0:00

Another scenario in which there is cy nasal imaging

0:05

is for CSF rhinorrhea.

0:08

Sometimes the clinicians cannot tell whether the fluid

0:11

coming out of the patient's nose is from just normal

0:15

sinus contents and fluid versus

0:19

coming from the cerebral spinal fluid.

0:21

Again, I mentioned previously that one

0:23

of the things they test for is transferrin,

0:26

which is present in the CSF

0:28

but not present in normal cy nasal secretions.

0:31

So when a patient is having this leakage, uh,

0:34

there is usually cause for CT scan evaluation.

0:39

What we see sometimes are these cephaloceles.

0:42

Now cephaloceles can occur congenitally when they occur.

0:45

Congenitally, the most common location is in

0:47

the occipital region.

0:49

We do see them sometimes around Meles cave

0:51

and from meles C, it can get into the sphenoid sinus,

0:54

but we also may see them in the fronton

0:57

nasal region as well.

0:58

Sometimes the encephalocele and the rhinorrhea is post-op,

1:03

and we've seen examples

1:05

where the endoscopic sinus surgeon has perforated

1:08

through the cribriform plate

1:09

and has CSF leakage on that basis,

1:12

or intracranial contents growing through

1:16

or projecting down through an area

1:19

where there's a gap in the bone.

1:23

Sometimes the CSF rhinorrhea is after trauma,

1:26

and in this case it may be from a fracture of the skull base

1:30

or herniation of tissue through that gap in the skull base.

1:35

Very commonly nowadays, we are seeing patients who have

1:39

CSF leakage secondary to

1:42

idiopathic intracranial hypertension, also known

1:45

as pseudotumor cerebri.

1:47

And this may be because of that high pressure intracranial,

1:51

which leads to leakage through the various areas

1:55

where the bone may be thinned

1:58

from the longstanding pressure.

2:01

This leakage of CSF,

2:03

however may consequentially lead

2:07

to intracranial hypotension.

2:10

So if it's constantly leaking either from a spinal source

2:14

or a skull base source,

2:16

the pressure intracranial may actually decrease.

2:19

In those situations,

2:20

you may have spontaneous intracranial hypotension.

2:23

Where we see the descent of the cerebellar tonsils

2:26

through the frame of magnum,

2:27

we see the decrease in the malo pontine distance.

2:30

We see the decrease in the super cell distance.

2:33

We see the dilatation of the vasculature

2:37

and the meninges where we may see subdural omas

2:41

or enhancement of the meninges.

2:43

All of these factors which may occur in spontaneous

2:46

intracranial hypotension,

2:48

sometimes you can just look at the transverse sinus

2:52

and if the transverse sinus walls are convex

2:55

and enlarged, it suggests intracranial hypotension. If

2:58

The transverse sinus walls are flattened

3:01

and there's stenosis,

3:03

it suggests idiopathic intracranial hypertension

3:06

or pseudotumor cerebra.

3:08

And finally, tumors themselves may lead

3:10

to CSF rhinorrhea when they grow through the skull base.

3:14

So here we have a patient who has a CT scan showing a mass,

3:19

which is present in the right nasal cavity.

3:23

Offhand we would say, well, what is this?

3:26

Is this a type of a polyp?

3:27

However, for those of you who are relatively astute, you see

3:30

that there is absence

3:31

of the cribriform plate bone margination here,

3:35

and this becomes much easier when we look at the

3:38

coronal MR in the same patient where we see herniation

3:42

of brain tissue

3:43

and meninges down into the right nasal cavity absence

3:48

of enhancing tissue.

3:49

So it's not a neoplasm.

3:51

And here you can see the drawing in

3:54

and puckering of the brain tissue as it goes

3:57

through the cribriform plate.

3:59

In this example of a patient who has a cephalic E

4:03

with both brain tissue

4:05

and meninges, as well as reactive brain

4:09

edema in the right frontal lobe.

4:12

Here again, another example of the coronal T two wade scan

4:17

and the T one wade scan showing that irregularity

4:21

of the brain tissue and the meninges

4:23

and the puckering downward

4:24

through the gap in the cribriform plate on the Sagal T one

4:28

Wade scan, this is a different patient

4:31

and a little bit of an older study,

4:33

but what one sees here is the temporal lobe herniating into

4:38

the sphenoid science OID air cell bilaterally.

4:42

Here's again, temporal lobe

4:44

with brain tissue in the OID extension of the

4:48

sphenoid science bilaterally.

4:50

In a patient who had idiopathic intracranial hypertension

4:54

or pseudotumor cerebri.