Site Of Cerebrospinal Fluid Leak Research Articles

Cirugía transnasal endoscópica para tumores de hipófisis

Introducción:Exponer la técnica utilizada y los resultados obtenidos en los primeros 52 pacientes portadores de tumores hipofisarios tratados por la vía endoscópica transnasal en el Hospital Italiano de Buenos AiresMétodos:Se llevó a cabo un análisis retrospectivo de 52 cirugías endoscópicas transnasales utilizadas en el tratamiento de tumores hipofisários. Las mismas fueron realizadas en el Hospital Italiano de Buenos Aires durante el período junio del 2011 a junio del 2012. Se analizaron las características demográficas de los pacientes, la patología de base y la morbimortalidad asociada a la cirugía.Resultados:La edad media de los pacientes fue de 41,52 años con un rango de 18-79. La distribución fue similar entre hombres y mujeres. Las patologías más frecuentes fueron: adenomas no funcionantes (40.4%), tumores productores de GH/Acromegalia (25%) y tumores productores de ACTH/Enfermedad de Cushing (23.1%). Aproximadamente el 70 % correspondieron a macroadenomas. Sólo un paciente presentó complicaciones. No se registro ningún óbito.Conclusión:Si bien podremos objetivar fehacientemente resultados más concluyentes en futuros trabajos, podemos decir a priori que, en la endoscopía el detalle anatómico es claramente superior al microscópico y que la posibilidad de la introducción del endoscopio en la silla turca permite la visualización directa de remanentes tumorales, de sitios de fístula y como así también de la glándula normal, ventajas que potencialmente podrían permitir obtener mejores resultados quirúrgicos, en términos de control de la enfermedad y tasa de complicaciones.

Pituitary enlargement in spontaneous intracranial hypotension—a diagnostic pitfall

Dear Editor Spontaneous intracranial hypotension (SIH) is an uncommon condition characterized by the depletion of cerebrospinal fluid (CSF) volume [3]. Enlargement of the pituitary gland may occur in SIH due to compensatory engorgement of the epidural venous plexus, which is a potential diagnostic pitfall [2]. We report a 46-year-old woman who presented with a 2-week history of headache and a partial right abducens nerve palsy. Her pituitary hormonal profiles were normal except for raised serum alpha-subunit, follicle stimulating hormone and luteinizing hormone levels, compatible with her previous oophorectomy. Magnetic resonance (MR) studies showed an enlarged pituitary gland, which was then diagnosed as a non-functioning pituitary macroadenoma. Less emphasis was placed on other MR findings including bilateral subdural effusion, pachymeningeal enhancement, and sagging of the midbrain, which were suggestive of SIH (Fig. 1). Endoscopic transsphenoidal surgery was performed, which revealed a diffusely enlarged pituitary gland. Biopsy showed no inflammatory or neoplastic changes. Her headache and diplopia resolved 2 weeks later. A follow-up MR study showed complete resolution of the pachymeningeal enhancement, bilateral subdural effusion, and pituitary enlargement. The overall picture was that of SIH that had resolved spontaneously. Fig. 1 a, b Post-contrast T1-weighted coronal images showing an enlarged and homogeneously enhancing pituitary gland, and diffuse pachymeningeal enhancement (arrows); c coronal FLAIR image showing the bilateral subdural effusion (arrows) SIH is most commonly due to spontaneous CSF leakage at the lower cervical and upper thoracic spine. Mechanical stress, meningeal diverticula, and connective tissue disorders have been identified as potential risk factors. The estimated incidence is around 5 per 100,000 per year, with a female predominance and a peak incidence around the 4th decade [8]. Patients may present with orthostatic headache, nausea, vomiting, neck rigidity, and cranial nerve palsies [4]. The characteristic MR findings include pachymeningeal thickening and enhancement, tonsillar descent into the foramen magnum, and subdural effusion [8]. As the craniospinal axis attempts to maintain volume homeostasis in the face of continuous CSF loss, dural hyperemia and associated enlargement of the pituitary gland may occur in up to two-thirds of the cases [6]. The initial MR findings should have raised the suspicion of SIH in our patient. On retrospective enquiry, her headache was indeed postural in nature. We performed surgery with a view to improve her abducens nerve palsy. The latter was a recognized feature of SIH, accounting for up to 80% of reported ocular manifestations of this syndrome [10]. The optic, oculomotor, trochlear, and trigeminal nerves may also be affected [1]. Other unusual pituitary manifestations of SIH include hemorrhage [9] and partial insufficiency [7]. Interestingly, an unusual case of SIH associated with a pituitary macroadenoma and subdural hemorrhage has also been described [5]. The majority of patients with SIH improve on conservative management, and almost all cases with pituitary enlargement have normalization of gland size on follow-up MR [2]. For refractory cases, myelography is the study of choice to identify the site of spinal CSF leakage, followed by definitive treatments such as epidural blood patching, percutaneous placement of fibrin sealant, and open surgical repair. In summary, SIH should be considered in patients who present with postural headache and the characteristic MR findings. Initial conservative management should be adopted, which is effective in the majority of cases. The present case illustrates the importance of careful history taking and clinical examination as well as an awareness of this diagnostic pitfall.

Treatment Outcomes of Endoscopic Repairs of Sinonasal Cerebrospinal Fluid Leaks

The objectives of the study were to evaluate the clinical characteristics of cerebrospinal fluid (CSF) leaks and determine the clinical parameters affecting endoscopic repair of CSF leaks of the anterior and central skull base. A retrospective study was undertaken to analyze the clinical characteristics of 28 patients who underwent endoscopic treatment of sinonasal CSF leaks between 2002 and 2009. The causes of sinonasal CSF leaks were traumatic (n = 27) and spontaneous (n = 1). The sites of CSF leaks included the frontal sinus and frontal recess (n = 9), ethmoid sinus (n = 9), sella and clivus (n = 6), and sphenoid sinus (n = 4). The success rate at first-attempt endoscopic repair was 86% (24/28). Cerebrospinal fluid leaks from the frontal sinus/recess had a high failure rate (44% [4/9]). Recurrent frontal CSF leaks were successfully salvaged by an open-endoscopic approach. The final success rate at second attempt was 93% (26/28). Among the variables affecting initial endoscopic success, the location of CSF leak and direct visualization were significant factors (P = 0.008 and 0.018, respectively [Fisher exact test]). No postoperative complications were noted. Our results showed that endoscopic repair of sinonasal CSF leaks is an effective treatment with a success rate of 93%. Open-endoscopic repair of frontal CSF leaks is feasible in treating endoscopic failures of frontal CSF leaks.

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.

Delayed Cerebrospinal Fluid Leak following Septoplasty

We report on the clinical syndrome of delayed cerebrospinal fluid leak following septoplasty. We describe 2 such cases that we treated, and 1 other case described in the literature. A review of these 3 cases indicates a characteristic clinical and radiologic presentation and a consistent site of cerebrospinal fluid leak. All cases presented with cerebrospinal fluid leak 12 to 22 weeks after septoplasty and had slit-shaped dehiscences at the horizontal lamella of the cribriform plate. Endoscopic repair was successful in all. Delayed cerebrospinal fluid leaks may occur as a consequence of septal surgery. It is probable that uncontrolled twisting and rocking manipulations of the perpendicular plate of the ethmoid bone are transmitted to, and injure, the cribriform plate.

IMAGING DIAGNOSIS: TRAUMATIC DURAL TEAR DIAGNOSED USING INTRATHECAL GADOPENTATE DIMEGLUMINE

A dog with traumatic monoplegia had a spinal cord lesion, identified using conventional magnetic resonance imaging. In addition, the intrathecal use of gadopentate dimeglumine allowed identification of two sites of cerebrospinal fluid leakage from the vertebral canal, supporting a diagnosis of brachial plexus avulsion. Veterinary

Intrathecal Preoperative Contrast Enhanced Computed Tomography (CT) and Intraoperative Fluorescein Dye for Cerebrospinal Fluid (CSF) Leaks

Objectives: To describe the utility of intrathecal contrast-enhanced computed tomography and intrathecal fluorescein dye injection for the preoperative localization and intraoperative control of CSF leaks. Study Design: Retrospective case series Methods: Preoperative assessment with intrathecal contrast-enhanced CT was used to predict the likely site of CSF leak. These sites were confirmed by the intraoperative identification of fluoresceincontaining CSF, and the skull base defect was repaired using established techniques. Results: In each patient, the site of CSF leakage corresponded to the region of primary concern on each of the contrast-enhanced CT scans. In one patient, fluorescein permitted the visualization of a small encephalocele protruding through the posterosuperior roof of the sphenoid sinus where an abnormality had been correspondingly identified on contrast-enhanced CT scan. Conclusions: Intrathecal fluorescein dye placement and intrathecal contrast-enhanced CT scans provide complementary information that may be used for the localization and control of CSF leaks.

Spontaneous Intracranial Hypotension Treated by Epidural Blood Patches

We present a case of spontaneous intracranial hypotension (SIH) diagnosed from the clinical symptoms and magnetic resonance imaging brain scans. After failure of conservative treatment, and lack of identification of the cerebrospinal fluid leak site, the headache was managed successfully and simply with two applications of an epidural blood patch (EBP). The strategy of our management for the patient was as follows: (1) application of an EBP to the lumbar epidural space initially and manipulating it into the proximity of the possible leak site; (2) a greater volume of autologous blood was injected at the second attempt of EBP; and (3) the patient was required to lie flat for at least 2 hours after the procedure. Better management of SIH is still developing. Traditionally, SIH is initially managed by conservative treatment. However, recent studies have shown that the success rate in arresting SIH after weeks or months of conservative treatment is not quite satisfactory. Hence, the EBP has proven to be more effective in treating SIH patients. Early EBP application may offer immediate relief of clinical symptoms. The role of the EBP in treating SIH patients should have greater emphasis and its application is worth recommendation.

Comparisons Between Heavily T2-Weighted MR and CT Myelography Studies in Two Patients with Spontaneous Intracranial Hypotension

Our previous study demonstrated that heavily T2-weighted magnetic resonance (MR) myelography could successfully detect abnormal cerebrospinal fluid (CSF) collections in patients with spontaneous intracranial hypotension (SIH); however, its ability to demonstrate ongoing CSF leakage sites is uncertain. Currently, computed tomographic (CT) myelography is still considered the study of choice for such a purpose. In this study, we compared the results of the two imaging modalities in two patients with SIH. CSF leakages, such as C1-2 extraspinal collections, CSF along nerve root sleeves, and epidural fluid collections were noted on both studies with minor discrepancies. CSF collection along nerve root sleeves demonstrated by MR myelography was the most likely ongoing leakage site in comparison with CT myelography. Targeted epidural blood patches in both patients resulted in complete headache resolution. Non-invasive, non-contrasted and time-saving MR myelography is a promising study for patients with SIH. Further large-scale validation studies are needed.

Atypical Spontaneous Intracranial Hypotension (SIH) With Nonorthostatic Headache

Some patients with spontaneous intracranial hypotension (SIH) often do not demonstrate typical orthostatic headache, which is contrary to the typical SIH syndrome. They usually have an obscure and intermittent headache, regardless of their positional change. The objective of this study is to investigate the clinical course of atypical SIH that manifests with diffuse pachymeningeal enhancement, but no orthostatic headaches. Between January 1997 and December 2005, we observed a total of 6 patients who revealed atypical presentations including nonpostural headaches and normal cerebrospinal fluid (CSF) pressure, despite the diffuse pachymeningeal enhancement seen on their MR images. For a comparison of the clinical features and the disease course, 13 other SIH patients with typical clinical manifestations were selected as a control group. Cerebrospinal fluid leakage sites were confirmed in only one patient through a variety of diagnostic tools; in contrast, definite focal CSF leakage sites were found in 12 of 13 patients with typical SIH. The 6 atypical SIH patients were treated with conservative treatment, including strict bed rest and intravenous hydration for 2 to 3 weeks. After a mean follow-up of 12 months, their headaches were gradually relieved after 2 to 3 weeks of conservative treatment only. All SIHs do not necessarily show the typical clinical manifestations. The atypical finding of SIH such as nonorthostatic headache or normal CSF pressure may be the result of a normal physiologic response to the typical SIH as a compensatory reaction. Therefore, when faced with patients showing findings compatible with SIH on the brain MR images, regardless of nonpostural headache, atypical SIH should be suspected.

Orthostatic Headache Diagnosed by Computed Tomography Myelography

Intracranial hypotension seems to be caused by cerebrospinal fluid (CSF) leakage from a spinal meningeal diverticulum or dura tear. It is characterized by orthostatic headache and diffuse meningeal enhancement on gadolinium-enhanced brain magnetic resonance imaging. Site of CSF leakage could be disclosed with radioisotope cisternography, and computed tomography myelography is useful when cisternography failed to unravel anatomical information. Epidural blood patch is very effective to stop the leakage. We report a case of orthostatic headache caused by intracranial hypotension in a 32-year-old woman. Computed tomography myelography confirmed a CSF leakage in the area of left L2 nerve root. The patient was successfully treated by epidural blood patch. (J Kor Neurotraumatol Soc 2007;3:116-118)

Surgical Anatomy Of Dural Defects In Spontaneous Spinal Cerebrospinal Fluid Leaks

Spontaneous intracranial hypotension is typically caused by a spontaneous spinal cerebrospinal fluid (CSF) leak. The configuration of the related dural defects can be complex. We describe our experience with the surgical anatomy of these defects. Thirteen consecutive patients with spontaneous spinal CSF leaks who underwent surgical exploration at Mayo Clinic between 1994 and 2003 were studied. All patients' records, imaging studies, detailed intraoperative findings, and outcomes were reviewed. There were four men and nine women with an average age of 40 years (range, 12-62 yr). Preoperative imaging studies revealed a single site of CSF leak in eight patients, two sites in three patients, and multiple sites in two patients. Intraoperatively, the exact site of leakage could not be found in four patients. Among the other nine patients, primary closure of a meningeal diverticulum was achieved in one patient. Significant regional attenuation of the dura prevented primary repair of the leak site in eight patients. Muscle, fibrin glue, and Gelfoam (Upjohn Co., Kalamazoo, MI) soaked in patient's own blood were commonly used to pack the epidural space in an attempt to seal the site of the leak. Ligation of two nonappendicular nerve roots allowed closure of the leak in one of these patients. Postoperatively, resolution of symptoms occurred in eight patients, significant improvement was noted in three patients, and only transient resolution in two. The mean duration of follow-up was 20.5 months. Surgery for closure of spontaneous spinal CSF leaks may not be straightforward. Even when extradural CSF leakage is discovered preoperatively by imaging studies, it may not always be possible to identify the exact site of the leakage intraoperatively. Furthermore, the anatomy of the dural defects may be complex and not amenable to primary closure. In such cases, the use of adjuvant techniques during surgical exploration may be effective.

Treatment of Idiopathic Intracranial Hypotension: Cervicothoracic and Lumbar Blood Patch and Peroral Steroid Treatment

Twelve consecutive patients with clinical symptoms and testing results compatible with a diagnosis of idiopathic intracranial hypotension (IIH), but no identifiable site of cerebrospinal fluid (CSF) leakage, were treated with a cervicothoracic or lumbar epidural "blood patch" (EBP) or orally administered steroids. Prompt and complete relief from headache persisting for at least 4 months was attained in 3 of 4 treatments with cervicothoracic EBP, 2 of 15 with lumbar EBP, and 4 of 8 with steroids. These results suggest that in patients who presumably suffer from IIH and yet have no identifiable site of CSF leakage, the presumed leakage more often occurs at the cervicothoracic level than the lumbar. In addition, our experience suggests that some IIH patients may be treated effectively with oral steroids and a trial of such therapy may be considered as an alternative to EBP.

Detection of cerebrospinal fluid leakage in intracranial hypotension with radionuclide cisternography and blood activity monitoring

Radionuclide cisternography is an indispensable examination to detect cerebrospinal fluid (CSF) leakage in patients suspected of having spontaneous intracranial hypotension (SIH). However, it sometimes fails to demonstrate the site of CSF leakage, and in such cases, early bladder visualization is utilized for the diagnosis of SIH as an indirect finding. The aim of this work is to improve the diagnostic ability of radionuclide cisternography and to reevaluate the reliability of early bladder visualization as an indirect finding of CSF leakage. We obtained serial images during the first hour after injection as well as the following time points in 4 patients with SIH and 5 with normal pressure hydrocephalus (NPH) as a control. We also performed blood sampling over time to measure blood radioactivity concentrations. All 4 patients with SIH demonstrated leakage, 2 of 4 within one hour after injection. Bladder visualization was observed falsely in 4 of 5 patients with NPH, considered to be the result of a lumbar puncture complication. In this false bladder visualization, blood radioactivity showed a more rapid raise and fall than in CSF leakage of SIH. The combination of radionuclide cisternography, including early time points and blood sampling, may enable accurate diagnosis of SIH.

Combined HRCT and MRI in the Detection of CSF Rhinorrhea

Cerebrospinal fluid (CSF) rhinorrhea is a potentially dangerous problem. Accurate preoperative localization of the site of leakage is mandatory. The standard diagnostic technique is computed tomography (CT) cisternography. Because of its related risks, however, various alternatives have been suggested. High-resolution CT (HRCT) provides good bony details, but fluid is poorly detected. In contrast, T2-weighted magnetic resonance imaging (MRI) shows CSF as a bright signal, but spatial resolution is poor as is the depiction of bony details. To overcome the shortcomings of both techniques, we superimposed the images obtained from each modality and used the result to plan surgical explorations. The sensitivity of HRCT was 88.25%. Fat-suppressed T2-weighted MRI detected a CSF-like density in 18 cases (90%) with a sensitivity of 88.88%. Superimposing the CTs and MRIs accurately localized the site of CSF leakage in 17 of 19 cases with a sensitivity of 89.74%. This finding compares favorably with the results of other techniques. We thus recommend this technique as the primary diagnostic method of choice for the investigation of patients with CSF rhinorrhea.

Incidence of cerebrospinal fluid leak after microsurgical removal of vestibular schwannomas.

Cerebrospinal fluid (CSF) leak still remains an unresolved problem after microsurgical removal of vestibular schwannomas (VS). 14 (6%) Cases of cerebrospinal fluid rhinorrhea and 3 cases with subcutaneous retro-auricular CSF collection, occurring in a series of 224 patients operated on by the senior author (JMG) on VS between 1989-2000 via the suboccipital retrosigmoidal approach were studied retrospectively. Prophylaxis of CSF leak was usually attempted by packing the unroofed posterior wall of internal acoustic meatus with muscle. The mastoid air cells were packed first with collagen then with muscle and bone dust. All CSF leaks were diagnosed within 2-7 days after surgery. We found no relation to tumour size. Treatment was initiated in all patients with continuous external lumbar cerebrospinal fluid drainage (CELCFD) for 7 days. In 11 cases with CSF rhinorrhea and all cases with retro-auricular CSF collection, the CSF leak was stopped. However, in 3 cases the CSF leak persisted despite the lumbar drain. These patients were operated on again with sealing the IAM and the mastoid cells again with muscle and collagen. No recurrence of CSF leak was noted after the second operation. There was no case of late onset CSF leak during the follow-up of one year. Although CSF leak is a common complication (6%) after vestibular schwannoma removal, aggressive treatment is required only in a few cases (1%). Most of the cases are successfully treated by (CELCFD). The suboccipital approach offers an advantage of opening only a part of mastoid air cells, which are in our opinion the second most common site of CSF leakage.

Spontaneous spinal cerebrospinal fluid leak and intracranial hypotension

A case of intracranial hypotension with spontaneous cerebrospinal fluid (CSF) leak was reported. A Tc-99m diethyltriaminepentacetic acid radionuclide cisternography (RNC) showed the accumulation of radioactivity in the area of the subarachnoid space, the poor migration of the isotope over the convexities, and the early appearance of kidney and bladder activity. To localize the site of CSF leak, RNC will be the choice, and when the time comes, RNC will work well in the location of the leak.

Spontaneous Intracranial Hypotension

The authors describe two patients with spontaneous intracranial hypotension. The patients had the cardinal features of a postural headache. In both patients, radionuclide cisternography revealed cerebrospinal fluid (CSF) leakage at the cervicothoracic junction and early accumulation of isotope in the urinary tract. Postmyelography CT scans showed no underlying structural abnormalities. Both patients were treated successfully by intravenous infusion of low-osmolarity fluid. Radionuclide cisternography obtained after treatment in one of the patients showed that the CSF leak had disappeared. Radionuclide cisternography enabled the causes of spontaneous intracranial hypotension to be differentiated and visualized the sites of CSF leakage. It was also useful for evaluating changes in a CSF leak after treatment. FIGURE 1 FIGURE 2

MR imaging of cerebrospinal fluid rhinorrhea following the suboccipital approach to the cerebellopontine angle and the internal auditory canal: Report of two cases

Cerebrospinal fluid (CSF) otorhinorrhea is one of the most common postoperative complications following the suboccipital approach to the cerebellopontine angle and the internal auditory canal. Accurate preoperative detection of the site of CSF leakage is important because inaccuracy may require a more extensive exploratory surgical procedure in the repair operation. There are few reports on evaluation of magnetic resonance (MR) imaging in diagnosing CSF leakage. MR imaging of two cases of postoperative CSF rhinorrhea is reported. A 53-year-old woman and a 29-year-old man underwent suboccipital operations for microvascular decompression of the facial nerve in hemifacial spasm and for removal of an acoustic schwannoma, respectively. In both cases, MR findings were useful in preoperatively delineating the site of the CSF leakage, which was confirmed during the repair operation. MR imaging may be useful in identifying the site of CSF leakage following the suboccipital approach to the cerebellopontine angle.

Long-term effects of radiation therapy for a catecholamine-producing glomus jugulare tumor

A 42-year-old woman presented with otorrhea 22 years after extracranial resection of a norepinephrine-secreting glomus jugulare tumor with intravascular embolization and radiation therapy to the intracranial portion of the tumor. Tumor growth was arrested and was associated with a decrease in blood and urine norepinephrine levels. Extensive evaluation of the otorrhea, including computerized tomography-cisternography, gadolinium-enhanced magnetic resonance imaging, and arteriography showed marked diffuse necrosis of the temporal bone and skull base with limited tumor vascularity. Cerebrospinal fluid (CSF) collected from the right ear showed norepinephrine levels of 2975 pg/ml; plasma norepinephrine levels were normal. The precise site of CSF leakage could not be delineated. Exploration of the posterior fossa revealed a large dural defect at the anteromedial aspect of the petrous bone through which CSF flowed over the surface of the residual extradural glomus tumor. The defect was successfully sealed with a fascial patch. Postoperatively, CSF norepinephrine levels were normal and no further leakage was observed.