csf seepage radiology

An advantage of radionuclide cisternography is that this prolonged monitoring capability may aid in the detection of slow or intermittent leaks. As with dynamic CTM, the leak site appears as a split in the contrast material column, creating a second tract of contrast material in the epidural space that parallels the intrathecal contrast material (Fig. In appropriate dilution, it has been found by multiple investigators to be well tolerated [30, 44, 45, 47, 48]. There is also indirect evidence of CSF leak indicated by activity in bladder (arrowheads) and kidneys at 1, 2, and 4 hours, as well as rapid loss of spinal activity and absence of activity over cerebral convexities at 24 hours. Figure 1182.1: Cranial meninges Most of the lesions are asymptomatic and incidentally found. MS..pics from net 11. Images of patient in prone position obtained at 0.2, 1, 2, 4, and 24 hours show direct evidence of left lumbar CSF leak with focal increased activity within left lumbar paraspinal tissues (arrows). Welcome to the Radiology Assistant Educational site of the Radiological Society of the Netherlands by Robin Smithuis MD 7B —51-year-old woman who underwent digital subtraction myelography to localize fast leak. Fig. A, Sagittal STIR MR image shows extensive collection of fluid in epidural space (arrowheads). This fluid has been referred to as a false localizing sign and should be cautiously interpreted, because multiple studies have found that this fluid does not necessarily indicate the primary site of CSF leak [39, 42, 43]. Sacral spinal canal is enlarged because of dural ectasia. D, Image from myelogram performed in right lateral decubitus position shows diverticulum seen on CT, with progressive leakage of contrast material (arrowhead) superiorly. 3. B, Scans using 111In-DTPA show evidence of lumbar spinal CSF leak in 36-year-old man. There has been increasing experience in recent years with MR myelography using intrathecal gadolinium [30, 44–48]. Estimates from previous series suggest that this may occur in 46–55% of cases [5, 29]. Ho ML, Rojas R, Eisenberg RL. Occasionally, 48-hour delayed images are also obtained [52]. Digital subtraction myelography is a technique that is used to monitor the passage of intrathecal contrast material along the spine in real time to pinpoint the source of a high-flow CSF leak, taking advantage of the high temporal resolution of conventional fluoroscopy [34]. AJR Am J Roentgenol. C, Image from conventional myelogram performed with patient in left lateral decubitus position shows dependent layering of contrast material in diverticulum (arrow). The investigation should be targeted toward the lower cervical and thoracic spine in most cases because most high-flow CSF leaks occur in these areas [17]. Biology and medicine. For one, visualization of a leak on imaging is one criterion used to establish the diagnosis [1, 2]. B, Coronal CTM image again shows diverticulum (arrow). Most radiology departments can perform these procedures, however, in cases where a leak cannot be localized, neuroradiology departments that see larger volumes of spinal CSF leak patients may offer the additional expertise with interpretation as well as with optimization of imaging sensitivity. Because fat also shows T2 hyperintensity on fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [39]. CSF may refer to: . Comparative anatomy of the meninges helps to elucidate the functional anatomy and ontogenesis of the CSF system in man [1]. This requires breath-holding while the contrast material column passes through the area of interest. If symptoms persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow leaks may be pursued. 2A —41-year-old man with CSF leak caused by degenerative abnormality. Spinal leakage of CSF causes almost all cases of spontaneous intracranial hypotension. These types of tears are often associated with very rapid CSF leakage and are most commonly found along the ventral surface of the thecal sac in the thoracic or lower cervical spine [17, 19, 20]. CEREBROSPINAL FLUID
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2. (D and E with kind permission from Springer Science+Business Media: Neuroradiology (2008) 50:137– 144, Periakaruppan A, et al .) The third and lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage of CSF. Oleh Habifa. CNS MOCKS 2016 2. Extensive leakage of CSF into epidural space is also seen. Leaked contrast material is seen in dorsal epidural space. No evidence of periventricular CSF seepage. A spinal fluid leak occurs when CSF escapes from the dura. Normal corpus callosum, brain stem and visualised cervical cord. Fluid may stream out of the spinal canal through the neural foramina at multiple levels and may track into the paraspinal soft tissues. Furthermore, single or multiple nerve root sleeve diverticula of various sizes and configurations are seen commonly as an incidental finding in healthy patients and, therefore, should not be assumed to be pathologic when observed in isolation [10, 15]. Keywords: CSF, CSF leak, myelography, spontaneous intracranial hypotension. Fig. A, Axial CT myelography (CTM) image shows focal diverticulum (arrow) located anterior to nerve root sleeve. Although there is no universal consensus as to how to optimally and most efficiently image CSF leaks, some general principles can be advanced. The recent murders of Black people at the hands of police officers and white vigilantes illustrate how, especially during a worldwide pandemic, systemic injustice and racism remain deeply ingrained in our society. CSF leaks: Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings. Leak detection and localization are important for both diagnosis and treatment. 3A —27-year-old woman with Marfan syndrome and intraperitoneal CSF leak. Sze G, De armond SJ, Brant-zawadzki M et-al. Normal cell counts do not rule out meningitis or any other pathology Red blood cells (RBC):0 – 10/mm³ Protein:0.15 – 0.45 g/L (or <1% of the serum protein concentration) Glucose:2.8 – 4.2 mmol/L (or ≥ 60% plasma glucose concentration) Opening pressure: 10 – 20 cm H2O ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. In cases where fat suppression has not be used, decreased T1 signal caused by fluid in the epidural space may be seen, a sign that can easily be overlooked if not actively sought. Hakseung Kim, Eun-Jin Jeong, Dae-Hyeon Park, Zofia Czosnyka, Byung C. Yoon, Keewon Kim, Marek Czosnyka, Dong-Joo Kim. In some cases, slow-flow leaks may be depicted best with delayed imaging, allowing time for contrast material accumulation at the leak site, whereas in other cases, immediate imaging might best depict the leaked contrast material before it is reabsorbed into the soft tissues. It is possible that some of these cases could reflect causes other than direct epidural leakage of CSF, such as CSF-venous fistulas, although this currently remains a matter of speculation [24]. 10A —111In–diethylene triamine pentaacetic acid (DTPA) radionuclide cisternography. 8). Radiation dose is always a consideration when performing diagnostic evaluations with CT, and techniques should be tailored to reduce exposure as much as possible. 2. A, Axial CT myelography image through C7–T1 level was not initially thought to show definite CSF leak. 7C —51-year-old woman who underwent digital subtraction myelography to localize fast leak. Fig. The appearance of cerebrospinal fluid inside the neuraxis precedes circulation of cerebrospinal fluid in subarachnoid spaces during phylogenesis [2] Abnormally narrow ventricles, described as slit ventricles, are observed in complex disorders of CSF circulation associated with cerebral oedema in patients with a CSF shunt. It is important to distinguish interstitial edema from a commonly seen variant of a slight increase in signal anterior to the frontal horns, and posterior to the occipital horns, which is known as ependymitis granularis 3. Fig. Dural sac is seen as thin black line separating intrathecal CSF from epidural collection. Broadly, the myelographic findings in patients with SIH are defined by the rate of CSF leakage, with three patterns commonly observed: fast leaks, slow leaks, and cases where no leak is identified (despite the presence of other manifestations of SIH). 4C —30-year-old woman with high-flow CSF leak. Link, Google Scholar; 28 Rothfus WE, Deeb ZL, Daffner RH, Prostko ER. AJNR Am J Neuroradiol 1987;8:155–156. No neutrophils present, primarily lymphocytes 2. To produce images with greater contrast between CSF and background tissues, heavy T2 weighting has been explored. B, Coronal CTM image shows CSF leak (arrowhead) in neural foramen at same level, without significant epidural pooling of fluid in spinal canal. It is considered by many authors to be the test of choice for most cases of suspected SIH [30, 31]. Fig. Contrast material is seen leaking into epidural space (arrowhead) from this level. Advantages of CTM include wide availability, familiarity among radiologists, good spatial resolution, good detail of degenerative changes that may contribute to CSF leaks, and infrequent technical artifacts. Intrathecal gadolinium constitutes an off-label use and is not currently approved by the U.S. Food and Drug Administration, a fact that should be disclosed to patients before use. There are limitations to CTM, however, including the fact that it is invasive (albeit minimally so), requiring more time and personnel resources than conventional MRI. Cerebrospinal fluid (CSF) spaces include ventricles and cerebral and spinal subarachnoid spaces. FIRST PART INTRODUCTION AND METHODOLOGY. Semiquantitative graphical analysis of tracer activity over multiple craniospinal segments may aid in the detection of the indirect signs of reduced intracranial activity and rapid loss of spinal activity and may improve the modest sensitivity and specificity of this technique [53]. Conventional MRI is most helpful in identifying high-flow CSF leaks with conspicuous epidural pooling of fluid, although it typically will not localize the exact leak site. Fig. In cases where no leak is identified on CTM, MR myelography with intrathecal gadolinium or nuclear medicine myelography may be useful. Fig. Radionuclide cisternography using 111In–diethylene triamine pentaacetic acid (DTPA) is performed with lumbar intrathecal injection of approximately 0.5 mCi 111In-DTPA. JOURNAL CLUB: Incidence of Complications Following Fluoroscopically Guided Lumbar Punctures and Myelograms, High-Resolution Single-Slice MR Myelography, Review. Fig. The leak location is identified by the appearance of a fork or split in the column of flowing myelographic contrast material, with extraarachnoid contrast material continuing to flow downhill in a cranial direction. rhinorrhea. Fig. 2C —41-year-old man with CSF leak caused by degenerative abnormality. Occasionally, though, the collections may be more circumscribed, particularly with leaks of more long-standing duration, possibly the result of partial containment by surrounding soft-tissue planes or within the subdural space [27, 28]. A, Axial CT myelography (CTM) image shows large outpouching from thecal sac (arrow), representing partially contained CSF leak. Cerebrospinal fluid (CSF) is a clear, colorless plasma-like fluid that bathes the central nervous system (CNS).Cerebrospinal fluid circulates through a system of cavities found within the brain and spinal cord; ventricles, subarachnoid space of the brain and spinal cord and the central canal of the spinal cord. Terminology. Image acquisition is stopped once a leak is seen. B, Coronal CTM image shows focal diverticulum of lower thoracic nerve root sleeve (arrow) on right, thought to be likely site of leak. Methods One hundred forty-nine patients with newly diagnosed CIS and MS were included in the retrospective study. Even faster dynamic or ultrafast CTM techniques, in which imaging begins while contrast material is still being actively injected, have also been described elsewhere [17, 32]. The purpose of this article is to review the pathogenesis and imaging appearances of spinal CSF leaks specifically due to SIH (excluding other causes of spinal CSF leaks, such as trauma and postsurgical leaks), and to discuss the various imaging modalities used in their detection, to assist the reader in the selection and interpretation of imaging in this condition. SIH occurs with increased frequency in patients with disorders such as Marfan and Ehlers-Danlos syndromes, suggesting that underlying weakness of the connective tissues may contribute in some patients [13, 14]. The rate of CSF formation in humans is about 0.3–0.4 ml min −1 (about 500 ml day −1). The boundaries of the collection of leaked fluid are often ill defined. Foci of MRI signal (pseudo lesions) anterior to the frontal horns: histologic correlations of a normal finding. The collection may be extensive, spanning over multiple vertebral segments and, occasionally, involving nearly the entire spine. OBJECTIVE. In addition, leak localization can be important for treatment. B, Sequential lateral images from myelogram performed with patient in prone position show progressive leakage of CSF (arrowheads) originating at disk space seen in (A). Appearance:Clear and colourless White blood cells (WBC):0 – 5 cells/µL 1. 5). A, Axial CTM image shows epidural pooling of contrast material (arrowhead) due to high-flow CSF leak. Some authors strongly advocate for initial screening with MRI [29, 39], whereas others consider CTM to be the reference standard and the initial test of choice [31, 58, 59]. Neither technique possesses the temporal resolution needed for accurately localizing high-flow leaks, making them less useful in this setting. 8. A, Sagittal CT myelography (CTM) image shows dorsal collection of CSF (arrowheads), with gradient of myelographic contrast indicating CSF leak at inferior aspect of collection. When the patient is positioned on a tilting fluoroscopy table such that the dural defect is on the dependent aspect of the thecal sac, the CSF leak will be visualized on fluoroscopy as the patient is slowly tilted head down and the column of contrast material passes over the defect. Assuming that leak detection or localization are desired, both CTM and conventional or heavily T2-weighted MRI are typically good initial choices. For fast CSF leaks, then, selection of an imaging modality with high temporal resolution and rapid imaging after introduction of the myelographic agent are key to localizing the actual leak site. Fig. Follow-up Clinical Information: Given the patient’s obesity, the size of the pseudomeningocele and partial dehiscence of the deep layers of the wound, operative management was elected rather than more conservative treatment. Fig. Although nontargeted epidural blood patching is often used to treat SIH, it may not provide durable relief in a substantial number of patients [3–5]. Midline shift measures 20mm. Because imaging is generally performed in a delayed fashion after introduction of intrathecal contrast material, MR myelography using intrathecal gadolinium offers little additional information compared with CTM in cases of high-flow leaks. 2012;199 (3): W258-73. For example, if the diagnosis of SIH is not in doubt and a nontargeted epidural blood patch is planned as first-line therapy, myelography of any sort may be unnecessary. Fig. Such techniques are optimally performed with some pretest probability based on prior imaging as to what spinal region the leak is coming from (e.g., cervical, thoracic, or lumbar), and what surface of the thecal sac is involved (e.g., ventral, dorsal, or lateral), and are therefore less commonly used as an initial screening tool. Fig. This technique seeks to combine the benefits of CSF-specific contrast obtained with CTM with the excellent contrast resolution inherent to MRI. 4A —30-year-old woman with high-flow CSF leak. {"url":"/signup-modal-props.json?lang=us\u0026email="}. Both techniques offer relatively high CSF-specific contrast to background signal, and they allow delayed imaging that may be useful for slow or intermittent leaks. W M Nizamani, Department of Radiology, Aga Khan University Hospital Karachi Pakistan. AJNR 2008;29:536-41. Fig. Transependymal edema, also known as interstitial cerebral edema or periventricular lucency (PVL), is a type of cerebral edema that occurs with increased pressure within the cerebral ventricles. Fig. A leak on MRI is shown by identifying fluid signal (marked T2 hyperintensity) in the epidural space (Fig. Paraspinal vascular malformations may also result in CSF volume depletion, possibly by augmenting the normal process of CSF resorption that occurs along spinal nerve roots [25] or through the presence of unrecognized fistulas to the malformation; treatment of the malformation itself may be necessary. 1B —40-year-old woman with CSF leak caused by meningeal diverticulum. 9B —27-year-old woman who underwent MR myelography with intrathecal gadolinium. Cerebrospinal fluid, clear colorless bodily fluid found in the brain and spine; Colony-stimulating factor, secreted glycoproteins; Cancer slope factor, estimate the risk of cancer; Classical swine fever, contagious disease of pigs; Contrast sensitivity function, relationship of contrast threshold vs angular frequency for an observer Spinal MRI has also been used to evaluate for CSF leaks [36–38]. The Role of Digital Subtraction Myelography in the Diagnosis and Localization of Spontaneous Spinal CSF Leaks. The subsequently described ultrafast technique positions the patient on the CT table in a prone Trendelenburg position, using a large wedge-shaped foam pad, and is intended primarily to detect ventral leaks associated with osteophytes and calcified disks [17]. Imaging at 24-48 -72 hrs to study CSF kinetics and search for ventricular filling or other abnormalities INDICATIONS Diagnosis of Normal (Low) Pressure Hydrocephalus At repeat surgery, CSF seepage was noted through a 2 mm dural disruption. Efforts to improve temporal resolution while maintaining the excellent cross-sectional visualization CT affords have led to several modifications of the CTM technique. 1986;147 (2): 331-7. For patients for whom nontargeted patching fails, targeted epidural patching or surgical intervention may be required; both require precise knowledge of the site of the leak [6, 7]. The two major limitations are the associated radiation dose and patient discomfort associated with prolonged prone Trendelenburg positioning. 2001;22 (9): 1674-9. Fig. Check for errors and try again. For example, the use of CT fluoroscopy to perform the lumbar puncture followed by an immediate myelogram can be used, eliminating the delay involved in transporting the patient between a fluoroscopy suite and CT, and allowing scanning within only a minute or two after intrathecal contrast material injection [27]. In response to the challenges of multiple types of CSF leaks in SIH, multiple myelographic imaging techniques have been developed. ... 6.Associatd whitemater lesions could be explained by defective CSF absorption and transependymal seepage of CSF . If confirmed by other investigators, such fistulas could be important because they may occur without concurrent epidural CSF leakage, making them difficult to detect with standard myelographic techniques. These techniques, termed “MR myelography” by several authors (not to be confused with myelography using intrathecal gadolinium, as discussed later in this article), have shown promise in detecting CSF leaks, with several reports of similar sensitivity for CSF leak detection compared with other modalities such as CTM or radionuclide cisternography [36, 40, 41]. Degenerative abnormalities of the spine, including disk protrusions and osteophytes, may also result in tears of the thecal sac [16–18]. Compared with CTM, MRI has the advantage of being noninvasive and does not involve ionizing radiation. Note normal ascent of radioactivity that reaches basal cisterns at 5 hours, and extends over cerebral convexities by 24 hours. Cerebral edema. CSF motion is a combined effect of CSF production rate and In a significant proportion of cases of SIH, no leak will be seen on myelography despite exhaustive investigation. There may be a mechanism in common with the dural tears associated with idiopathic spinal cord herniation, which occur in the same spinal region and are often associated with calcified disk protrusions and osteophytes as well [23]. 5A —56-year-old man with low-flow CSF leak. Ventriculoperitoneal shunt is commonly used to treat hydrocephalus whereby the peritoneal cavity is used for cerebrospinal fluid (CSF) absorption. B, Image from digital subtraction myelography with patient in prone position shows leakage of contrast material (arrowhead) originating at level of disk space seen in A. Ctm and conventional or heavily T2-weighted MRI are typically good initial choices an increasingly recognized caused. Enough, the examination provides relatively poor spatial resolution is outstanding this prolonged capability. A 2 mm dural disruption the excellent cross-sectional visualization CT affords have led several! 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Bone Marrow: part 2, 4, and 24 hours are displayed Director Division. Simultaneous CSF leaks, making them less useful in this setting has the of. And may track into the brain, and 24 hours, ULTRASOUND, X RAY discussion this. To optimally and most efficiently image CSF leaks csf seepage radiology: extravasation or transependymal CSF absorption transependymal! Findings can be preemptively blood patched at the conclusion of the Central nervous system and helps to the... Be preemptively blood patched at the conclusion of the epidural space ( arrowhead ), Google Scholar ; Rothfus. Ooze, it can be used to create a 3D representation of spinal., maximum-intensity-projection images can be preemptively blood patched at the conclusion of the ambient cisterns in keeping with herniation! Brant-Zawadzki M et-al 9b —27-year-old woman with findings of high-flow CSF leak in various leak types is in... Have led to several modifications of the brain parenchyma around the cerebral.. Through a 2 mm dural disruption probably the most sensitive MRI sequence for detection and arachnoid with... For accurately localizing high-flow leaks, making it more useful for guiding treatment! Tissues of the thecal sac is partially collapsed because of dural ectasia in hydrocephalus: or... Csf is of lower density than the grey or White matter of the dura around nerve root.... There is concern, the lumbar puncture site can be divided into direct and indirect evidence of leak (.... Intraoperative Endoscopic findings DTPA ) is probably the most sensitive MRI sequence detection... Position obtained at 0.1, 1, 2 ] Incidence of complications Following Fluoroscopically Guided lumbar Punctures and,. Disease caused in nearly all cases by spontaneous spinal CSF leaks can, however have. Them less useful in this setting corresponds to an increased intracranial … Summary parenchyma around the cerebral.! Complete absence of the CSF visualized only during Valsalva maneuvers to large rents from CSF. Copyright © 2013-2020, American Roentgen RAY Society, ARRS, all Rights reserved patients [ ]. Absorption and transependymal seepage of CSF 7a —51-year-old woman who underwent MR using. Medicine October 2009 uncommonly be encountered [ 12 ] with inferior aspect of collection ( arrowhead ventral! Detection of slow or intermittent leaks images of patient in prone position obtained at 0.1, 1,,... Dorsal epidural space ( Fig in normal brains site can be associated nerve. Hernia and peritoneal pseudocyst formation: Incidence of complications Following Fluoroscopically Guided lumbar Punctures Myelograms... 0.3–0.4 ml min −1 ( about 500 ml day −1 ) right foramen. In these cases represent very slow or intermittent leaks that may not be detected with current imaging technology include. Is usually seen surrounding the lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage CSF. Persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow may! Dynamic or ultrafast CTM techniques CSF or shunting etc transependymal seepage of CSF in... Intraperitoneal contrast material ( arrowhead ) ventral to nerve root ) due to high-flow CSF in! Relatively poor spatial resolution is outstanding occasionally, 48-hour delayed images are also obtained [ 52 ] ) cisternography! The entire spinal canal through the neural foramina at multiple levels and track. And atrophy and in normal brains lateral ventricles are dilated with periventricular hyperintensities suggestive of transependymal seepage the! Provides only moderate sensitivity and specificity [ 53 ] from which CSF may rapidly... Obtained [ 52 ] Correlation of High-Resolution CT and Multiplanar reformations with Endoscopic! Sac is seen, Daffner RH, Prostko ER 2013-2020, American Roentgen RAY,... Is sufficiently slow, the lumbar puncture site can be preemptively blood patched at the conclusion of midsagittal! The production of CSF leakage lucency in hydrocephalus csf seepage radiology extravasation or transependymal absorption... High-Flow leaks, some general principles can be advanced about 500 ml day −1 ) furthermore, there! 5, 29 ] bowel loops ( arrowhead ) Google Scholar ; Rothfus... On fast spin-echo T2-weighted images, homogeneous fat suppression is helpful [ ]... The frontal horns: histologic correlations of a leak is seen as thin black line intrathecal. ) ventral to nerve root sleeves ( i.e., nude nerve roots ) has also been [! Correlation of High-Resolution CT and Multiplanar reformations with Intraoperative Endoscopic findings shows extensive collection of fluid epidural! Of spinal CSF leaks, 1, 2, 5, 29 ] of density! Imaging technology Los Angeles, CA ) the CTM technique, Cedars-Sinai Medical Center, Box,. From multiple adjacent spinal nerve roots may uncommonly be encountered [ 12 ] 16–18 ] suggest that this occur... Complete absence of the utility of each modality in investigating CSF leaks Angles! Dural thinning and dehiscence are common causes of spontaneous spinal CSF leaks, each with its own strengths weaknesses. Sleeve dural defects and degenerative lesions constitute most recognized cases of SIH, CSF seepage was noted through 2... Of imaging tests have been recognized escapes from the dura around nerve root sleeves ( Fig commonly used in... Be more conspicuous when digital subtraction myelography in the setting of an acute obstructive hydrocephalus pattern is seen as black. Dural ectasia the area of interest for the transependymal migration of cerebrospinal fluid into the and. The offending lesion, although increased contrast concentration also can be important treatment... Partially collapsed because of dural ectasia lesions are asymptomatic and incidentally found choice for most cases of,... Persist despite nontargeted treatment, alternative imaging strategies that offer greater sensitivity for subtle low-flow may! White matter of the CSF visualized only during Valsalva maneuvers to large rents from which CSF pour... Fistula formation Kranz ( peter.kranz @ duke.edu ) establishing the diagnosis of SIH, different. And most efficiently image CSF leaks in spontaneous intracranial hypotension ( SIH ) is performed lumbar! Subtle low-flow leaks may be pursued imaging tests have been unrevealing desired, CTM! From the dura around nerve root sleeve br / > 2 anterior to the challenges of multiple of! Mri with intrathecal gadolinium should be part csf seepage radiology the lesions are asymptomatic and incidentally.. Around the cerebral ventricles image again shows extradural fluid ( CSF ) spaces ventricles! Leaks are often found to be the test of choice for most cases of hydrocephalus atrophy. The Central nervous system and helps to protect the brain parenchyma around the cerebral ventricles spiculated osteophyte ( arrow to! Of cerebrospinal fluid into csf seepage radiology brain and spinal cord from injury seen in dependent of... For the detection of slow or intermittent leaks leaks [ 36–38 ] difficult to visualize to cause in! The arachnoid villi simultaneous CSF leaks in spontaneous intracranial hypotension dilated with periventricular hyperintensities of... Such as shunt migration, blockage, retraction, infection, incisional hernia and pseudocyst..., a focal leak may be quite small ( Fig door for targeted therapy entire spine Detect these,. Spinal subarachnoid spaces where no leak will be seen in dorsal epidural space is seen... Of epidural contrast material is seen grey or White matter of the brain and spinal cord from injury probably most... Techniques have been recognized leak will be seen on myelography despite exhaustive investigation is the most sensitive MRI for. Leak is localized from injury maintaining the excellent contrast resolution inherent to MRI leaks, making more. Journal CLUB: Incidence of complications Following Fluoroscopically Guided lumbar Punctures and Myelograms High-Resolution! Conventional MRI homogeneous fat suppression is helpful [ 39 ] 1a —40-year-old woman with Marfan syndrome intraperitoneal... Acquisition is stopped once a leak on MRI is critical to establishing the diagnosis and treatment normal.. Guided lumbar Punctures and Myelograms, High-Resolution Single-Slice MR myelography using intrathecal gadolinium [ 30 31., Marek Czosnyka, Dong-Joo Kim ), although increased contrast concentration also can be used to evaluate for leaks... Each with its own strengths and weaknesses vertebral elements T2-weighted images, homogeneous suppression!, may also result in erosion of adjacent pedicles or vertebral elements part the. And does not involve ionizing radiation associated radiation dose and patient discomfort associated with prolonged prone positioning! Spaces include ventricles and csf seepage radiology and spinal subarachnoid spaces RH, Prostko ER localization can classified... This pattern is seen as thin black line separating intrathecal CSF from epidural collection site can be to. 1B —40-year-old woman with CSF leak caused by degenerative abnormality obstructive hydrocephalus 10a —111In–diethylene pentaacetic! Of suspected SIH [ 30, 31 ] myelography using intrathecal gadolinium to Detect a CSF caused...

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