RIC Evidences of Spinal CSF

Leaks
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======SLIDE-1======
SIH/CSF Leak/CSF Hypovolemia
Ideal Triad:

RIC Evidences of Spinal CSF

Leaks
* Orthostatic Headache
* Low CSF Pressure
* DPMGE ombked MRS
Variability is Substantial in every aspect
======SLIDE-2======
SIH/CSF Leak
* Atypical and doubtful cases are many and are increasingly encountered in tertiary and referral centers
* Often one fundamental question needs to be addressed to start with: "is there or is there not
a leak present?"
* Is there a study that can determine presence or absence of active CSF Leak?
* Radioisotope Cisteronography is quite helpful in this regard
======SLIDE-3======
RIC, Technical Principles
Isotope is introduced IT via routine LP
Sequential images are obtained shortly thereafter (often < 20 minutes), and at predetermined intervals up to
24 or 48 hours
Typically PA view images are obtained to follow the Cephalad Extension
PA views more clearly show intraspinal activity and renal activity
AP views more clearly show the bladder activity
======SLIDE-4======
RIC, Technical Principles (Cont.)
The activity should reach:
* Basilar Cisterms by 1-2 hrs.
* Front Poles by 2-5 hrs.
* Sylviant interhemisphere by 3-65 hrs.
* Cerebral Convexities by 10-12 hrs.
By 24 hrs. much activity is noted over vertext along SSS
======SLIDE-5======
RIC, Technical Principles (Cont.)
Cephalad Ascent is faster in the young and decreases with age
Not affected by activity or posture after injection
2/3 of IT injected isotope is cleared via kidneys by 24 hrs.
By 9 hrs. bladder activity increases in about 70% -- and in many cases earlier
======SLIDE-6======
Evidence of Spinal CSF Leak on RIC
Direct Evidence
* Paradural activity (Extravasation)
Indirect Evidence
* Incomplete Cephalad Migration
* Early activity in urinary bladder and kidneys
* Activity in systemic circulation -- "silhouette sign"
Pitfalls
* Backwash phenomenon
* Inadvertant Epidural injection
* Meningeal Diverticula
======SLIDE-7======

RIC Evidences of Spinal CSF

Leaks

RIC Evidences of Spinal CSF

Leaks
Evidence
Direct

Indirect

Finding

Pitfall

Paradural activity
(Extravasation)

Meningeal Diverticula
Inadvertant Extradural injection
Backwash

Incomplete Cephalad
migration of activity

NPH but major other

differences
Past SDH, Meningitis
(often but always theoretical)

Early activity in kidneys

4 Urinary bladder

Inadvertant Extradural Injection

Backwash

Strong activity in Systemic

Inadvertant Extradural injection
Circulation ("Silhouette Sign") significant backwash
BUT can be seen in leaks if the
flow is fast enough
Typically very obvious in fast
flow leaks