Detection Of Cerebrospinal Fluid Leakage Research Articles

Functional Endoscopic Sinus Surgery: Key Points for Safer Surgery.

Objectives: To review measures for safer functional endoscopic sinus surgery (FESS). Methods: PubMed, EBSCO, UpToDate, Proquest Central at Kırıkkale University, Google, and Google Scholar were used in the literature review. The search was performed using keywords of "functional endoscopic sinus surgery," "FESS," "Safety," "Image-Guided," and "complications" between 2000 and 2024. Results: Inflammatory and infectious sinus illnesses are the most prevalent indications for FESS. The 4 most common methods for FESS are endoscopic uncinectomy, maxillary antral ostomy/ethmoidectomy, anterior ethmoidectomy, and posterior ethmoidectomy. FESS has a complication rate of 0% to 1.5% for significant problems and 1.12% to 20.8% for minor issues. Sinus surgery outcomes can be improved and problems avoided with careful preoperative preparation. Powered instrumentation may enhance the severity of the problems rather than the number of occurrences. Intraoperative detection of cerebrospinal fluid leakage necessitates immediate localization and fixing of the leaking structure. The danger of infection increases and hospital stays are longer when investigation is delayed. In image-guided surgery, surgeons employ preoperative imaging data to pinpoint the exact position of a surgical tool concerning surrounding anatomical structures in real time. Although initially designed for use in neurosurgery, endoscopic sinus surgery has quickly become one of the most popular applications of this technique. Conclusion: Safer FESS can be accomplished with accurate CT scans, good patient preparation, surgical knowledge and training, and by using image guidance for endoscopic sinus surgery.

Phosphorylated tau 181 (p-tau181) as an innovative, fast and robust biomarker for cerebrospinal fluid leaks.

Cerebrospinal fluid (CSF) leaks can lead to serious complications if left untreated, making rapid and accurate diagnosis essential. Biomarkers such as β2-transferrin (B2TRF) and β-trace protein are used to detect CSF leaks, but their limitations warrant the exploration of alternative markers. This study investigates the potential of phosphorylated tau at threonine 181 (p-tau181) as a biomarker for CSF leaks. Samples from 56 subjects were analyzed for B2TRF and p-tau181 using immunoaffinity blotting and chemiluminescent enzyme immunoassay, respectively. Data analysis included Mann-Whitney test to assess the overall difference in median p-tau181 concentrations between B2TRF positive and negative patients and a receiver operating characteristic (ROC) curve analysis to determine optimal p-tau181 cutoff values for predicting B2TRF positivity. p-tau181 levels were significantly higher in B2TRF positive samples compared to negative samples (p < 0.001). ROC analysis showed high diagnostic performance for p-tau181, with an optimal cutoff of 13.22 pg/mL providing 92.0% sensitivity and 93.1% specificity. Excluding hemolyzed samples improved further the diagnostic performances, maintaining high sensitivity (90.9%) and achieving perfect specificity (100.0%). This study highlights the potential of p-tau181 as a valuable biomarker for the detection of CSF leaks due to its high diagnostic accuracy and practical advantages over the current biomarkers. The characteristics of p-tau181 assay being both quantitative and rapid, with high diagnostic accuracy, suggest that it could be a valuable tool for the detection of CSF leaks. Further research are now needed to validate these findings.

Spontaneous Cerebrospinal Fluid Leak in a Patient with Asymptomatic Idiopathic Intracranial Hypertension

BackgroundSpontaneous cerebrospinal fluid (CSF) leaks occur when there is a tear in the dura mater. Spontaneous CSF leaks are rare, and often associated with conditions like intracranial hypertension, connective tissue disorders, or congenital defects in the dura mater. Case ReportThe patient was a 66-year-old woman who presented to the Emergency Department with clear, positional nasal discharge from her left nostril for 1 week. She had a history of chronic headaches, which seemed to have been relieved around the time of onset of her rhinorrhea. Diagnostic imaging, including computed tomography and magnetic resonance imaging scans, confirmed the presence of a CSF leak and a left temporal meningoencephalocele. The patient subsequently underwent surgical repair of the leak and ventriculoperitoneal shunt placement, and was discharged home in stable condition. Why Should an Emergency Physician Be Aware of This?Early detection of CSF leaks require a thorough history and physical examination, and is crucial in preventing potentially life-threatening complications such as meningitis and intracranial abscesses.

Development of a shortwave infrared sinuscope for the detection of cerebrospinal fluid leaks.

Cerebrospinal fluid (CSF) rhinorrhea (leakage of brain fluid from the nose) can be difficult to identify and currently requires invasive procedures, such as intrathecal fluorescein, which requires a lumbar drain placement. Fluorescein is also known to have rare but significant side effects including seizures and death. As the number of endonasal skull base cases increases, the number of CSF leaks has also increased for which an alternative diagnostic method would be highly advantageous to patients. We aim to develop an instrument to identify CSF leaks based on water absorption in the shortwave infrared (SWIR) without the need of intrathecal contrast agents. This device needed to be adapted to the anatomy of the human nasal cavity while maintaining low weight and ergonomic characteristics of current surgical instruments. Absorption spectra of CSF and artificial CSF were obtained to characterize the absorption peaks that could be targeted with SWIR light. Different illumination systems were tested and refined prior to adapting them into a portable endoscope for testing in 3D-printed models and cadavers for feasibility. We identified CSF to have an identical absorption profile as water. In our testing, a narrowband laser source at 1480nm proved superior to using a broad 1450nm LED. Using a SWIR enabling endoscope set up, we tested the ability to detect artificial CSF in a cadaver model. An endoscopic system based on SWIR narrowband imaging can provide an alternative in the future to invasive methods of CSF leak detection.

Detection of Cerebrospinal Fluid Leaks Using the Endoscopic Fluorescein Test in the Postoperative Period following Pituitary and Ventral Skull Base Surgery.

Objective Diagnosis of cerebrospinal fluid (CSF) leaks is sometimes challenging in the postoperative period following pituitary and ventral skull base surgery. Intrathecal fluorescein (ITF) may be useful in this setting. Design Retrospective chart review. Setting Tertiary care center. Methods and Participants All patients who underwent pituitary and ventral skull base surgery performed by a single rhinologist between January 2017 and March 2020 were included. There were 103 patients identified. Eighteen patients received 20 ITF injections due to clinical suspicion for CSF leak during the postoperative period without florid CSF rhinorrhea on clinical exam. Computed tomography scans with new or increasing intracranial air and intraoperative findings were used to confirm CSF leaks. Clinical courses were reviewed for at least 6 months after initial concern for leak as the final determinate of CSF leak. Main Outcome Measures Specificity and safety of ITF. Results Eleven (61%) ITF patients were female and 7 (39%) were male. Average patient age was 52.50 ± 11.89. There were six patients with confirmed postoperative CSF leaks, 3 of whom had evaluations with ITF. ITF use resulted in 2 true positives, 1 false negative, 17 true negatives, and 0 false positives. ITF sensitivity was 67%, specificity was 100%, and positive and negative predictive values were 100 and 94.4%, respectively. There were no adverse effects from ITF use. Conclusions Existing modalities for detecting postoperative CSF leaks suffer from suboptimal sensitivity and specificity, delayed result reporting, or limited availability. ITF represents a specific and safe test with potential utility in the postoperative setting.

The Feasibility of Magnetic Resonance Imaging for the Differentiation of Cerebrospinal Fluid Leak From Middle Ear Effusion: A Quantitative Analysis.

Assess quantitatively whether magnetic resonance imaging (MRI) signal intensity can be used to distinguish cerebrospinal fluid (CSF) leaks in the temporal bone from middle ear effusions. Retrospective case review. Tertiary referral center. Forty-nine patients, 18 with middle ear effusions (MEE), 30 with CSF leaks, and 1 with an MEE on one side and a CSF leak on the other, were evaluated in the study. Primary inclusion criteria for CSF leak patients were operative management of CSF leak with confirmatory diagnosis in follow-up. Primary inclusion criteria for MEE patients were electronic medical record documentation of an effusion with subsequent resolution on follow-up. For all patients, inclusion criteria included MRI imaging with 3D-T2 weighted sequences (3DT2) and fluid-attenuated inversion recovery (FLAIR) sequences performed within 1 year of diagnosis code entry. Computational analysis of signal intensity of fluid collections in MRI imaging. Sensitivity and specificity of 3DT2 and FLAIR signal intensity in the detection of CSF leak. For 3DT2 sequences with a chosen normalized signal intensity threshold (CSF leak if ≥ 0.5), sensitivity was 100% (95% CI: 86.3-100) and specificity was 83.3% (95% CI: 51.6-97.9). For FLAIR sequences with a threshold of 1.0 (CSF leak if < 1.0), sensitivity was 77.4% (95% CI: 58.9-90.4) and specificity was 85.7% (95% CI: 63.6-97.0). For a combined test in which a fluid collection was considered CSF if both 3DT2 ≥ 0.5 and FLAIR < 1.0, sensitivity was 76% (95% CI: 54.9-90.6) and specificity was 100% (95% CI: 73.5-100).

Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage.

We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.

Detection of cerebrospinal fluid leakage by specific measurement of transferrin glycoforms.

A simple and rapid detection of cerebrospinal fluid (CSF) leakage would benefit spine surgeons making critical postoperative decisions on patient care. We have assessed novel approaches to selectively determine CSF β2-transferrin (β2TF), an asialo-transferrin (aTF) biomarker, without interference from serum sialo-transferrin (sTF) in test samples. First, we performed mild periodate oxidation to selectively generate aldehyde groups in sTF for capture with magnetic hydrazide microparticles, and selective removal with a magnetic separator. Using this protocol sTF was selectively removed from mixtures of CSF and serum containing CSF aTF (β2TF) and serum sTF, respectively. Second, a two-step enzymatic method was developed with neuraminidase and galactose oxidase for generating aldehyde groups in sTF present in CSF and serum mixtures for magnetic hydrazide microparticle capture. After selectively removing sTF from mixtures of CSF and serum, ELISA could detect significant TF signal only in CSF, while the TF signal in serum was negligible. The new approach for selective removal of only sTF in test samples will be promising for the required intervention by a spine surgeon.

The importance of standardizing acquisition settings and interpretation criteria of radionuclide cisternography.

Dear Editor We read with interest the paper by Lu and colleagues on radionuclide cisternography (RNC) entitled “The Value of Changing Position in the Detection of CSF Leakage in Spontaneous Intracranial Hypotension Using Tc-99m DTPA Scintigraphy: Two Case Reports”, claiming an additive value of scanning the patients in the upright position for the detection of cerebrospinal fluid (CSF) leakage (1). In two cases of spontaneous intracranial hypotension (SIH), the authors observed the appearance of multiple images of increased radioactivity on both sides of the spinal canal after changing the patient position, which were interpreted as direct signs of CSF leaks. We fully agree with Lu and colleagues that direct signs of leakage should be always looked for in RNC, as early appearance of bladder radioactivity is an unreliable indirect sign, probably due to traumatism after lumbar puncture. This was elegantly shown by Takahashi et al. (2) and subsequently confirmed by others. However, in our opinion, the images of increased radioactivity showed by Lu et al. symmetrically distributed on both sides of the spinal canal, should not be regarded as direct signs of leakage. Rather, these images might correspond to prominent structural abnormalities such as meningeal diverticula or nerve root cysts. These anatomical variants together with any other structural meningeal weaknesses, are known to confer an increased risk of CSF leaks, potentially requiring corrective surgery (3). When the patient stands up, CSF is likely to spread to the loci of least resistance, not seen in the supine position. Correlative radiological imaging would be needed to show underlying anatomical abnormalities. In Figures 1 and ​and22 we give an example of that. Figure 1. Anterior projection of a radionuclide cisternography showing multiple small images of increased radioactivity on both sides of the spinal canal (left). On the right, there is the corresponding volumetric magnetic resonance reconstruction showing multiple ... Figure 2. The spine at the cervico-thoracic level in the same patient. Nerve root cysts (arrows) are seen on both radionuclide cisternography (left) and magnetic resonance imaging (right). SIH is being more frequently recognized as an important cause of persistent headache with rather typical clinical presentation (3). Symptom relief after epidural blood patching often provides a “ex-juvantibus” diagnosis. Although MRI and CT-myelography have nowadays the greatest impact on the diagnostic workout, being able to accurately define the extent and location of CSF leaks. However, RNC may still play a role in selected, uncertain cases. Unfortunately, a limitation of RNC is represented by the lack of a standardized acquisition protocol. Some authors suggested to acquire multiple early images in the lateral position after intrathecal injection (2), while our group and others have favored a change of posture for detecting CSF leaks with increased sensitivity (4, 5). Image quality and the choice of radionuclide represent additional issues, as signs of extradural activity accumulation are often subtle and difficult to detect. In conclusion, we think that the paper by Lu et al. provides a valuable suggestion for improving the RNC acquisition technique. However, larger case series are needed to prove whether changing the patient’s position does really offer a diagnostic advantage in terms of direct leakage detection. Moreover, comparative imaging would also be warranted in order to standardize the interpretation criteria of RNC, providing a compelling definition of its current role in the diagnosis of CSF leakage.

Detection of Cerebrospinal Fluid Leaks by Intrathecal Contrast-Enhanced Magnetic Resonance Myelography

A 70-year-old woman had double vision, nausea, neck pain, and acute bilateral hypacusis. The neurological examination showed nerve VI palsy on the right. There was no history of trauma. Brain magnetic resonance (MR) imaging was indicative of intracranial hypotension, with diffuse pachymeningeal thickening, strong dural enhancement, and frontoparietal subdural hygromas. A radioisotope cisternography, performed in the search for a potential spinal cerebrospinal fluid (CSF) leak, was inconclusive. Thus, intrathecal gadolinium-enhanced MR myelography was considered as a possible alternative. Before intrathecal gadolinium administration, an MR image of the spinal cord showed a small perineural cyst at the level of L2 on the right but no evidence of a CSF leakage. The intrathecal gadolinium-enhanced MR myelography provided clear-cut evidence of dural leaks along the right L2 and L3 nerve roots (Figure). According to these findings, targeted epidural blood patching was performed and the patient’s symptoms gradually improved during the following month. At 1-year follow-up, she was asymptomatic.

Evaluation of high resolution gel β2-transferrin for detection of cerebrospinal fluid leak

Cerebrospinal fluid (CSF) leaks are potentially life-threatening conditions that can be diagnosed by detection of β(2)-transferrin using protein electrophoresis. Another less commonly available test is β-trace protein quantitation using immunoassay. The objectives of this study were to evaluate a new immunofixation-based β(2)-transferrin test for detection of CSF leaks and to compare it to an existing agarose gel electrophoresis test and β-trace protein immunoassay. For method comparison, 63 consecutive samples from physician-ordered β(2)-transferrin tests were analyzed using two different electrophoresis methods, agarose gel fractionation followed by acid-violet staining, and high resolution agarose gel electrophoresis followed by β(2)-transferrin immunofixation. A subset of samples (16/63) were analyzed for β-trace protein. Results were compared against patient chart data for the presence of a CSF leak. Additional studies were performed to assess the stability, detection limit, and analytical specificity of the β(2)-transferrin immunofixation test. The β(2)-transferrin immunofixation test had a sensitivity of 100 % (40/40) and specificity of 71 % (12/17) for detection of CSF leaks. By comparison, the agarose gel test had a sensitivity of 87 % (35/40) and specificity of 94 % (16/17). β-trace protein had a sensitivity of 100 % (10/10) and specificity of 86 % (5/6). Serum and saliva could be differentiated from CSF by the β(2)-transferrin immunofixation test based on their migration patterns. However, whole blood samples appeared positive for β(2)-transferrin at a threshold of ~ 4 g/L hemoglobin. At a cut-off of 3 mg/L, β-trace protein was increased in 10/10 cases with documented CSF leak and in 1/6 patients without CSF leak. Both the new immunofixation test for β(2)-transferrin and the β-trace protein were effective at detecting CSF leaks. Users of the β(2)-transferrin immunofixation test should be cautioned against interpreting samples with blood contamination.

The Value of Changing Position in the Detection of CSF Leakage in Spontaneous Intracranial Hypotension Using Tc-99m DTPA Scintigraphy: Two Case Reports

Radionuclide Cisternography (RNC) is of potential value in pointing out the sites of cerebrospinal fluid (CSF) leakage in patients with spontaneous intracranial hypotension (SIH). In the current report, we present two patients who underwent RNC for suspected CSF leakage. Both patients underwent magnetic resonance imaging (MRI) and RNC for evaluation. We describe a simple method to increase the detection ability of RNC for CSF leakage in patients with SIH.

Use of HRCT‐MRI Fusion Imaging in the Detection of Cerebrospinal Fluid Leaks

Objective1) Determine the accuracy of high resolution computed tomography and magnetic resonance fused imaging in detecting skull base cerebrospinal fluid leaks. 2) Develop a comprehensive algorithm for the diagnostic workup of anterior skull base cerebrospinal fluid leaks.MethodWe retrospectively reviewed 16 cases of patients who underwent HRCT‐MRI fusion studies with intraoperative fluorescein localization for the evaluation and repair of CSF leaks during a 3‐year period between 2008 and 2011 at the Mount Sinai Medical Center.ResultsSixteen HRCT‐MRI fusion studies were evaluated from 16 different patients suspected of having CSF leaks. Eleven out of the 16 subjects had a confirmed diagnosis of CSF leak on intraoperative nasal endoscopy. HRCT‐MRI fusion imaging accurately identified the CSF leak and its location in each of the 11 subjects yielding a sensitivity of 100%. Three of the 16 patients were found to have no signs of active leak or skull base defect on intraoperative nasal endoscopy, 2 of which correlated with negative findings on fusion imaging.ConclusionHRCT‐MRI fusion is an excellent imaging modality that not only provides accurate identification and localization of CSF leaks but also acts as a great adjunct for intraoperative localization and repair. HRCT‐MRI fusion should be incorporated into the diagnostic algorithm for management of CSF leaks.

Detection and Management of Skull Base Cerebrospinal Fluid Leaks Using HRCT-MRI Fusion Imaging

Background: Endoscopic repair of cerebrospinal fluid (CSF) leaks has been well described in the literature as an effective method for the treatment of sinonasal skull base defects. However, despite the ongoing evolution of the endoscopic techniques for repair, site localization is a diagnostic challenge. The limitations and morbidity associated with diagnostic imaging studies such as high-resolution computer tomography (HRCT), magnetic resonance imaging (MRI), and computed tomography (CT) cisternography in detecting CSF leaks has created a need for more accurate and less invasive radiographic imaging modalities. In our study, we evaluate a novel technique of fusing HRCT and MRI imaging for the detection of CSF leaks, as well as its ability to aid in intraoperative localization of skull base defects through computer-assisted image guidance.

Detection of CSF leaks with magnetic resonance imaging in intracranial hypotension syndrome

Intracranial hypotension syndrome (IHS) is a rare disorder characterized by postural headache, low cerebrospinal fluid (CSF) pressure, dural thickening and pachymeningeal contrast enhancement as a consequence of decreased CSF volume. The present report is a case of spontaneous IHS due to dural leak at the level of T12-L1. The site of CSF leakage was not detectable on either conventional magnetic resonance imaging (MRI) or T2-weighted MR myelography. However, it was evident on contrast-enhanced MR myelography (CE-MRM). The present report discusses the efficacy of CE-MRM in the detection of CSF leaks according to the literature so far.

Detection of cerebrospinal fluid leakage: initial experience with three-dimensional fast spin-echo magnetic resonance myelography

The pathogenesis of cerebrospinal fluid (CSF) hypovolemia is supposed to be caused by CSF leakage through small dural defects. To compare source three-dimensional (3D) fast spin-echo (FSE) images of magnetic resonance (MR) myelography with radionuclide cisternography findings, and to evaluate the feasibility of MR myelography in the detection of CSF leakage. A total of 67 patients who were clinically suspected of CSF hypovolemia underwent indium-111 radionuclide cisternography, and 27 of those who had direct findings of CSF leakage were selected for evaluation. MR myelography with 3D FSE sequences (TR/TE 6000/203 ms) was performed at the lumbar spine for all patients. We evaluated source images and maximum intensity projection (MIP) images of MR myelography, and the findings were correlated with radionuclide cisternography findings. MR myelography of five healthy volunteers was used as a reference. The MR visibility of the CSF leakage was graded as definite (leakage clearly visible), possible (leakage poorly seen), or absent (not shown). CSF leakage was identified with source 3D FSE images in 22 (81.5%) of 27 patients. Of the 22 patients, 16 were graded as definite and six were graded as possible. For the definite cases, 3D FSE images clearly showed the extent of the leaked CSF in the paraspinal structures. In the remaining five patients with absent findings, radionuclide cisternography showed only slight radionuclide activity out of the arachnoid space. Source 3D FSE images of MR myelography seem useful in the detection of CSF leakage. Invasive radionuclide cisternography may be reserved for equivocal cases only.

The role of three-dimensional fast spin-echo magnetic resonance myelography in the detection of cerebrospinal fluid leakage

The role of three-dimensional fast spin-echo magnetic resonance myelography in the detection of cerebrospinal fluid leakage

LOCALIZATION OF CEREBROSPINAL FLUID LEAKS BY GADOLINIUM-ENHANCED MAGNETIC RESONANCE CISTERNOGRAPHY

Intrathecal gadolinium (Gd)-enhanced magnetic resonance (MR) cisternography is a newly introduced imaging method. Two main objectives of this study were to investigate the sensitivity of Gd-enhanced MR cisternography for presurgical localization of cerebrospinal fluid (CSF) leaks in patients with CSF rhinorrhea and to study the potential long-term adverse effects of intrathecal Gd application. Fifty-one patients (19 women; mean age, 36.2 yr) with CSF rhinorrhea were included in the study. A total of 0.5 ml of Gd was injected into the lumbar subarachnoid space. T1-weighted MR cisternographic images were obtained to detect CSF leakage. The patient's neurological states and vital signs were recorded for the first 24 hours after the procedure. Neurological evaluations were repeated 1, 3, and 12 months after the procedure. The patients were followed for at least 3 years with annual neurological examinations. Gd-enhanced MR cisternography demonstrated CSF leaks in 43 of the 51 patients. The sensitivity of Gd-enhanced MR cisternography for localization of CSF leaks was 84%. Forty-four patients underwent surgery to repair dural tears. Surgical findings confirmed the results of Gd-enhanced cisternography in 43 of the 44 patients who underwent surgery (98%). Eight patients with negative Gd-enhanced MR cisternography had no active rhinorrhea at the time of procedure, and seven of them did not need surgery. None of the patients developed an acute adverse reaction that could be attributed to the procedure. None of the patients developed any neurological symptoms or signs caused by intrathecal Gd injection during a mean follow-up period of 4.12 years. Gd-enhanced MR cisternography is a sensitive and safe imaging method for detection of CSF leaks in patients with rhinorrhea.

Neural Tube Defects Cannot Be Diagnosed Prenatally by Electrophoresis of Amniotic Fluid Transferrin Isoforms

Prenatal diagnosis of neural tube defects (NTDs) is based on ultrasonography; but uncertainty exists in a few cases, and biochemical analysis of amniotic fluid (AF) is required. Electrophoresis of AF acetylcholinesterase is a specific and sensitive method for diagnosis of myelomeningocele (1)(2). Although false-positive results are rare, another biochemical technique would be of great value. Adult and infant cerebrospinal fluid (CSF) is characterized by a specific marker, asialotransferrin or β2-transferrin, because it migrates more slowly in electrophoresis than β1-tetrasialotransferrin, the main isoform in all biological fluids (3). The specific behavior of β2-transferrin is used for the detection of CSF leakage from the subarachnoid space into the nasal or aural cavity (4)(5). Assuming that CSF would leak from a myelomeningocele-affected fetus into the AF, we screened AF …

Intracranial Subdural Hematomas and Cerebral Herniation after Labor Epidural with No Evidence of Dural Puncture

Intracranial Subdural Hematomas and Cerebral Herniation after Labor Epidural with No Evidence of Dural Puncture