CT Cisternography Research Articles

282 Radiological Features Predicting Shunt Response in Normal Pressure Hydrocephalus, a Systematic Review and Meta-Analysis

Abstract Aim To produce a systematic review and meta-analysis to identify radiological features that predict shunt response in normal pressure hydrocephalus (NPH), evaluate their effectiveness and therefore recommend the most predictive feature. Method The authors searched MEDLINE, Embase, Scopus, PubMed, Google scholar and JSTOR databases for all original studies investigating NPH radiological features that predict shunt response. Selected studies were assessed with ROBINS-1 tool and included studies were evaluated by a univariate meta-analysis. Results 301 full text papers were selected from screening, 28 studies were included, and 26 features were identified, of these 5 were selected for the meta-analysis based off the inclusion criteria: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The diagnostic odds ratios of colossal angle (1.88) and periventricular white matter changes (1.01) showed they were significant differentiators between shunt responders from non-responders. None of the other features could differentiate between the two. Conclusions Colossal angle and periventricular white matter changes are the only statistically effective features which can identify shunt responders. Their role, however, may be overstated as their DORs approximate 1, therefore it is advised they be used in combination with other diagnostic predictors, such as clinical tests, of shunt responders. More research is required to evaluate the combined use of multiple radiological features together.

Pediatric Spontaneous Cerebrospinal Fluid Leak Repair: An Endoscopic Endonasal Approach.

Background: Spontaneous cerebrospinal fluid (CSF) rhinorrhea in the pediatric population is an exceedingly rare condition that occurs when the dura mater is breached, resulting in CSF drainage from the subarachnoid space into surrounding sinonasal tissue. Objective: This work delineates a step-by-step surgical approach to visually demonstrate the feasibility of an uninarial endoscopic endonasal approach for pediatric spontaneous CSF leak repair. Postoperative Outcome: A 2-year-old male with a 6-month history of clear rhinorrhea, intermittent headaches, and a previous episode of bacterial meningitis was evaluated as an inpatient consultation. Computed tomography cisternography revealed active CSF extravasation at the right sphenoid sinus roof. An endoscopic endonasal approach was performed including a complete sphenoethmoidectomy plus middle turbinectomy to provide access to the skull base defect. Once identified, a middle turbinate free mucosal graft was placed for cranial base reconstruction given the child's young agre. Sinonasal debridement 3 weeks following surgery under anesthesia revealed an intact viable graft with no evidence of CSF leak. There was no evidence of CSF leak recurrence or complications 1 year following surgery. Conclusion: The uninarial endoscopic endonasal approach is a safe and effective option for the surgical management of spontaneous CSF leak rhinorrhea in the pediatric population.

To evaluate the role of Intrathecal Iohexol-enhanced Mr Cisternography in detecting CSF Rhinorrhea with correlation to Ct Cisternography

To evaluate the role of Intrathecal Iohexol-enhanced Mr Cisternography in detecting CSF Rhinorrhea with correlation to Ct Cisternography

Fluoroscopy-guided multiphase flat panel CT cisternography to diagnose complex skull base CSF leaks

Skull base cerebrospinal fluid (CSF) leaks can be challenging to diagnose. We describe a first technical report on a fluoroscopy-guided multiphase flat panel computed tomography cisternography to diagnose a CSF leak in a complex postoperative anterior cranial fossa. The entry point, pathway of leakage, and exit point were visualized in detail. The feasibility and technical details are described. This technique could be an additional asset in the diagnostic work up of complex CSF leaks, not only of the anterior cranial fossa, but also complex CSF leaks of the middle cranial fossa.

Cerebrospinal fluid rhinorrhea: a novel approach

Background: This study aimed to describe the use of nasal endoscopic technique in the management of cerebrospinal fluid (CSF) rhinorrhea repair. Over the last decade, endoscopic surgery has established itself as the most widely used technique for the repair of CSF leak. Methods: 20 patients diagnosed with CSF rhinorrhea undergoing endoscopic CSF rhinorrhea repair were included in this study. To confirm the diagnosis beta-2 transferrin test was done. Accurate localization of site of lesion using CT cisternography was done. Results: Spontaneous onset of CSF rhinnorhea was noted in 75% of patients. The most common cause of CSF rhinorrhea in our study was spontaneous and the second most common cause was post traumatic. Almost 45% of patients presented with headache as primary complaint, 30% with only CSF leak, 20% with nasal obstruction and rest 5% with hyposmia. Conclusions: Multilayered closure of the dural defect was done. It can be concluded that middle aged people presented as CSF rhinorrhea with female predominance and there was high success rate of endoscopic CSF rhinorrhea repair with low morbidity.

Spontaneous cerebrospinal fluid fistula secondary to hyper-pneumatized paranasal sinuses and skull base: two case reports

BackgroundSpontaneous cerebrospinal fluid (CSF) fistulas occur due to various reasons other than well-identified causes such as trauma, neoplasia or infection. Various contributory factors are attributed to formation of spontaneous CSF leaks such as idiopathic intracranial hypertension leading to prominent arachnoid granulations. Further, presence of hyper-pneumatized paranasal sinuses or the skull base weakens the bone and predisposes to development of spontaneous defects and further fistulas. This case report highlights two cases of spontaneous CSF leaks associated with hyper-pneumatized petrous bone and sphenoid sinus.Case presentationA 26-year-old female patient with history of right rhinorrhea with imaging evidence of bilateral hyper-pneumatized petrous bones and a bony defect in the right petrous bone on computed tomography (CT). Subsequent CT cisternography demonstrated CSF leak extending into the right pneumatized petrous apex cells, Eustachian tube, middle ear cavity, aditus, antrum and mastoid air cells. Pooling of contrast in the right nasal cavity and ethmoid cells was also seen. A 49-year-old female patient with history of right rhinorrhea with features of hyper-pneumatization of sphenoid bone involving right greater wing of sphenoid bone and bilateral pterygoid process with a bony defect in the right greater wing of sphenoid was demonstrated on CT. Corroborative magnetic resonance imaging (MRI) brain Constructive interference in steady state (CISS) sequence revealed a meningoencephalocele. Additionally, a suspicious focal dehiscence was observed in the right cribriform plate CSF pockets herniating into right ethmoid sinus.ConclusionHyper-pneumatized petrous bone and paranasal sinuses can be attributed as a risk factor for formation of spontaneous CSF leaks.

Otologist's Perspective of Recurrent Meningitis

Objectives: Congenital cerebrospinal fluid (CSF) leaks of the ear can be a potential cause of recurrent meningitis. Diagnosing the otogenic cause can be a challenge due to the spectrum of presentations. We aim at studying the various modes of presentation, radiology, and intraoperative findings of such CSF leaks. Methodology: This was a retrospective study of six patients of recurrent meningitis. Detailed history and clinical signs were noted. Audiometry was done. Computed tomography (CT) scan of the paranasal sinus and high-resolution CT of the temporal bone were done. CT cisternography was done for confirmation. Magnetic resonance brain was done in the immediate postmeningitic phase when CT cisternography is contraindicated. All the cases were explored surgically to identify and repair the site of the leak. Results: One had unilateral deafness and five had bilateral deafness. Two had incomplete partition (IP)-I deformity and four had IP-II. Surgical exploration revealed the leak site as only oval window in three patients and both round and oval windows in two. Conclusion: Otorhinology consultation is a must for all cases of recurrent meningitis. It is important to pick up subtle clinical signs for diagnosis. Multiple leak sites should be anticipated in such cases intra-operatively.

Radiological predictors of shunt response in the diagnosis and treatment of idiopathic normal pressure hydrocephalus: a systematic review and meta-analysis

BackgroundPatients with the dementia subtype idiopathic normal pressure hydrocephalus (iNPH) may improve clinically following cerebrospinal fluid (CSF) diversion (shunt) surgery, though the predictors of shunt response remain debated. Currently, radiological features play an important role in the diagnosis of iNPH, but it is not well established which radiological markers most precisely predict shunt responsive iNPH.ObjectiveTo conduct a systematic review and meta-analysis to identify radiological predictors of shunt responsiveness, evaluate their diagnostic effectiveness, and recommend the most predictive radiological features.MethodsEmbase, MEDLINE, Scopus, PubMed, Google Scholar, and JSTOR were searched for original studies investigating radiological predictors of shunt response in iNPH patients. Included studies were assessed using the ROBINS-1 tool, and eligible studies were evaluated using a univariate meta-analysis.ResultsOverall, 301 full-text papers were screened, of which 28 studies were included, and 26 different radiological features were identified, 5 of these met the inclusion criteria for the meta-analysis: disproportionately enlarged subarachnoid space (DESH), callosal angle, periventricular white matter changes, cerebral blood flow (CBF), and computerized tomography cisternography. The meta-analysis showed that only callosal angle and periventricular white matter changes significantly differentiated iNPH shunt responders from non-responders, though both markers had a low diagnostic odds ratio (DOR) of 1.88 and 1.01 respectively. None of the other radiological markers differentiated shunt responsive from shunt non-responsive iNPH.ConclusionCallosal angle and periventricular changes are the only diagnostically effective radiological predictors of shunt responsive iNPH patients. However, due to the DORs approximating 1, they are insufficient as sole predictors and are advised to be used only in combination with other diagnostic tests of shunt response. Future research must evaluate the combined use of multiple radiological predictors, as it may yield beneficial additive effects that may allow for more robust radiological shunt response prediction.

Diagnostic value of computed tomographic cisternography and magnetic resonance hydrography in cerebrospinal fluid rhinorrhea

Objective:To evaluate the accuracy of preoperative computed tomographic cisternography（CTC） and magnetic resonance hydrography（MRH）in the diagnosis of cerebrospinal fluid（CSF） rhinorrhea. Methods:Retrospective analysis was made on the data of 38 patients diagnosed as cerebrospinal rhinorrhea who completed preoperative HRCT, CTC and MRH examinations in the Department of Otolaryngology Head and Neck Surgery of Tianjin Huanhu Hospital from October 2016 to January 2022. The diagnostic accuracy of preoperative imaging examinations was compared according to the leak location found during operation. Results:Among all the 38 cases with CSF rhinorrhea, the detection rates of HRCT, CTC, and cranial MRH were 31.58%, 89.47%, and 60.53%, respectively. The accuracy of CTC was significantlyhigher than that of MRH （ χ²=8.49, P=0.007）, and the accuracy of MRH was significantly higher than that of HRCT （χ²=6.41, P=0.01）. Subgroup analyses were performed according to the precise positioning of cerebrospinal fluid rhinorrhea leakage. In patients with cerebrospinal fluid rhinorrhea located in ethmoid sinus, the accuracy of CTC（80.95% vs. 14.29%，P<0.01）and MRH（52.38% vs. 14.29%，P=0.02）were significantly higher than that of HRCT, but the accuracy but the difference between CTC and MRH between CTC and MRH was not statistically significant （P=0.10）. The accuracy of CTC was significantly higher than that of MRH （100.00% vs. 61.54%, P=0.04） and HRCT （100.00% vs. 53.85%, P<0.01） in patients with CSF rhinorrhea located in sphenoid sinus. However, there was no significant difference in the accuracy between MRH and HRCT （ P=1.00）. However, There was no significant difference in the accuracy of CTC, MRH and HRCT in patients with cerebrospinal fluid rhinorrhea located in frontal sinus. The accuracy of CTC and MRH was 84.62% and 57.69% respectively in 26 patients who failed to detect a CSF rhinorrhea by HRCT, and the difference was not statistically significant（χ²=4.59, P=0.06）. Conclusion:The comprehensive application of the multiple imaging methods has important guiding significance for the accurate treatment and prognosis evaluation. CTC and MRH could improve the accuracy of the localization diagnosis of cerebrospinal fluid rhinorrhea.

Traumatic Subdural Hygroma Due to Injury of an Ommaya Reservoir: A Case Report

A 68-year-old male patient was transferred to the emergency department after a passerby found him lying on the road with a bicycle. He had been diagnosed with neurolymphomatosis in 2006 and had an Ommaya reservoir targeted to the right lateral ventricle via the right Kocher’s point for chemotherapy. His initial mental status was stuporous. Brain computed tomography (CT) showed multiple traumatic injuries. Seven days after admission, bilateral subdural hygroma (SDG) developed. We performed CT cisternography. The contrast was directly injected into the Ommaya reservoir and CT images were obtained. On cisternography, contrast leakage points were identified from the Ommaya reservoir. The patient underwent surgery for Ommaya reservoir removal and occlusion of the permanent tract of the Ommaya reservoir. This case shows a rare etiology of traumatic SDG and demonstrates the usefulness of CT cisternography to determine cerebrospinal fluid leakage from an implant.

Efficacy of Imaging Methods in the Detection and Diagnosis of Cerebrospinal Fluid Rhinorrhea.

To assess the diagnostic efficacy of various imaging methods in patients with suspected cerebrospinal fluid (CSF) rhinorrhea. The PubMed, EMBASE, SCOPUS, Web of Science, Cochrane Trials, and Google Scholar databases were searched up to December 2021. Diagnostic accuracy was compared among seven radiological methods: computed tomography (CT), CT cisternography (CTC), magnetic resonance imaging (MRI), magnetic resonance cisternography (MRC), CT + MRI, radionuclide cisternography, and intrathecal gadolinium (Gd)-MRC. Sensitivity, specificity, and accuracy were used as outcomes of the analysis. Both a traditional pairwise meta-analysis and a network meta-analysis were performed. Twenty-three trials were included in the analysis. The results of a network meta-analysis performed on a network consisting of seven diagnostic methods showed that all imaging modalities had greater diagnostic accuracy than CT, with the exception of CTC, which had lower sensitivity. Only intrathecal Gd-MRC was significantly superior to other imaging methods with regard to sensitivity and accuracy. Gd-MRC also showed the greatest surface under the cumulative ranking curve values for all of the outcomes (sensitivity: 0.9200; specificity: 0.8364; accuracy: 0.8920). This network meta-analysis demonstrates that intrathecal Gd-MRC is the most useful diagnostic method to detect CSF rhinorrhea. Laryngoscope, 133:1281-1287, 2023.

CSF rhinorrhea: non-contrast CT, contrast-enhanced CT cisternography or combined?

BackgroundRadiologic diagnosis of CSF leaks is challenging. We evaluated the diagnostic value of non-contrast CT and contrast-enhanced CT cisternography in identifying the presence of CSF rhinorrhea and site of leak as well as comparing them to surgical data and/or clinical follow-up.ResultsFifty patients (20 males and 30 females) were included in our study with age ranging from 19 to 67 years. 76% of cases had spontaneous CSF rhinorrhea. Cribriform plate defect was the most common site of CSF leak, accounting for about 50% of cases. The highest sensitivity, specificity, PPV and NPV for diagnosis of CSF rhinorrhea were observed with the combined NCCT and CECTC with values 87%, 100%, 100% and 67%, respectively.ConclusionAccurate surgical planning and successful dural repair requires accurate localization of the dural and osseous defects. CT cisternography which already involves pre-cisternography non-contrast images holds great sensitivity in detection of the exact defect site together with confirmation of the CSF leak.

Delineation of Subarachnoid Cisterns Using CT Cisternography, CT Brain Positive and Negative Contrast, and a Three Dimensional MRI Sequence: A Pictorial Review.

The basic anatomy and morphology of subarachnoid cisterns of the brain are interesting and challenging topics with high clinical significance. These enlarged CSF-filled expansions are important as they transmit various neurovascular structures. The cisterns can be classified based on their location as supratentorial, at the level of the tentorium, and infratentorial. They are also classified as paired and unpaired cisterns. The anatomical and radiological information about the cisterns is clinically and surgically relevant in diagnosing and managing many neurological disorders. It is also essential in medical teaching. This pictorial essay reviews the radiological images where the subarachnoid cisterns are delineated in four unique circumstances.

Intraoperative Injection of Normal Saline Through Lumbar Drainage for Transnasal Endoscopic Repair of Complex CSF Leaks.

ObjectiveIt is well known that accurate location of the leak in the operation is crucial for repairing cerebrospinal fluid leakage. The study aims to investigate the application of intraoperative injection of normal saline through lumbar drainage in repairing complex leaks.MethodsThe fistulas of all patients with CSF leak were located by computed tomography cisternography (CTC) or heavy T2 magnetic resonance imaging (MRI) before surgery. Before anesthesia, the patient underwent lumbar drainage implantation, and then 20 ml of normal saline was slowly injected through the lumbar drainage to observe the patient's response. The surgical approach was designed based on the preoperative imaging data. When the operation was near to the suspected fistula, normal saline was injected through lumbar drainage (20 ml each time) to confirm the leak location. After CSF leak repair, saline was injected again to confirm whether the repair was successfully.ResultOf the 5 patients with complex leaks, 4 cases were repaired by transnasal endoscopy method, and 1 case was repaired by transnasal endoscopy method and epidural method. A total of 7 leaks were found during the operation. During the operation, 40–120 ml of normal saline was injected through lumbar drainage. Cauda equina neuralgia was developed in patients who received 120 ml normal saline, which was relieved by intrathecal injection of dexamethasone. During the follow-up of 3 months, 1 case suffered from brain abscess, which was controlled by vancomycin. There was no recurrence of rhinorrhea.ConclusionIntraoperative injection of normal saline through lumbar drainage can not only better expose the complex leak but also check the repair effect of the leak during transnasal endoscopic repair, which is effective and avoids side effects.

Usefulness of imaging studies for diagnosing and localizing cerebrospinal fluid rhinorrhea: A systematic review and meta-analysis.

Our aim in this study was to determine the usefulness of diagnosis by imaging studies for the localization of cerebrospinal fluid (CSF) rhinorrhea. PubMed, SCOPUS, Embase, Web of Science, and Cochrane Library databases were searched up to July 2021. True and false positive and negative data were collected along with the characteristics of each study. Methodologic quality was assessed using the QADAS-2 tool. Sixteen studies involving 472 patients were included. The diagnostic odds ratio (DOR) of imaging studies was 13.6195 (95% confidence interval [CI], 7.4756-24.8129; I2 =28.1%). The area under the summary receiver-operating characteristic curve was 0.712. Sensitivity, specificity, negative predictive value, and positive predictive value were 0.8507 (0.7773-0.9029), 72.1%; 0.7827 (0.6865-0.8556), 26.8%; 0.5828 (0.4398-0.7132), 67.4%; and 0.9407 (0.8935-0.9678), 59.1%, respectively. In the subgroup analysis, there were significant differences for sensitivity (computed tomography [CT], 0.7421; computed tomography cisternography [CTC], 0.8872; magnetic resonance imaging [MRI], 0.8365; magnetic resonance cisternography [MRC], 0.8565; intrathecal gadolinium magnetic resonance cisternography [GaMRC], and 0.9307; radionuclide cisteronography [RNC], 0.7097; p=0.0481) and for negative predictive value among imaging modalities (CT, 0.3028; CTC, 0.4848; MRI, 0.4658; MRC, 0.7465; GaMRC, 0.8611; and RNC, 0.5263; p=0.0046). There were no significant differences among imaging modalities for specificity, positive predictive value, or DOR (p>0.05). Imaging studies can be used in the diagnosis of CSF rhinorrhea. Gadolinium magnetic resonance cisternography showed the highest diagnostic accuracy. MRC showed fair diagnostic accuracy without intrathecal injection.

Diagnosis and Localization of Cerebrospinal Fluid Rhinorrhea: A Systematic Review.

BackgroundCerebrospinal fluid (CSF) rhinorrhea results from abnormal communications between the subarachnoid and sinonasal spaces. Accurate preoperative diagnosis and localization are vital for positive clinical outcomes. However, the diagnosis and localization of CSF rhinorrhea remain suboptimal due to a lack of accurate understanding of test characteristics.ObjectiveThis systematic review aims to assess the diagnostic accuracy of various tests and imaging modalities for diagnosing and localizing CSF rhinorrhea.MethodsA systematic review of the MEDLINE and EMBASE databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.ResultsOur search identified 4039 articles—53 cohort studies and 24 case series describing 1622 patients were included. The studies were heterogeneous and had a wide range of sensitivities and specificities. Many specificities were incalculable due to a lack of true negative and false positive results, thus precluding a meta-analysis. Median sensitivities and specificities were calculated for cohort studies of the following investigations: high-resolution computed tomography (HRCT) 0.93/0.50 (sensitivity/specificity), magnetic resonance cisternography (MRC) 0.94/0.77, computed tomography cisternography (CTC) 0.95/1.00, radionuclide cisternography (RNC) 0.90/0.50, and contrast-enhanced magnetic resonance cisternography (CEMRC) 0.99/1.00, endoscopy 0.58/1.00, topical intranasal fluorescein (TIF) 1.00/incalculable, intrathecal fluorescein (ITF) 0.96/1.00. Case series were reviewed separately. Etiology and site-specific data were also analyzed.ConclusionMR cisternography is more accurate than high-resolution CT at diagnosing and localizing CSF rhinorrhea. CT cisternography, contrast-enhanced MR cisternography, and radionuclide cisternography have good diagnostic characteristics but are invasive. Intrathecal fluorescein shows promising data but has not been widely adopted for purely diagnostic use. Office endoscopy has limited data but does not sufficiently diagnose CSF rhinorrhea independently. These findings confirm with current guidelines and evidence.

Application of different imaging methods for the localization of cerebrospinal fluid rhinorrhea: a comparative study.

CSF rhinorrhea is a type of CSF leakage caused by an aseptic abnormal passage between the subarachnoid space and the adjacent sinus and nasal cavity due to a cranial dural defect. At present, the value of computed tomography cisternography (CTC) in locating CSF rhinorrhea has been widely recognized, and magnetic resonance hydrography (MRH), as a heavy T2-weighted water imaging, plays a pivotal role in showing the location of the leak. In this paper, we retrospectively summarize the imaging manifestations seen at our hospital of patients with clinically confirmed CSF rhinorrhea at the skull base and evaluate the diagnostic value of different imaging methods in the localization of CSF rhinorrhea by means of preoperative imaging analysis using CTC and MRH. Fifty-five patients with CSF rhinorrhea admitted to our department from October 2016 to January 2021 were retrospectively analyzed. The patients' conventional CT, CTC, and MRH imaging data were compared, and the location of the leak determined preoperatively matched the location of the leak found during surgery. Moreover, there was no recurrence during the follow-up period of 4 months to 3 years. There were statistically significant differences between the diagnostic positivity rate of CTC and spiral CT (χ2=16.755, P<0.00), and between the diagnostic positivity rate of cranial MRH and spiral CT (χ2=6.338, 6.338=0.01), and no statistically significant difference between the diagnostic positivity rate of CTC and cranial MRH (χ2=2.625, P=0.1). The combined use of imaging techniques has important practical significance for the proper treatment and prognostic evaluation of CSF rhinorrhea. CTC has the highest positive rate for the diagnosis of CSF rhinorrhea, followed by MRH, while spiral CT is safer. CTC and MRH can promote the diagnostic rate in determining the location of CSF rhinorrhea, and selective combined application can be an important guide to surgery.

CT Cisternogram Findings in Idiopathic Cerebrospinal Fluid Leaks with Emphasis on Long Term Management.

To study the various computed tomography (CT) cisternogram findings in idiopathiccerebrospinal fluid (CSF) leaks and the long term treatment modalities after surgical repair of idiopathic CSF leaks. This was a descriptive study conducted among 25 patients in MCV memorial ENT trust hospital, Pollachi between May 2014 and May 2020 amongst patients who underwent CT cisternogram for unilateral or bilateral spontaneous rhinorrhea with or without associated headache, visual disturbances and papilloedema diagnosed to be idiopathic CSF leak by investigations. These patients then underwent CSF leak repair and postoperatively were managed with weight reduction, low salt diet and diuretic therapy. Post surgery these patients were followed up for a period of 12months and were evaluated on the basis of presence or absence of headache, rhinorrhea and papilloedema at the end of 1st month, 3rd month, 6th month and 1year and data was collected. CT cisternogram findings were evaluated by proportion method and evaluation of long term management was done using proportion and repeated measures ANOVA for all patients. Evidence of the presence of previously mentioned CT cisternogram or contrast MRI findings at the end of 1year of post-surgical treatment was recorded where patients were willing for the same. CT Cisternography was done for all patients and 72% patients had empty sella appearance while 28% had partially empty sella. Other findings included perioptic filling, optic blunting and arachnoid pits which were found in 11(44%), 8(32%) and 12(48%) of patients respectively. Only 3(12%) out of 25 patients had an encephalocoele. The commonest site of leak in CT cisternography was the cribriform plate (52%) followed by lateral recess of sphenoid (48%). None of the patients had multiple sites of leak in CT cisternography. On follow up post surgery maximum resolution of symptoms was found at the end of 12months where 23 out of 25 patients improved. In our study, out of 25 only 5 patients agreed to undergo post diuretic therapy MRI scan out of which 2 patients had partially empty sella and 3 had normal sella indicating resolution of BIH. CT cisternography is an important investigation which aids in the diagnosis of CSF rhinorrhea due to idiopathic intracranial hypertension (IIH). The medical management of IIH post surgery such as weight reduction, salt restriction and diuretic therapy is also crucial to prevent recurrence of symptoms.

Endoscopic third ventriculostomy and cerebrospinal fluid shunting for pure communicating hydrocephalus in children.

Recent reports regarding endoscopic third ventriculostomy (ETV) for pediatric hydrocephalus revealed that ETV could avoid cerebrospinal fluid (CSF) shunting in certain types of hydrocephalus. However, the effectiveness of ETV for "pure" communicating hydrocephalus that has no obstruction through CSF pathway is still unknown. In this study, we report clinical outcome of ETV and CSF shunting for communicating hydrocephalus and discuss the efficacy of ETV for pure communicating hydrocephalus. Children less than 15years old who underwent ETV or CSF shunting for communicating hydrocephalus were retrospectively reviewed. The absence of obstruction through CSF circulation was confirmed by CT cisternography or cine-contrast image in MRI. Sixty-three patients (45 CSF shunting and 18 ETV) were included. The mean follow-up period was 6.1years. The success rate was 60% in CSF shunting and 67% in ETV at the last visit (p = 0.867). Normal development was observed in 24 patients (53%) in CSF shunting and 12 patients (67%) in ETV (p = 0.334). There was a significant difference in the mean time to failure (CSF shunting: 51.1months, ETV 3.6months, p = 0.004). The factor that affected success rate in ETV was the age at surgery (success 21.6months, failure 4.4months, p = 0.024) and ETV success score (success 66.7, failure 50.0, p = 0.047). Clinical outcomes of ETV were not inferior to those of CSF shunting in patients with communicating hydrocephalus. Further studies is required to elucidate to establish the consensus of ETV as a treatment option for communicating hydrocephalus.

CT cisternography to visualize epidermoid tumors for stereotactic radiosurgery treatment planning

The visualization of intracranial epidermoid tumors is often limited by difficulties associated with distinguishing the tumor from the surrounding cerebrospinal fluid using traditional computed tomography (CT) or magnetic resonance imaging (MRI) modalities. This report describes our experience using CT cisternography to visualize intracranial epidermoid tumors in three illustrative cases. CT cisternography of the epidermoid tumor provides more clarity and precision compared to traditional neuroimaging modalities. We demonstrate the feasibility of using CT cisternography to produce high-resolution images with well-defined tumor margins that can be used effectively for precise SRS treatment planning.