CT Cisternography Research Articles

The Endonasal Endoscopic Management of Cerebrospinal Fluid Rhinorrhea.

IntroductionCerebrospinal fluid (CSF) rhinorrhea is the result of a bony defect at the skull base with disruption of the arachnoid, dura mater, and sinonasal mucosa that leads to an active CSF leak and flow of clear fluid from the nose. The endoscopic repair of CSF leaks and skull defects have been used by an increasing number of surgeons and is the standard of care for repairing CSF leaks.Materials and methodsWe conducted a retrospective study of all cases of CSF leaks managed via the endonasal endoscopic approach from 2010 to 2020 at a tertiary referral hospital of King Fahad Specialist Hospital, Dammam (KFSH-D).ResultsOver 10 years, 61 procedures were performed on a total of 56 patients (average age, 39.9 years) with 26 spontaneous CSF leaks and 30 traumatic CSF leaks. The leak sites were frontal bone in 14% of the cases, the roof of the ethmoid in 25%, the cribriform plate of ethmoid in 39%, and the walls of sphenoid sinus in 21%; multiple site defects were found in eight patients. The defect was localized by high-resolution computed tomography (CT) of the paranasal sinuses and skull base and magnetic resonance imaging (MRI) in all patients. CT cisternography, intrathecal fluorescein injection, and topical application of fluorescein dye were used in patients as required. A combination of free grafts and flaps materials were used in most patients. A middle and inferior turbinate graft was used in 12 patients, a septal cartilage graft in 18 patients, and a pedicled nasoseptal flap in 12 patients. The success rate was 92% after the first closure attempt. A recurrence of CSF leaks was observed in four patients. The mean hospitalization time was 6.5 days. The postoperative follow-up period ranged from one year to 10 years with a mean postoperative follow-up time of three years.ConclusionsThe endonasal endoscopic approach is the current standard of care for repairing most CSF leaks and skull base defects. We have had an excellent experience with endonasal endoscopic CSF leak repair, with high success rates and low morbidity. Our results support the effectiveness and safety of this technique and should encourage otolaryngologists to apply the procedure in cases of CSF leak.

Recurrent pneumococcal meningitis due to occult middle fossa encephalocele

AbstractRecurrent bacterial meningitis is not a frequent clinical condition. We describe here the case of a woman with recurrent pneumococcal meningitis caused by the leakage of CSF due to an occult middle fossa encephalocele related to chronic otitis media. To detect an extremely small encephalocele, detailed evaluation by bone CT and RI cisternography are very useful. In the treatment of recurrent bacterial meningitis, clinicians should examine for the presence of a small encephalocele early and perform an appropriate surgical therapy, because the condition could be fatal.

Cerebrospinal fluid dynamics along the optic nerve in patients with spontaneous cerebrospinal fluid rhinorrhea: a retrospective computed tomographic cisternography study.

Spontaneous cerebrospinal fluid (CSF) rhinorrhea is related to intracranial pressure (ICP) and dynamic changes. This study investigated CSF dynamics along the optic nerve (ON) in patients with spontaneous CSF rhinorrhea. The computed tomographic (CT) cisternographies of 66 patients (132 eyes) with spontaneous CSF rhinorrhea were analysed. The contrast-loaded CSF (CLCSF) density was measured in Hounsfield units (HU) at three regions of interest (ROIs) along the ON and adjusted by the basal cistern density. The CLCSF density and ON sheath diameter (ONSD) were analysed between both sides in the different ICP groups. When comparing the density of CLCSF along the ON, no significant differences were found between the ipsilateral and contralateral sides of the leakage. The distribution of CLCSF along the ON showed a highly significant density reduction from the canalicular segment to the bulbar segment on both sides. The CLCSF density significantly decreased on the ipsilateral ON in the canalicular segment and tended to decrease on the ipsilateral ON in thebulbar and canal segments compared with that on the contralateral ON in the low-ICP group. The ONSD tended to decrease on the ipsilateral side of leakage. According to the CLCSF density on CT cisternography, CSF dynamics along the ON may bilaterally decrease from the optic canal to the retrobulbar segment. Cerebrospinal fluid (CSF) dynamics are possibly influenced by differences in ICP, and a lower ICP may cause more obvious differences or impairments in CSF dynamics along the ipsilateral ON.

High-Resolution Gadolinium-Enhanced MR Cisternography Using Compressed-Sensing T1 SPACE Technique for Detection of Intracranial CSF Leaks.

In patients with CSF rhinorrhea, accurate identification of the CSF leakage site is crucial for surgical planning. We describe the application of a novel gadolinium-enhanced high-resolution 3D compressed-sensing T1 SPACE technique for MR cisternography and compare findings with CT cisternography and intraoperative results. In our pilot experience with 7 patients, precise detection of CSF leaks was feasible using compressed-sensing T1 SPACE, which appeared to be superior to CT cisternography.

Complex neuroimaging of traumatic brain injury: radiography and computed tomography

Every year, 1.5 million people die from traumatic brain injury, 50 thousand of them in Russia. A modern diagnostics of traumatic brain injury (TBI) reduces the mortality and improves the quality of medical care. The article discusses the advanced instrumental methods for diagnosing TBI: X-ray and CT of the skull, CT angiography, CT cisternography (CT-C), CT perfusion and selective cerebral angiography.
 The advantages and disadvantages of each method are considered. The authors also described the indications for each of the above-mentioned methods.

Deossification of the Otic Bone in High Pressure CSF Otorhinorrhea: A New Radiological Finding.

To highlight a new radiological feature in a patient with labyrinthine malformation presenting with bilateral spontaneous high pressure cerebrospinal fluid (CSF) otorhinorrhea. Study design-retrospective case review. Setting-academic, tertiary cochlear implant center. A cochlear implantee with Incomplete Partition Defect (Type 1) presented with meningitis and CSF otorhinorrhea for which she initially underwent medical treatment. High resolution computed tomography (HRCT) of the temporal bone with CT cisternography was performed for identifying the site of the CSF leak. HRCT and CT cisternography revealed a defect in the region of the stapes foot plate and marked thinning/deossification of the cochlear promontory. These two findings were absent in the pre-implant imaging of the patient done 3years ago. Surgery by endaural approach was undertaken to close the site of CSF leak. Intraoperatively, marked thinning of the cochlear promontory was observed, corresponding to 'blue lining' of the labyrinth in otologic surgery. This intraoperative finding indicating high intralabyrinthine CSF pressure correlated well with the imaging findings. Primary surgical repair resulted in successful CSF leak closure followed by theco-peritoneal shunting to prevent recurrence of the leak. The patient is using her cochlear implant and doing well with auditory verbal therapy. She is asymptomatic till date. Thinning and deossification of the otic capsule on HRCT is an important indicator of high CSF pressure in patients with labyrinthine malformations. Our case study highlights the need for heightened radiological and clinical vigilance in this subgroup of patients to predict complications and ensure prompt intervention.

Evaluation of periventricular hypodensity in adult hydrocephalus with CT cisternography and xenon-enhanced CT.

Metrizamide CT cisternography and Xenon-enhanced CT were employed to evaluate the periventricular hypodensity (PVH). CT cisternography was performed on adult cases with suspected communicating hydrocephalus, of which 43 cases showing ventricular reflux were investigated. In those cases in which significant transition of metrizamide into the area of PVH was followed after the ventricular reflux and stasis, the shunt operation was effective. The PVH disappeared post-operatively. However, in cases with PVH in which the metrizamide penetration did not occur, the PVH did not disappear post-operatively and clinical improvement was not detected. Xenon-enhanced CT was performed in six cases. Three cases exhibited communicating hydrocephalus, in which the area of PVH was not enhanced by metrizamide with CT cisternography. The other cases demonstrated acute high pressure hydrocephalus. The PVH in the former cases was neither enhanced by Xenon nor metrizamide, while the latter was enhanced significantly. Studies suggested that the reversible PVH was the result of an abnormally increased transition of cerebrospinal fluid through the ependymal layer, while the irreversible PVH resulted from the axonal destruction or demyelination of the periventricular white matter.

Economic implications of localization strategies for cerebrospinal fluid rhinorrhea.

The direct costs associated with different diagnostic algorithms to localize cerebrospinal fluid (CSF) rhinorrhea have not been described. A decision-tree analysis of imaging modalities used to localize CSF rhinorrhea was performed to compare associated direct costs. The primary outcome was cost, which was determined based on reimbursement data published by the Centers for Medicare and Medicaid Services in 2018. The model was parameterized after a literature review of published studies was performed from 1990 to 2018 to estimate the sensitivity CSF rhinorrhea localization of the following radiographic modalities: high-resolution computed tomography (HRCT), magnetic resonance cisternography (MRC), and CT cisternography (CTC). In addition to base case analysis, 1-way sensitivity analyses were also performed to evaluate the robustness of results to changes in model parameters. Among patients with a high suspicion for CSF rhinorrhea, use of HRCT followed by exploration in the operating room if preliminary HRCT was negative was found to be the optimal localization modality from a cost perspective ($172.25). The next least costly algorithm was HRCT followed by MRC ($294.10). Imaging algorithms beginning with CTC were the next least costly modality ($727.37). Sensitivity analyses generally supported HRCT to be the optimal initial radiographic strategy over a wide range of parameter values. This work advocates HRCT as first-line modality to localize CSF rhinorrhea from a cost perspective. Although algorithms beginning with MRC were on average $35 more expensive than those starting with CTC, associated risks of CTC were not modeled and may play a role in decision making.

CT Cisternography for Target Delineation in Post MVD Failed Complex Anatomy Trigeminal Neuralgia

CT Cisternography for Target Delineation in Post MVD Failed Complex Anatomy Trigeminal Neuralgia

Approach to Management of Cerebrospinal Fluid Rhinorrhea: Institutional Based Protocol.

The role of otolaryngologist in the management of CSF rhinorrhea is expanding. It is prudent to evaluate all cases of CSF leak, understand the etiological causes and formalize a working approach to management of such cases to yield better outcome. A retrospective descriptive study of 39 cases of proven CSF rhinorrhea treated at a tertiary care center between January 2014 to August 2019. The data retrieved were analyzed for age, gender, weight, etiology, recurrence of the disease, history of meningitis, nasal or neurosurgical intervention in past, imaging inform of CT and MR cisternography as and when required. This was aimed at understanding the various etiological types of CSF rhinorrhea and work out a management approach. The patients with skullbase tumors who presented with CSF Rhinorrhea were excluded from the study sample. There were 18 cases of spontaneous CSF rhinorrhea and 20 cases of traumatic CSF rhinorrhea. The mean BMI of spontaneous gp was 32.9 ± 2.46kg/m2 while in traumatic group was 25.7 ± 2.94kg/m2 and difference was statistically significant. None of the spontaneous CSF rhinorrhea cases showed features of raised ICP preoperatively either clinically or on imaging except empty sella in 14 of 18 cases. 6 of 18 cases of spontaneous category while 01 of 20 cases in traumatic had recurrence and the recurrence rate was significantly (p < 0.05) higher in spontaneous group. In traumatic group 7 were iatrogenic, 8 were occult traumatic and rest were acute traumatic. 4 of traumatic and 1 spontaneous group had history of meningitis and the incidence was 12.8% in our study group. Early identification and localization of CSF fistula is necessary to reduce morbidity and mortality associated with it. Risk of meningitis is high in CSF rhinorrhea especially in traumatic group. The etiology of CSF rhinorrhea has a bearing on the management and spontaneous CSF rhinorrhea has higher rate of recurrence.

Outcome of Endoscopic Cerebrospinal Fluid Rhinorrhoea Repair: An Institutional Study.

Cerebrospinal fluid Rhinorrhoea is caused by an abnormal open communication between the subarachnoid space and the nasal cavity. The most common anatomic sites of such abnormal communication are found in the anterior skull base, namely, ethmoid roof, olfactory groove, roof of the sphenoid sinus and the posterior wall of the frontal sinus. It can be classified into traumatic or spontaneous. Spontaneous leaks are associated with highest recurrence rates following surgical repair. The repair of CSF Rhinorrhoea has rapidly evolved over the past 30years. Prior to the advent of the endoscopic approach, craniotomy was used for repairs which carried a variable success rate and morbidity. The purpose of our study was to ascertain the outcome after Transnasal Endoscopic Repair of spontaneous CSF leaks. This was a prospective study conducted at the Department of ENT at Safdarjung Hospital, New Delhi between January 2015 and June 2016. The study comprised of eleven patients who presented with the complaint of watery nasal discharge and were diagnosed to have spontaneous CSF Rhinorrhoea. Proper clinical examination, nasal endoscopy and biochemical and cytological analysis of nasal secretions of the patient was done. High Resolution Computed Tomography and MRI scans of the nose and paranasal sinuses were done to identify precise location of CSF leak and the size of fistula. CT cisternography was done wherever required. Fistula was repaired via Transnasal endoscopic approach in a multi layered underlay fashion. Out of all eleven patients with spontaneous CSF leaks, most common site of leak was from left cribriform area. Four patients (36.36%) were found to have meningoencephalocele. No associated intracranial lesion was found and all patients did not have any benign intracranial hypertension. Our success rate of endoscopic repair on first attempt was 100% with recurrence in 1 patient after 4months of repair. Endoscopic repair of CSF rhinorrhoea is safe and effective, with a very low complication rate. It has almost completely replaced the older open techniques. Accurate localization of leak site followed by multilayered closure of dural defect appear to be essential for successful endoscopic repair.

Spontaneous cerebrospinal fluid rhinorrhea: A case report and analysis: Erratum.

The diagnosis of CSF rhinorrhea requires the performance of a thorough history and physical examination. Often no objective findings can be found and further evaluation will be required. In our experience, metrizamide CT cisternography yields the most information for localization of the fistula. When indicated, patients can be protected against meningitis by using prophylactic antibiotics for 4-6 weeks to allow a fistula to close spontaneously. If the fistula fails to close during this time, surgical closure with dural or muscle graft with or without waxing of the bone is the treatment of choice.

Computed Tomography Cisternography for the Management of Cerebrospinal Fluid Fistulae

Computed Tomography Cisternography for the Management of Cerebrospinal Fluid Fistulae

Imaging review of cerebrospinal fluid leaks.

Cerebrospinal fluid (CSF) leak occurs due to a defect in the dura and skull base. Trauma remains the most common cause of CSF leak; however, a significant number of cases are iatrogenic, and result from a complication of functional endoscopic sinus surgery (FESS). Early diagnosis of CSF leak is of paramount importance to prevent life-threatening complications such as brain abscess and meningitis. Imaging plays a crucial role in the detection and characterization of CSF leaks. Three-dimensional, isotropic, high resolution computed tomography (HRCT) accurately detects the site and size of the bony defect. CT cisternography, though invasive, helps accurately identify the site of CSF leak, especially in the presence of multiple bony defects. Magnetic resonance imaging (MRI) accurately detects CSF leaks and associated complications such as the encephaloceles and meningoceles. In this review, we emphasize the importance and usefulness of 3D T2 DRIVE MR cisternography in localizing CSF leaks. This sequence has the advantages of effective bone and fat suppression, decreased artefacts, faster acquisition times, three-dimensional capability, y and high spatial resolution in addition to providing very bright signal from the CSF.

Computed Tomography Cisternography for the Management of Cerebrospinal Fluid Fistulae

Computed Tomography Cisternography for the Management of Cerebrospinal Fluid Fistulae

Non-Invasive and Minimally Invasive Imaging Evaluation of CSF Rhinorrhoea - a Retrospective Study with Review of Literature.

SummaryBackgroundLocalization of a cerebrospinal fluid [CSF] fistula is a diagnostic challenge. The choice of an optimal imaging technique is necessary to locate the site of CSF leak which is required for surgical/endoscopic repair of the CSF fistula.Material/MethodsRetrospective analysis of imaging was performed in 33 patients who presented with symptoms suggestive of CSF rhinorrhoea over a period of two years. Either a bone defect on high resolution CT [HRCT] or CSF column extending extracranially from the subarachnoid space with or without brain/ meningeal herniation on magnetic resonance [MR] cisternography was considered positive for CSF leak. The MR imaging technique included 1-mm heavily T2-weighted [TR 2000 ms; TE-200 ms] fast spin echo study in coronal and sagittal planes. HRCT sections involved 0.625 to 0.8-mm sections in the coronal plane, with or without axial planes, through the paranasal sinuses, reconstructed in a sharp algorithm and acquired with the patient in prone position. Imaging findings were compared with endoscopic findings, being the gold standard for the assessment of CSF rhinorrhea.ResultsA total of 25 patients had a combination of HRCT and MR cisternography. The sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] of both MR cisternography and HRCT together were 93%, 100%, 100% and 50% respectively. Two patients underwent only MR cisternography, 5 patients underwent only HRCT and one patient underwent HRCT, MR cisternography and CT cisternography. Though PPV was 100% in the groups with HRCT alone, MR cisternography alone and combined CT cisternography, HRCT and MR cisternography, the results were not statistically significant as the number of patients in those groups was lower.ConclusionsCombination of MR cisternography and HRCT appears to be complementary, accurate and non-invasive and should be considered as optimal imaging modality for pre-op imaging in the evaluation of CSF rhinorrhoea.

A rare case of cerebrospinal fluid rhinorrhea post external dacryocystorhinostomy surgery

Cerebrospinal fluid (CSF) leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery. We report a rare case of CSF rhinorrhea following external dacryocystorhinostomy (DCR) surgery. A 38-year-old healthy lady was diagnosed to have chronic dacryocystitis for which right side external DCR was done. At the evening of first postoperative day, the patient noticed a discharge of clear fluid coming through the right nostril, in sitting posture. The fluid was sent for biochemical analysis. Based on clinical and biochemical tests of fluid, a diagnosis of iatrogenic CSF rhinorrhea was made. Contrast enhanced computed tomography and computed tomography cisternography failed to reveal any site of active leakage. However, the patient improved with conservative management only. CSF leakage occurs very rarely in external dacryocystorhinostomies with only a few case reports found in the literature. Knowledge of anatomy and thorough preoperative assessment may predict areas at high-risk for encountering this problem.

Value of combined three dimensional constructive interference in steady state with phase-contrast MR in diagnosis of hydrocephalus children

Objective To investigate the value of combined 3D-constructive interference in steady state(3D-CISS) with phase-contrast MR(PC-MR) in diagnosis of hydrocephalus children. Methods We collected retrospectively 28 children with hydrocephalus who caused by obstructive membranes.They all underwent MR imaging examination with a 1.5 T consisting of 3D-CISS, conventional sequences and PC-MR. With the result of surgery and CT cisternography as gold standard,we analysised different sequence in the diagnosis of membranous obstruction. The results of obstructive were analysed by χ2 test between 3D-CISS combined with PC-MR and conventional sequences. Results The study included 28 children, of whom 16 showed obstructive membranes in CSF pathways of ventricle and 12 displayed obstructive membranes in CSF pathways of cistern. Conventional sequences diagnosed obstructive membranes of 15 children, and obstructive membranes of 11 children were consistent with gold standard, and 4 cases were false positive. The 3D-CISS diagnosed obstructive membranes of 40, and 12 cases were false positive.There were significant difference between 3D-CISS combined with PC-MR and conventional sequence about obstructive membranes diagnosis of CSF pathways(χ2=24.410, P=0.001). Conclusions Making use of jointing 3D-CISS sequence and PC-MR sequence successively, and we can diagnose the position of obstructive membrane for hydrocephalus, which can be helpful to select a perfect surgical approach. Key words: Hydrocephalus; Magnetic resonance imaging

Petrous apex cephalocele presenting with cerebrospinal fluid rhinorrhea in an adult

Petrous apex cephalocele (PAC) is a rare condition with very few case reports in the literature. We report a 26-year-old man with cerebrospinal fluid rhinorrhea that was misdiagnosed elsewhere and operated unsuccessfully via the endonasal route. CT cisternography revealed a 3mm right PAC for which he underwent a right subtemporal extradural approach and successful repair. We present what is to our knowledge the first case report in the literature of an adult presenting with cerebrospinal fluid leak and discuss the diagnostic dilemmas in the diagnosis of PAC, difficulties in management and review the available literature.

Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations.

Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. A systematic review of the literature was performed using PubMed, EMBASE, and Cochrane databases from January 1990 through September 2014, to examine 9 diagnostic and localization modalities for CSF rhinorrhea. Benefit-harm assessments, value judgments and recommendations were made based on the available evidence. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. All authors agreed on recommendations through an iterative process. We reviewed 68 studies examining 9 practices pertinent to the diagnosis of CSF rhinorrhea, with a highest aggregate grade of evidence of C. The literature does not support the use of the ring sign, glucose testing, radionuclide cisternography (RNC), or computed tomography cisternography (CTC) for identification of CSF leak. Beta-2 transferrin is the most reliable confirmatory test for CSF leak. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. Higher-level studies are needed to better determine optimal diagnostic and clinical management approaches.