The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea

Abstract

The aim of this prospective study was to evaluate the value of unenhanced (three-dimensional constructive interference in steady state (3D-CISS)) and contrast-enhanced MR cisternography (CE-MRC) in detecting the localisation of cerebrospinal fluid (CSF) leak in patients with rhinorrhoea. 17 patients with active or suspected CSF rhinorrhoea were included in the study. 3D-CISS sequences in coronal and sagittal planes and fat-suppressed T1-weighted spin-echo sequences in three planes before and after intrathecal contrast media administration were obtained. Images were obtained of the cribriform plate and sphenoid sinus. In addition, high-resolution CT (HRCT) was performed in order to evaluate the bony elements. The leak was present in 9/17 patients with 3D-CISS and 10/17 patients with CE-MRC. The leak from the cribriform plate to the nasal cavity in six patients and from the sphenoid sinus in four patients was nicely shown by CE-MRC. Eight of those patients were surgically treated, but spontaneous regression of the symptoms in two precluded any intervention. The leak localisations shown with CE-MRC were fully compatible with surgical results. The sensitivities of HRCT, 3D-CISS and CE-MRC for showing CSF leakage were 88%, 76% and 100%, respectively. In conclusion, 3D-CISS is a non-invasive and reliable technique, and should be the first-choice method to localise CSF leak. CE-MRC is helpful in conditions when there is no leak or in complicated cases with a positive beta2-transferrin measurement.

Figure 1

A 24-year-old male patient with rhinorrhoea after trauma (Case 2). (a) Coronal three-dimensional constructive interference in steady state (3D-CISS) image showing vague hyperintensity at the left ethmoidal cells suspicious for cerebrospinal fluid leak (arrow). (b,c) Coronal contrast-enhanced MR cisternography (CE-MRC) images showing that the cribriform plate is intact and there is no leak.

Figure 2

A 54-year-old man with recurrent meningitis (Case 5). Coronal high-resolution CT images demonstrate a fracture at the roof of the right sphenoid sinus (arrow in (a)). Leak towards the sphenoid sinus (arrows) is seen in (b,c) sagittal coronal three-dimensional constructive interference in steady state (3D-CISS) images and (d) a coronal contrast-enhanced MR cisternography (CE-MRC) image. Leak was confirmed via surgery.

Figure 3

An 18-year-old man with recurrent meningitis after trauma (Case 15). Coronal high-resolution CT images demonstrate the bone defect in the left cribriform plate (arrow in (a)). (b) Cerebrospinal fluid (CSF) leak from the left cribriform plate is nicely seen on the coronal three-dimensional constructive interference in steady state (3D-CISS) image (arrow). The size and relationship of the defect with neighbouring structures and CSF leak (arrows) is clearly depicted on (b) non-enhanced coronal, (d) axial and (e) coronal contrast-enhanced MR cisternography (CE-MRC) images. (f) The defect of the cribriform plate (arrow) was proven surgically.