double ring sign csf

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. A large defect is noted, and the meningocele has been resected. [QxMD MEDLINE Link]. 1993:22[4]:718.). Gadolinium-enhanced T1-weighted axial MRI shows diffuse moderate dural thickening with contrast enhancement. Algin O, Hakyemez B, Gokalp G, Ozcan T, Korfali E, Parlak M. The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea. eCollection 2023 Feb. Please refer to Etiology for further details. Conclusion: The fluid can be placed on filter paper and a "halo" or double ring may be seen. The investigators suggested that intracranial hypertension may put patients at risk for developing these defects. Penetrating and closed-head trauma are responsible for 90% of all cases of CSF leaks. A suggested algorithm for the diagnosis of a CSF fistula follows. 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. MeSH MR cisternography and myelography can accurately localize CSF leaks in the cranium and spine. This image represents an endoscopic view with a 70-degree telescope through the left frontal recess. Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension. 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 Byrne JV, Ingram CE, MacVicar D, et al. [1] The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. [7], A literature review by Lobo et al indicated that in addition to increased ICP, risk factors for spontaneous CSF leaks include obesity, female gender, and obstructive sleep apnea. 2009 Oct. 72(4):341-5; discussion 346. 2000 Jul. 2003 Aug. 129(8):859-63. [14]. 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. A high index of suspicion should be maintained with all pediatric intranasal masses, particularly those occurring at the midline. J Neurol Neurosurg Psychiatry. 2020;42[12]:31; http://bit.ly/2HVJcdt. 30 (6):424-9. Methods: A variety of filter paper agents were used, including standard laboratory filter paper, paper towels, coffee filters, and bed linens. This website also contains material copyrighted by 3rd parties. Since then, endoscopic repair has become the preferred method of addressing CSF rhinorrhea, given the high success rate of 90-95% and the decreased morbidity associated with this approach. 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). Endoscopy may reveal an encephalocele or meningocele. Michael G D'Antonio, MD Associate Professor of Clinical Radiology, Department of Radiology, Section of Neuroradiology, Louisiana State University Health Sciences Center in New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associate, Inc, West Jefferson Medical CenterDisclosure: Nothing to disclose. Clin Radiol. The localization of one or multiple leaks can make possible and facilitate therapeutic CT-guided epidural blood patching. Am J Rhinol. [QxMD MEDLINE Link]. AJNR Am J Neuroradiol. Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. 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. Background: In contrast to traumatic leaks, only 50% of patients with iatrogenic CSF leaks present within the first week after the insult. Once in contact with the paper, any CSF will separate from any blood or mucus. Am J Rhinol Allergy. Spinal MRI findings are also potentially reversible after successful ablation of a CSF fistula. Neurosurgery. The resulting communication with the central nervous system (CNS) can result in a multitude of infectious complications that impart significant morbidity and potentially disastrous long-term deficits for the patient. The dye reaches the skull base in 6 hours and is present over the cerebral convexities in 24 hours. Triplanar images of a patient with a left lateral recess meningoencephalocele. The .gov means its official. Other stresses include Valsalva-like maneuvers during nose blowing or straining. Medscape Education, A Review of Rare Conditions Across the Lifespan: Pediatric Neuromuscular Disorders, encoded search term (CSF Rhinorrhea) and CSF Rhinorrhea, Autonomic Dysreflexia in Spinal Cord Injury, Prevention of Thromboembolism in Spinal Cord Injury, Cardiovascular Concerns in Spinal Cord Injury, 'Snake Oil' Fake Cures for Long COVID Leave Patients at Risk, Ozzy's Wearable Cyborg May Be The Future of Physical Therapy. Axial fast spin-echo T2-weighted MRI demonstrates widened extra-axial fluid spaces but no focal extra-axial fluid collection. However, if CSF rhinorrhea persists beyond this point, or if a large skull base defect is observed at the time of injury, surgical repair is warranted. The site is secure. Otolaryngology procedures, including FESS and septoplasty, can lead to a skull base defect and CSF rhinorrhea. Several surgical options for repair of CSF leaks arising from the anterior skull base exist. Dodson EE, Gross CW, Swerdloff JL, et al. Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New ZealandDisclosure: Nothing to disclose. [QxMD MEDLINE Link]. Int J Pediatr Otorhinolaryngol. All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries. Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. 32(5):832-8. [QxMD MEDLINE Link]. government site. [5]. A high percentage of fast leaks have spinal extradural fluid collections on preliminary MRI spine scans. [16] Contemporary computer-reconstructed coronal images are usually of diagnostic quality, and direct CT coronal images may not be necessary. Unable to load your collection due to an error, Unable to load your delegates due to an error. BMJ Case Rep. 2017 Apr 22;2017:bcr2016218995. Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). Radiology. 142:43-7. The cerebral dural venous sinuses may be engorged. The https:// ensures that you are connecting to the 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. Fluid contained in the meningocele and leaked fluid in the sphenoid sinus outline the meningocele membrane. [2] (See the images below. Hugh J F Robertson, MD, DMR, FRCPC, FRCR, FACR Professor Emeritus of Radiology, Louisiana State University Health Sciences Center, New Orleans; Clinical Professor of Radiology, Tulane University School of Medicine 2018 Dec;38(4):1384-1392. doi: 10.1088/1361-6498/aae39b. This occurred on bed linen, filter paper, absorbent paper, and coffee filters. In many cases, a CSF leak will heal on its own accord following conservative treatment, including strict bed rest, increased fluid intake and caffeine. It cushions your brain and spinal cord from injury. Joseph M Scianna, MD Co-Director of Sinus and Sleep Disorders, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, Loyola University Medical CenterJoseph M Sciannais a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Rhinologic Society, Srinivas Mukkamala, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, Loyola University of Chicago Medical Center. CT myelography is used in the detection of spinal CSF leak. However, an astute clinician noted the double ring sign on the stretcher sheet, as noted in the Figure 1. The growth of benign tumors does not commonly result in CSF rhinorrhea. Spinal radiological findings in nine patients with spontaneous intracranial hypotension. Another technique, the injection of intrathecal fluorescein, has been used not only to diagnose CSF rhinorrhea but to localize the site(s) where it occurs. Once in contact with the paper, any CSF will separate from any. Circulation of CSF is maintained by the hydrostatic differences between its rate of production and its rate of absorption. The osteoplastic flap provides the surgeon with a view of the entire posterior table of the frontal sinus and is especially useful for defects more than 2 cm above the floor and lateral to the lamina papyracea. In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult. Breaking News: A Catastrophic Match: Now What? Neurosurgery. Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow). [QxMD MEDLINE Link]. A new approach for simple radioisotope cisternography examination in cerebrospinal fluid leakage detection. and transmitted securely. Br J Neurosurg. Intervention for elevated intracranial pressure improves success rate after repair of spontaneous cerebrospinal fluid leaks. The fluid from his ear dripped onto the bedsheet, showing a halo pattern (Figure 1). AJNR Am J Neuroradiol. You are being redirected to [QxMD MEDLINE Link]. 2022. MR cisternography may demonstrate inactive CSF fistulas. Blood alone does not produce a ring. This site needs JavaScript to work properly. If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea and skull base defects: a review of twenty-nine cases. Neurol India. CSF rhinorrhoea: the place of endoscopic sinus surgery. A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma. All material on this website is protected by copyright, Copyright 1994-2023 by WebMD LLC. [QxMD MEDLINE Link]. Fast spin-echo T2-weighted coronal image of a patient with a spontaneous onset of cerebrospinal fluid rhinorrhea demonstrates an empty-sella configuration. The entire spine is scanned up to 24 hours in cases of spontaneous intracranial hypotension, spinal trauma, or postoperative CSF leaks. Pre-cut Filter Paper for Detecting Anti-Japanese Encephalitis Virus IgM from Dried Cerebrospinal Fluid Spots. Oh JW, Kim SH, Whang K. Traumatic Cerebrospinal Fluid Leak: Diagnosis and Management. 2001 Feb. 15(1):8-12. CT-guided epidural blood patching of directly observed or potential leak sites for the targeted treatment of spontaneous intracranial hypotension. Cisternography with an intrathecal injection of radioisotope or nonionic iodinated myelographic contrast medium or MRI cisternography usually localizes the CSF leak. 2015 Apr 28. [QxMD MEDLINE Link]. When CSF rhinorrhea is suspected, fluorescein may be injected into the lumbar subarachnoid space. Kim DH, Kim SW, Han JS, Kim GJ, Basurrah MA, Hwang SH. CSF leak from the ear. Intense extradural contrast enhancement is noted in congested epidural veins. Br J Neurosurg. Korean J Neurotrauma. Epub 2015 Sep 15. Would you like email updates of new search results? Defects in the closure of the anterior neuropore can result in the herniation of central nervous tissue through anterior cranial fossa. [QxMD MEDLINE Link]. 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. Bharucha T, Chanthongthip A, Phuangpanom S, Phonemixay O, Sengvilaipaseuth O, Vongsouvath M, Lee S, Newton PN, Dubot-Prs A. PLoS Negl Trop Dis. Adv Med Sci. Please confirm that you would like to log out of Medscape. (See images below.). Int Forum Allergy Rhinol. A basal layer Na+/K+ ATPase is responsible for actively transporting Na+ into epithelial cells, after which water follows across this gradient. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. The test for CSF fluid involves placing a sample of what the doctor suspects to be CSF discharge on a piece of filter paper. Copyright 2023, CMA Impact Inc.or its licensors. 92(5):873-6. 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. Iatrogenic causes include neurosurgical and otolaryngologic approaches to neoplastic disease, as well as functional endoscopic sinus surgery (FESS). Hence, educating the patient regarding the common symptoms associated with a CSF leak such as salty or metallic taste is of paramount importance. Vanopdenbosch LJ, Dedeken P, Casselman JW, Vlaminck SA. This finding is consistent with a meningoencephalocele of the temporal bone. The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow). [29]. All of these changes are reversible with ablation of the cause of CSF leak, which is usually in the spine. Other signs of anterior basilar skull fractures include partial or total loss of vision and smell as well as eye movement defects due to cranial nerve damage. In the study, about 72% of patients with spontaneous CSF leaks were female, and about 45% had obstructive sleep apnea. Methods: (Ann Emerg Med. Even if the tumor itself does not lead to CSF rhinorrhea, the resection typically results in immediate leakage. CSF rhinorrhea following a traumatic injury is classified as immediate (within 48 hours) or delayed. Curr Opin Otolaryngol Head Neck Surg. Evaluation of high-resolution CT and MR cisternography in the diagnosis of cerebrospinal fluid fistula. CSF is colorless, clear, and typically devoid of cells such as polymorphonuclear cells and mononuclear cells (< 5/L). 1993:22[4]:718.) Ray BS, Bergland RM. 2017 Oct. 2 (5):215-24. [19]. The images may demonstrate a CSF fistula, but this technique is used less frequently than other cisternographic methods. 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. 2002 Feb. 222(2):555-9. 2022 Feb;45(1):831-841. doi: 10.1007/s10143-021-01614-1. 28.10). HHS Vulnerability Disclosure, Help Cerebrospinal fluid fistula: clinical aspects, techniques of localization, and methods of closure. [QxMD MEDLINE Link]. This sign appears when CSF mixes with blood on an absorbent surface, such as paper or bed sheets, and creates a double ring pattern. 1993 Apr. Typically, the leak is caused by either spontaneous dural dehiscence or dural tears caused by degenerative causes. [Full Text]. Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine [QxMD MEDLINE Link]. 1-7. On occasion, the patient has a history of headache relieved by drainage of CSF. In-111 has minimal background activity and does not accumulate in the brain. 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. J Neurosurg. The https:// ensures that you are connecting to the AJR Am J Roentgenol. 2013 Jul;7(7):1447-9. doi: 10.7860/JCDR/2013/5377.3170. 83(987):225-32. 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. A positive diagnosis of CSF fistula is made by finding direct continuity of the CSF fistula with the subarachnoid space. Lawrence SK, Delbeke D, Partain CL. The management of CSF rhinorrhea depends on the cause, location, and severity of the leak. Gadolinium-enhanced, T1-weighted axial MRI obtained 2 weeks after a 7-mL extradural blood patch was applied to the midlumbar region. Toxicology Rounds: A Non-Diabetic with Lactic Acidosis? [QxMD MEDLINE Link]. 2015 Oct 14. [QxMD MEDLINE Link]. Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck SocietyDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10
Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)
Received ownership interest from Cerescan for consulting for: Neosoma, MI10. The pledgets are examined for green fluorescence in a dark room with ultraviolet light 6 hours after the intrathecal PSP injection. 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. Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. Double ring sign. Endoscopic endonasal minimal access approach to the clivus: case series and technical nuances. Share cases and questions with Physicians on Medscape consult. [Full Text]. Sellar repair in endoscopic endonasal transsphenoidal surgery: results of 170 cases. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. Goel G, Ravishankar S, Jayakumar PN, et al. Typically, 0.5 mL of a 10% fluorescein solution is injected into the lumbar subarachnoid space over more than 1 minute. 30(4):399-405. [QxMD MEDLINE Link]. nSAIDs and aspirin . 52:768-770. We are prepared to diagnose any electrical problem you're facing and resolve it. Although the value of this sign has been debated, an experiment showed that the sign was consistently visible when CSF concentrations were 30%90% when mixed with blood.2 However, the sign was not specific to CSF: mixtures of blood with saline, tears or rhinorrhea also produced halos; filter paper, paper towel, coffee filters and linen all showed a ring.2, Guidelines recommend a CT scan of the head when basal skull fracture is suspected.3 Although CSF leakage occurs in 2%21% of basal skull fractures, a recent review does not support the use of prophylactic antibiotics to prevent the development of meningitis.4. A halo pattern on a bedsheet produced by bloody otorrhea from a 27-year-old man who had been in a motor vehicle collision. Eljamel MS, Pidgeon CN, Toland J, et al. Additional hardware or software is not required to perform MR myelography or cisternography. -2 transferrin is a protein found in CSF, but not in serum, nasal secretions, or adjacent tissue. For example, anosmia (present in 60% of individuals with post-traumatic rhinorrhea), indicates an injury in the olfactory area and anterior fossa, especially when it is unilateral. 51(6):704, 706. Cerebrospinal fluid rhinorrhoea in closed head injuries. An official website of the United States government. Despite the multifactorial causes of elevated ICP, once this problem ensues, the pressure exerted on areas of the anterior skull base such as the lateral lamella of the cribriform or lateral recess of the sphenoid sinus results in bone remodeling and thinning. Traumatic causes include both blunt and penetrating facial injuries. Spontaneous intracranial hypotension syndrome in a patient with chronic headaches, which began after lumbar puncture. Chiapparini L, Farina L, D'Incerti L, et al.

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