Radioisotope Cisternography Research Articles

Spontaneous Intraventricular Tension Pneumocephalus

Here, we report a very rare case of spontaneous intraventricular tension pneumocephalus. This case concerns a 40-year-old patient with medical history of a tumor of the pineal region and a secondary hydrocephalus treated by multiple ventriculoperitoneal shunts. He presented in the emergency room because of unusual headaches, nausea, and visual loss. In addition, he reported slight rhinorrhea in the past few weeks. The initial brain computed tomography scan revealed a spontaneous intraventricular tension pneumocephalus. There was no history of recent head trauma and no sign of disconnection of the shunt system. A complementary radiologic assessment including a thin-slice bone computed tomography scan and a radioisotope cisternography revealed an osseous defect and an isotope leakage at the junction between the tegmen tympani and the squamous part of the left temporal bone. A middle cranial fossa surgery was performed to repair the osteo-meningeal breach.

Modern approaches to the diagnosis and treatment of spontaneous intracranial hypotension (a literature review)

The aim of this review is to analyze and summarize the existing evidence regarding the diagnosis and treatment of spontaneous intracranial hypotension. Spontaneous intracranial hypotension occurs due to a decrease in cerebrospinal fluid (CSF) volume as a result of its spontaneous leakage and has a variety of clinical and neuroimaging features, sometimes different from CSF hypotension after a lumbar puncture. Anatomical changes in spontaneous CSF leakage are complex and are often associated with structural disorders of the connective tissue, weakness of certain areas of the dura mater and its diverticulosis. One consequence of decreased CSF volume is brain descent. This leads to traction of pain-sensitive brain structures and, therefore, to headaches that are orthostatic or with some orthostatic features. The methods of choice to identify the site of CSF leak are CT-myelography and radioisotope cisternography. Epidural blood patch is the main treatment in most cases. Conclusions. The study on the most informative and minimally invasive methods to locate the site of CSF leak, conservative and surgical methods of treatment efficacy evaluation depending on the etiological factors of spontaneous intracranial hypotension are extremely important and promising scientific fields requiring further research with the development of personalized approaches considering the individual characteristics of each patient.

Use of combined radioisotope cisternography with SPECT/CT for identifying the site of cerebrospinal fluid leakage: a report of three cases

Use of combined radioisotope cisternography with SPECT/CT for identifying the site of cerebrospinal fluid leakage: a report of three cases

The Cervical Spine as a Predominant Site of Cerebrospinal Fluid Leak: Preliminary Results Using the Overflow Leak Test

Cerebrospinal fluid (CSF) hypovolemia is usually treated via an epidural blood patch (EBP). Accurate placement of the EBP at the site of CSF leakage is required for successful treatment of CSF hypovolemia. The thoracolumbar spine is evidently a common site of leakage, but because rates of detection of the leakage site via conventional imaging have historically not been high, there may be other common leakage sites. In this study, CSF leakage sites were identified via a combination of conventional imaging, a new method called the overflow leak test, and patient interviews. CSF leakage sites were identified using computed tomography myelography, radioisotope cisternography, and the overflow leak test in 14 patients with CSF hypovolemia. The patients were also asked about their history with regard to potential trauma. EBP was performed, and the accuracy of leakage site identification was assessed. Conventional imaging identified a leakage site in 7 of 14 patients, and in most cases it was in the lumbar spine. In the remaining 7 cases, the overflow leak test and ascertaining a history of trauma facilitated identification of the cervical spine as a leakage site. The site of the EBP was the cervical spine in 10 patients and the lumbar spine in 4 patients. Complete recovery was observed in 13 of 14 patients. The cervical spine was a common leakage site in this study. Leakage in the cervical spine was undetectable via conventional imaging, suggesting that many cases of cervical spine leakage may remain undetected.

Predictors of the Response to an Epidural Blood Patch in Patients with Spinal Leakage of Cerebrospinal Fluid

Background and PurposeAn epidural blood patch (EBP) is a highly effective therapy for spinal cerebrospinal fluid (CSF) leakage. However, the factors predicting the response to an EBP have not been fully elucidated. The aim of this study was to elucidate factors predicting the response to an EBP.MethodsWe retrospectively examined the relationship between the response to an EBP and clinical variables of 118 patients with spinal CSF leakage, such as patient age, sex, etiology, interval from the onset to EBP application, CSF opening pressure (OP), radioisotope (RI) cisternography findings, rate of RI remaining in the CSF space, computed tomography (CT) myelography findings, magnetic resonance imaging (MRI) findings, and subjective symptoms (headache, vertigo/dizziness, visual disturbance, nausea, numbness, nuchal pain, back pain/lumbago, fatigability, photophobia, and memory disturbance). The correlations between these variables and the responses to EBPs were analyzed statistically.ResultsA positive response to an EBP was significantly (p<0.05) correlated with the following variables: <1.5 years from the onset to EBP application, age <40 years, CSF OP <7 cm H2O, epidural CSF leakage in RI cisternography, epidural CSF collection in MRI, <20% RI remaining after 24 hours, orthostatic headache, nausea, nuchal pain, and photophobia. The other variables did not show significant correlations with the responses to EBPs.ConclusionsIt might be prudent to take the following variables into account when applying an EBP to treat spinal CSF leakage: the interval from the onset to EBP application, age, CSF OP, epidural CSF leakage in RI, epidural CSF collection in MRI, rate of remaining RI, orthostatic headache, nuchal pain, photophobia, and nausea.

Predictors of the Treatment Response of Spontaneous Intracranial Hypotension to an Epidural Blood Patch.

Spontaneous intracranial hypotension (SIH) is characterized by postural headache because of low cerebrospinal fluid (CSF) pressure. Brain magnetic resonance imaging (MRI) and radioisotope (RI) cisternography can be used to identify the site of a CSF leakage. Although autologous epidural blood patch (EBP) is a very effective treatment modality, some patients require a repeat autologous EBP. We investigated whether autologous EBP responses correlate with surrogate markers of quantitative findings.All cases of autologous EBP for SIH from January 2006 to December 2014 were enrolled. The demographic variables, number of EBPs, pain scores, RI cisternography (early visualization of bladder activity), and MRI findings (subdural fluid collections, pachymeningeal enhancement, engorgement of venous structures, pituitary hyperemia, and sagging of the brain) were reviewed.Patients with early bladder activity on RI cisternography had a tendency to need a higher number of autologous EBPs. Only sagging of the brain and no other variables showed a statistically significant negative correlation with the number of autologous EBPs.The response to autologous EBP may be related to the radiologic findings of early bladder activity on RI cisternography and sagging of the brain on MRI.

A new approach for simple radioisotope cisternography examination in cerebrospinal fluid leakage detection.

We developed a new quantitative interpretation technique of radioisotope cisternography (RIC) for the diagnosis of spontaneous cerebrospinal fluid hypovolemia (SCH). RIC studies performed for suspected SCH were evaluated. (111)In-DTPA RIC images were taken at 0, 1, 3, 6, and 24-h after radioisotope injection following the current protocol. Regions of interest (ROI) were selected on 3-h images to include brain, spine, bladder or the whole body. The accumulative radioactivity counts were calculated for quantitative analysis. Final diagnoses of SCH were established based on the diagnostic criteria recently proposed by Schievink and colleagues. Thirty-five patients were focused on. Twenty-one (60.0%) patients were diagnosed as having SCH according to the Schievink criteria. On the 3-h images, direct cerebrospinal fluid leakage sign was detected in nine of 21 SCH patients (42.9%), as well as three patients with suspected iatrogenic leakage. Compared to non-SCH patients, SCH patients showed higher bladder accumulation at 3-h images (P = 0.0002), and higher brain clearance between the 6- and 24-h images (P < 0.0001). In particular, the 24-h brain clearance was more conclusive for the diagnosis than 24-h whole cistern clearance. The combination of direct sign and 24-h brain accumulation resulted in 100% of accuracy in the 32 patients in whom iatrogenic leakage was not observed. 1- and 6-h images did not provide any additional information in any patients. A new simple ROI setting method, in which only the 3-h whole body and 24-h brain images were necessary, was sufficient to diagnose SCH.

Use of fat-suppressed T2 -weighted sagittal images after infusion of excess saline into the subarachnoid space as a new diagnostic modality for cerebrospinal fluid hypovolemia: technical note

The diagnosis of CSF hypovolemia remains controversial. The primary diagnostic factor relies on confirmation of leakage of the CSF based on reduced spinal fluid pressure. Determining the specific leakage site is the most important issue for effective treatment but remains a difficult task. Although CT myelography, radioisotope cisternography, and MRI are commonly performed in the diagnosis of CSF hypovolemia, these techniques can rarely identify the precise leakage site. Therefore, an epidural blood patch is performed in the lumbar spine in many cases. This study reports a new diagnostic modality that can help to confirm the leakage site. Fat-suppressed T2-weighted sagittal images were compared before and after the infusion of 20 ml of saline into the subarachnoid space of the lumbar region to detect the specific leakage site with high probability. Three patients were successfully treated by the epidural blood patch based on data obtained with the new diagnostic modality. Two patients were treated in the cervical region and 1 in the lumbar region. The use of fat-suppressed T2-weighted sagittal images after saline infusion could be a relevant diagnostic modality compared with images obtained by CT myelography, radioisotope cisternography, and ordinary MRI to achieve accurate diagnosis and effective treatment of patients with CSF hypovolemia.

Spontaneous Intracranial Hypotension.

Spontaneous intracranial hypotension results from CSF volume depletion, nearly always from spontaneous CSF leaks. Spontaneous intracranial hypotension is increasingly diagnosed in practice; the number of atypical, unconfirmed, and doubtful cases is also increasing, as are treatment failures. These confront neurologists and create many challenges. This review provides neurologists with a guide to diagnosis, evaluation, and treatment of spontaneous intracranial hypotension. The clinical spectrum of spontaneous intracranial hypotension is expanding. Spontaneous CSF leak is considered a disorder with a variety of clinical manifestations and imaging features, sometimes quite different from what may be seen after dural puncture. The anatomy of the spontaneous CSF leak is frequently complex, with contributions from disorders of the connective tissue matrix and associated preexisting areas of dural weakness and meningeal diverticula. To locate the site of the leak, CT myelography is still the study of choice. For rapid-flow leaks, dynamic CT myelography has been very helpful, while slow-flow leaks can remain a lingering challenge. The fundamental question of whether a CSF leak is present in uncertain cases can be best answered by radioisotope cisternography. In most cases, epidural blood patch is the main treatment; however, bilevel or multilevel epidural injections are gaining some momentum as treatment for selected cases. This article outlines various clinical aspects of spontaneous intracranial hypotension, including headache characteristics, CSF changes, and imaging findings and their underlying mechanisms, as well as treatments and disease complications.

Cerebrospinal fluid leakage. Indications, technique and results of treatment with a blood patch

In most cases cerebrospinal fluid (CSF) leaks are iatrogenic and caused by medical interventions, such as lumbar puncture, peridural anesthesia and surgical interventions on the spine, However, spontaneous cerebral hypotension is currently detected more frequently due to improvements in diagnostic possibilities but often the cause cannot be clarified with certainty. There are various diagnostic tools for confirming the diagnosis and searching for the site of CSF leakage, such as postmyelography computed tomography (postmyelo-CT), indium(111) radioisotope cisternography and (myelo) magnetic resonance imaging (MRI), which show different sensitivities. In accordance with own experience native MRI with fat-saturated T2-weighted sequences is often sufficient for diagnosing CSF leakage and the site. For the remaining cases an additional postmyelo-CT or alternatively myelo-MRI is recommended. In some patients with spontaneous cranial hypotension multiple CSF leaks are found at different spinal levels. The main symptom in most cases is an orthostatic headache. While post-puncture syndrome is self-limiting in many cases, spontaneous CSF leakage usually requires blood patch therapy. A lumbar blood patch can be safely carried out under guidance by fluoroscopy. In the case of a cervical or dorsal blood patch, CT guidance is recommended, which ensures epidural application of the blood patch and minimizes the risk of damaging the spinal cord. Despite a high success rate at the first attempt with a blood patch of up to 85%, some cases require repeating the blood patch. A targeted blood patch of a CSF leak should generally be favoured over a blindly placed blood patch; nevertheless, if a CSF leak cannot be localized by CT or MRI a therapeutic attempt with a lumbar blood patch can be carried out. After a successful blood patch intracranial hygromas and pachymeningeal enhancement in the head show fast regression; however, epidural hygromas of the spine can persist for a period of several months, even though patients are already free of symptoms. In total, blood patch therapy is a safe and technically relative simple method with a high success rate. Therefore, it represents the therapy of choice in patients with spontaneous cerebrospinal fluid leakage as well as in cases of post-lumbar puncture syndrome refractory to conservative therapy.

Neuro-otological Studies of Patients Suffering from Dizziness with Cerebrospinal Fluid Hypovolemia after Traffic Accident-associated Whiplash Injuries

Vertigo and dizziness are common clinical manifestations after traffic accident-associated whiplash injury. Recently, Shinonaga et al. (2001) suggested that more than 80% of patients with whiplash injury complaining of these symptoms showed cerebrospinal (CSF) hypovolemia on radioisotope (RI) cisternography (111In-DTPA). However, neuro-otological studies to investigate the pathophysiological mechanisms underlying these symptoms have been insufficient. In the present study, patients complaining of these symptoms with CSF hypovolemia after traffic accidents were investigated with posturography and electronystagmography (ENG). Fourteen patients (4 men, 10 women; 24-52 yr) were examined with posturography and showed parameters (tracking distance & area) significantly (p<0.01) larger than those of healthy subjects. Among them, five cases (1 man, 4 women; 31-52 yr) were further investigated with ENG. The slow phase peak velocities of optokinetic nystagmus (OKN) and optokinetic-after nystagmus (OKAN) were significantly (p<0.01) reduced (62.64±6.9 SD deg/sec, 60.76±10.74 SD deg/sec, respectively) and frequencies of OKN were reduced (139.7±10.75 SD), while the ocular smooth pursuit was relatively preserved. Magnetic resonance images (sagittal view) of these five patients demonstrated the downward displacement of the cerebellar tonsils and flattening of the pons, which are characteristic features of CSF hypovolemia, called "brain sagging." Our results suggest that brain sagging due to CSF hypovolemia impairs vestibular and vestibulocerebellar functions, which may cause dizziness and vertigo.

3D-CT Epidurography Can Detect Cerebrospinal-Fluid Leakage in a Patient with Spontaneous Intracranial Hypotension: A Case Report.

Spontaneous intracranial hypotension presents with many symptoms including orthostatic headache, dizziness, and nausea due to cerebrospinal-fluid (CSF) leakage from the spinal dural sac. Although CSF leakage can be estimated by radioisotope (RI) cisternography or computed tomography/magnetic resonance imaging myelography, it is not easy to detect the leakage point using these modalities. Here, we describe a patient with spontaneous intracranial hypotension in whom three-dimensional computed tomography (3D-CT) performed just after an epidural blood patch (EBP) containing contrast medium detected leakage point. The contrast medium injected into the epidural space at the L3/4 level migrated into the intradural space at the lower cervical spine level. RI cisternography performed before EBP did not show the CSF leakage point or any intracranial extension of the tracer. The rostral extension of the RI may be blocked by the collapse of the CSF space due to a large amount of CSF leakage, and due to the compression of the intradural CSF space by epidural CSF. 3D-CT epidurography may be useful to detect the fistula of a CSF leakage even in patients where other modalities including MRI, CT, or RI cisternography cannot specify the leakage point.

Radioisotope cisternography in spontaneous CSF leaks: interpretations and misinterpretations.

A broadening of the clinical and imaging features of the spontaneous cerebrospinal fluid (CSF) leaks is now well recognized, far beyond what was thought only two decades ago. This has resulted in increasing number of patients with atypical and unusual features who, not unexpectedly, are directed to headache specialists and tertiary referral centers. In many cases, obviously the fundamental question of presence or absence of CSF leak will need to be addressed prior to proceeding with further and often more involved, more invasive, and more costly diagnostic and therapeutic considerations. Radioisotope cisternography often proves to be very helpful in these situations by demonstrating reliable, although indirect, evidences of CSF leak while it is less helpful in directly identifying the exact site of the CSF leakage. In this overview article, the expectations from and the limitations of this diagnostic method are described along with some personal observations in the past 25 years.

Radioisotope Cisternography: A Potentially Useful Tool for Headache Diagnosis in Patients with an IDD Pump

Background: Spontaneous intracranial hypotension (SIH) and related headache after intrathecal pump implantation is a possibility. Knowing the exact location of the cerebrospinal fluid (CSF) leak is mandatory for managing with interventional therapies. Objectives: Radioisotope cisternography (RICG) is a common procedure in nuclear medicine and may be used as an additional procedure in the differential diagnosis of headaches due to intracranial liquor hypotension syndrome caused by microleakage of CSF. Study Design: We report an imaging case of complex chronic headache in a patient with an implanted drug delivery pump. The symptomatology of the patient was considered typical of spontaneous intracranial hypotension (SIH). Therefore, the initial suspicion was the loss of CSF due to the implanted pump catheter. The negativity of the routine headache test can exclude any leakage of CSF at the site of catheter insertion. Setting: Anesthesia, Critical Care, and Multidisciplinary Pain Management Department, General University General Hospital, Valencia, Spain. Results: Many patients are treated with implanted intrathecal infusion systems. In these patients, any neurological symptoms are readily attributed to the invasive neuroaxial system, especially severe cephalalgia. RICG was helpful in this particular case to make a diagnosis of exclusion of the diagnosis of SIH due to CSF leakage. Conclusion: RICG may be considered as an additional diagnostic technique in patients with chronic pain and implanted spinal infusion devices for whom standard detection procedures have been exhausted. Key words: Intrathecal drug delivery (IDD), chronic headache (CH), radiosotope cisternography (RICG), cerebrospinal fluid leakage, spontaneous intracranial hypotension (SIH)

A Rare Case of Chiari Type-1 Malformation Accompanied by Symptomatic Cerebrospinal Fluid Hypovolemia: Comparison of Congenital Chiari Type-1 Malformation and Acquired Chiari Malformation Secondary to Cerebrospinal Fluid Hypovolemia: Case Report

A 23-year-old woman was injured in a rear-end collision. She had general malaise and posterior neck pain, which were more severe when she was in an upright position. Magnetic resonance imaging (MRI) revealed the presence of cerebellar tonsil descensus and syringomyelia in the spinal cord. Radioisotope (RI) cisternography showed signs of an early accumulation of RI in the bladder, and a delayed accumulation of RI in the cerebral fornix. We considered the possibilities of cerebrospinal fluid (CSF) hypovolemia and congenital Chiari type-1 malformation as being responsible for her headache. To obtain a definitive diagnosis, we performed gadolinium (Gd)-enhanced MR cisternography and found evidence of CSF leakage. We performed an epidural blood patch (EBP), and her symptoms resolved. In 2 years since the episode, her symptoms have not recurred, and additional treatment has not been required. In addition, MRI performed 2 years after the EBP did not reveal any changes. There seems no previous report which described successful differentiation of pre-existing congenital Chiari type-1 malformation from the acquired one caused by symptomatic CSF hypovolemia. Because treatment protocols differ between these two conditions, the establishment of a correct diagnosis is important.

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.

Detection of Surgery-related Spinal Cerebrospinal Fluid Leakage Using Magnetic Resonance Myelography

An incidental dural tear resulting in cerebrospinal fluid (CSF) leakage is a complication of spinal surgery, with a reported incidence of between 0.3% and 16% (1, 2). The patient is likely to experience symptoms of CSF hypovolemia, including postural headache plus nausea, vomiting, pain or tightness in the neck or back, dizziness, diplopia, photophobia, tinnitus, and/or blurred vision. The usual treatment of CSF leakage consists of drainage of the CSF through a subarachnoid catheter (3) and surgical repair of the dural tear (4), although an epidural blood patch may also be used (5). To provide appropriate treatment, it is essential to detect the exact site of CSF leakage. Among the diagnostic modalities used to determine the site of CSF leakage are magnetic resonance (MR) imaging, computed tomographic (CT) cisternography, and radioisotope cisternography. Here, we describe two patients with surgery-related CSF leakage in whom the leakage sites were accurately detected on MR myelography.

Floating Dural Sac Sign is a Sensitive Magnetic Resonance Imaging Finding of Spinal Cerebrospinal Fluid Leakage

We would like to propose floating dural sac sign, which is observed as a hyperintense band or rim around the spinal dural sac on axial T2-weighted images, as a sensitive sign to identify cerebrospinal fluid (CSF) leakage. One hundred patients with orthostatic headache were prospectively registered in 11 hospitals. These patients were examined by brain magnetic resonance (MR) imaging (n = 89), radioisotope cisternography (n = 89), MR myelography (n = 86), axial T2-weighted imaging of the spine (n = 70), and computed tomography myelography (n = 2). In this study, we separately evaluated the imaging findings of intracranial hypotension and spinal CSF leakage. Among 100 patients, 16 patients were diagnosed as having spinal CSF leaks. Of 70 patients examined with axial T2-weighted imaging, 14 patients were diagnosed with spinal CSF leaks, and floating dural sac sign was observed in 17 patients, 13 patients with spinal CSF leaks and 4 without CSF leaks (sensitivity 92.9%, specificity 92.9%). Of 86 patients examined by MR myelography, extradural fluid was observed in only 3 patients (sensitivity 21.4%, specificity 100%). The floating dural sac sign was a sensitive sign that can be used to identify CSF leakage. Spinal axial T2-weighted imaging might be a good screening method for spinal CSF leakage that can help to avoid the need for lumbar puncture.

A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery

Background:In spinal surgery, cerebrospinal fluid (CSF) fistulas attributed to deliberate dural opening (e.g., for tumors, shunts, marsupialization of cysts) or inadvertent/traumatic dural tears (DTs) need to be readily recognized, and appropriately treated.Methods:During spinal surgery, the dura may be deliberately opened to resect intradural lesions/tumors, to perform shunts, or to open/marsupialize cysts. DTs, however, may inadvertently occur during primary, but are seen more frequently during revision spinal surgery often attributed to epidural scarring. Other etiologies of CSF fistulas/DTs include; epidural steroid injections, and resection of ossification of the posterior longitudinal ligament (OPLL) or ossification of the yellow ligament (OYL). Whatever the etiology of CSF fistulas or DTs, they must be diagnosed utilizing radioisotope cisternography (RIC), magnetic resonance imaging (MRI), computed axial tomography (CT) studies, and expeditiously repaired.Results:DTs should be repaired utilizing interrupted 7-0 Gore-Tex (W.L. Gore and Associates Inc., Elkton, MD, USA) sutures, as the suture itself is larger than the needle; the larger suture occludes the dural puncture site. Closure may also include muscle patch grafts, dural patches/substitutes (bovine pericardium), microfibrillar collagen (Duragen: Integra Life Sciences Holdings Corporation, Plainsboro, NJ), and fibrin glues or dural sealants (Tisseel: Baxter Healthcare Corporation, Deerfield, IL, USA). Only rarely are lumbar drains and wound-peritoneal and/or lumboperitoneal shunts warranted.Conclusion:DTs or CSF fistulas attributed to primary/secondary spinal surgery, trauma, epidural injections, OPLL, OYL, and other factors, require timely diagnosis (MRI/CT/Cisternography), and appropriate reconstruction.

Concentric visual field defect related to spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is a rare syndrome characterized by postural headache associated with a low cerebrospinal fluid pressure in the absence of dural puncture or penetrating trauma. Cranial magnetic resonance imaging (MRI) typically shows diffuse pachymeningeal gadolinium enhancement, subdural fluid collections, prominence of cerebral venous sinuses and brain descent. Visual signs and symptoms have been described infrequently in patients with SIH. These include third or sixth nerve palsy, superior nasal quadrantanopia and temporal hemianopia. We report a 34 year-old woman who presented with a two-year history of orthostatic headache, dizziness and transient visual obscurations. Campimetry showed a bilateral concentric visual field defect. She also described that intermittently a transparent fluid leaked out of her nose. She had no past history of trauma, sinus surgery or intracranial surgery. Cranial MRI was normal. Neuro-ophthalmological examination ruled out any other causes of concentric visual field defects. Lumbar puncture showed a cerebrospinal fluid (CSF) opening pressure of 9 cm H2O. Radioisotope cisternography suggested a dural leak at cribiform plate. The cribiform plate region was repaired endoscopically with improvement of all symptoms. One year later she remains asymptomatic and the visual field defects have improved.