Radionuclide Imaging With SPECT/CT in Suspected Cerebrospinal Fluid Leakage

Delayed Diagnosis and Treatment of Cerebrospinal Fluid Leakage in Current Practice

As delayed diagnosis and treatment of cerebrospinal fluid (CSF) leakage are common in current practice, this study was performed to determine associated factors and discuss appropriate strategies to deal with these problems. A retrospective analysis of all cases of CSF leakage in our hospital from 2007 to 2018, including 41 patients with CSF rhinorrhea and 5 with CSF otorhinorrhea, was performed. Symptoms, associated diseases, misdiagnoses, history of skull base repair surgical, previous medical costs, and number of hospital visits before visiting our institution were reviewed. The diagnoses, surgical reconstruction methods, and prognoses of the patients were analyzed. In 18 patients, CSF leakage was spontaneous, in 14 the cause was trauma, and in the remaining 14 the origin was iatrogenic. Twelve patients had been misdiagnosed with allergic rhinitis, rhinosinusitis, or otitis media. Twelve cases had intracranial infection and 14 suffered airway infection. Six had undergone unsuccessful craniotomy, endonasal endoscopic surgery, or ear surgery for treatment of CSF leakage before visiting our institute. This resulted in an average of 5.13 ± 1.32 referrals and medical costs of up to 20,795.7 ± 4553.80 RMB. The success rate was 97.83% after repairing CSF fistulae in our hospital. The septal floor flap (SFF) method (based on ethmoidal arteries) to treat CSF rhinorrhea showed a success rate of 100% in 12 patients. Therefore, early localization, clinical diagnosis, and appropriate repair surgery can avoid the occurrence of delayed events. Pedicled flaps, including SFF, are recommended to manage challenging CSF rhinorrhea.

Detection of Cerebrospinal Fluid Leaks: Is There a Radiologic Standard of Care? A Systematic Review

INTRODUCTION

Diagnosis of cerebrospinal fluid (CSF) leaks traditionally involves laboratory testing of markers and appropriate imaging. Surgical localization can be difficult, and the inability to accurately localize skull base defects leads to increased rates of repair failure and complications. Many imaging techniques localizing and identifying CSF leaks have been proposed. Comparisons of current and investigational imaging techniques used to localize CSF leaks are reviewed.

METHODS

A comprehensive and systematic search through PubMed, Scopus, and reference lists from relevant articles was completed to identify literature on sensitivities of different imaging methods for localization and detection of CSF leaks. Prospective, retrospective, and case series published since 1995 that addressed imaging techniques for CSF leaks confined to the skull base were included. Sensitivities of each major imaging technique proposed were recorded and analyzed.

RESULTS

In total, 133 studies initially were screened from 2125 studies on preliminary search. Of these, 38 studies were included based on inclusion criteria. Studies were segregated by imaging modality. A total of 1000 patients with CSF leaks subsequently were evaluated.

CONCLUSIONS

Although radionuclide cisternography has been the historical standard, recent imaging techniques have emerged considering the low sensitivity. Computed tomography cisternography with contrast also has low sensitivity, even in active leaks. Although high-resolution computed tomography is commonly the initial study of choice, magnetic resonance imaging methods, particularly 3-dimensional imaging, may prove to be a more sensitive study of choice. Computed tomography/magnetic resonance imaging combination methods may show promise in localizing CSF leaks. Stratifying by status and etiology may be an important determinant. Further studies investigating various imaging techniques for localizing CSF leaks are needed.

Visual and Quantitative Analysis of Cisternography for the Detection of Cerebrospinal Fluid Leakage

We herein present a case of a 29-year-old man with clear rhinorrhea, which persisted for 8 years following a myringotomy. After cotton pledgets were placed in several different regions of the nasal cavity, cisternography using Tc-99m DTPA was performed to measure the radioactivity of each pledget. Cisternography showed subtle uptake in the nasal cavity. However, intense uptake was detected in the pledget placed in the right eustachian tube orifice, where the pledget:serum count ratio was 10.3:1. The patient underwent duroplasty and cranioplasty, and the rhinorrhea resolved.