double ring sign csf

AJNR Am J Neuroradiol. This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Spontaneous middle fossa encephalocele and cerebrospinal fluid leakage: diagnosis and management. Respir Med Case Rep. 2023 Feb 11;42:101814. doi: 10.1016/j.rmcr.2023.101814. An axial CT of a patient with a spontaneous CSF leak reveals a defect in the posterior table of the left frontal sinus. [QxMD MEDLINE Link]. Several texts have suggested that CSF will separate from blood when the mixture is placed on filter paper or other media and will produce a clinically detectable sign, which has been referred to as a ring sign, double ring sign, or halo sign. CSF represents the end product of the ultrafiltration of plasma across epithelial cells in the choroid plexus lining the ventricles of the brain. The underlying defect responsible for cerebrospinal fluid (CSF) leaks, regardless of the etiology, is the same: disruption in the arachnoid and dura mater coupled with an osseous defect and a CSF pressure gradient that is continuously or intermittently greater than the tensile strength of the disrupted tissue. Ear Nose Throat J. Methods: Burns BJ. [QxMD MEDLINE Link]. Magnetic resonance cisternography (MRC) should be used for CSF leak identification as a second line for each of these if beta-2 transferrin is not available or if HRCT is ambiguous. The clinical findings most frequently associated with CSF rhinorrhea are meningitis (30%) and pneumocephalus (30%). [QxMD MEDLINE Link]. For more information, please refer to our Privacy Policy. J Neurol Neurosurg Psychiatry. Am J Rhinol Allergy. Blood alone does not produce a ring. 1998 Apr. [QxMD MEDLINE Link]. Radionuclide cisternography may be useful to detect an intermittently active CSF fistula. [10]. Several surgical options for repair of CSF leaks arising from the anterior skull base exist. Normal CSF pressure is approximately 10-15 mm Hg, and elevated pressure constitutes an intracranial pressure (ICP) greater than 20 mm Hg. Sagittal magnetic resonance myelogram demonstrates a traumatic cerebrospinal fluid leak (small arrows) with disruption of the ligamentum flavum posteriorly (large arrow). Skull radiographs are of limited diagnostic use in CSF leaks, but they may show a relevant skull fracture or the presence of empty sella. Carbonic anhydrase catalyzes the formation of bicarbonate inside the epithelial cell. 2015 Jan-Feb. 29 (1):77-81. Ultimately, a defect is formed. To study the development of a ring sign when blood is mixed with various fluids. 19(4):627-31. Gubbels SP, Selden NR, Delashaw JB Jr, McMenomey SO. AJNR Am J Neuroradiol. 2016 Jan. 206 (1):8-19. L Gill Naul, MD Professor and Head, Department of Radiology, Texas A&M University College of Medicine; Chair, Department of Radiology, Baylor Scott and White Healthcare, Central Division Double ring sign. G-CSF-induced vasculitis has been reported to occur in 0.47% of patients. 1979 Oct 25;97(40):1814-20. Typically, 0.5 mL of a 10% fluorescein solution is injected into the lumbar subarachnoid space over more than 1 minute. HHS Vulnerability Disclosure, Help [QxMD MEDLINE Link]. Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. CT scans may demonstrate skull base defects resulting from accidental or iatrogenic trauma, an underlying anatomic or developmental abnormality, or an erosive lesion such as a neoplasm. Contrast medium has drained out of the meningocele, but a small amount remains in the sphenoid sinus around the meningocele. Endoscopic Endonasal Skull Base Surgery Complication Avoidance: A Contemporary Review. Leakage of CSF due to trauma or basilar skull fracture Halo test/double ring sign + (paper) How to test for CSF rhinorrhea urine dipstick: glucose (=CSF) paper: + halo test/double ring sign CSF rhinorrhea treatment Surgical repair of skull defect Auricular hematoma Blood between cartilage and perichondrium When CSF rhinorrhea is suspected, fluorescein may be injected into the lumbar subarachnoid space. These symptoms also occur in multiple common conditions and so should be evaluated by an ENT specialist if they are not easily explained or do not clear up on their own in a week or so. Lippincott Williams and Wilkins, Philadelphia 2000; Otolaryngol Clin North Am. Extradural fluid collections are common in spinal CSF leak. 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. AJNR Am J Neuroradiol. Traumatic cerebrospinal fluid leak. Pledgets are scanned in a glass tube at intervals of 2-24 hours, with the highest count rate indicating a possible leak site. This feature is the basis for a specific test for CSF based on immunoelectrophoresis. Since then, endoscopic repair has become the preferred method of addressing CSF rhinorrhea, given the high success rate of 90-95% and the decreased morbidity associated with this approach. The site is secure. Clipboard, Search History, and several other advanced features are temporarily unavailable. 1998 Apr. Izumoto Y, Matsuyama T, Mizuhira M, Imaseki H, Hamano T, Sakai Y, Oguri Y, Yoshii H. J Radiol Prot. He had been wearing a seat belt. Surgical repair of spontaneous cerebrospinal fluid (CSF) leaks: A systematic review. 2009 Oct. 72(4):341-5; discussion 346. Study objective: Surg Neurol. May be # of temporal bone, may involve CN 7/8. 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. may email you for journal alerts and information, but is committed Cerebrospinal fluid imaging. 2014 Sep. 59 (2):196-9. High-Resolution Computed Tomography as an Initial Diagnostic and Localization Tool in Patients with Cerebrospinal Fluid Rhinorrhea: A Meta-Analysis. [QxMD MEDLINE Link]. 2016 Nov. 6 (11):1126-30. Surgical repair of skull base defects resulting in cerebrospinal fluid (CSF) rhinorrhea is contraindicated in any patient who is not medically stable to undergo a general anesthetic or comply with postoperative care. This sign appears when CSF mixes with blood on an absorbent surface, such as paper or bed sheets, and creates a double ring pattern. Lemonnier LA, Tessema B, Kuperan AB, et al. The most common anatomic sites of spontaneous cerebrospinal fluid (CSF) leaks are the areas of congenital weakness of the anterior cranial fossa and areas related to the type of surgery performed. Please try after some time. For otorrhea, 1 cotton pledget is placed in each external auditory canal. CSF and blood disseminate at different rates due to different fluid densities creating a double ring with blood surrounded by a ring of CSF. Various other authors, including Dohlman (1948), Hirsch (1952), and Hallberg (1964), subsequently reported successful repair of CSF rhinorrhea through different external approaches. Study exclusion criteria were language other than English, pre-1990 studies, case reports, and nonrhinologic leak. Ask about Metformin Anyway, Special Report: Tackling the Behavioral Health Boarding Crisis, Evidence-Based Medicine: Ditch Diphenhydramine for Headache, Emergency Medicine Practice: The Future is Bright (Because We're in Flames), Quick Consult: Symptoms: Head Injury and Confusion after a Fall, Privacy Policy (Updated December 15, 2022). If a double ring sign is present, however, it is still important to make sure nothing is missed. Our services include electrician services, electrical repair, and home electrical wiring. Outcomes of endoscopic repair of cerebrospinal fluid rhinorrhea without lumbar drains. Enrique Palacios, MD, FACR Professor of Radiology, Tulane University Medical Center CSF will separate from blood when the mixture is placed on filter paper resulting in a central area of blood with an outer ring or halo. AJNR Am J Neuroradiol. Please try again soon. Zuckerman JD, DelGaudio JM. 142:43-7. Outcomes of outpatient endoscopic repair of cerebrospinal fluid rhinorrhea. A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma. (See images below.). 2005;38[4]:597), an elegant study from 1993 shows the double ring sign is neither sensitive nor specific for CSF. official website and that any information you provide is encrypted Lee TJ, Huang CC, Chuang CC, et al. CSF is manufactured continuously in areas of the brain called ventricles, and the bloodstream absorbs it. However, increased intracranial pressure is not always present in the case of spontaneous CSF rhinorrhea. They found that saline, normal rhinorrhea, and tap water all separate from blood in a manner similar to CSF, producing the characteristic double ring sign. These nsignatures together form a ring signature on behalf of pk. The ring is a result of the different densities of blood and CSF, and is concerning for a basilar skull fracture." While the presence of a double ring sign (sometimes called a halo sign) is often cited as indicating the presence of CSF ( Sapira's Art and Science of Bedside Diagnosis. Kevin C Welch, MD Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Rhinology and Skull Base Surgery, Northwestern University, The Feinberg School of Medicine The intrathecal injection of 0.5 mL of gadopentetate dimeglumine diluted in 3-5 mL of CSF for MR cisternography has been reported to have high sensitivity and specificity for detection of active CSF fistula, exceeding the rate of fistula demonstration by CT, nuclear medicine, or noncontrasted MR cisternography. 2022 Feb;45(1):831-841. doi: 10.1007/s10143-021-01614-1. Cerebrospinal fluid fistula: detection with MR cisternography. Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). Paraspinal fluid collections can be localized for needle aspiration with ultrasound guidance. Once in contact with the paper, any CSF will separate from any blood or mucus. 2015 Apr 28. From the third ventricle, the fluid circulates into the forth ventricle and out into the subarachnoid space via the foramina of Magendie and Luschka. In contrast to traumatic leaks, only 50% of patients with iatrogenic CSF leaks present within the first week after the insult. CSF leaks will often resolve within seven days with very few complications, and no clear evidence supports antibiotic prophylaxis for these leaks in the first seven days. Kevin C Welch, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic SocietyDisclosure: Nothing to disclose. [QxMD MEDLINE Link]. Get new journal Tables of Contents sent right to your email inbox, Letter to the Editor: Double Ring Sign Does Not Exclude CSF Leak. [1, 2, 3, 4, 5, 6]. Hence, educating the patient regarding the common symptoms associated with a CSF leak such as salty or metallic taste is of paramount importance. Fluid leaking from the nose or external auditory canal must first be positively identified as CSF. Ryall RG, Peacock MK, Simpson DA. The resulting fluid is termed cerebrospinal fluid. Fraser JF, Nyquist GG, Moore N, Anand VK, Schwartz TH. Enrique Palacios, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. Endoscopic endonasal CSF rhinorrhea repair in children: Systematic review with meta-analysis. 2020 Apr 10. Share cases and questions with Physicians on Medscape consult. Imaging findings were correlated with both the clinical findings and nasal pledget counts obtained as part of this study. NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. Hence, the surgical team should be prepared to repair the resulting CSF leak at the time of the resection, either transcranially or endoscopically. Please enable scripts and reload this page. Chiapparini L, Farina L, D'Incerti L, et al. Double Ring Sign: CSF mixed with blood or nasal discharge forms two rings because CSF being a watery fluid invades linen more than blood called the double-ring sign, halo sign, or . Circulation of CSF is maintained by the hydrostatic differences between its rate of production and its rate of absorption. CT myelography is used in the detection of spinal CSF leak. Accessibility 22(2):151-4. (Defect measured approximately 7mm.). FOIA The enzymatic breakdown or destruction of the bony architecture results in inflammation and potential violation of the dura. Alternatively, with the patient lying prone on a stretcher, the patient's hips can be raised above the level of the head for 1-2 minutes to concentrate the contrast medium over the anterior and posterior regions of the skull base. All rights reserved. 33(3):535-40. government site. The growth of benign tumors does not commonly result in CSF rhinorrhea. A doctor can use a number of tests to diagnose a CSF leak. A 58-year-Old non-smoking woman with intractable cough and rhinorrhea. [QxMD MEDLINE Link]. Michael G D'Antonio, MD Associate Professor of Clinical Radiology, Department of Radiology, Section of Neuroradiology, Louisiana State University Health Sciences Center in New Orleans; Consulting Staff Radiologist, Jefferson Radiology Associate, Inc, West Jefferson Medical CenterDisclosure: Nothing to disclose. Am J Rhinol. Int Forum Allergy Rhinol. If CSF is present, a dextrose stick test may be positive. 2022 Nov;36(11):859-864. doi: 10.13201/j.issn.2096-7993.2022.11.010. Cotton pledgets are placed in the nose, as for radionuclide cisternography. Elmorsy SM, Khafagy YW. In most cases of iatrogenic injury presenting in a delayed fashion, surgical repair is necessary. 2016 Mar. Axial CT image was obtained with the patient in the supine position. [QxMD MEDLINE Link]. Confirm or exclude the presence of CSF in leaking fluid by means of an immunoelectrophoretic study of the fluid for beta-2 transferrin (B2Tr) or, where available, beta-trace protein. Find many great new & used options and get the best deals for DOUBLE HEART FILIGREE .925 Sterling SILVER Ring - 1.5g Size 7.5 at the best online prices at eBay! The upper cervical epidural veins are congested. Background: 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. A high percentage of fast leaks have spinal extradural fluid collections on preliminary MRI spine scans. Optic nerve deficits suggest a lesion in the region of tuberculum sellae, sphenoid sinus, or posterior ethmoid cells. Triplanar images help to identify and conceptualize the location of this lateral recess encephalocele. Makary CA, Zalzal HG, Ramadan J, Ramadan HH. A high rate of fistula detection may be possible with imaging in the prone position, but this may be uncomfortable for the patient. Intrathecal gadolinium-enhanced MR cisternography in the evaluation of clinically suspected cerebrospinal fluid rhinorrhea in humans: early experience. The doublering sign found in contrastenhanced computed tomography, which reflects inflammatory changes in the adventitia and oedema of the intima, is thought to be characteristic of. In patients with nonsurgical trauma, waiting a period of 5-7 days to allow conservative measures (bed rest, stool softeners, and lumbar drainage) to assist with secondary closure of the traumatic defect is reasonable. The investigators suggested that intracranial hypertension may put patients at risk for developing these defects. Coronal CT image of the temporal bone demonstrates a bone defect (small arrows) in the tegmen tympani with a protruding soft-tissue meningoencephalocele (large arrows). The image also shows a right-sided meningocele (large arrow) protruding through the cribriform plate, which was not suspected but was surgically repaired at the same time as the left cribriform cerebrospinal fluid leak site. Marshall AH, Jones NS, Robertson IJ. Accessibility Clin Neurol Neurosurg. Li L, Gao FQ, Zhang B, Luo BN, Yang ZY, Zhao J. Overdosage of intrathecal gadolinium and neurological response. Spinal cerebrospinal fluid leaks detected by radionuclide cisternography and magnetic resonance imaging in patients suspected of intracranial hypotension. [20, 21, 22, 23] This technique is based on the intrinsic T2 contrast between CSF and adjacent structures. All rights reserved. Careers. [14]. We do not capture any email address. CSF leak; CSF rhinorrhea; cerebrospinal fluid; diagnosis; diagnostic algorithm; localization. Meningoencephaloceles usually present in childhood as an intranasal/extranasal mass that transilluminates and expands with crying (Furstenberg sign). NSF/NFD has occurred in patients with moderate to end-stage renal disease who have been given a gadolinium-based contrast agent to enhance MRI or MRA scans. Once in contact with the paper, any CSF will separate from any blood or mucus. 2017 Feb. 78 (1):18-23. Bethesda, MD 20894, Web Policies Otol Neurotol. Benedict PA, Connors JR, Timen MR, Bhatt N, Lebowitz RA, Pacione DR, Lieberman SM. Thank you for your interest in spreading the word on CMAJ. Halo sign (target sign or double ring sign), when the CSF Rhinorrhea is blood-stained and dries out, a central bloodstain surrounded by a clear ring is seen. Please confirm that you would like to log out of Medscape. In many cases, a CSF leak will heal on its own accord following conservative treatment, including strict bed rest, increased fluid intake and caffeine. 1993 Apr. A basal layer Na+/K+ ATPase is responsible for actively transporting Na+ into epithelial cells, after which water follows across this gradient. Your message has been successfully sent to your colleague. Laryngoscope. Traumatic causes include both blunt and penetrating facial injuries. Results: Please enable it to take advantage of the complete set of features! J Neurosurg. Despite relatively low levels of evidence, recommendations for the diagnosis and management of CSF rhinorrhea can be made based on the current literature. 1969 Apr. Arterial injury may occur with skull trauma that causes CSF leakage. Obstructive sleep apnea (OSA) has also been linked to elevated ICP. Spontaneous intracranial hypotension syndrome in a patient with chronic headaches, which began after lumbar puncture. Results: Axial fast spin-echo T2-weighted MRI demonstrates widened extra-axial fluid spaces but no focal extra-axial fluid collection. Management and Disposition Identify underlying brain injury, which is best accomplished by CT. CT is also the best diagnostic tool for identifying the fracture site, but fractures may not always be evident. High-resolution CT (HRCT) is then recommended as the first-line study for localization. 4th ed. MeSH Double Ring Sign (on bedding, paper) CSF Leakage will form appearance of watermelon in cross section Large Inner ring of pink, bloody CSF fluid Small outer ring of clear CSF fluid (analogous to the rind of a watermelon) Bedside Glucose of draining fluid CSF fluid will have bedside Glucose >30 mg/dl IV. What is the current clinical practice in pituitary adenoma surgery in Europe? [QxMD MEDLINE Link]. 2017 Oct. 2 (5):215-24. 1994 Nov. 111(5):600-5. J Neurotrauma. It should be kept in mind, however, that this test does not provide information regarding the site or laterality of the defect. Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck SocietyDisclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10
Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)
Received ownership interest from Cerescan for consulting for: Neosoma, MI10. 2011 May. Case report. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the sclera of the eyes; joint stiffness with difficulty moving or straightening the arms, hands, legs, or feet; pain deep in the hips or ribs; and muscle weakness. With one method, the average total time for coronal and sagittal imaging is 48 minutes. [QxMD MEDLINE Link]. Epub 2013 Jul 1. 2018 Dec;38(4):1384-1392. doi: 10.1088/1361-6498/aae39b. [QxMD MEDLINE Link]. Drainage may be intermittent as the fluid accumulates in one of the paranasal sinuses and drains externally with changes in head position (ie, reservoir sign). Fortschr Med. If you log out, you will be required to enter your username and password the next time you visit. Emily Ann King of Clear Lake, Texas and Craig Anthony Przyborski of Conroe, Texas were united in marriage on June 14, 2003 at 7:30 in the evening at St. Paul the Apostle . The high T2 signal from CSF fistula may be difficult to differentiate from that of sinusitis on axial images. (See images below.). Neuroradiology. Adams AS, Russell PT, Duncavage JA, Chandra RK, Turner JH. 2017 Oct. 13 (2):63-67. High-resolution computed tomography (CT) scanning is the imaging modality of choice for identifying a skull base defect associated with CSF rhinorrhea. Additional hardware or software is not required to perform MR myelography or cisternography. [QxMD MEDLINE Link]. Neurosurgery. Apr 2012. When there is doubt about the origin of the blood, the diagnosis of a basilar skull fracture must be excluded. Lucien M Levy, MD, PhD is a member of the following medical societies: American Cancer Society, American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, American Society of Neuroradiology, Radiological Society of North AmericaDisclosure: Nothing to disclose. The embryologic defect is typically a patent fonticulus frontalis or foramen cecum. A halo pattern on a bedsheet produced by bloody otorrhea from a 27-year-old man who had been in a motor vehicle collision. The management of CSF rhinorrhea depends on the cause, location, and severity of the leak. 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. J Neurol Neurosurg Psychiatry. double-ring sign (Figure 1B). double ring sign: two concentric rings around the optic nerve characteristic of optic nerve hypoplasia. Before Head images are acquired 2, 6, 12, and 24 hours after injection of the isotope. C Douglas Phillips, MD, FACR is a member of the following medical societies: American College of Radiology, American Medical Association, American Society of Head and Neck Radiology, American Society of Neuroradiology, Association of University Radiologists, Radiological Society of North AmericaDisclosure: Nothing to disclose. The site is secure. [QxMD MEDLINE Link]. Conclusion: These are infrequently associated with CSF rhinorrhea. It is produced in epithelial cells of the choroid plexus and meninges and is found in CSF, perilymph, seminal fluid, and urine. Would you like email updates of new search results? This image shows complete resolution of the previous dural thickening and contrast enhancement. Predicting Fast Spinal CSF Leaks in Patients with Spontaneous intracranial Hypotension. CMAJ. In most cases, the patient will have been discharged when the leak presents itself. The image demonstrates dense contrast medium layering in the empty sella and contained within the meningocele (arrow). Matsumura A, Anno I, Kimura H, Ishikawa E, Nose T. Diagnosis of spontaneous intracranial hypotension by using magnetic resonance myelography. [Full Text]. 2004 Aug. 114(8):1475-81. The role of MR myelography with intrathecal gadolinium in localization of spinal CSF leaks in patients with spontaneous intracranial hypotension. Endonasal endoscopic repair of spontaneous cerebrospinal fluid leaks. Typical imaging parameters include a repetition time of 10,000 ms, an effective echo time of 200 ms, 4 signals acquired, an echo train length of 16, a matrix of 512 X 192, no phase-wrap option, 3-mm sections interleaved contiguously (0-mm gap), and a 16-cm field of view.

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