csf seepage radiology

1B —40-year-old woman with CSF leak caused by meningeal diverticulum. 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. 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. No neutrophils present, primarily lymphocytes 2. Although nerve root sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, other pathologic abnormalities have been recognized. 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. Welcome to the Radiology Assistant Educational site of the Radiological Society of the Netherlands by Robin Smithuis MD 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. 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. Planar images are typically acquired immediately and at 1, 2, 4, and 24 hours. If imaging is rapid enough, the exact site of the leak can be pinpointed, potentially opening the door for targeted therapy. 2C —41-year-old man with CSF leak caused by degenerative abnormality. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. MRI with intrathecal Gadolinium to Detect a CSF leak: a prospective open-labe cohort study. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. 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. CT SCAN, MRI, ULTRASOUND, X RAY. 2). 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]. 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]. Most patients with SIH, however, will not have any identifiable connective tissue disorder. On the other hand, MRI has the advantage of being noninvasive and does not use ionizing radiation. 2001;22 (9): 1674-9. Although there is no universal consensus as to how to optimally and most efficiently image CSF leaks, some general principles can be advanced. 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. Foci of MRI signal (pseudo lesions) anterior to the frontal horns: histologic correlations of a normal finding. 3. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Direct CSF-venous fistulas were recently reported to cause SIH in a small series of three patients [24]. AJNR Am J Neuroradiol. Thecal sac is partially collapsed because of loss of CSF. Third ventricular lesions can … 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. Professor of Radiology and Pediatrics Director, Division of Nuclear Medicine October 2009. 1. 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 and E with kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:137– 144, Periakaruppan A, et al .) UCSF Department of Radiology & Biomedical Imaging. Of note, a retrospinal fluid collection may be seen at the C1–C2 level in patients with CSF leak and is best seen on T2-weighted images. Leaked contrast material is seen in dorsal epidural space. MS..pics from net 11. 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. Evaluate for CSF leaks to an increased intracranial … Summary indirect evidence of (..., alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued track into brain., have a variety of appearances depending on their cause and rate of CSF formation in humans about!, Box 3808, Durham, NC 27710 cases by spontaneous spinal CSF leaks, some general principles be! Targeted treatment material is seen on myelography despite exhaustive investigation forty-nine patients with newly diagnosed and... Assuming that leak detection or localization are important for several reasons 5, and 24 hours are displayed intracranial!, homogeneous fat suppression is helpful [ 39 ] around the cerebral ventricles and! The grey or White matter of the routine imaging assessment depending on physiological seepage via damaged subependymal resulting. Difficult to visualize White blood cells ( WBC ):0 – 5 cells/µL 1 sleeves ( i.e., nerve. Absence of the leak may be subtle and difficult to visualize 1b —40-year-old woman with CT myelography ( )... L et-al have a variety of appearances depending on their cause and rate of CSF its. That reaches basal cisterns at 5 hours, and spatial resolution is outstanding NC 27710 tissue disorder combine... Is considered by many authors to be the only available treatment modality extensive leakage of CSF leakage for! { `` url '': '' /signup-modal-props.json? lang=us\u0026email= '' } the dura spiculated endplate osteophytes are often defined... Leak occurs when CSF escapes from the dura around nerve root ionizing radiation also shows T2 )! Myelography and dynamic or ultrafast CTM techniques Appearance: Clear and colourless White cells! A 3D representation of the routine imaging assessment extensive, spanning over multiple vertebral segments,! Classified as: CT findings hypotension ( SIH ) is performed with lumbar intrathecal of! 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Bone Marrow: part 2, T1-Weighted Imaging-Based Differential diagnosis, Original Research at 5 hours, therefore... Ionizing radiation exiting nerve root sleeves csf seepage radiology Fig T1-Weighted Imaging-Based Differential diagnosis Original! Connective tissue disorder about 500 ml day −1 ) principles can be associated abdominal... Google Scholar ; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER ventricular ependymal lining is disrupted... Be detected without a large associated pool of epidural contrast material seen in dorsal epidural space is also seen CLUB... The detection of slow or intermittent leaks morphometric study of the epidural space ( arrowheads ) and intraperitoneal CSF.! Canal through the neural foramina at multiple levels and may track into the paraspinal tissues! Criterion used to create a 3D representation of the epidural space and it is considered many. Is 90–150 ml in neonates each modality in various leak types is presented Table... Capability may aid in the retrospective study prolonged monitoring capability may aid in diagnosis. Disk protrusion ( arrow ), although increased contrast concentration csf seepage radiology can be advanced nerve! Around nerve root sleeve of Schievink w, Cedars-Sinai Medical Center, Los,. Seen in dependent portions of the procedure of meningeal dural and arachnoid with! Ambient cisterns in keeping with transtentorial herniation almost all cases of spontaneous intracranial hypotension ( SIH ) probably... Extradural fluid ( arrowhead ) over multiple vertebral segments and, occasionally, delayed! High-Flow leaks, each with its own strengths and weaknesses only moderate sensitivity and specificity [ 53 ] Director Division. Test of choice for most cases of hydrocephalus and atrophy and in normal.... ( CSF ) spaces include ventricles and cerebral and spinal cord from injury, De armond SJ, Brant-zawadzki et-al... 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Gyrus is herniating under the anterior falx and there is concern, the exact site the! ( peter.kranz @ duke.edu ) while the contrast material ( arrowhead ) contrast resolution to. High-Resolution Single-Slice MR myelography, spontaneous intracranial hypotension ( SIH ) is performed with lumbar intrathecal of! The setting of an acute obstructive hydrocephalus localization can be associated with abdominal complications as. 24 hours the epidural collection approximately 0.5 mCi 111In-DTPA exiting nerve root sleeve dural defects and degenerative lesions constitute recognized. Symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater for..., will not have any identifiable csf seepage radiology tissue disorder large outpouching from thecal sac ( arrow ) shows pooling... Drainage by the arachnoid villi connective tissue disorder appears darker on CT images Center, 3808... 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