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Describe in brief recent techniques to localize the site of CSF leak.

  • The clinical finding of CSF rhinorrhoea represents only the site of existing CSF but not the origin of the fistula.
  • Accurate definition of the leakage site is undoubtedly the must important factor in successful treatment of the problem.

Imaging

  • confirm the presence of the CF leak.
  • Identify any underlying cause, anatomical abnormality.
  • Determine the anatomical site,side and size of fistula.
  • Assists in planning the surgical approach
  • Look for : Bone defects
  • Air fluid levels
  • Erosions

Plain films:

  • demonstrate pneumocephalus/air fluid levels/
coronalAxial (1mm or len)
most helpful in evaluating anterior cranial fossa leaks.evaluates anterior and posterior table of the frontal sinus
integrity of cribriform plate, fovea ethmoidalis the planum sphenoidale, the floor of the frontal sinus, pituitary fossa orbital roof.any extension of linear into the frontal sinuses
Medial orbitals wals
1 plate of ethmoid

MRI:

  • Not recommended as a 1st line imaging modality.
  • Only when enephalocele is suspected.
  • Doesn’t delineate bony defect/costly/time consuming.

CT cisternography:

  • Better localization of the site of CSF leak.
  • Intrathecal injection of contrast (metrizamide neurotoxicity. Next generation Iohexol).
  • It may miss cribriform/ethmoid sinus defects
  • invasive procedure
  • ADR: N/V , headache, acute organic psychotic symptoms.

MR cysternography:

  • Avoids exposure to ionization radiation.
  • Avoids intrathecal infection of contrast(benefits)
  • T2 weighted image detects the pressure of CSF in the sinonasal cavity and pulse sequence if performed enhances probability of detecting CSF .
  • False negative result may be there.
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