Neuroradiology 15, 185-187 (1978)

@ by Springer-Verlag 1978

Neuroradiologv

The Diagnosis of CSF Fistulas with Rhinorrhea by Isotope Cisternography

G. Salar, A. Carteri and P. Zampieri Neurosurgical Institute, Universityof Padua, Padua, Italy

Summary. The experience with the use of R I H S A cisternography in cases of spontaneous or posttraumatic CSF rhinorrhea is reported. The utility of this method for identifying the fistulous tract so that the neurosurgeon can, as far as he is able, carry out a direct and not solely exploratory operation is pointed out.

Key words: Rhinorrhea - CSF fistula - Isotope cisternography.

the bony structures of the cranial base, the frontal and middle fossa, and more complicated examinations such as cisternography, using both gas and radiopaque materials [8, 9, 10, 11, 12, 13, 14]. Unfortunately, the results have not always been sarisfactory. However, isotope cistemography, widely used for many years [2, 7, 15-29], has shown itself ot be simple, reliable demonstrative and capable in certain cases of resolving the problems of diagnosis and localization.

This is a report of experience with isotope cisternography in the study of spontaneous and post-traumatic cerebrospinal fluid rhinorrhea. In cases of CSF rhinorrhea, the preoperative identification of the fistulous tract, between the endocranium and the paranasal cavities is a great advantage for the neurosurgeon. It is possible to carry out a limited operation if the exact site of the bony fracture, not always visible by X-ray is known; surgical exploration of the frontal cranial fossa may also be of an investigative nature. The areas through which the cerebrospinal fluid can enter the base of the cranium, either after cranial trauma or spontaneously, are, in order of frequency: the frontal sinus, the lamina cribrosa, the sphenoid sinus via the sella and the petrous bone via the middle ear and the eustachian tube [1, 2, 3, 4, 5, 6, 7]. The question of diagnosis: the presence or otherwise of a CSF fistula and topography, the location and course of the fistula and its tract, gave rise to the use of various methods, some of which are no longer used. Instead, dyes and fluorescent substances are now used, together with special X-ray technics. The most important of these is the stratigraphic study of

Methods
Di Chiro et al. [16] described cisternography with radioiodinated human serum albumin (RIHSA) in 1964 and later, reported his studies on the perimedullary and intracranial subarachnoid spaces [30]. Di Chiro's method, based on the detection of the spontaneous diffusion of a radioisotope introduced by lumbar puncture, showed itself to be of use not only for the study of the subarachnoid spaces, their extent and permeability, but also for showing the exclusion of areas limited by such spaces or their abnormal dilatation and, furthermore, the presence of CSF fistulas. The technic wich has been adopted in our Institute for the past 7 years requires an injection of RIHSA labelled with a31I or 99mTc, doses being 100-150 micro curies and 1.5-2 milli curies respectivelly. The radioactive tracer is introduced by lumbar puncture. Scans are made at 3, 5, 8 and 12 h. To exploit the spontaneous spread of the serum albumin after 3 and 5 h, various positions of the head are tried, with the aim of trying to force the fistulous

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G. Salar et al.: The Diagnosis of CSF Fistulas with Rhinorrhea by Isotope Cisternography

Fig. 1. RIHSA cisternography: scan made at the 5th h. Both cases show post-traumatic CSF rhinorrhea with fistulous tract starting from the lamina cribrosa (left in Case A, right in Case B)

Fig. 2. RIHSA cisternography: scan made at the 5th h. Post-traumatic CSF rhinorrhea with fistulous tract from sella to right sphenoid sinus (Case A); post-traumatic CSF rhinorrhea in patient with an "empty sella" (Case B)

Fig. 3o RIHSA cisternography: scan made at the 12th h (Case A) and 5th h (Case B). Posttraumatic CSF rhinorrhea starting from lamina cribrosa (Case A) and from frontal sinus (Case B)

G. Salar et at.: The Diagnosis of CSF Fistulas with Rhinorrhea by Isotope Cisternography

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tract, so that a hyperacculumation of the tracer in its site can be obtained. Of course if the first scintigraphs are positive, the examination can be stopped.
Material Twenty-eight patients hospitalized in the Institute of Neurosurgery of the University of Padua were studied, 18 with 131I and 10 with 99mTc. Seven of these patients had recurrent meningitis without ever having had CSF rhinorrhea or severe cranial trauma; 12 had had repeated episodes of CSF rhinorrhea after serious cranial trauma and nine, upon hospitalization, had evident CSF rhinorrhea of post-traumatic origin. Radioisotope examination was definitely positive and showed the fistulous tract in 1 1 patients, in all of whom CSF rhinorrhea had been definitely observed. The picture was doubtful in five patients who did not have CSF rhinorrhea at the time of hospitalization. The examination turned out to be negative in 12 patients in whom CSF rhinorrhea had been observed before hospitalization or who suffered from recurrent meningitis without apparent cause. Figures 1-3 show the scintigraphic record of six significant cases of CSF fistula with rhinorrhea. Conclusions

Isotope cisternography turned out to be a very useful technic for identifying CSF fistulas with rhinorrhea since, when the image was significant, it showed the location of the fistulous tract and, according to the extent of the accumulated tracer, its size also. It is therefore an examination and can be used by the neurosurgeon for carrying out directly aimed, nonexploratory operations. In our experience, cisternography is not of use in those patients who have recurrent meningitis but do not have CSF rhinorrhea.
References
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Received: March 27, 1978

Dr. Giuseppe Salar Istituto di Neurochirurgia dell'Universit~ degli Studi Padova (Italia)