Additionally, a mixture of at least 30 percent CSF to blood was required to produce a double ring sign reliably, so the absence of a double ring sign does not exclude a CSF leak. [QxMD MEDLINE Link]. A thorough history is the first step toward accurate diagnosis. According to another theory, the tear and bony defect are present from the time of the original injury, but the leak occurs only after the masking hematoma dissolves. All fluids, when mixed with blood, gave rise to a ring sign; blood alone did not. Once in contact with the paper, any CSF will separate from any. Lanny Garth Close, MD Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons This sign has been debated in the literature, and as you noted from the 1993 study, it is neither sensitive nor specific. In patients with head trauma, a mixture of blood and CSF may make the diagnosis difficult. [QxMD MEDLINE Link]. A study by Lieberman et al found evidence of a significant incidence of multiple simultaneous skull base defects in cases of spontaneous CSF rhinorrhea, reporting the existence of such defects in eight out of 44 patients (18.2%) in the study. All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association or its subsidiaries. Wolters Kluwer Health, Inc. and/or its subsidiaries. Copyright 2023, CMA Impact Inc.or its licensors. doi: 10.1371/journal.pntd.0004516. CT cranial cisternography is performed with injection of 5-7 mL of nonionic myelographic contrast medium into the lumbar subarachnoid space. 2001 Aug. 43(8):622-7. If persistent fluid drainage occurs after a fracture, the fluid may be evaluated to test for the presence of CSF. Once in contact with the paper, any CSF will separate from any blood or mucus. A control pledget for lacrimal secretions is placed under one inferior nasal turbinate. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvMzM4OTg5LW92ZXJ2aWV3. Rapid echo-planar imaging with the patient in the prone position and performing a Valsalva maneuver may allow for limited coronal imaging and increase the accuracy of MR cisternography. 33:690-94. Intrathecal fluorescein (IF) may also be of benefit in certain clinical scenarios. Zuckerman JD, DelGaudio JM. Cerebrospinal fluid (CSF) leaks are generally classified as traumatic, iatrogenic, and spontaneous/idiopathic. However, even in this situation, exceptions can occur. Laryngoscope. Skull base injuries can vary from simple cracks in the bony architecture to large (>1 cm) defects with disruption of the dura and potentially brain parenchyma. Positive predictive values of selected clinical signs associated with skull base fractures. The most rudimentary test is for a so-called double ring sign (Fig. 1954 Jul;42(171):1-18. doi: 10.1002/bjs.18004217102. 19(4):633-9. [QxMD MEDLINE Link]. ), She stated that the cerebrospinal fluid (CSF) double ring sign raises concern about a CSF leak. Cerebral arteriography is not used in the diagnostic imaging workup to localize the site of a CSF leak. Surgical outcomes of the endonasal endoscopic approach within a standardized management protocol for repair of spontaneous cerebrospinal fluid rhinorrhea. Baltimore: Lippincott, Williams & Wilkins; 2003. More than half of these present within 48 hours. Letter to the Editor: Double Ring Sign Does Not Exclude CSF The localization of one or multiple leaks can make possible and facilitate therapeutic CT-guided epidural blood patching. Double ring sign. 2000 Jul. Magnetic resonance myelogram demonstrates pseudomeningoceles secondary to a stretch injury of the lumbosacral nerve roots. L Gill Naul, MD is a member of the following medical societies: American College of Radiology, American Medical Association, American Roentgen Ray Society, Radiological Society of North AmericaDisclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug ReferenceDisclosure: Received salary from Medscape for employment. Federal government websites often end in .gov or .mil. The most rudimentary test is for a so-called double ring sign (Fig. Conservative treatment has been advocated in cases of immediate-onset CSF rhinorrhea following accidental trauma, given the high likelihood of spontaneous resolution of the leak. Several surgical options for repair of CSF leaks arising from the anterior skull base exist. Neuroradiology. Paraspinal fluid collections can be localized for needle aspiration with ultrasound guidance. All of these changes are reversible with ablation of the cause of CSF leak, which is usually in the spine. 2002 Feb. 44(2):143-50; discussion 151-2. Dula DJ, Fales W. The 'ring sign': is it a reliable indicator for cerebral spinal fluid?. Epub 2021 Aug 2. Ear Nose Throat J. [QxMD MEDLINE Link]. 2010 Sep. 67(3 Suppl Operative):ons150-8; discussion ons158. If the defect is large, brain parenchyma may also herniate through the defect (encephalocele). Lateral 24-hour cranial scintigraphic image from a nuclear medicine cisternographic study in a patient with clinically evident right-sided cerebrospinal fluid rhinorrhea. Unauthorized use of these marks is strictly prohibited. Brain tissue herniation is best seen on MRI. The .gov means its official. The opposite is true for nontraumatic leaks, as only one third stop spontaneously. A small cribriform plate encephalocele is observed only after removing the middle turbinate. Please enable it to take advantage of the complete set of features! [1] The fluid leak is a result of meningeal dural and arachnoid laceration with fistula formation. [QxMD MEDLINE Link]. Transnasal endoscopic repair of cerebrospinal fluid rhinorrhea: a meta-analysis. Thomas DL, Menda Y, Graham MM. 2022 Dec 8;12(12):1685. doi: 10.3390/brainsci12121685. Serum glucose, chloride,. El Gammal T, Sobol W, Wadlington VR, et al. [QxMD MEDLINE Link]. 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. Other local services are: Electrical . 2022 Feb;45(1):831-841. doi: 10.1007/s10143-021-01614-1. A doctor can use a number of tests to diagnose a CSF leak. 51(6):704, 706. The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow). The leakage stops within 1 week in 70% of patients, within 3 months in 20-30%, and within 6 months in most patients. Careers. Cisternography with an intrathecal injection of radioisotope or nonionic iodinated myelographic contrast medium or MRI cisternography usually localizes the CSF leak. 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. ENT Eponymous Signs Flashcards | Quizlet 2017 Oct. 2 (5):215-24. CSF separates from blood when it is placed on filter paper, and it produces a clinically detectable sign: the ring sign, double-ring sign, or halo sign. Please try again soon. [QxMD MEDLINE Link]. Hegarty SE and Millar JS. A biopsy should never be obtained unless a complete imaging workup has been conducted. 2016 Jan. 206 (1):8-19. Most spontaneous, or primary, causes of CSF rhinorrhea are now thought actually to be secondary to elevations in intracranial pressure (ICP) that might be seen in patients with idiopathic intracranial hypertension (IIH). Ohwaki K, Yano E, Shinohara T, Watanabe T, Ogawa A, Fujii N, et al. An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. Gadolinium-enhanced, coronal, T1-weighted MRI shows dural and tentorial thickening with contrast enhancement. PDF DualRing: Generic Construction of Ring Signatures with E cient