Diagnosis Of Cerebrospinal Fluid Leakage Research Articles

Cut-off value for β-trace protein (β-TP) as a rapid diagnostic of cerebrospinal fluid (CSF) leak detection.

To find an adequate cut-off point for beta trace protein (β-TP) in nasal secretion (NS) and validate this diagnostic test with a large sample of patients. Likewise, we evaluated β-TP test efficacy to confirm the cerebrospinal fluid (CSF) leakage closure after treatment. We performed a retrospective analysis with 207 samples from 162 patients with suspected CSF leakage received in the Hospital Universitario Virgen de la Arrixaca between 2010 and 2016. Twenty-five samples were included in the control group. Samples were obtained from NS through a swab to determine β-TP using a nephelometry-based assay. Sensitivity, specificity, and area under the curve (AUC) for β-TP in NS were assessed using the receiver operator characteristic (ROC) analysis. Using imaging techniques, the diagnosis of CSF leak was confirmed in 57 patients (35.19%), while 105 had a negative diagnosis (64.81%). Patients with CSF leakage had significantly higher β-TP values in NS (16.07 ± 16.94 mg/L, p < .001) than the control group (0.33 ± 0.12 mg/L) and patients without CSF leakage (0.61 ± 2.34 mg/L). Applying a 1 mg/L cut-off point resulted in 96.5% sensitivity and 97.1% specificity. Positive and negative predictive values (PPV and NPV) at this cut-off were 94.9% and 98.6%, respectively. Finally, this cut-off point yields a test efficacy for CSF leak diagnosis of 97% (95% CI 92.9-98.9). Our study has established a 1 mg/L β-TP concentration in NS as a cut-off point for CSF leakage diagnosis with high sensibility and specificity. These results suggest that β-TP analysis could be useful to check CSF leak resolution. 4.

To Evaluate the Frequencies of Post- Traumatic Cerebrospinal Fluid Leak in Patients Presenting with Traumatic Brain Injury

Introduction: Traumatic brain injury is the fourth largest cause of fatal trauma worldwide. The social and economic implications of traumatic brain injuries are immense whilst the physical and mental bearing upon the patient is devastating. Objective: Objective of this study is to evaluate the frequencies of post- traumatic cerebrospinal fluid leak in patients presenting with traumatic brain injury. Methodology of the study: This study was conducted at Neuro Surgery Department of Lady Reading Hospital, Peshawar during 20/7/2020 to 20/1/2021.In the current study a total of 303 patients presenting with initial head trauma presenting within 24 hours with Glasgow coma score ≤15, patients in age between 18 to 65 years and both gender (male/female) were included in the study. All the patients were subjected for detailed history, clinical examination and radiological examination i.e. CT and MRI was done for the confirmation of brain injury. All the patients were followed till 7th post operative day for the diagnosis of Cerebrospinal fluid leak. It is clear water cerebrospinal fluid discharge diagnosed on clinical examination till 7th post-trauma day and was determined in terms of rhinorrhea or otorrhea. Results: Our study shows that among 303 patients was analyzed as 215(71%) patients were in age range 18-40 years, 88(29%) patients were in age range 41-65 years. 239(79%) patients were male and 64(21%) patients were female. More over 18(6%) patients had CSF leak while 285(94%) patients didn’t had CSF leak. Practical Implication: This study will be useful for finding the post-traumatic cerebrospinal fluid leak. Conclusion: Our study concludes that the frequencies of post-traumatic cerebrospinal fluid leak was 6% in patients presenting with traumatic brain injury. Keywords: Post-traumatic cerebrospinal fluid leak, traumatic brain injury.

Symptom: Runny Nose Six Years After Acoustic Neuroma Surgery

A 58-year-old woman presented with a history of right-sided hearing loss and synkinesis following her vestibular schwannoma resection in 2016 elsewhere. She showed some improvement in synkinesis after botulinum toxin treatment. However, on questioning the patient notes that she experienced persistent, clear water-like nasal drainage while bending over, exercising, or doing household work. In 2019, she underwent a right trans-canal cerebrospinal fluid leakage repair with the closure of the Eustachian tube at an outside facility. Eight months later, the symptoms recurred. Her examination showed an obese female (body mass index of 35.1) with clear external auditory canal with tissue behind the tympanic membrane on the right. Nasal exam was normal with no evidence of allergic rhinitis.Figure 1: Axial (horizontal) T1 FLAIR non-enhanced MRI showing the Eustachian tube packing is still in place. Clinical Consultation, runny nose, acoustic neuroma surgery, cerebrospinal fluid leak.Figure 2: Axial (horizontal) CT of temporal bones after contrast injection into the CSF space showing the contrast in the CSF. Clinical Consultation, runny nose, acoustic neuroma surgery, cerebrospinal fluid leak.Figure 3: Coronal (parallel to the face) CT of temporal bones after contrast injection into the CSF space showing no gross contrast in the middle ear indicating not a fast flow leak. Clinical Consultation, runny nose, acoustic neuroma surgery, cerebrospinal fluid leak.Figure 4: Axial (horizontal) T2 MRI demonstrating ischemic changes in middle cerebellar peduncle and cerebellum on left side of image (patient’s right side) from the surgical resection. Clinical Consultation, runny nose, acoustic neuroma surgery, cerebrospinal fluid leak.Figure 5: Coronal (parallel to the face) T2 demonstrating the anatomy in the coronal plane. Clinical Consultation, runny nose, acoustic neuroma surgery, cerebrospinal fluid leak.DIAGNOSIS: CEREBROSPINAL FLUID LEAK Negaar Aryan, MD; Karen Tawk, MD; Mehdi Abouzari, MD, PhD; and Hamid R. Djalilian, MD Clear fluid coming from the nose after a skull base surgery should alarm the clinician of a possible -cerebrospinal fluid (CSF) leak. CSF is a colorless liquid that provides nutrients, hormones, and signaling molecules. It maintains a constant intracranial pressure through production or reabsorption, and clears out unnecessary or toxic metabolic byproducts from the brain. On average, humans have 150 cc of CSF but 450 cc of CSF is produced daily and 450 cc of CSF has to be absorbed. Any imbalances in this equilibrium will lead to excess production of fluid, causing an elevation in intracranial pressure, implicated in idiopathic intracranial hypertension (IIH), hydrocephalus, brain trauma, brain tumors, and stroke. 1,2 CSF leak is a rare but severe condition with serious and potentially fatal outcomes. They are classified into two groups, traumatic and spontaneous. The traumatic group is divided into iatrogenic (related to nasal, ear, or cranial surgery) and non-iatrogenic (related to blunt or penetrating trauma) subgroups. The spontaneous group is further divided into high-pressure and low-pressure subgroups (according to CSF pressure). 3 Idiopathic intracranial hypertension is defined as an increase of CSF pressure inside the skull without any identifier cause. The vast majority of patients (about 90%) are obese women. The pathophysiology of IIH is still unclear, but cerebral venous hypertension is known as the primary underlying cause, which leads to dysfunctional arachnoid granulation, reduced CSF resorption, and elevated intracranial pressure. Patients mostly present with headaches (usually daily, mostly upon waking), vision loss (brief episodic blurring or loss of peripheral vision), and bilateral papilledema. Pulsatile tinnitus and dizziness may also become chief complaints of undiagnosed patients. On the other hand, in patients who have undergone brain surgery, the arachnoid villi (which facilitate reabsorption of CSF) may get clogged up with blood during the surgery, and this may lead to communicating hydrocephalus or decreased absorption, which in the presence of IIH can exacerbate symptoms. Diagnosis of CSF leaks is still a challenge. Diagnosis of post-traumatic leaks is immediate, whereas in spontaneous leaks it is more difficult since they are characterized by intermittent symptoms, and are dependent on disease etiology, leading to delayed diagnosis. The diagnostic algorithm includes clinical otolaryngology assessment with neurosurgical and ophthalmological consultation, radiological imaging, and laboratory findings of the nasal liquid. In clinical evaluations, performing some maneuvers (e.g., occluding the jugular vein, the Valsalva maneuver or having the patient bend over for a few minutes) can increase the intracranial pressure and reveal the leak. Nasal endoscopy is used to detect bone defects, meningoceles, or meningoencephaloceles in the nose. Neuro-ophthalmologists have an important in the diagnosis of intracranial hypertension. They use fundoscopy and visual field testing to evaluate the retina and optic nerve head and papilledema, and use optical coherence tomography to check the optic nerve changes. Neuro-ophthalmologists are the primary clinicians who treat IIH. Neuroradiological evaluations, including fine cut CT scan and magnetic resonance imaging (MRI), are important for suspected or diagnosed CSF leaks. 5,6 Findings on CT scans, such as bony defect of the skull base (dehiscence in the anterior skull base or and temporal bone) can be helpful in the diagnosis. MRIs can show the presence of meningoceles (dura and CSF outpouching), meningoencephaloceles (brain, dura, and CSF outpouching), and inflammation of the dura in the area in question on post-contrast imaging. MRI also plays an important role in the diagnosis of spontaneous CSF leak in IIH by demonstrating noteworthy signs including an empty sella, flattening of the posterior globes, optic nerve head protrusions, distention of the optic nerve sheaths, tortuosity of the optic nerve, cerebellar tonsillar herniation, meningoceles, CSF leaks, and transverse venous sinus stenosis. The most sensitive and specific laboratory tests for CSF leak diagnosis are beta2-transferrin and beta trace protein which are used on collected nasal secretions. Nasal endoscopy with intrathecal 5% fluorescein is indicated when no signs of leak are found on nasal endoscopy or imaging and when beta2-transferrin and beta trace protein are inconclusive or unavailable. If no CSF leak is found, pseudo-CSF leak diagnosis is made and an intranasal ipratropium trial is indicated. Finally, if the patient shows no improvement, then surgical exploration and treatment are indicated. In addition, screening for medication that can exacerbate IIH, including doxycycline, carbidopa, levodopa, cyclosporine, danazol, lithium, phenytoin, vitamin A, and some contraceptive drugs is also necessary. 3,4 This patient’s imaging showed no leak at the site of the previous craniotomy. Her MRI showed the Eustachian tube packing is still in place (Figures 1 and 2). In addition, contrast concentration (per pixel) in bilateral acoustic meatus or paranasal sinuses measured on radionuclide cisternography did not reveal any rapid or high-flow leak (Figure 3). These findings might be attributable to a very slow-flow and intermittent CSF leakage that cannot be identified using standard imaging—as in this case, the tracer did not have the time to egress the subarachnoid space. Treatment includes conservative and surgical therapies. Conservative therapy is the first choice in patients without an immediate need for intervention. It is recommended for patients to be on bed rest with the head raised by 30 degrees for 1-2 weeks. Medications include antitussives, antiemetics, corticosteroids, and stool softeners. Diuretics such as acetazolamide, reduce the CSF production at the choroid plexus, resulting in lower intracranial (IC) pressure. Lumbar puncture with opening pressure is recommended in patients with high IC pressure. Surgical strategies include wound exploration, mastoid obliteration, Eustachian tube occlusion, and lumboperitoneal shunts placement. Since late-onset CSF leak following a vestibular schwannoma resection can be due to increased intracranial pressure, patient’s evaluation is completed by a referral to a neuro-ophthalmologist. Since patient workup (nasal endoscopy, CT scan, MRI, radionuclide cisternography) (Figures 4 and 5) showed no sign of CSF leak, an intranasal ipratropium trial (0.03%, twice a day for two weeks) was initiated. In addition, the patient was advised to see a neuro-ophthalmologist for further evaluation of intracranial hypertension. The patient came back after two weeks with no improvement, and therefore, our next step was to discuss surgical options. The two main options included exploration of the previous craniotomy wound versus left-sided transcanal and transnasal endoscopic (transtympanic) CSF leakage control with blockage of the Eustachian tube given the history of multiple late leaks in this patient. Patients with CSF leaks need to be evaluated by a neuro-ophthalmologist after closure of the leak as the closure of the leak can lead to increased intracranial pressure again. The CSF leak creates a pressure valve that will decrease the intracranial pressure while open. However, when the leak is closed, the intracranial pressure can start increasing. BONUS ONLINE VIDEOS: VISUAL DIAGNOSIS Read this month’s Clinical Consultation case, then watch the accompanying videos from Hamid R. Djalilian, MD, to review the patient’s imaging for yourself. Video 1. Axial (horizontal) T1 FLAIR non-enhanced MRI showing the Eustachian tube packing is still in place. Video 2. Axial (horizontal) CT of temporal bones after contrast injection into the CSF space showing the contrast in the CSF. Video 3. Coronal (parallel to the face) CT of temporal bones after contrast injection into the CSF space showing no gross contrast in the middle ear indicating not a fast flow leak. Video 4. Axial (horizontal) T2 MRI demonstrating ischemic changes in middle cerebellar peduncle and cerebellum on left side of image (patient’s right side). Video 5. Axial (horizontal) CISS MRI showing the different density in the mastoid and middle ear representing scar, fat, and fluid. Video 6. Coronal (parallel to the face) T1 FLAIR demonstrating the anatomy in the coronal plane. Watch the patient videos online at thehearingjournal.com.

The diagnosis of cerebrospinal fluid leakage after microvascular decompression surgery and management via lumbar drain

Objective: In posterior fossa surgery such as microvascular decompression (MVD), cerebrospinal fluid (CSF) leakage is a crucial problem. In this study, we explored the accurate diagnosis and effective non-surgical management of postoperative CSF leakage.Methods: We reviewed 749 patients who underwent MVD surgery from August 2018 to April 2022. Although we significantly reduced the CSF leakage problem by using the triple-layer closing technique (TLCT), CSF leakage was still a problem in a few cases. We managed these patients with the same diagnostic flow and treatment regimen using a lumbar drain (LD).Results: Among the 749 patients in the cohort, 11 (1.4%) had CSF leakage, and each of those cases presented with rhinorrhea. Five patients (45.5%) had the symptom on the first day, two patients (18.2%) on the second day, one patient (9.1%) on the third day, and three patients (27.3%) on the fifth day after surgery. After conservative treatment including CSF drainage via LD for 5.4 days on average, none of the patients had recurrent symptoms suggesting CSF leakage; thus, there was no need for wound repair surgery.Conclusion: Despite diligent attempts to prevent CSF leakage in open microsurgery, leaks inevitably occur in some cases and are more frequent in posterior fossa surgery. Although we cannot fully prevent leakage, we should limit the complication to ensure that it does not progress into other severe problems, such as meningitis. A closing technique such as TLCT is useful, but the early diagnosis and management of CSF leakage with LD is also important.

Diagnosis and management of pediatric cerebrospinal fluid leakage secondary to inner ear malformations: A report of 13 cases

ObjectivesInner ear malformations (IEM) with cerebrospinal fluid (CSF) leakage in children is a rare condition, nevertheless, it may lead to meningitis. Early diagnosis and treatment are crucial. The aims of the study were to summarize the clinical characteristic of pediatric CSF leakage secondary to IEM, and to recommend transcanal endoscopic ear surgery (TEES) as an effective surgical technique for the treatment of CSF leakage with IEM in children. MethodsThis was a retrospective study. Thirteen children and fourteen ear surgery were included. Demographics, detail history, laboratory data, Audio test, and imageological examination results were recorded. All the pediatric patients underwent TEES. ResultsMost (92.31%) of the children presented with a history of rhinorrhea. 69.23% (9/13) of the children had suffered from meningitis, and the other had presented with respiratory tract infections. The follow-up duration ranged from 0.75 years to 5.29 years. Transcanal endoscopic repair of CSF leakage secondary to IEM was the first surgery with a success rate of 92.86% (13 out of 14 cases). A fistula could be found in the stapes footplate in all pediatric patients. ConclusionEven if there has been no history of meningitis, the diagnosis of CSF leakage in children suffering from unilateral rhinorrhea and recurrent respiratory tract infection is considered. Auditory brainstem response (ABR) and Temporal bone computed tomography (CT) examinations are suggested to identify IEM. The TEES procedure is recommended in our study as the first choice that repairs CSF leakage secondary to IEM.

Retrospective validation of a β-trace protein interpretation algorithm for the diagnosis of cerebrospinal fluid leakage.

Cerebrospinal fluid (CSF) leakage is a rare condition that can potentially lead to the development of serious complications. In the last decade, β-trace protein (β-TP) has been shown to be a valuable immunological biomarker that allows prompt and non-invasive identification of CSF leakage. At our institution, the measurement of β-TP has been included in the diagnostic work-up of CSF leakage for more than 10 years. According to our diagnostic algorithm, the presence of CSF in secretion is excluded when β-TP values are <0.7 mg/L, whereas β-TP values ≥1.3 mg/L indicate the presence of CSF in secretion. β-TP values between 0.7 and 1.29 mg/L indicate the presence of CSF if the β-TP ratio (β-TP secretion/β-TP serum) is ≥2. This study aimed to validate this diagnostic algorithm using clinically defined nasal/ear secretions. We performed a retrospective statistical analysis of three β-TP interpretation strategies using data of 236 samples originating from 121 patients with suspect CSF leakage received at our laboratory between 2004 and 2012. The highest odds ratio was obtained when the proposed algorithm has been used for the interpretation of β-TP results, showing a sensitivity of 98.3% and a specificity of 96%. Positive and negative predictive values were 89.2% and 99.4%, respectively. Our data suggest that the proposed β-TP interpretation algorithm is a valuable tool for the diagnosis of CSF leakage in the clinical practice.

Pneumocephalus leading to the diagnosis of cerebrospinal fluid leak and esophageal perforation after cervical spine surgery

Pneumocephalus is a collection of air within in the intracranial cavity, most commonly seen following traumatic injury or cranial surgeries. Esophageal injury and cerebrospinal fluid (CSF) leak are rare complications that may occur following anterior cervical discectomy and fusion (ACDF). We present a novel case of pneumocephalus arising from unrestricted leakage of CSF via coincident esophageal injury and durotomy in a patient who underwent an ACDF after trauma. A 21-year-old man presented to an outside hospital with C5/C6 subluxation, complete spinal cord injury, and quadriplegia from a motor vehicle accident. He underwent an ACDF, during which a CSF leak was observed. He was then transferred to our institution for rehabilitation and tracheostomy placement 1week after the ACDF surgery. Following the tracheostomy, the patient developed intractable fevers and nonspecific symptoms. A CT scan demonstrated frontal pneumocephalus without mass effect. Air was found in the retropharyngeal space. There were no accumulations of CSF in the neck. Extravasation of contrast around instrumentation at C5/C6 on a cine esophagogram demonstrated an esophageal perforation at that level. Pneumocephalus may form when large volumes of CSF escape from the intracranial space and air is drawn into the space by the negative pressure. In this unusual case, the esophageal perforation promoted the formation of the pneumocephalus. Treatment included closure of both defects, disrupting the suspected communication between the intracranial space and the esophagus.

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.

False negative β-2 transferrin in the diagnosis of cerebrospinal fluid leak in the presence of Streptococcus pneumoniae.

The objectives of this study were to examine the presence of β-2 transferrin (β2TRNSF) in cerebrospinal fluid (CSF) contaminated in vitro by various bacteria and explore the mechanism (passive or active) responsible for β2TRNSF elimination. Early diagnosis of CSF leakage may change treatment decisions and minimize the risk of meningitis and encephalitis. β2TRNSF is a protein present exclusively in CSF. Its detection is highly useful in cases of CSF leakage, although it has never been examined in the presence of central nervous system infection. Prospective patient analysis. Sterile CSF drawn from patients was contaminated in vitro with several microorganisms chosen for their ability to cause neurosurgical-related infections: Streptococcus pneumoniae, methicillin-sensitive Staphylococcus aureus, Staphylococcus epidermidis, and Pseudomonas aeruginosa. β2TRNSF was examined at two time points: following immediate inoculation (t0) and following an overnight incubation (t18) over various bacterial concentrations. Samples of CSF inoculated with S pneumoniae were also examined in the presence of ciprofloxacin. For β2TRNSF analysis we used immunoblotting electrophoresis and enzyme-linked immunosorbent assay (ELISA). CSF samples collected from nine patients were analyzed. β2TRNSF was not detected following S pneumoniae inoculation at both time points when immunoblotting electrophoresis was used. Quantitative analysis using ELISA demonstrated significant β2TRNSF concentration decrease. The addition of ciprofloxacin led to the same results. CSF leak detection using β2TRNSF may be deceiving in the presence of a S pneumoniae cerebral nervous system infection. A passive process is suggested, as β2TRNSF disappeared either immediately or following incubation with inactive bacteria.

Predictability of Quantification of Beta-Trace Protein for Diagnosis of Cerebrospinal Fluid Leak: Cutoff Determination in Nasal Fluids with Two Control Groups

Cerebrospinal fluid (CSF) leak of the anterior skull base is an abnormal communication between the subarachnoid space and the nasal cavity or the paranasal sinus. Its presence increases the incidence of complications, as meningitis, with risk of sequelae. The early and correct diagnosis of the CSF leaks is important to perform surgical treatment as soon as possible. The CSF detection in nasal fluids could be made through the beta2-transferrin (beta2Tr) immunoelectrophoretic test, an expensive and cumbersome immunologic test, not available to the majority of the Brazilian hospitals. Recently, the detection of beta-trace protein (betaTP) for identification of CSF leaks has been described. The literature suggests there may be similar sensitivity and specificity to tests of beta2Tr, because betaTP is also a specific brain protein and it is present in CSF in high concentrations. The majority of Brazilian hospitals have the nephelometric equipment for betaTP detection. This study was designed to determine threshold values for betaTP concentrations in nasal cavity secretions as a predictor of CFS leak. Nasal secretions were collected from patients with suspicion of CSF leak and from healthy volunteers. Pure CSF samples were used. A nephelometric assay was used to determine the betaTP concentration in samples. Values between 0.244 and 0.496 mg/L were determined for the cutoff. Beta-trace concentrations above 0.496 mg/L are highly suggestive of the presence of CSF in examined nasal secretion. Positive predictive value and negative predictive value were 100%. BetaTP nephelometric test can predict the side of the CSF leak.

Symptom Predictors of Cerebrospinal Fluid Leaks

Spinal cerebrospinal fluid (CSF) leaks, which are considered a cause of intracranial hypotension, generally do not cause any local symptoms. Although symptoms are key elements for further evaluation, few studies have examined symptom predictors of intracranial hypotension. The aim of this study was to determine what symptoms are predictors of CSF leaks in patients suspected of intracranial hypotension. We performed radionuclide cisternography in 207 consecutive patients suspected of intracranial hypotension. Intracranial hypotension was suspected when a patient had a history of minor trauma and complained about uncontrolled headache, cranial nerve dysfunction, autonomic dysfunction, or higher brain dysfunction. The leakage of CSF was defined as direct signs of tracer leak into the spinal epidural space or early accumulation of the tracer in the urinary bladder. We obtained information on 16 symptoms commonly reported in previous studies. CSF leaks were observed in 154 cases (74%). Back pain, limb pain, and limb numbness were inversely associated with CSF leaks (p = 0.042, p = 0.045, and p = 0.006, respectively). In logistic regression analysis, diplopia was a positive predictor of CSF leaks (odds ratio [OR], 6.53; 95% confidence interval [CI], 1.49 to 28.51), whereas limb numbness was a negative predictor (OR, 0.38; 95% CI, 0.17 to 0.84). Of the 21 patients in whom diplopia was present and limb numbness was absent, 20 had CSF leaks (specificity, 98%; positive predictive value, 95%). Some symptoms may be helpful in the diagnosis of CSF leaks in patients suspected of intracranial hypotension.

Tracer Clearance in Radionuclide Cisternography in Patients with Spontaneous Intracranial Hypotension

We semiquantitatively analysed radionuclide cisternography in three patients with spontaneous cerebrospinal fluid (CSF) leakage diagnosed by typical symptoms and magnetic resonance imaging findings before and several months after treatment with epidural blood patch. Radioactivity in the whole CSF space was measured immediately after and at 1, 5, 7 and 24 h after intrathecal injection of (111)In-diethylenetriaminepentaacetic acid (DTPA). Initial findings included the vague appearance of leakage in the thoracic spine in two patients, early bladder filling at 1 h in one and a lack of tracer filling into the high cranial convexity in all three. The radioactivity count rapidly decreased within several hours after injection and reached 20% of the initial value at 24 h. In contrast, no rapid decrease was observed after treatment and more than 50% of tracer remained at 24 h after injection. Semiquantitative analysis of tracer clearance may provide additional information in the diagnosis of CSF leakage, especially with no obvious qualitative findings.

Differentiation Between Cerebrospinal Fluid and Serum with Electronic Nose

The study investigates the ability of the electronic nose to differentiate between cerebrospinal fluid (CSF) and serum and to identify an unknown specimen as CSF or serum. CSF and serum specimens were heated and tested with an organic semiconductor-based Cyranose 320 electronic nose (Cyrons Sciences, Pasadena, CA). Data from the 32-element sensor array were subjected to principal component analysis to depict differences in odorant patterns. The electronic nose was able to distinguish between CSF and serum isolates with Mahalanobis distance >5. Furthermore, the electronic nose was able to place unknown specimens in the appropriate class of CSF or serum. The electronic nose is a novel method that may allow rapid, low cost, and reliable distinction between CSF and serum in a clinical setting. Because the results are available almost immediately, the electronic nose is a powerful tool that in the future may allow for rapid diagnosis of CSF leaks in the office setting.

β-Trace Protein as a Marker for Cerebrospinal Fluid Rhinorrhea

Cerebrospinal fluid (CSF) leakage occurs mainly as a complication of head injuries or skull-base surgeries, but may also occur spontaneously or as a result of nontraumatic processes such as inflammatory disorders or tumors (1). Detection and management of CSF leakage is essential to prevent possible life-threatening infections of the central nervous system (2). Radiologic and invasive procedures may be used for the diagnosis of CSF leaks, but these procedures are laborious, expensive, and present potential risk to the patient. Therefore, noninvasive laboratory methods serve as screening procedures before definitive procedures are used to localize the site of the defect. Laboratory assessment of CSF leakage relies on compositional differences between CSF and other body secretions. The β2-transferrin (β2Tr) τ-fraction, or asialotransferrin, is a brain-specific variant of transferrin that lacks neuraminic acid. It therefore can be distinguished from serum transferrin by electrophoretic procedures and used to detect CSF rhinorrhea (3)(4). However, β2Tr is present in aqueous humor and in perilymph fluid and can be detected in serum, especially in chronic alcohol abusers and in patients with inborn errors of glycoprotein metabolism or genetic variants of transferrin (5)(6). β-Trace protein (βTP), recently identified as prostaglandin D2 synthase (7), is another brain-specific protein that is produced mainly in the leptomeninges and the choroid plexus and is secreted into the CSF. βTP is the second most abundant protein in CSF after albumin. However, it is also present in other body fluids, including serum, albeit at much lower concentrations than in CSF (8). Immunoelectrophoretic methods for βTP have been applied as a screening procedure for CSF leaks (9)(10). Recently, a nephelometric assay for the quantification of βTP was introduced that promised several advantages over current CSF detection methods, including enhanced sensitivity and reduced turnaround time (11 …

Bowel visualization during indium-111-labelled diethylene triamine penta-acetic acid cisternography due to massive cerebrospinal fluid leak

We report a case of massive cerebrospinal fluid (CSF) leakage where the tracer injected intra-thecally for radionuclide cisternography was later visualized in the bowel as well as the nasopharynx. We discuss the potential implications of this finding in patients with CSF leaks. A brief review of the diagnosis of CSF leaks is included.

Radionuclide demonstration of ventriculoatrial shunt-cutaneous fistula with cerebrospinal fluid leak

Radionuclide techniques have commonly been used to assess ventriculovenous shunt function, cerebrospinal fluid dynamics, and for the diagnosis of cerebrospinal fluid leaks. All of these techniques were utilized in this unusual case of retrograde migration of a ventriculoatrial catheter into the neck, with cutaneous fistulization and CSF leak.

Radioisotope cisternography in the diagnosis of cerebrospinal fluid leakage

Radioisotope cisternography in the diagnosis of cerebrospinal fluid leakage