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Head and Neck
Diagnosis
Skull Base Lesions
Diffuse or Multifocal Skull Base Disease
Skull Base CSF Leak
Skull Base CSF Leak
Surjith Vattoth, MD, FRCR; Patricia A. Hudgins, MD, FACR
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KEY FACTS

  • Imaging

    • Top Differential Diagnoses

      • Pathology

        • Clinical Issues

          TERMINOLOGY

          • Definitions

            • Osseous dural defect or osteodural defect (ODD): Focal gap though dura & underlying skull base (SB) bone
              • Acquired; seen commonly with intracranial hypertension
              • May result from underlying congenital fissures, bone thinning, or arachnoid pits due to aberrant arachnoid granulations (AbAG)
            • AbAG: Arachnoid granulations that penetrate dura but fail to reach dural venous sinus
              • Typically at lateral edges of cribriform plate, or in floor of middle cranial fossa involving sphenoid or temporal bone from lateral wall of sella to tegmen tympani 
              • Rarely between transverse sinus & bony labyrinth or jugular foramen region

          IMAGING

          • Imaging Recommendations

            • General Features

              • CT Findings

                • MR Findings

                  DIFFERENTIAL DIAGNOSIS

                    PATHOLOGY

                    • General Features

                      CLINICAL ISSUES

                      • Presentation

                        • Demographics

                          • Natural History & Prognosis

                            • Treatment

                              DIAGNOSTIC CHECKLIST

                              • Consider

                                • Image Interpretation Pearls

                                  • Reporting Tips

                                    Selected References

                                    1. Hanz SZ et al: Low incidence of true Sternberg's canal defects among lateral sphenoid sinus encephaloceles. Acta Neurochir (Wien).162(10):2413-20, 2020
                                    2. Hiremath SB et al: Cerebrospinal fluid rhinorrhea and otorrhea: a multimodality imaging approach. Diagn Interv Imaging. 100(1):3-15, 2019
                                    3. Oakley GM et al: Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 6(1):8-16, 2016
                                    4. DelGaudio JM et al: Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base. Int Forum Allergy Rhinol. 5(4):333-8, 2015
                                    5. Hasheminia D et al: A 7-year study of 1,278 patients with maxillofacial trauma and cerebrospinal fluid leak. J Maxillofac Oral Surg. 14(2):258-62, 2015
                                    6. Stevens SM et al: Obesity related complications in surgery. Curr Opin Otolaryngol Head Neck Surg. 23(5):341-7, 2015
                                    7. Aghaei Lasboo A et al: Emergent image-guided treatment of a large CSF leak to reverse "in-extremis" signs of intracranial hypotension. AJNR Am J Neuroradiol. 2008 Oct;29(9):1627-9. Epub 2008 Jun 26. Erratum in: AJNR Am J Neuroradiol. 31(3):E38, 2010
                                    8. Algin O et al: The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea. Br J Radiol. 83(987):225-32, 2010
                                    9. Selcuk H et al: Intrathecal gadolinium-enhanced MR cisternography in the evaluation of CSF leakage. AJNR Am J Neuroradiol. 31(1):71-5, 2010
                                    10. Tabaee A et al: Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg. 112(5):1070-7, 2010
                                    11. Banks CA et al: Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg. 140(6):826-33, 2009
                                    12. Barañano CF et al: Sternberg's canal: fact or fiction? Am J Rhinol Allergy. 23(2):167-71, 2009
                                    13. Castellan L et al: Computed tomography myelography for the assessment of iatrogenic cerebrospinal fluid (CSF) leak. J Neuroradiol. 36(2):115-7, 2009
                                    14. Hoxworth JM et al: Localization of a rapid CSF leak with digital subtraction myelography. AJNR Am J Neuroradiol. 30(3):516-9, 2009
                                    15. Rabadán AT et al: Pituitary tumors: our experience in the prevention of postoperative cerebrospinal fluid leaks after transsphenoidal surgery. J Neurooncol. 93(1):127-31, 2009
                                    16. Sampaio MH et al: Predictability of quantification of beta-trace protein for diagnosis of cerebrospinal fluid leak: cutoff determination in nasal fluids with two control groups. Am J Rhinol Allergy. 23(6):585-90, 2009
                                    17. Han ZL et al: Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg. 110(6):570-9, 2008
                                    18. La Fata V et al: CSF leaks: correlation of high-resolution CT and multiplanar reformations with intraoperative endoscopic findings. AJNR Am J Neuroradiol. 29(3):536-41, 2008
                                    19. Lloyd KM et al: Imaging of skull base cerebrospinal fluid leaks in adults. Radiology. 248(3):725-36, 2008
                                    20. Scholsem M et al: Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience. Neurosurgery. 62(2):463-9; discussion 469-71, 2008
                                    21. Stangherlin P et al: Benign intracranial hypertension with recurrent spontaneous cerebrospinal fluid rhinorrhoea treated by laparoscopic gastric banding. Acta Chir Belg. 108(5):616-8, 2008
                                    22. Meco C et al: Comprehensive algorithm for skull base dural lesion and cerebrospinal fluid fistula diagnosis. Laryngoscope. 114(6):991-9, 2004
                                    23. Schlosser RJ et al: Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol. 17(4):191-5, 2003
                                    24. Fujimaki H et al: Cerebrospinal fluid leak demonstrated by three-dimensional computed tomographic myelography in patients with spontaneous intracranial hypotension. Surg Neurol. 58(3-4):280-4; discussion 284-5, 2002
                                    25. Mahapatra AK et al: Anterior encephaloceles: a study of 92 cases. Pediatr Neurosurg. 36(3):113-8, 2002
                                    26. Lund VJ et al: Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea. J Laryngol Otol. 114(12):988-92, 2000
                                    Related Anatomy
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                                    Related Differential Diagnoses
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                                    References
                                    Tables

                                    Tables

                                    KEY FACTS

                                    • Imaging

                                      • Top Differential Diagnoses

                                        • Pathology

                                          • Clinical Issues

                                            TERMINOLOGY

                                            • Definitions

                                              • Osseous dural defect or osteodural defect (ODD): Focal gap though dura & underlying skull base (SB) bone
                                                • Acquired; seen commonly with intracranial hypertension
                                                • May result from underlying congenital fissures, bone thinning, or arachnoid pits due to aberrant arachnoid granulations (AbAG)
                                              • AbAG: Arachnoid granulations that penetrate dura but fail to reach dural venous sinus
                                                • Typically at lateral edges of cribriform plate, or in floor of middle cranial fossa involving sphenoid or temporal bone from lateral wall of sella to tegmen tympani 
                                                • Rarely between transverse sinus & bony labyrinth or jugular foramen region

                                            IMAGING

                                            • Imaging Recommendations

                                              • General Features

                                                • CT Findings

                                                  • MR Findings

                                                    DIFFERENTIAL DIAGNOSIS

                                                      PATHOLOGY

                                                      • General Features

                                                        CLINICAL ISSUES

                                                        • Presentation

                                                          • Demographics

                                                            • Natural History & Prognosis

                                                              • Treatment

                                                                DIAGNOSTIC CHECKLIST

                                                                • Consider

                                                                  • Image Interpretation Pearls

                                                                    • Reporting Tips

                                                                      Selected References

                                                                      1. Hanz SZ et al: Low incidence of true Sternberg's canal defects among lateral sphenoid sinus encephaloceles. Acta Neurochir (Wien).162(10):2413-20, 2020
                                                                      2. Hiremath SB et al: Cerebrospinal fluid rhinorrhea and otorrhea: a multimodality imaging approach. Diagn Interv Imaging. 100(1):3-15, 2019
                                                                      3. Oakley GM et al: Diagnosis of cerebrospinal fluid rhinorrhea: an evidence-based review with recommendations. Int Forum Allergy Rhinol. 6(1):8-16, 2016
                                                                      4. DelGaudio JM et al: Magnetic resonance cisternogram with intrathecal gadolinium with delayed imaging for difficult to diagnose cerebrospinal fluid leaks of anterior skull base. Int Forum Allergy Rhinol. 5(4):333-8, 2015
                                                                      5. Hasheminia D et al: A 7-year study of 1,278 patients with maxillofacial trauma and cerebrospinal fluid leak. J Maxillofac Oral Surg. 14(2):258-62, 2015
                                                                      6. Stevens SM et al: Obesity related complications in surgery. Curr Opin Otolaryngol Head Neck Surg. 23(5):341-7, 2015
                                                                      7. Aghaei Lasboo A et al: Emergent image-guided treatment of a large CSF leak to reverse "in-extremis" signs of intracranial hypotension. AJNR Am J Neuroradiol. 2008 Oct;29(9):1627-9. Epub 2008 Jun 26. Erratum in: AJNR Am J Neuroradiol. 31(3):E38, 2010
                                                                      8. Algin O et al: The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea. Br J Radiol. 83(987):225-32, 2010
                                                                      9. Selcuk H et al: Intrathecal gadolinium-enhanced MR cisternography in the evaluation of CSF leakage. AJNR Am J Neuroradiol. 31(1):71-5, 2010
                                                                      10. Tabaee A et al: Endoscopic management of spontaneous meningoencephalocele of the lateral sphenoid sinus. J Neurosurg. 112(5):1070-7, 2010
                                                                      11. Banks CA et al: Endoscopic closure of CSF rhinorrhea: 193 cases over 21 years. Otolaryngol Head Neck Surg. 140(6):826-33, 2009
                                                                      12. Barañano CF et al: Sternberg's canal: fact or fiction? Am J Rhinol Allergy. 23(2):167-71, 2009
                                                                      13. Castellan L et al: Computed tomography myelography for the assessment of iatrogenic cerebrospinal fluid (CSF) leak. J Neuroradiol. 36(2):115-7, 2009
                                                                      14. Hoxworth JM et al: Localization of a rapid CSF leak with digital subtraction myelography. AJNR Am J Neuroradiol. 30(3):516-9, 2009
                                                                      15. Rabadán AT et al: Pituitary tumors: our experience in the prevention of postoperative cerebrospinal fluid leaks after transsphenoidal surgery. J Neurooncol. 93(1):127-31, 2009
                                                                      16. Sampaio MH et al: Predictability of quantification of beta-trace protein for diagnosis of cerebrospinal fluid leak: cutoff determination in nasal fluids with two control groups. Am J Rhinol Allergy. 23(6):585-90, 2009
                                                                      17. Han ZL et al: Cerebrospinal fluid rhinorrhea following trans-sphenoidal pituitary macroadenoma surgery: experience from 592 patients. Clin Neurol Neurosurg. 110(6):570-9, 2008
                                                                      18. La Fata V et al: CSF leaks: correlation of high-resolution CT and multiplanar reformations with intraoperative endoscopic findings. AJNR Am J Neuroradiol. 29(3):536-41, 2008
                                                                      19. Lloyd KM et al: Imaging of skull base cerebrospinal fluid leaks in adults. Radiology. 248(3):725-36, 2008
                                                                      20. Scholsem M et al: Surgical management of anterior cranial base fractures with cerebrospinal fluid fistulae: a single-institution experience. Neurosurgery. 62(2):463-9; discussion 469-71, 2008
                                                                      21. Stangherlin P et al: Benign intracranial hypertension with recurrent spontaneous cerebrospinal fluid rhinorrhoea treated by laparoscopic gastric banding. Acta Chir Belg. 108(5):616-8, 2008
                                                                      22. Meco C et al: Comprehensive algorithm for skull base dural lesion and cerebrospinal fluid fistula diagnosis. Laryngoscope. 114(6):991-9, 2004
                                                                      23. Schlosser RJ et al: Elevated intracranial pressures in spontaneous cerebrospinal fluid leaks. Am J Rhinol. 17(4):191-5, 2003
                                                                      24. Fujimaki H et al: Cerebrospinal fluid leak demonstrated by three-dimensional computed tomographic myelography in patients with spontaneous intracranial hypotension. Surg Neurol. 58(3-4):280-4; discussion 284-5, 2002
                                                                      25. Mahapatra AK et al: Anterior encephaloceles: a study of 92 cases. Pediatr Neurosurg. 36(3):113-8, 2002
                                                                      26. Lund VJ et al: Optimum imaging and diagnosis of cerebrospinal fluid rhinorrhoea. J Laryngol Otol. 114(12):988-92, 2000