Drops of fluid from a CSF leak placed on absorbent filter paper may result in the double-ring sign, a central circle of blood and an outer clear ring of CSF. If you log out, you will be required to enter your username and password the next time you visit. Am J Rhinol. A defect in the skull base is measured with a sterile ruler. [QxMD MEDLINE Link]. 2008 Mar-Apr. [QxMD MEDLINE Link]. Magnetic resonance myelogram demonstrates pseudomeningoceles secondary to a stretch injury of the lumbosacral nerve roots. The high T2 signal from CSF fistula may be difficult to differentiate from that of sinusitis on axial images. [Full Text]. Traumatic causes include both blunt and penetrating facial injuries. This terminology seems to imply that spontaneous CSF leaks are idiopathic in nature; however, recent evidence has led us to realize that spontaneous CSF rhinorrhea may in reality be secondary to an intracranial process, namely elevated intracranial pressure (ICP). 4 5 7 Immunofixation electrophoresis is the [QxMD MEDLINE Link]. Free shipping for many products! Serum glucose, chloride, and total protein tests of the fluid are not specific or conclusive for CSF. A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma. 2015 Sep. 123 (3):732-6. Okizaki A, Shuke N, Aburano T, Hashizume K, Nakai H, Tanaka T. Detection of cerebrospinal fluid leak by dual-isotope spect with In-111 DTPA and Tc-99m HMDP. CT showed decreased thickening of the arterial wall and was negative for the double-ring sign (Figure 1B). Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. The most rudimentary test is for a so-called double ring sign (Fig. Usefulness of beta 2-transferrin assay in the detection of cerebrospinal fluid leaks following head injury. [QxMD MEDLINE Link]. Observe with a Wood lamp 30 minutes later for fluorescence of nasal discharge; if present, this confirms CSF . [QxMD MEDLINE Link]. Jinkins JR, Rudwan M, Krumina G, Tali ET. 2000 May. Confirm or exclude the presence of CSF in leaking fluid by means of an immunoelectrophoretic study of the fluid for beta-2 transferrin (B2Tr) or, where available, beta-trace protein. Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). Head images are acquired 2, 6, 12, and 24 hours after injection of the isotope. A high rate of fistula detection may be possible with imaging in the prone position, but this may be uncomfortable for the patient. 63 (2):197-201. The entire spine is scanned up to 24 hours in cases of spontaneous intracranial hypotension, spinal trauma, or postoperative CSF leaks. eCollection 2023 Feb. CSF is produced at a rate of approximately 20 mL/h for a total of approximately 500 mL daily. J Neurosurg. If persistent fluid drainage occurs after a fracture, the fluid may be evaluated to test for the presence of CSF. Conclusion: Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. Cerebrospinal fluid (CSF) rhinorrhea is a rare but potentially devastating condition that can lead to significant morbidity and mortality for the patient. Most spontaneous, or primary, causes of CSF rhinorrhea are now thought actually to be secondary to elevations in intracranial pressure (ICP) that might be seen in patients with idiopathic intracranial hypertension (IIH). 2022 Jan 18;84(1):17-23. doi: 10.1055/a-1722-4433. The doublering sign found in contrastenhanced computed tomography, which reflects inflammatory changes in the adventitia and oedema of the intima, is thought to be characteristic of. AJNR Am J Neuroradiol. [QxMD MEDLINE Link]. [QxMD MEDLINE Link]. 2007 Dec. 28(8):1131-9. [QxMD MEDLINE Link]. The enzyme B2Tr is produced in the brain by neuraminidase activity and is present in CSF, perilymph, and ocular aqueous humor but not in sinonasal mucous secretions and tears. If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). CSF consists of a mixture of water, electrolytes (Na+, K+, Mg2+, Ca2+, Cl-, and HCO3-), glucose (60-80% of blood glucose), amino acids, and various proteins (22-38 mg/dL). [1] The standard diagnostic test for temporal arteritis is biopsy; however, ultrasound and MRI show promise for replacing it. Multiple studies demonstrate a 90-95% success rate with closure of skull base defects using the endoscopic approach. J Neurol Neurosurg Psychiatry. What is the current clinical practice in pituitary adenoma surgery in Europe? Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the sclera of the eyes; joint stiffness with difficulty moving or straightening the arms, hands, legs, or feet; pain deep in the hips or ribs; and muscle weakness. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%). A doctor can use a number of tests to diagnose a CSF leak. Gadolinium-enhanced, coronal, T1-weighted MRI shows dural and tentorial thickening with contrast enhancement. The opposite is true for nontraumatic leaks, as only one third stop spontaneously. How . Therefore, it is important to keep in mind exactly what you said while also making sure a CSF leak and a basilar skull fracture are not missed. This image represents an endoscopic view with a 70-degree telescope through the left frontal recess. One drop of blood and one drop of either spinal fluid, saline, tap water, or rhinorrhea fluid were placed simultaneously on filter paper, and the specimens were examined after ten minutes for the development of a ring. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. Ashley Field of Conroe, Texas and Justin Kahn of Conroe, Texas were united in marriage in a 3 p.m. ceremony on January 12, 2002. Cappabianca P, Cavallo LM, Esposito F, et al. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. Disclaimer. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. Disruption of the barriers between the sinonasal cavity and the anterior and middle cranial fossae is the underlying factor leading to the discharge of CSF into the nasal cavity. However, an astute clinician noted the double ring sign on the stretcher sheet, as noted in the Figure 1. The use of topical intranasal fluorescein in endoscopic endonasal repair of cerebrospinal fluid rhinorrhea. CT cranial cisternography is performed with injection of 5-7 mL of nonionic myelographic contrast medium into the lumbar subarachnoid space. Magnetic resonance cisternogram with cerebrospinal fluid rhinorrhea demonstrates a meningocele extending into the left lateral recess of the sphenoid sinus (arrows). FOIA The primary site of CSF production is the choroid plexus, which is responsible for 50-80% of its daily production. Other than notation of the patients fluctuating score on the Glasgow Coma Scale and movement of his four limbs, a neurologic examination was not documented before intubation. [QxMD MEDLINE Link]. A thorough history is the first step toward accurate diagnosis. A 58-year-Old non-smoking woman with intractable cough and rhinorrhea. double ring sign: two concentric rings around the optic nerve characteristic of optic nerve hypoplasia. Once in contact with the paper, any CSF will separate from any. 2022. Allows to idebtify if bloody fluid from ears/ nose contains CSF. Hence, educating the patient regarding the common symptoms associated with a CSF leak such as salty or metallic taste is of paramount importance. Albu S, Florian IS, Bolboaca SD. 2008 Jun. 2022 Nov;36(11):859-864. doi: 10.13201/j.issn.2096-7993.2022.11.010. 2009 Jul. Lopatin AS, Kapitanov DN, Potapov AA. 2002 Feb. 44(2):143-50; discussion 151-2. The sella turcica and sphenoid sinus are involved in 15% of the cases as well. 8(4):433-7. [26, 27] Severe brain injury has been reported in a patient who received erroneously 30 times the intended dose of gadolinium in an MRI myelogram. HHS Vulnerability Disclosure, Help Matsumura A, Anno I, Kimura H, Ishikawa E, Nose T. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. 28.10). Careers. In most cases, the patient will have been discharged when the leak presents itself. Neuroradiology. 29 (3):207-10. Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. 2nd edition. Digital subtraction radiographic cisternography can be similarly performed with a spinal subarachnoid injection of nonionic iodinated contrast medium. 2022 Dec 8;12(12):1685. doi: 10.3390/brainsci12121685. [6] Include all of the paranasal sinuses and petrous temporal bones in the scans. James Stankiewicz, MD is a member of the following medical societies: American College of SurgeonsDisclosure: Nothing to disclose. Arch Otolaryngol Head Neck Surg. PMC Apr 2012. Small series of patients had no apparent adverse effect from the gadolinium contrast medium. West J Emerg Med. Would you like email updates of new search results? Cerebrospinal fluid imaging. J Neurol Neurosurg Psychiatry. All of these changes are reversible with ablation of the cause of CSF leak, which is usually in the spine. You may be trying to access this site from a secured browser on the server. A large defect is noted, and the meningocele has been resected. The intrathecal injection of 0.5 mL of gadopentetate dimeglumine diluted in 3-5 mL of CSF for MR cisternography has been reported to have high sensitivity and specificity for detection of active CSF fistula, exceeding the rate of fistula demonstration by CT, nuclear medicine, or noncontrasted MR cisternography. The image also shows a right-sided meningocele (large arrow) protruding through the cribriform plate, which was not suspected but was surgically repaired at the same time as the left cribriform cerebrospinal fluid leak site. 2005;38[4]:597), an elegant study from 1993 shows the double ring sign is neither sensitive nor specific for CSF. ), Leakage of CSF into the epidural space through a defect in the thecal sac has been found to be the underlying cause of almost all cases ofspontaneous intracranial hypotension (SIH). The cerebral ventricles may be reduced in size, and the pituitary gland may appear enlarged. Nadieska Caballero, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, American Rhinologic SocietyDisclosure: Nothing to disclose. This article discusses current concepts in the etiology, diagnosis, and treatment of CSF rhinorrhea, as well as long-term management of patients following successful treatment. This image shows complete resolution of the previous dural thickening and contrast enhancement. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defect: ten-year experience. [QxMD MEDLINE Link]. Bookshelf For more information, see Medscape. However, locally aggressive lesions such as inverted papilloma and malignant neoplasms can erode the bone of the anterior cranial fossa. Diagnostic strategies employed for cases of cerebrospinal fluid (CSF) rhinorrhea vary widely due to limited evidence-based guidance. To study the development of a ring sign when blood is mixed with various fluids. Image demonstrates increased tracer accumulation in the nasal region (arrow). Izumoto Y, Matsuyama T, Mizuhira M, Imaseki H, Hamano T, Sakai Y, Oguri Y, Yoshii H. J Radiol Prot. CT cisternographic findings in CSF leak include the concentration of contrast medium in portions of a paranasal sinus or within ethmoid or mastoid air cells. Pre-cut Filter Paper for Detecting Anti-Japanese Encephalitis Virus IgM from Dried Cerebrospinal Fluid Spots. [QxMD MEDLINE Link]. [20, 21, 22, 23] This technique is based on the intrinsic T2 contrast between CSF and adjacent structures. Ryall RG, Peacock MK, Simpson DA. Fast CSF leaks have rapid contrast diffusion and may not be localized to a 2-vertebral segment of the spinal canal (suitable for local treatment by extradural blood patch or alternate therapy) by routine postmyelogram CT spine scan. The lateral lamella of the cribriform plate appears to be involved in approximately 40% of the cases, whereas a defect in the region of the fontal sinus is detected 15% of the time. However, the presence of a ring sign is not exclusive to CSF and can lead to false-positive results. Optic nerve deficits suggest a lesion in the region of tuberculum sellae, sphenoid sinus, or posterior ethmoid cells. Baltimore: Lippincott, Williams & Wilkins; 2003. Temporal lobe gyral herniation may occur through a petrous temporal bone tegmen tympani defect. 2001 Feb. 15(1):8-12. Cochrane Database Syst Rev. Curr Opin Otolaryngol Head Neck Surg. By the same principles as those applied in planar chromatography, the drainage of bloody discharge onto the patient's pillow or a paper towel can be seen to . Diagnostic Nuclear Medicine. Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane. [29]. [QxMD MEDLINE Link]. Traumatic cerebrospinal fluid leak. Thank you for your interest in spreading the word on CMAJ. J Neurosurg. Teachey W, Grayson J, Cho DY, Riley KO, Woodworth BA. Gadolinium-enhanced, T1-weighted axial MRI obtained 2 weeks after a 7-mL extradural blood patch was applied to the midlumbar region. Hegazy HM, Carrau RL, Snyderman CH, et al. The Canadian CT Head Rule for patients with minor head injury, Antibiotic prophylaxis for preventing meningitis in patients with basilar skull fractures, Sodiumglucose cotransporter-2 inhibitors in patients without diabetes, www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.120055/-/DC1. This site needs JavaScript to work properly. Typical imaging parameters include a repetition time of 10,000 ms, an effective echo time of 200 ms, 4 signals acquired, an echo train length of 16, a matrix of 512 X 192, no phase-wrap option, 3-mm sections interleaved contiguously (0-mm gap), and a 16-cm field of view. Spontaneous CSF rhinorrhea: prevalence of multiple simultaneous skull base defects. 92(5):873-6. The dye reaches the skull base in 6 hours and is present over the cerebral convexities in 24 hours. The test for CSF fluid involves placing a sample of what the doctor suspects to be CSF discharge on a piece of filter paper. Data is temporarily unavailable. CSF fistula can usually be demonstrated by using some method of cisternography. High-resolution CT (HRCT) is then recommended as the first-line study for localization. Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. nSAIDs and aspirin . 2020;42[12]:31; http://bit.ly/2HVJcdt. Radionuclide cisternography in detecting cerebrospinal fluid leak in spontaneous intracranial hypotension: a series of four case reports. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. Bonnie Kaplan, MD, showed a picture of blood leaking from the ear of an injured patient onto a bed sheet, which forms a double ring sign, in the December Quick Consult. The probe indicates that access to the defect is performed through the maxillary sinus and pterygopalatine fossa. The cerebral dural venous sinuses may be engorged. Cerebrospinal fluid (CSF) leak may occur from the nose (rhinorrhea), from the external auditory canal (otorrhea), or from a traumatic or operative defect in the skull or spine. Sign in 0 Cart; Gifts for Mom; Jewelry & Accessories . Some error has occurred while processing your request. Perform high-resolution, thin-section axial and coronal cranial and facial computed tomography (CT) scanning. [QxMD MEDLINE Link]. (See images below.). In one study of 45 patients, CT of the skull and facial bones with high-resolution, thin-section axial and coronal images had an accuracy of 92%, a sensitivity of 92%, and a specificity of 100% in depicting the presence or absence of CSF fistula. NSF/NFD is a debilitating and sometimes fatal disease. Epub 2018 Sep 24. Artist's rendering of a tegmen tympani bone defect with a herniated meningoencephalocele. Axial CT image was obtained with the patient in the supine position. The type of filter paper did not affect the development of a ring. Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care. Spinal MRI findings are also potentially reversible after successful ablation of a CSF fistula. 1-6 The clinical value of this sign as described in trauma texts must be considered anecdotal because no Lu X, Zhai X, Li H, Yang X, Hang W, Liu G. Lin Chuang Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 33:690-94. Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. These symptoms also occur in multiple common conditions and so should be evaluated by an ENT specialist if they are not easily explained or do not clear up on their own in a week or so. Each patient subsequently underwent a procedure for an epidural blood patch, and all patients experienced symptomatic relief. Background: PMC Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. Cervical MR imaging in postural headache: MR signs and pathophysiological implications. Europe PMC is an archive of life sciences journal literature. The resulting fluid is termed cerebrospinal fluid. Spelle L, Boulin A, Tainturier C, Visot A, Graveleau P, Pierot L. Neuroimaging features of spontaneous intracranial hypotension. double-ring sign (Figure 1B). [2] A halo pattern on a bedsheet produced by bloody otorrhea from a 27-year-old man who had been in a motor vehicle collision. Enrique Palacios, MD, FACR Professor of Radiology, Tulane University Medical Center Ultimately, a defect is formed. Therefore, imaging is usually done with the patient in the supine position. The specificity is almost 100% for contemporary radionuclide cisternography. Skull base injuries can vary from simple cracks in the bony architecture to large (>1 cm) defects with disruption of the dura and potentially brain parenchyma. 1994. FOIA This finding is suggestive of a site of cerebrospinal fluid leak. All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. 2016 Nov 1. Yousry I, Forderreuther S, Moriggl B, et al. All methods of cisternographyradionuclide, CT, and MRprovide improved or optimal CSF fistula detection when the fistula is active and when a Valsalva maneuver or jugular venous compression is added to the imaging protocol. [8, 9, 10]. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl [QxMD MEDLINE Link]. This coronal CT cisternogram was obtained after an intrathecal injection of contrast material (Omnipaque 300, 8 mL) into the lumbar thecal sac and subsequent positioning of the contrast agent in the head. Mjovsk M, Grotenhuis A, Foroglou N, Zenga F, Froehlich S, Ringel F, Sampron N, Thomas N, Komarc M, Netuka D. Neurosurg Rev. On occasion, the patient has a history of headache relieved by drainage of CSF. Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. J Neurol Surg B Skull Base. The incidence of CSF fistula detection varies from 22 to 100% in clinical studies. Please confirm that you would like to log out of Medscape. Follow-up 48- or 72-hour scans are possible with 111In and may be useful in the detection of intermittent CSF fluid leaks. Lemonnier LA, Tessema B, Kuperan AB, et al. Once in contact with the paper, any CSF will separate from any blood or mucus. The pledgets are examined for green fluorescence in a dark room with ultraviolet light 6 hours after the intrathecal PSP injection. Basal skull fracture should be considered in all patients with head injuries, especially those with physical signs such as otorrhea, Battle sign or periorbital ecchymoses.1 The halo or double-ring sign is a classic image in medicine and was taught as a method for determining whether bloody discharge from the ears or nose contained cerebrospinal fluid (CSF). The dura of the anterior cranial base is subject to wide variations in CSF pressure because of several factors, including normal arterial and respiratory fluctuations. 26(7):628-9. Get new journal Tables of Contents sent right to your email inbox, Letter to the Editor: Double Ring Sign Does Not Exclude CSF Leak. [5]. (See images below.). A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. Please enable scripts and reload this page. What's the Most Likely Cause of This Man's Severe Headaches? Drainage of CSF in some cases may often be elicited on endoscopy by having the patient perform a Valsalva maneuver or by compressing both jugular veins (Queckenstedt-Stookey test). The ring sign: Is it a reliable indicator for cerebral spinal fluid? 134:110044. The site is secure. 2017 Feb. 78 (1):18-23. [QxMD MEDLINE Link]. Common sites of injury secondary to endoscopic sinus surgery include the lateral lamella of the cribriform plate and the posterior ethmoid roof near the anterior and medial sphenoid wall. These leaks were typically approached via a frontal craniotomy. Clipboard, Search History, and several other advanced features are temporarily unavailable. Kranz PG, Gray L, Taylor JN. Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA. All rights reserved. AJNR Am J Neuroradiol. According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves. Extradural fluid collections are common in spinal CSF leak. Pledgets are placed close to the cribriform plate, in the middle meatus, and in the sphenoethmoidal recess of the right and left nasal cavities. No double ring sign was identied using this test. In the study, about 72% of patients with spontaneous CSF leaks were female, and about 45% had obstructive sleep apnea. 2nd edition. An official website of the United States government. Another Na+/K+ ATPase lining the ventricular side of the epithelium extrudes Na+ into the ventricle, with water following across this ionic gradient. Septal bone is used as an underlay graft in the repair of this skull base defect in a patient with a spontaneous leak and encephalocele. 5 Testing fluid from the ear or nose for -2 transferrin is the recommended method to assess patients for a cranial CSF leak because this approach is noninvasive as well as highly sensitive and specific. for: Medscape. A suggested algorithm for the diagnosis of a CSF fistula follows. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. G-CSF-induced vasculitis has been reported to occur in 0.47% of patients.1 The double-ring sign, which reflects inflammatory changes in the adventitia and oedema of the intima, is thought to be characteristic of Takayasu arteritis (TA); however, herein, it was also observed for G-CSF-induced vasculitis.2 It is 2018 Dec;38(4):1384-1392. doi: 10.1088/1361-6498/aae39b. Utility of preoperative high-resolution CT and intraoperative image guidance in identification of cerebrospinal fluid leaks for endoscopic repair. J Neurotrauma. Coronal and sagittal imaging is necessary. (EMN. Surg Neurol. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. [QxMD MEDLINE Link]. 8600 Rockville Pike [4], CT cisternography or radionuclide cisternography may be useful if CT and MR cisternography do not show the CSF fistula. Cerebrospinal fluid rhinorrhoea in closed head injuries. This website also contains material copyrighted by 3rd parties. If persistent fluid drainage occurs after a fracture, the fluid may be evaluated to test for the presence of CSF. -2 transferrin is a protein found in CSF, but not in serum, nasal secretions, or adjacent tissue. Fortschr Med. [QxMD MEDLINE Link]. 33(3):535-40. (See images below.). Reddy M, Baugnon K. Imaging of Cerebrospinal Fluid Rhinorrhea and Otorrhea. The benefit of early lumbar drain insertion in reducing the length of CSF leak in traumatic rhinorrhea. 2 transferrin is specific for CSF (absent in nasal discharge) Olfactory slit - cribriform plate of Ethmoid Bone (most common site)In traumatic CSF leak, CSF and blood are mixed - double ring sign or target sign; Immediate Management - Antibiotics and Observation Persistent Case Treated surgically by nasal endoscopy or intracranial route High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. 1 The double-ring sign, which reflects inflammatory changes in the adventitia and oedema of the intima, is thought to be characteristic of Takayasu arteritis (TA . 52:768-770. Contrast medium has drained out of the meningocele, but a small amount remains in the sphenoid sinus around the meningocele. Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic SocietyDisclosure: Nothing to disclose. Spinal radiological findings in nine patients with spontaneous intracranial hypotension.
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