Detection

of a Cerebrospinal

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JONATHAN

Computed tomography tice of neuroradiology. infarcts, tumors, and has been well documented. first case of an air-filled mented by CT.

M. LEVY,1

Fluid Fistula

FRED

K. CHRISTENSEN,2

(CT) has revolutionized the pracThe utility of CT in detection of other intracranial abnormalities To our knowledge this is the cerebrospinal fluid fistula docu-

Pupils

were

equal

and

reactive,

and

fundoscopic

a diagnosis

of pneumocephalus

and

possible

PAUL

W. NYKAMP1

fascia

approximately

2 cm

square

third day The night cnibiform large hole A piece

was

sutured

the hole.

The patient’s condition deteriorated slowly over the next 10 days. Cerebrospinal fluid cultures were negative; and no further leak could be detected. He died 10 days after surgery. At

Report

autopsy, in the adjacent

the brain anterior

showed

inflammatory

perforating

to and

and

substance.

at some

distance

tract into the right frontal

There from

infanctive was

the

vasculitis

fistula.

horn had closed

The

changes both fistulous

to a narrow

slit.

Discussion

Numerous cerebrospinal

techniques for the identification of sites of fluid rhinorrhea have been reported. Conventional films of the base of the skull as well as conventional tomography are sometimes helpful in localizing a fracture site and thereby the site of leakage. However, these techniques are often unrewarding, and the dural tear may be at some distance from the site of the extracnanial leak [1 2].

ex-

amination was normal. He had profuse rhinorrhea from both nostrils. Lumbar puncture was performed and the specimen sent for chemical and bacteriologic analysis. He was admitted with

temporalis

over

A 42-year-old white male had a transnasal ethmoidectomy at another hospital for chronic ethmoiditis. Six days after discharge, he was readmitted to the hospital with confusion and headache. He had copious nasal discharge. Skull films revealed pneumocephalus. He was referred to our institution for neurosurgical evaluation. On examination, the patient’s blood pressure was 130/80, pulse 58. He would lie asleep unless disturbed, and could answer questions but preferred not to talk. He had mild nuchal rigidity.

AND

Tomography

entire length of the fistulous tract (fig. 1B). On the after admission, a bicoronal scalp flap was turned. frontal lobe was exposed and retracted, exposing the plate. The brain could be seen herniating through a in the cnibiform plate approximately 1 cm in diameter. of

Case

by Computed

meningitis.

A CT scan was performed which showed a tract extending from the right ethmoid air cells to the anterior horn of the right lateral ventricle (fig. 1A). Coronal sections demonstrated the

,

Fig . 1 . -A , CT scans , transverse sections. Upper left, Lowest section showing hole in cribiform plate. Upper right, Fistulous tract. Lower left, Tract

adjacent

to

lateral

ventricle.

Lower right, Tract entering anterior horn of ventricle. B, Coronal section showing entire length of tract extending from ethmoid sinus to antenor

Received December 20, 1977; accepted Department of Diagnostic Radiology,

‘

toJ.

after

revision

Scottsdale

March

Memorial

horn

of right

lateral

ventricle.

24, 1978.

Hospital,

7400

East Osborn

Road, Scottsdale,

Arizona

85251

.

Address

reprint

requests

M. Levy.

2 Department Am J Ro.ntg.nol C 1978 American

of Neurosurgery, 131:344-345,

Roentgen

Scottsdale

August 1978 Ray Society

Memorial

Hospital,

Scottsdale,

344

Arizona

85251.

0361

-803X/78/08-0344

$00.00

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CASE Dyes and fluorescent substances have been used to localize cerebrospinal fluid fistulas [3]. These are injected intrathecally, cotton pledgets placed in the nose, and the pledgets then observed for dye to localize the site of leak. Most of these dyes, and particularly methylene blue, can cause significant morbidity [1]. Radioactive tracers such as 9”Tc human serum albumin have also been used for detection of leaks, both by pledget counting and by cisternography using the method devised by di Chiro (cited in [4]). These techniques are not uniformly successful. Positive contrast radiography with Pantopaque to detect fistulas has also been associated with meningeal irritation [5]. The anatomic site and extent of the cerebrospinal fluid fistula in our case was accurately detected by CT. Admittedly, this large leak would probably have been detected by several of the other methods described. However, the ease of performance and anatomic detail provided by CT are greater than those of the other techniques. Recent introduction of water soluble contrast material for myelography, combined with CT, has provided a new dimension in visualizing the basal subarachnoid cisterns [6]. A fistula from the sphenoid sinus to the nares has been detected using this method [7], and smaller fistulas

345

REPORTS should be detectable tion of cerebrospinal the remarkable utility nial disease.

using contrast material. fluid fistulas is another of CT in the evaluation

The detecexample of of intracra-

REFERENCES 1 . Duckert LG, Mathog RH: Diagnosis las. Laryngoscope 87 : 1 8-25, 1977.

2. Hudson diagnosis

in persistent

WR, Hughes LA: Cerebrospinal and management. South Med

fluid

CSF

fistu-

rhinorrhea;

J 68:1520-1523,

1975

3. Raaf J: Posttraumatic

CSF leaks.

Arch

Surg

95:648-651,

1967

4. Ommaya

AK:

Spinal

fluid

fistulae.

Clin

Neurosurg

23:363-

392, 1976 5. Doron

Y, Simon

J, Peyser

E: Positive

contrast

myeloence-

phaiography

for visualization of cerebrospinal fluid fistula. Neuroradiology 3 : 228-230, 1972 6. Roberson GH, Taveras JM, Tadmor R, Kleefield J, Ellis G: Computed tomography in metnizamide cisternography: importance of coronal and axial views. J Comput Assist Tomog 7. Drayer

1 :241-245, BP, Wilkins

AE: Cerebrospinal zamide 1977

1977 RH, Boehnke

fluid

CT cisternography.

rhinorrhea

M, Horton

JA, Rosenbaum

demonstrated by metniAm J Roentgenol 129 : 149-151,