Evaluation of CSF leaks: high-resolution CT compared with contrast-enhanced CT and radionuclide cisternography.
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BACKGROUND AND PURPOSE: Radiologic evaluation of CSF leaks is a diagnostic challenge that often involves multiple imaging studies with the associated expense and patient discomfort. We evaluated the use of screening noncontrast high-resolution CT in identifying the presence and site of CSF rhinorrhea and otorrhea and compared it with contrast-enhanced CT cisternography and radionuclide cisternography. METHODS: We retrospectively reviewed the imaging studies and medical records of all patients who were evaluated for CSF leak during a 7-year period. Forty-two patients with rhinorrhea and/or otorrhea underwent high-resolution CT of the face or temporal bone and then had CT cisternography and radionuclide cisternography via lumbar puncture. The results of the three studies were compared and correlated with the surgical findings in 21 patients. RESULTS: High-resolution CT showed bone defects in 30 of 42 patients (71%) with CSF leak. High-resolution, radionuclide cisternography and CT cisternography did not show bone defects or CSF leak for 12 patients (29%) who had clinical evidence of CSF leak. Among the 30 patients with bone defects, 20 (66%) had positive results of their radionuclide cisternography and/or CT cisternography. For the 21 patients who underwent surgical exploration and repair, intraoperative findings correlated with the defects revealed by high-resolution CT in all cases. High-resolution CT identified significantly more patients with CSF leak than did radionuclide cisternography and CT cisternography, with a moderate degree of agreement. CONCLUSION: Noncontrast high-resolution CT showed a defect in 70% of the patients with CSF leak. No radionuclide cisternography or CT cisternography study produced positive results without previous visualization of a defect on high-resolution CT. CT cisternography and radionuclide cisternography may be reserved for patients in whom initial high-resolution CT does not identify a bone defect or for patients with multiple fractures or postoperative defects. (+info)
Spontaneous cerebrospinal fluid leakage detected by magnetic resonance cisternography--case report.
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A 49-year-old male with no history of head trauma suffered cerebrospinal fluid (CSF) discharge from the left nostril for one month. Coronal computed tomography (CT) showed lateral extension of the sphenoid sinus on both sides and CSF collection on the left side. CT cisternography could not identify the site of CSF leakage. Heavily T2-weighted magnetic resonance (MR) imaging (MR cisternography) in the coronal plane clearly delineated a fistulous tract through the sphenoid bone into the sphenoid sinus. Patch graft with muscle fragment completely relieved the CSF rhinorrhea. Postoperative three-dimensional CT showed the two bone defects identified during surgery. Small bony dehiscences in the sphenoid bone and lateral extension of the sphenoid sinus predisposed the present patient to CSF fistula formation. MR cisternography in the coronal and sagittal planes is superior to CT scanning or CT cisternography for detection of the site of active CSF leakage. (+info)
CSF rhinorrhoea from unusual site : report of two cases.
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CSF rhinorrhoea is associated with high morbidity and mortality. Bone and dural defects may result from trauma or enlarging 'pitholes' or breach in lateral recess of sphenoid sinus. Unless surgically corrected, they tend to cause meningitis and rhinorrhoea. Unusually delayed rhinorrhoea is a diagnostic problem. (+info)
A retrospective analysis of spontaneous sphenoid sinus fistula: MR and CT findings.
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BACKGROUND AND PURPOSE: The sphenoid sinus is rarely implicated as a site of spontaneous CSF fistula. We undertook this study to evaluate the potential etiopathogenesis of spontaneous CSF fistula involving the sphenoid sinus and to review the imaging findings. METHODS: We retrospectively reviewed the imaging findings of 145 cases of CSF fistula from our departmental archives (August 1995 through August 1998). Fifteen (10%) patients had CSF fistulas involving the sphenoid sinus. Eleven (7%) patients had spontaneous CSF fistulas, whereas in four patients, the CSF fistulas in the sphenoid sinus were related to trauma. Of the 11 patients, nine underwent only plain high-resolution CT and MR cisternography. One patient additionally underwent contrast-enhanced CT cisternography, and one other patient underwent MR cisternography only. For each patient, the CSF fistula site was surgically confirmed. The MR imaging technique included T1-weighted and fast spin-echo T2-weighted 3-mm-thick coronal sequences obtained with the patient in the supine position. The plain high-resolution CT study included 3-mm-thick, and sometimes 1- to 1.5-mm-thick, coronal sections obtained with the patient in the prone position. Similar sections were obtained after injecting nonionic contrast material intrathecally via lumbar puncture for the CT cisternographic study. We evaluated each of the 11 patients for the exact site of CSF leak in the sphenoid sinus. We also determined the presence of pneumatization of lateral recess of the sphenoid sinus, orientation of the lateral wall of the sphenoid sinus, presence of arachnoid pits, presence of brain tissue herniation, and presence of empty sella in each of these patients. RESULTS: The exact sites of the CSF fistulas were documented for all 11 patients by using plain high-resolution CT, MR cisternography, or CT cisternography. In nine (82%) patients, the sites of the CSF fistulas were at the junction of the anterior portion of the lateral wall of the sphenoid sinus and the floor of the middle cranial fossa. In the remaining two (18%) patients, the sites of the CSF fistulas were along the midportion of the lateral wall of the sphenoid sinus. Of these 11 patients, one had bilateral sites of the CSF fistula at the junction of the anterior portion of the lateral wall of the sphenoid sinus with the floor of the middle cranial fossa. In nine (82%) patients, the presence of brain tissue herniation was revealed, and this finding was best shown by MR cisternography. Ten (91%) patients had extensive pneumatization of the lateral recess of the sphenoid sinus, with an equal number having outward concave orientation of the inferior portion of the lateral wall of the sphenoid sinus. In seven (63%) patients, the presence of arachnoid pits, predominantly along the anteromedial aspect of the middle cranial fossa, was shown. In seven (63%) patients, empty sella was shown. For comparison, we reviewed the CT studies of the paranasal sinuses in 100 age-matched control subjects from a normal population. Twenty-three had extensive lateral pneumatization of the sphenoid sinus along with outward concavity of the inferior portion of the lateral wall. None of these 23 patients had arachnoid pits. CONCLUSION: The sphenoid sinus, when implicated as a site of spontaneous CSF leak, yields a multitude of imaging findings. These are extensive pneumatization of the lateral recess of the sphenoid sinus, outward concave orientation of the inferior portion of the lateral wall of the sphenoid sinus, arachnoid pits, and empty sella. Considering the normative data, we speculate that this constellation of findings could play a role in the etiopathogenesis of spontaneous sphenoid sinus fistulas. Our findings also show the efficacy of noninvasive imaging techniques, such as plain high-resolution CT and MR cisternography, in the evaluation of sphenoid sinus CSF leak. Our data also suggest that spontaneous sphenoid sinus CSF leak is not an uncommon occurrenc (+info)
Delayed cerebrospinal fluid rhinorrhea seven months after transsphenoidal surgery for pituitary adenoma--case report.
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A 51-year-old female had undergone transsphenoidal surgery for pituitary adenoma producing growth hormone. Cerebrospinal fluid (CSF) leakage occurred during surgery. The sella turcica and sphenoid sinus were packed with abdominal fat and fibrin glue, buttressing the closure with a fragment of sphenoid bone. No CSF rhinorrhea occurred postoperatively. Severe meningitis developed 7 months later. CSF rhinorrhea occurred 10 days after readmission. Exploration through the transsphenoidal approach identified a small hole at the floor of the sella and CSF leaking into the sphenoid sinus through the hole. The CSF leakage stopped after the second surgery. Delayed CSF rhinorrhea without bromocriptine administration is very rare. The cause of delayed CSF rhinorrhea remains unclear. CSF rhinorrhea should be suspected if meningitis develops even months after transsphenoidal surgery. (+info)
Cerebrospinal fluid rhinorrhea associated with untreated prolactinoma--case report.
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An 80-year-old female presented with non-traumatic cerebrospinal fluid (CSF) rhinorrhea due to untreated prolactinoma, with simultaneous development of bilateral leg pains and gait disturbance due to lumbar canal stenosis. Neuroimaging showed an intrasellar mass extending into the sphenoid sinus, right cavernous sinus, and suprasellar cistern. Computed tomography cisternography clearly showed the CSF pathway through the tumor. Subtotal removal of the tumor and reconstruction of the sellar floor via a transsphenoidal approach resulted in resolution of the CSF rhinorrhea. Both the invasive features and/or spontaneous shrinkage of the tumor might have created the abnormal CSF pathway. The clinical manifestation of lumbar canal stenosis might be triggered by such profound CSF leakage. (+info)
Recovery from Duret hemorrhage: a rare complication after craniotomy--case report.
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A 44-year-old female presented with Duret hemorrhage due to transtentorial herniation by extradural hematoma as a complication after craniotomy for treatment of spontaneous middle cranial fossa cerebrospinal fluid leakage through the oval window. Brain computed tomography revealed linear hemorrhage in the midbrain and the rostral pons. She awoke after 2 weeks in a coma, despite showing ocular bobbing and bilateral intranuclear ophthalmoplegia. She was discharged from the hospital with minimal neurological defects. Duret hemorrhage is usually fatal, but this case shows that early surgical decompression is the most important factor to avoid the worst sequelae. (+info)
Characterization of chemical meningitis after neurological surgery.
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We reviewed the records of 70 consecutive adult patients with meningitis after a neurosurgical procedure, to determine the characteristics that might help to distinguish a sterile postoperative chemical meningitis from bacterial infection. The spinal fluid profiles in bacterial and chemical meningitis are similar. The exceptions are that a spinal fluid white blood cell count > 7500/microL (7500 x 10(6)/L) and a glucose level of < 10 mg/dL were not found in any case of chemical meningitis. The clinical setting and clinical manifestations were distinct enough that no antibiotic was administered after lumbar puncture to 30 (43%) of the 70 patients with postoperative meningitis. Chemical meningitis was infrequent after surgery involving the spine and sinuses. Patients with chemical meningitis did not have purulent wound drainage or significant wound erythema or tenderness, coma, new focal neurological findings, or onset of a new seizure disorder. They rarely had temperatures > 39.4 degrees C or cerebrospinal fluid rhinorrhea or otorrhea. (+info)