Laryngoscope Investig Otolaryngol. A 58-year-Old non-smoking woman with intractable cough and rhinorrhea. [Diagnostic value of computed tomographic cisternography and magnetic resonance hydrography in cerebrospinal fluid rhinorrhea]. eCollection 2023 Feb. A biopsy should never be obtained unless a complete imaging workup has been conducted. The fluid from his ear dripped onto the bedsheet, showing a halo pattern (Figure 1). Wolters Kluwer Health Nadieska Caballero, MD Fellow in Rhinology and Skull Base Surgery, Sinus and Nasal Institute of Florida Digital subtraction radiographic cisternography can be similarly performed with a spinal subarachnoid injection of nonionic iodinated contrast medium. Clin Nucl Med. Other common locations include the posterior fovea ethmoidalis and the posterior aspect of the frontal recess. 1992 Nov. 77(5):737-9. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. [QxMD MEDLINE Link]. We do not capture any email address. Please refer to Etiology for further details. Serum glucose, chloride, and total protein tests of the fluid are not specific or conclusive for CSF. Clinical images are chosen because they are particularly intriguing, classic or dramatic. Neuroradiology. Epub 2018 Sep 24. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. 1979 Oct 25;97(40):1814-20. 2022 Jan 18;84(1):17-23. doi: 10.1055/a-1722-4433. NSF/NFD has occurred in patients with moderate to end-stage renal disease who have been given a gadolinium-based contrast agent to enhance MRI or MRA scans. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. The ring sign: Is it a reliable indicator for cerebral spinal fluid? Several texts have suggested that CSF will separate from blood when the mixture is placed on filter paper or other media and will produce a clinically detectable sign, which has been referred to as a ring sign, double ring sign, or halo sign. Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. 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. Perform high-resolution, thin-section axial and coronal cranial and facial computed tomography (CT) scanning. Byrne JV, Ingram CE, MacVicar D, et al. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. Localization of the leak to the right or left nasal cavity may be difficult because of the tendency of the fluid to cross sides and flow from both nostrils. Please try after some time. 1997. All authors agreed on recommendations through an iterative process. Cerebrospinal fluid imaging. 2000 May. Intense extradural contrast enhancement is noted in congested epidural veins. Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. Elmorsy SM, Khafagy YW. Please enable it to take advantage of the complete set of features! [QxMD MEDLINE Link]. Otol Neurotol. Iatrogenic CSF rhinorrhea results from surgical disruption of the skull base and dura as previously discussed. The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow). The management of CSF rhinorrhea depends on the cause, location, and severity of the leak. Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane. MRI cisternography, and the localization of CSF fistulae. EM Board Bombs with Blake Briggs, MD, and Iltifat Husain, MD, The Physician Grind @ EMN with Zahir Basrai, MD, Current Procalcitonin Utilization and Publications, Procalcitonin: Risk Assessment in COVID-19 Bacterial Co-Infection. [30] The sensitivity for CSF leaks is in the range of 50-100%. Results: 2002 Dec. 51(6):1365-71; discussion 1371-2. CSF leaks will often resolve within seven days with very few complications, and no clear evidence supports antibiotic prophylaxis for these leaks in the first seven days. Royal College of Physicians and Surgeons of Canada, American Society of Functional Neuroradiology, American Society of Head and Neck Radiology. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. 2001 Aug. 43(8):622-7. AJNR Am J Neuroradiol. Immediate traumatic leaks result from a bony defect or fracture in conjunction with a dural tear. 8(4):433-7. These are infrequently associated with CSF rhinorrhea. 2017 Sep. 127 (9):2011-6. 2012 Mar. The sella turcica and sphenoid sinus are involved in 15% of the cases as well. 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. To study the development of a ring sign when blood is mixed with various fluids. Matsumura A, Anno I, Kimura H, Ishikawa E, Nose T. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. Brain Sci. Liquorrhea - an overview | ScienceDirect Topics 2017 Jan. 55 (1):167-187. The upper cervical epidural veins are congested. [QxMD MEDLINE Link]. 2018 Dec;38(4):1384-1392. doi: 10.1088/1361-6498/aae39b. Doublering sign in granulocyte colonystimulating factorinduced 1954 Jul;42(171):1-18. doi: 10.1002/bjs.18004217102. Some error has occurred while processing your request. Cerebral arteriography is not used in the diagnostic imaging workup to localize the site of a CSF leak. These nsignatures together form a ring signature on behalf of pk. Fast spin-echo T2-weighted coronal image of a patient with a spontaneous onset of cerebrospinal fluid rhinorrhea demonstrates an empty-sella configuration. [QxMD MEDLINE Link]. The pledgets are examined for green fluorescence in a dark room with ultraviolet light 6 hours after the intrathecal PSP injection. Dodson EE, Gross CW, Swerdloff JL, et al.