CSF leak Definition A CSF. Radioisotope test of the CSF to track the leakage; Treatment Depending on the cause of the leak. This is called a blood patch, because a blood clot can be used to seal the leak. Treatment of Spontaneous Intracranial Hypotension Ansaar Rai. A generous CSF leak was identified at C2 on. A case of spontaneous intracranial hypotension. Treatment; Prognosis; Resources. Videos; Patient Stories. When epidural blood patching is unsuccessful or if symptoms recur. Cerebrospinal Fluid Leaks. Cerebrospinal fluid (CSF). An epidural blood patch is used in patients with spinal leaks who fail noninvasive measures. Successful treatment of spontaneous cerebrospinal fluid leak headache with fluoroscopically guided epidural blood patch: a report of four cases. Treatments for spinal CSF leaking vary from conservative to surgical procedures. A favorable response to an epidural blood patch supports the diagnosis of a leak but often lacks. Cerebrospinal Fluid (CSF) Leaks. Treatment of CSF leak may include bed rest. Surgical repair may be performed in patients that fail blood patch if the site of the leak has been identified. There are also some similar syndromes where the compliance of the intracranial compartment is too high, causing similar symptoms when the brain sags downward on standing, and floats back upward supine. It is estimated that CSF leaks have an incidence of about 5/1. A CSF leak is an escape of the fluid that surrounds. This is called a blood patch. You probably have a recurrence of leaking CSF if it is again a ' track Symptoms of CSF leak commonly include headaches, which are more severe in the upright position. Trendelenburg) positioning. These. symptoms are nonspecific as they are commonly encountered in migraine. Cognitive decline has also been reported (Hong. Pleasure et al, 1. The diagnostic criteria of the International Headache Society include: Orthostatic headache (headache worse upright than supine)At least one associated symptom among. Evidence of low CSF pressure or leakage by at least one of the following. MRI showing indirect signs of low CSF pressurelumbar puncture recording CSF pressure < 6. H2) in the lateral decubitus. CT myelography. Radionuclide cisternography showing the site of leakage. Of these symptoms, neck pain or stiffness, nausea and vomiting are the most common symptoms. If we consider which symptoms are the most specific, this is obviously #3. The associated symptoms are common human complaints - - for example, severe tinnitus is endorsed by 6% of the population, and migraine headaches which commonly include photophobia and nausea affect roughly 1. Regarding #3, It has been our observation that brain MRI showing indirect signs of CSF pressure (i. Orthostatic HA without CSF Leak. Distensible dura. Trephine syndrome - - large skull defect. Low CSF pressure of uncertain etiology (spontaneous intracranial hypotension)Cysts of CSF pathways (e. Colloid cyst)Leep and Mokri (2. CSF. leak. They speculate that in these patients, there might be either an. One would think that there would be postural hearing fluctuations in the trephine syndrome, but to our knowledge, this has not been tested. Postural headaches. CSF pathways such as in colloid cysts (see image below) or a cyst of the septum pellucidum. Low CSF pressure without a leak being found, called . These may be dectected from dural enhancement or lumbar puncture. As this is an otoneurology site, we will go into the hearing related symptoms of CSF leaks. While CSF leak is generally accompanied by an orthostatic. Oncel et al, 1. 99. Orthostatic tinnitus. Arai, Takada et al. The hearing loss of CSF leak likely. CSF pressure, which lowers perilymphatic (inner ear). Meniere's. disease. Locations of CSF leaks. CSF leaks are typically at the level of the spine, particularly the thoracic. Sometimes. they are unintentional consequences of an overdraining CSF shunt (e. According to Heaton et al (2. CSF leak following sinus surgery often have an anatomic variation such as a steep skull base angle and a lower cribiform plate height relative to the ethmoid roof. CSF leaks can also. CSF leaks into the middle. Potential sites. of CSF leak include the oval and round windows, the stapes footplate. Practically however, the middle. We also do not know of any study in which infection. To be sure that there is no CSF leak. CT scan in every. At this writing, perhaps. CSF leaks, this is not generally done. The video above (courtesy of Dr. Wiet, who was referred this patient with the tube in place), shows. CSF pulsating in a ventilation tube. CSF leaks may follow mastoid surgery. The roof of the mastoid sinus is adjacent to the underside of the temporal lobe. As long as the dura remains intact, no leak will occur. See this link for a picture of this situation. Sinus. surgery and pituitary surgery are the main sources of leaks through the. In this case. the leak is at the site of the puncture. Hearing impairment is commonly associated with spinal anesthesia (2. Cosar et al, 2. 00. Symptoms from this kind of leak can be delayed. Lybecker and Anderson, 1. It seems likely that these. Sometimes the leaks are discovered when brain imaging documents a new fluid accumulation in the brain (see image below). Acquired leaks can be caused by head or spine. Infections: Only 2. Manjunath, 2. 00. Congenital leaks are most often associated with the development of anomalous transcranial pathways. Spontaneous leaks Spontaneous leaks from the nose are uncommon (1/2. Mokri. 1. 99. 7; 3. Seth, 2. 01. 0). According to Seth et al (2. Supporting this idea, CSF leaks have been reported due. Miyazawa et al, 2. Vishteh, Schievink et al. When we originally advanced this idea in 2. Recently. however, using radioisotope cisternography, Ishikawa et al. CSF leaks primarily in the lumbar. Other things that can look like a leak Other conditions to exclude when considering the diagnosis of CSF leak are. BPPV, and orthostatic. When considering leaks from the nose, of course other fluids than. CSF can leak out of the nose. CSF leaks can also result from high- pressure hydrocephalus. In this situation. Tosun et al, 2. 00. Diagnostic testing. Tests not requiring lumbar puncture: MRI of head (engorgement, Chiari, subdural)Spine MRIHigh- resolution CT scan of temporal bone (if there are ear symptoms). Abdominal binder. Before starting the discussion, lets first say that none of these. The best, at the present time, involves. MRI to find side effects of low CSF pressure - - venous. Head MRI findings include diffuse meningeal gadolinium enhancement due to engorgement. Mokri et al, 1. 99. Chiari malformation (Paynor, 1. Spine MRI may show extra- arachnoid fluid, meningeal diverticuli. Miyazawa et al, 2. Medina et al, 2. 01. Starling et al, 2. Bonetto et al, 2. The engorgement of the. MRI. While this finding suggests that a CSF leak is possible, it does not identify the site of leak. It does not replace myelography. The image above shows an epidural collection outside the cerebellum. Bonetto et al (2. T1 from T2 weighted spinal MRI was highly. All of Bonetto's patients also had meningeal. In other words, these. Response to abdominal binders is both used as a treatment as well as a diagnostic maneuver. It seems likely that compression garments, such as the . The C1- C2 sign is a focal area of fluid between the spinous. C1 and C2 (image to left above). Spinal fluid hygromas (see image above to right), are similar fluid collections. When found in the setting of orthostatic headaches, they are a good reason to pursue the diagnosis of CSF leaks. Spontaneous leaks into the middle ear are usually. CT scans. This may reveal discrete tegmen. These can be. repaired via a middle fossa craniotomy (Leonetti et al, 2. Chen et al., 2. 00. Doppler may. show increased flow velocity. It may be difficult to find a sonographer. We have not tried to use this method in. Chicago - - and it also seems unlikely to work in any case. MRI. may show collapse of the superior opthalmic vein (Chen et al., 2. We have not had any. Leaks. of spinal fluid from the nose or external ear can be detected by. Bachman et al, 2. Wernecke et al, 2. It is too soon to say if. It is our thought. Tests requiring lumbar puncture: Checking of spinal fluid pressure. Radioisotope cisternography (early appearance of tracer in. CT or MR myelography (extra- CSF dye)Fluorescein injection into spinal fluid. Opening pressure on LPIn adults, CSF opening pressure is generally considered normal between 1. H2. 0 (Wright et al, 2. In normal children values may be even higher (2. Radioactive labels. Use of radioactive material into the spinal fluid is logical as it can be detected with extremely high sensitivity, and also there is no natural source for radioactive secretions. Radioactive label materials may include technetium or indium 1. Indium is. an agent that attaches specifically to CSF proteins. A major disadvantage of. Radioisotope cisternography characteristically shows a decrease or absence. Radiologic studies are also useful - - CT contrast cisternography after metrizamide. This may be impractical. Lue and Manolidis 2. CT also requires radiation. MRI myelography. Gadolinium MRI documenting location of CSF leak (arrow). Image from Jinkins et al, 2. A new test, injection of a small amount of gadolinium contrast into. MRI is very promising (Jinkins et. Gadolinium is not as toxic as is CT contrast dye, and also. CT contrast could be confused with bony structures, gadolinium is. Of course, MRI can scan the. In our practice in Chicago. Morton Grove Illinois (a suburb. Chicago). MRI is sometimes repeated at 1 and 2 days post injection. Older methods, not recommended at this date. Although not recommended as a diagnostic test, on. CSF. pressure is 4. However, if this is found, one still needs. The other half of patients may have normal. CSF pressure so a lumbar puncture is not 1. CSF pressure. Of course, there is some danger of causing a leak, per. In a small minority of patients with CSF leak, CSF pressure. MRI findings. Perhaps this indicates an intermittent situation. Spinal. fluid testing may show a minor pleocytosis of 5 or more cells, and a. Mokri et al, 1. 99. In the past it was thought that CSF could be distinguished from other fluids. Testing of the fluid dripping from the nose for glucose. Testing for beta- transferrin may help determine. CSF or something else. We not difficult to implement, have not had much success with this method. A. surer method is to inject radioactive label or a fluorescent dye into. Nasal. pledgets can be left in the nose for extended periods, enabling. CSF is used (according to Hilinski et al, 2. Smaller. amounts are used in children. It is useful to. use control pledgets under the upper lip for comparison. No complications were reported by. Montgomery in more than 2. Seth et al. (2. 01. However some authors have. Audiometry. (hearing testing) is sometimes affected by CSF- leak. Walsted, Salomon et al. Walsted, Salomon et al. Walsted. Salomon et al. Walsted, Nielsen et al. Walsted, Nilsson et. Walsted, Salomon et al. Walsted 1. 99. 8; Walsted 2. One would also think that tests that correlate with hearing, such as OAEs, could be postural too. Unfortunately, a confounding problem with both postural hearing and OAE testing, is that middle ear pressure may change with posture. Treatment of CSF leaks. Watch/wait (i. e. Abdominal binders may be helpful.
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September 2016
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