government site. Lu X, Zhai X, Li H, Yang X, Hang W, Liu G. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. However, if CSF rhinorrhea persists beyond this point, or if a large skull base defect is observed at the time of injury, surgical repair is warranted. Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula. Ratilal BO, Costa J, Pappamikail L, Sampaio C. Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures. J Neurosurg. 2015 Oct 14. 1969 Apr. Intrathecal gadolinium-enhanced magnetic resonance cisternography in cerebrospinal fluid rhinorrhea: road ahead?. Epub 2018 Sep 24. The Canadian CT Head Rule for patients with minor head injury, Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, Sodiumglucose cotransporter-2 inhibitors in patients without diabetes, www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.120055/-/DC1. [2] Any surgical manipulation near the skull base can result in an iatrogenic CSF leak. [11, 12, 5, 7, 13], Methods for detecting CSF fistulas with intrathecal injections of dye pose a risk of chemical meningitis. Other than notation of the patients fluctuating score on the Glasgow Coma Scale and movement of his four limbs, a neurologic examination was not documented before intubation. Lucien M Levy, MD, PhD [QxMD MEDLINE Link]. Kranz PG, Luetmer PH, Diehn FE, Amrhein TJ, Tanpitukpongse TP, Gray L. Myelographic Techniques for the Detection of Spinal CSF Leaks in Spontaneous Intracranial Hypotension. Conclusion: Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. This website also contains material copyrighted by 3rd parties. Bethesda, MD 20894, Web Policies A short repetition time can be used to achieve a result similar to that of the technique above, with slightly faster imaging times. Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. How . Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. Various other authors, including Dohlman (1948), Hirsch (1952), and Hallberg (1964), subsequently reported successful repair of CSF rhinorrhea through different external approaches. FOIA [QxMD MEDLINE Link]. This site needs JavaScript to work properly. double-ring sign (Figure 1B). Ear Nose Throat J. [QxMD MEDLINE Link]. 2001 Aug. 22(7):1239-50. Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. Therefore, imaging is usually done with the patient in the supine position. CSF is manufactured continuously in areas of the brain called ventricles, and the bloodstream absorbs it. eCollection 2016 Mar. Halo sign (target sign or double ring sign), when the CSF Rhinorrhea is blood-stained and dries out, a central bloodstain surrounded by a clear ring is seen. Respir Med Case Rep. 2023 Feb 11;42:101814. doi: 10.1016/j.rmcr.2023.101814. This image shows complete resolution of the previous dural thickening and contrast enhancement. In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult. Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. 1994. Curr Opin Otolaryngol Head Neck Surg. Hegarty SE and Millar JS. J Neurosurg. DeConde AS, Suh JD, Ramakrishnan VR. European Pituitary Adenoma Surgery Survey (EU-PASS) results-technical part. 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 If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). Laryngoscope Investig Otolaryngol. Copyright 2023, CMA Impact Inc.or its licensors. [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. (See images below.). Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, American Society of Neuroradiology, Louisiana State Medical Society, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, Royal Society of Medicine, Orleans Parish Medical Society, American Society of Spine Radiology, American Society of Functional Neuroradiology, Southern Radiology ConferenceDisclosure: Nothing to disclose. Oh JW, Kim SH, Whang K. Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management. These leaks were typically approached via a frontal craniotomy. 110(7):1166-72. Leakage of CSF due to trauma or basilar skull fracture Halo test/double ring sign + (paper) How to test for CSF rhinorrhea urine dipstick: glucose (=CSF) paper: + halo test/double ring sign CSF rhinorrhea treatment Surgical repair of skull defect Auricular hematoma Blood between cartilage and perichondrium Double Ring Sign: CSF mixed with blood or nasal discharge forms two rings because CSF being a watery fluid invades linen more than blood called the double-ring sign, halo sign, or . Cerebrospinal fluid rhinorrhoea in closed head injuries. Bookshelf Disruption of the barriers between the sinonasal cavity and the anterior and middle cranial fossae is the underlying factor leading to the discharge of CSF into the nasal cavity. J Neurotrauma. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Generally, the goal of imaging is confirmation of the diagnosis of SIH through the visualization of a leak, as well aslocalization of the leak, to facilitate targeted treatment with either epidural patching or surgery. Gadolinium-enhanced, coronal, T1-weighted MRI shows dural and tentorial thickening with contrast enhancement. J Clin Diagn Res. [3]. CSF produced at the choroid plexus typically circulates from the lateral ventricles to the third ventricle via the aqueduct of Sylvius. By the same principles as those applied in planar chromatography, the drainage of bloody discharge onto the patient's pillow or a paper towel can be seen to . A possible cause of a delayed traumatic leak is a previously intact dural layer that has slowly herniated through a bony defect, finally tearing and allowing the cerebrospinal fluid (CSF) to leak. Results: The leak almost never recurs. Compared with external techniques, endoscopic techniques have several advantages, including better field visualization with enhanced illumination and magnified, as well as angled, visualization. Other local services are: Electrical . 51(6):704, 706. CT myelography is used in the detection of spinal CSF leak. Other common locations include the posterior fovea ethmoidalis and the posterior aspect of the frontal recess. Before [28], In a small series of patients withspontaneous intracranial hypotension (SIH), instillation of preservative-free normal saline into the thecal sac followed by intrathecal Gd infusion was found to be a safe technique thatincreased the detection of a CSF leak on MR myelography images. The high T2 signal from CSF fistula may be difficult to differentiate from that of sinusitis on axial images. Spontaneous CSF rhinorrhea occurs in patients without antecedent causes. 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. Sign in 0 Cart; Gifts for Mom; Jewelry & Accessories . CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. 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. Additional hardware or software is not required to perform MR myelography or cisternography. Triplanar images of a patient with a left lateral recess meningoencephalocele. Bonnie Kaplan, MD, showed a picture of blood leaking from the ear of an injured patient onto a bed sheet, which forms a double ring sign, in the December Quick Consult. Clipboard, Search History, and several other advanced features are temporarily unavailable. West J Emerg Med. Cerebrospinal fluid (CSF) leak may occur from the nose (rhinorrhea), from the external auditory canal (otorrhea), or from a traumatic or operative defect in the skull or spine. 2016 Jan. 6 (1):8-16. Skull base injuries can vary from simple cracks in the bony architecture to large (>1 cm) defects with disruption of the dura and potentially brain parenchyma. Another technique, the injection of intrathecal fluorescein, has been used not only to diagnose CSF rhinorrhea but to localize the site(s) where it occurs. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 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. Accessibility 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). Lippincott Williams and Wilkins, Philadelphia 2000; Otolaryngol Clin North Am. Radionuclide cisternography is performed by administering a lumbar subarachnoid intrathecal injection of Indium-111 (111In) diethylenetriamine pentaacetic acid (DTPA) in a 500 Ci dose. (EMN. Korean J Neurotrauma. However, an astute clinician noted the double ring sign on the stretcher sheet, as noted in the Figure 1. Methods: Circulation of CSF is maintained by the hydrostatic differences between its rate of production and its rate of absorption. official website and that any information you provide is encrypted Gadolinium-enhanced T1-weighted axial MRI shows diffuse moderate dural thickening with contrast enhancement. 2015 May. Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA. 2011 May. For more information, see the eMedicine topic Nephrogenic Systemic Fibrosis. Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane. [QxMD MEDLINE Link]. The frequency of cerebrospinal fluid (CSF) rhinorrhea is determined by the underlying etiology. The fluid can be placed on filter paper and a "halo" or double ring may be seen. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. 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.
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