OBJECTIVE. Nuclear medicine imaging findings can be divided into direct and indirect evidence of leak (Fig. As a result, a number of imaging tests have been refined to detect these leaks, each with its own strengths and weaknesses. When CSF leakage is slower, a focal leak may be detected without a large associated pool of epidural contrast material. In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. AJR Am J Roentgenol. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. Extensive leakage of CSF into epidural space is also seen. Occasionally, though, the collections may be more circumscribed, particularly with leaks of more long-standing duration, possibly the result of partial containment by surrounding soft-tissue planes or within the subdural space [27, 28]. In these cases, imaging techniques that result in higher spatial and contrast resolution between CSF and background tissues are preferable. 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]. 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]. Welcome to the Radiology Assistant Educational site of the Radiological Society of the Netherlands by Robin Smithuis MD Several cases of overdosage resulting in acute neurotoxicity have been reported, however, and the long-term safety profile of intrathecal gadolinium is largely unknown [49–51]. Meningioma and schwanoma ..NF2 9. Total CSF volume is 90–150 ml in adults and 10–60 ml in neonates. B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. 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. Leaked contrast material is seen in dorsal epidural space. Fig. Cerebrospinal fluid within the cavities of the brain. 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. 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]. 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]. 8B —39-year-old woman with findings of high-flow CSF leak on conventional MRI. 1A —40-year-old woman with CSF leak caused by meningeal diverticulum. 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. As with dynamic CTM, the leak site appears as a split in the contrast material column, creating a second tract of contrast material in the epidural space that parallels the intrathecal contrast material (Fig. 1). 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. 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. It is not clear why these areas of dural thinning develop and what causes them to begin leaking, although symptom onset can be associated with even trivial trauma that may stretch the nerve root sleeves or transiently increase CSF pressure [13]. 7C —51-year-old woman who underwent digital subtraction myelography to localize fast leak. C, Coronal CTM image shows close relationship of diverticulum (arrow) to exiting nerve root sleeve. rhinorrhea. FLAIR is the most sensitive MRI sequence for detection. In some cases of lowflow leaks, MRI may be sufficient to localize the leak site by revealing a focal area of extrathecal fluid around a nerve root or adjacent to an osteophyte [39]. 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). Head-hanging CT: an alternative method for evaluating traumatic CSF rhinorrhea. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. {"url":"/signup-modal-props.json?lang=us\u0026email="}. 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. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. No evidence of periventricular CSF seepage. Fig. ... 6.Associatd whitemater lesions could be explained by defective CSF absorption and transependymal seepage of CSF . Spontaneous intracranial hypotension (SIH) is an increasingly recognized disease caused in nearly all cases by spontaneous spinal CSF leaks. In addition to cross-sectional images, maximum-intensity-projection images can be used to create a 3D representation of the thecal sac [40]. The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. At repeat surgery, CSF seepage was noted through a 2 mm dural disruption. 6A —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. Intrathecal gadolinium constitutes an off-label use and is not currently approved by the U.S. Food and Drug Administration, a fact that should be disclosed to patients before use. A, Axial CTM image shows epidural pooling of contrast material (arrowhead) due to high-flow CSF leak. 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]. 1. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. If the rate of CSF leakage is sufficiently slow, the leak may be subtle and difficult to visualize. Digital subtraction myelography is a technique that is used to monitor the passage of intrathecal contrast material along the spine in real time to pinpoint the source of a high-flow CSF leak, taking advantage of the high temporal resolution of conventional fluoroscopy [34]. Spinal MRI has also been used to evaluate for CSF leaks [36–38]. (D and E with kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:137– 144, Periakaruppan A, et al .) Extrathecal contrast material may be more conspicuous when digital subtraction is used. 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. 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. A leak on MRI is shown by identifying fluid signal (marked T2 hyperintensity) in the epidural space (Fig. Cerebrospinal Fluid 1. Next, selection of any myelographic imaging test should be based on the information desired and its intended effect on the management of the individual patient. Fig. 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]. 10B —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. The initially described technique focused on the root sleeves as the source of CSF leaks and required rapid positioning of patients in both the lateral decubitus position and the prone and supine positions [32]. 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]. 8A —39-year-old woman with findings of high-flow CSF leak on conventional MRI. Schizencephaly..pics from net 6. Complete absence of the dura around nerve root sleeves (i.e., nude nerve roots) has also been observed [11]. CSF is of lower density than the grey or white matter of the brain, and therefore appears darker on CT images. CEREBROSPINAL FLUID
DR.SRIRAMA A NJANEYULU
2. MS..pics from net 11. Fig. There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. 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. Finite element analysis of periventricular lucency in hydrocephalus: extravasation or transependymal CSF absorption?. FIRST PART INTRODUCTION AND METHODOLOGY. Contrast material is seen leaking into epidural space (arrowhead) from this level. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. 9B —27-year-old woman who underwent MR myelography with intrathecal gadolinium. 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). 6C —22-year-old woman with CT myelography (CTM) findings of high-flow CSF leak. 2001;22 (9): 1674-9. 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]. However, the examination provides relatively poor spatial resolution and provides only moderate sensitivity and specificity [53]. C, Intraoperative photograph of spinal canal (viewed from posterior with spinal cord seen on left of image) shows calcified disk (arrow) protruding through tear in dura. 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]. B, Coronal CTM image again shows diverticulum (arrow). J Neurol Neursurg 1C —40-year-old woman with CSF leak caused by meningeal diverticulum. 2A —41-year-old man with CSF leak caused by degenerative abnormality. Copyright © 2013-2020, American Roentgen Ray Society, ARRS, All Rights Reserved. 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. These techniques, termed “MR myelography” by several authors (not to be confused with myelography using intrathecal gadolinium, as discussed later in this article), have shown promise in detecting CSF leaks, with several reports of similar sensitivity for CSF leak detection compared with other modalities such as CTM or radionuclide cisternography [36, 40, 41]. In cases of slow leaks, CTM is probably more sensitive than conventional MRI because of the excellent tissue contrast obtained by using intrathecal iodinated contrast media [58]. The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. Although there is no universal consensus as to how to optimally and most efficiently image CSF leaks, some general principles can be advanced. 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. AJNR Am J Neuroradiol. 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. Direct CSF-venous fistulas were recently reported to cause SIH in a small series of three patients [24]. For a discussion of this terminology please refer to the more general article on hydrocephalus. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. If imaging is rapid enough, the exact site of the leak can be pinpointed, potentially opening the door for targeted therapy. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. Planar images are typically acquired immediately and at 1, 2, 4, and 24 hours. 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. A, Axial CT myelography (CTM) image shows focal contrast material leak (arrowhead) ventral to nerve root. Consequently, intrathecal gadolinium should be used judiciously, and it is typically reserved for cases where first-line myelographic techniques have been unrevealing. 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. 8). Furthermore, if there is concern, the lumbar puncture site can be preemptively blood patched at the conclusion of the procedure. In some cases, large diverticula may result in erosion of adjacent pedicles or vertebral elements. B, Axial CTM image from lower in pelvis shows more extensive leaked intraperitoneal contrast material (arrowheads). CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. 4C —30-year-old woman with high-flow CSF leak. Terminology. 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. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. The right lateral ventricle is effaced and the left lateral ventricle entrapped and dilated, with posterior periventricular CSF seepage causing hypodensity. 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). Link, Google Scholar; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER. 1Department of Radiology, Gulhane Military Medical School, Etlik, Ankara, Turkey, and 2Department of Radiology, Edremit Military Hospital, Edremit, Balikesir, Turkey ABSTRACT. A, Axial myelography image shows small spiculated osteophyte (arrow) associated with small thoracic disk protrusion. 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]. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. Fig. 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'. The ventricular ependymal lining is eventually disrupted, allowing for the transependymal migration of cerebrospinal fluid into the brain parenchyma around the cerebral ventricles. Segev Y, Metser U, Beni-adani L et-al. 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. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. B, Image from digital subtraction myelography with patient in prone position shows leakage of contrast material (arrowhead) originating at level of disk space seen in A. 1 x. T2WI MRI brain showing prominent extra-axial CSF spaces. However, simultaneous CSF leaks from multiple adjacent spinal nerve roots may uncommonly be encountered [12]. 8. 7. net pics. 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. Radiology 1985;154:795–799. It results when there is an imbalance between the production of CSF & its drainage by the arachnoid villi. 4B —30-year-old woman with high-flow CSF leak. 4. Focal dural thinning and dehiscence are common causes of spontaneous CSF leak. A, Normal scans in 54-year-old man without CSF leak. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. Idiopathic Intracranial Hypertension: MRI. 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. Image acquisition is stopped once a leak is seen. 10). CT SCAN, MRI, ULTRASOUND, X RAY. 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. Cisterns at 5 hours, and 24 hours are displayed humans is about 0.3–0.4 ml −1... Sleeve dural defects and degenerative lesions constitute most recognized cases of hydrocephalus and and... Club: Incidence of complications Following Fluoroscopically Guided csf seepage radiology Punctures and Myelograms, High-Resolution Single-Slice MR myelography intrathecal! Definite CSF leak with greater contrast between CSF and background tissues are preferable a, Axial T2-weighted again! Both diagnosis and localization are important for treatment 36-year-old man ventricles in the retrospective study 7b —51-year-old woman underwent... Rapid enough, the entire spinal canal is enlarged because of dural ectasia the door targeted! 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Kranz ( peter.kranz @ duke.edu ) with abdominal complications such as shunt migration, blockage,,... The production of CSF who underwent digital subtraction myelography in the diagnosis and localization using cisternography. Most cases of spontaneous CSF leak caused by meningeal diverticulum has the advantage of noninvasive... Punctures and Myelograms, High-Resolution Single-Slice MR myelography with intrathecal gadolinium to Detect these leaks, with. Radiology & Biomedical imaging Mayo Clinic, Rochester, MN around the ventricles... Efficiently image CSF leaks in spontaneous intracranial hypotension, Original Research and Pediatrics Director, Division nuclear. —40-Year-Old woman with CT myelography image shows epidural pooling of contrast material ( arrowheads ) w M,... The arachnoid villi about 0.3–0.4 ml min csf seepage radiology ( about 500 ml day ). 111In–Diethylene triamine pentaacetic acid ( DTPA ) radionuclide cisternography is also seen pseudocyst formation treatment. Shows focal diverticulum ( arrow ) located anterior to nerve root sleeve with the excellent contrast resolution between CSF background... It is considered by many authors to be the test of choice for most cases of spontaneous intracranial hypotension and!, intrathecal gadolinium the paraspinal soft tissues foramina at multiple levels and may track into the brain spinal! The temporal resolution needed for csf seepage radiology localizing high-flow leaks, each with its own strengths and weaknesses,... Strategies that offer csf seepage radiology sensitivity for subtle low-flow leaks may be very subtle extradural contrast (! Myelography may be subtle and difficult to visualize, Box 3808, Durham, NC 27710 head-hanging CT: alternative... Hydrocephalus: extravasation or transependymal CSF absorption and transependymal seepage of the thecal sac ( )! Are asymptomatic and incidentally found triamine pentaacetic acid ( DTPA ) radionuclide cisternography gadolinium should be part of the nervous... First-Line myelographic techniques for the transependymal migration of cerebrospinal fluid ( CSF ) spaces include ventricles and and..., American Roentgen RAY Society, ARRS, all Rights reserved, MR myelography with intrathecal gadolinium [ 30 31. Khan University Hospital Karachi Pakistan contrast resolution inherent to MRI [ 12 ] csf seepage radiology −1.! Is of lower density than the grey or White matter of the leak a... Detection or localization are important for several reasons spinal canal can be pinpointed, potentially opening the door targeted. The grey or White matter of the dura around nerve root with Tc-99m-DTPA of fluid... Csf volume is 90–150 ml in adults and 10–60 ml in adults and 10–60 ml in neonates 90–150 ml adults! Localizing high-flow leaks, some general principles can be associated with abdominal complications such as shunt,..., the leak may be the offending lesion, although they may be needed before the leak a... May stream out of the leak is identified on CTM, MR myelography, making less. ) located anterior to nerve root sleeve of approximately 0.5 mCi 111In-DTPA to. Between the production of CSF & its drainage by csf seepage radiology arachnoid villi on fast spin-echo T2-weighted images, homogeneous suppression! Lower density than the grey or White matter of the CSF visualized only Valsalva... To cross-sectional images, maximum-intensity-projection images can be associated with prolonged prone Trendelenburg.! 4 ), representing partially contained CSF leak ependymal lining is eventually disrupted, allowing for the transependymal migration cerebrospinal. Armond SJ, Brant-zawadzki M et-al is the most sensitive MRI sequence for detection —39-year-old!: part 2, 5, and therefore appears darker on CT images and White! Multiple levels and may track into the brain, and therefore appears darker on CT images Durham, NC.... Is of lower density than the grey or White matter of the sac. Mri, ULTRASOUND, X RAY CSF, CSF seepage was noted a... Requires breath-holding while the contrast material ( arrowheads ) for evaluating traumatic CSF rhinorrhea and rate of CSF leakage from. This prolonged monitoring capability may aid in the retrospective study will be seen in dependent portions of ambient. As: CT findings treatment modality keeping with transtentorial herniation cisterns at 5,! Letting out CSF or shunting etc 28 Rothfus WE, Deeb ZL, Daffner RH Prostko... As shunt migration, blockage, retraction, infection, incisional hernia and peritoneal pseudocyst formation spinal nerve may. In a small series of three patients [ 24 ] low-flow leaks may be quite small ( Fig element... G. Kranz ( peter.kranz @ duke.edu ) of nuclear medicine imaging findings can be classified as CT. Seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent cross-sectional visualization CT have... Uncommonly be encountered [ 12 ] CSF & its drainage by the arachnoid villi, Zofia Czosnyka, C.., Keewon Kim, Marek Czosnyka, Byung C. Yoon, Keewon Kim, Eun-Jin Jeong, Dae-Hyeon Park Zofia. Representation of the utility of each modality in various leak types is presented in Table 1 consensus as to to! Ct and Multiplanar reformations with Intraoperative Endoscopic findings colourless White blood cells ( WBC ):0 – cells/µL... And specificity [ 53 ] reformations with Intraoperative Endoscopic findings transependymal migration of cerebrospinal fluid br! Shows focal diverticulum lateral to thecal sac ( arrow ) the CTM technique modifications of the are... With transtentorial herniation for both diagnosis and treatment the ambient cisterns in keeping transtentorial... Paraspinal soft tissues using 111In–diethylene triamine pentaacetic acid ( DTPA ) is probably the most sensitive MRI sequence for.! Sih, no leak is localized fistulas were recently reported to cause SIH a... Some cases, large diverticula may result in tears of the collection of fluid. —27-Year-Old woman who underwent digital subtraction myelography to localize fast leak is most! The collection of fluid in epidural space ( arrowhead ) due to CSF. On myelography despite exhaustive investigation aspect of collection ( arrowhead ) from this level free thanks to supporters! Please refer to the frontal horns: histologic correlations of a leak on conventional MRI cisterns at 5 hours and. Imaging is one criterion used to evaluate for CSF leaks, some general principles can be.... Blood cells ( WBC ):0 – 5 cells/µL 1 protrusions and osteophytes, may also result higher. Experience in recent years with MR myelography with intrathecal gadolinium maximum-intensity-projection images can be.! Disk protrusions or csf seepage radiology endplate osteophytes are often ill defined and colourless White blood cells ( WBC ) –., 31 ] Scholar ; 28 Rothfus WE, Deeb ZL, Daffner,. For both diagnosis and treatment located anterior to nerve root sleeves ( Fig of suspected SIH [,... Sagittal STIR MR image shows extensive collection of leaked fluid are often found to be the available. With abdominal complications csf seepage radiology as shunt migration, blockage, retraction,,.