Detection of rhinorrhoea by cisternography in combination with single photon emission tomography, following lumbar injection of iodine-123-labelled albumin

Diagnosis and Localization of Cerebrospinal Fluid Rhinorrhea: A Systematic Review

Background

Cerebrospinal fluid (CSF) rhinorrhea results from abnormal communications between the subarachnoid and sinonasal spaces. Accurate preoperative diagnosis and localization are vital for positive clinical outcomes. However, the diagnosis and localization of CSF rhinorrhea remain suboptimal due to a lack of accurate understanding of test characteristics.

Objective

This systematic review aims to assess the diagnostic accuracy of various tests and imaging modalities for diagnosing and localizing CSF rhinorrhea.

Methods

A systematic review of the MEDLINE and EMBASE databases was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Results

Our search identified 4039 articles—53 cohort studies and 24 case series describing 1622 patients were included. The studies were heterogeneous and had a wide range of sensitivities and specificities. Many specificities were incalculable due to a lack of true negative and false positive results, thus precluding a meta-analysis. Median sensitivities and specificities were calculated for cohort studies of the following investigations: high-resolution computed tomography (HRCT) 0.93/0.50 (sensitivity/specificity), magnetic resonance cisternography (MRC) 0.94/0.77, computed tomography cisternography (CTC) 0.95/1.00, radionuclide cisternography (RNC) 0.90/0.50, and contrast-enhanced magnetic resonance cisternography (CEMRC) 0.99/1.00, endoscopy 0.58/1.00, topical intranasal fluorescein (TIF) 1.00/incalculable, intrathecal fluorescein (ITF) 0.96/1.00. Case series were reviewed separately. Etiology and site-specific data were also analyzed.

Conclusion

MR cisternography is more accurate than high-resolution CT at diagnosing and localizing CSF rhinorrhea. CT cisternography, contrast-enhanced MR cisternography, and radionuclide cisternography have good diagnostic characteristics but are invasive. Intrathecal fluorescein shows promising data but has not been widely adopted for purely diagnostic use. Office endoscopy has limited data but does not sufficiently diagnose CSF rhinorrhea independently. These findings confirm with current guidelines and evidence.

Clinical evaluation of SPECT/CT fusion imaging for the diagnosis and determination of localisation of cerebrospinal rhinorrhea

OBJECTIVE

The objective was to evaluate the clinical value of the single photon emission computerized tomography/computed tomography (SPECT/CT) fusion imaging for the diagnosis and determination of localisation of cerebrospinal rhinorrhea.

METHODS

A total of 33 patients with cerebrospinal rhinorrhea were preoperatively injected with (99m)Tc-diethylenetriamine pentaacetic acid (DTPA) through lumbar puncture and then subjected to planar imaging of the cistern 120 min and 180 min after operation. CT and ECT were then performed. Finally, the rhinorrhea ventage and leaking path were confirmed by fusion image analysis.

RESULTS

Thirty-one patients who underwent fusion imaging and 30 patients who underwent planar imaging showed abnormal nuclide activity in the cavity between the basis cranii and the nose. After operation, 30 patients who underwent fusion imaging and 18 patients who underwent planar imaging showed complete correction of the leakage. The diagnosis sensitivity and positional accuracy of fusion imaging were 93.9% (31/33) and 90.9% (30/33) at P>.05. The values of planar imaging were 93.5% (29/31) and 79.3% (23/29) at P<.05.

CONCLUSION

(99m)Tc-DTPA SPECT/CT fusion imaging of the cistern is an efficient, simple, and accurate method that may be used for diagnosing and determining the localisation of cerebrospinal rhinorrhea ventage and leakage path.

The Clinical Correlation of Temporal Bone Fractures and Spiral Computed Tomographic Scan: A Prospective and Consecutive Study at a Level I Trauma Center

BACKGROUND

Undetected temporal bone fractures (TBFs) can lead to complications such as hearing loss, facial nerve paralysis, otorrhea, or otorhinorrhea, and can be the cause of life-threatening bacterial meningitis and can easily be missed.

METHODS

We prospectively studied patients with head trauma between January 2000 and January 2001. All patients were examined by the attending trauma physician and then underwent cranial helical computed tomographic (CT) scan independent of clinical findings and Glasgow Coma Scale (GCS) score to determine the proportion of TBFs that would have been missed if diagnosis had been based only on clinical evaluation.

RESULTS

Three-hundred fifty consecutive patients with head trauma were studied during the 12-month period (GCS score: range, 3-15; median, 13). In 34 (9.7%) of these patients, 38 TBF (30 unilateral and 4 bilateral) were diagnosed by CT scan. However, clinical signs of TBF were present in only 22 of the 34 patients (65%). All missed TBFs were unilateral. Of the patients with missed TBFs, 8 of 20 (40%) had GCS scores of 14 to 15, 1 of 8 (12.5%) had a GCS score of 9 to 13, and 3 of 6 (50%) had GCS scores < 9. Four of 34 (12%) patients developed clinical complications.

CONCLUSION

TBFs are common injuries in patients with head trauma. More than one third of these fractures may be missed by clinical diagnosis alone. Although the clinical importance of the missed TBF is debatable, 12% of our patients developed complications. Therefore, to rule out these lesions, routine cranial helical CT scan should be recommended in all patients presenting with head trauma, independent of clinical findings and GCS score.

Magnetic resonance cisternography and thin coronal computerized tomography in the evaluation of cerebrospinal fluid rhinorrhea

In recent years cerebrospinal fluid (CSF) rhinorrhea has been managed successfully with transnasal endoscopic techniques. The most important and often most difficult step is the precise localization of the fistula. Computerized tomographic and radionuclide cisternography are two commonly used techniques for preoperative identification of the CSF fistula when it cannot be seen clearly with nasal endoscopy. Each of these requires a lumbar puncture, and the intrathecal placement of contrast material has been associated with transient neurotoxicities. Magnetic resonance cisternography (MRC) is a noncontrast study that does not require a lumbar puncture and has been used recently in the diagnosis of spontaneous and traumatic CSF leaks. Magnetic resonance cisternography utilizes a fast spin-echo sequence with fat suppression and video image reversal that highlights CSF. This allows precise localization of the fistula in both coronal and sagittal planes. Thin section coronal computed tomography (TCCT) is another noninvasive technique that can be helpful in localizing CSF leaks. The technique of MRC and TCCT and the results of 16 CSF leaks in 15 patients are reported. There was good correlation between MRC, TCCT, and intraoperative findings. Magnetic resonance cisternography and thin coronal computerized tomography appear to be accurate and complementary, noninvasive radiographic studies that should be considered in the evaluation CSF rhinorrhea.

Beta-2-transferrin and cerebrospinal fluid rhinorrhoea

Beta-2-transferrin is a protein produced by neuraminidase activity in the brain which is uniquely found in the cerebrospinal fluid (CSF) and perilymph. Its absence in other body secretions makes its detection invaluable in diagnosing a CSF leak. In this series samples were analysed from 25 patients with suspected CSF rhinorrhoea. The presence of beta-2-transferrin was determined by immuno-fixation electrophoresis. Out of 25 patients 16 were positive for beta-2-transferrin. A dural defect and CSF leak were confirmed during surgery in 13 of the 16 patients. In three patients the rhinorrhoea stopped spontaneously. Out of nine patients who were negative for beta-2-transferrin in the nasal fluids, two underwent a craniotomy and neither had evidence of CSF leak or dural effect. Two of the eight patients had a normal computerized coronal tomography (CT) despite a CSF leak. Seventeen patients underwent CT cisternography (six in the beta-2-transferrin negative group and 11 in the positive group). A leak was shown by CT cisternography in seven patients in the positive beta-2-transferrin group, but a leak could not be confirmed in the other four patients. No leak was demonstrated in the six patients in the negative beta-2-transferrin group. Beta-2-transferrin is a valuable and sensitive means of confirming the diagnosis of CSF leaks. Patients with a suspected CSF leak but no beta-2-transferrin in their nasal discharge can avoid unnecessary invasive investigations.

Head trauma: use of SPECT

Brain damage inflicted by head trauma may not be visible on computed tomography or magnetic resonance imaging. This is true not only for mild head trauma, but also for moderate and severe head trauma. Perfusion imaging with single-photon emission computed tomography has proved in several controlled studies to be more sensitive than either computed tomography or magnetic resonance imaging in detecting brain abnormalities in patients with head trauma.